It has been 11 years since the Institute of Medicine published its report To Err Is Human and put forth the goal of improving patient outcomes by reducing the rate of medical errors by 50% in 5 years.1 One of the most important elements in patient outcomes is the quality of nursing care that a patient receives. The issue of nurse-to-patient ratios has been a hot button for many years. From a practical standpoint, the procedure of staffing a unit can be all-consuming for nursing directors. However, staffing ratios aren't just numbers to meet and they do impact upon patient outcomes.
There has been significant work in the intervening years that supports the association between increased nurse staffing and improved patient outcomes.2-3 This work and national discussion has prompted many states to propose legislation or to have passed bills in favor of mandatory staffing ratios in acute care hospitals. From the outside, this may seem like an effective way to force hospitals to comply with a higher standard, but it bears closer examination. Does an arbitrary number represent what a nurse in a CCU must do daily to safely care for his or her patients? Generally speaking, in critical care the proposed standard is a maximum of two patients to one critical care RN.
One of the concerns with this approach is the inequality on levels of patient acuity across the country. A Level I trauma center has a higher level acuity patient in the ICU than a small rural hospital that has four ICU beds and airlifts its acutely ill patients to a tertiary care center. The patients in the ICU in a rural setting for postoperative monitoring may be very safely cared for at a 3:1 ratio. The patients in a tertiary care center may require 1:1 nursing care or greater. If a number is applied with impunity, other patients in those institutions may suffer because staff has to be pulled in order to comply with the legislation.
The next question is a financial one. Although these additional full-time equivalents will improve patient outcomes, and cost savings or cost avoidance with improved outcomes may offset the initial costs, the practicality of having cash on hand to fund the initial changes may be impossible for some institutions.
It makes intuitive sense that the level of safety is best assessed by the nurses working in the unit. The concept of acuity-based staffing has also been put forth with many models. However, it hasn't been universally adopted. The development of a user-friendly assessment tool, created by nurses for nurses, that would reflect the patient workload, salient safety practices, and demonstrate improved patient outcomes, would be nirvana. I don't believe that this can be achieved by assigning an arbitrary number. This is nursing's opportunity to utilize a growing body of data and knowledge to make evidence-based decisions about our practice.
Kate J. Morse, RN, CCRN, CRNP, MSN
Editor-in-Chief Assistant Clinical Professor Acute Care Nurse Practitioner Tract Coordinator Critical Care Nurse Practitioner, Chester County Hospital West Chester, Pa. [email protected]
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