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Workplace Update: Nursing

What are the most pressing issues facing nursing today?

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"Is it safe for my staff to be expected to work so many hours with so many patients?"

It's a question ever present on the minds of chief nursing officers, nurse managers and staff nurses and knowledgeable stakeholders.

Recently, ADVANCE asked with three distinguished clinicians from around the country their thoughts of these fundamental nursing issues and more.

ADVANCE: Do nurse-to-patient ratios work?

Donna Poduska, MS, RN, NE-BC, NEA-BC, ACHE, vice president and chief nursing officer at the Magnet-designated Poudre Valley Hospital, Fort Collins, CO: They do to a certain point. When determining nurse-to-patient ratios, we also consider what support services are available, such as nursing assistants on the floor, clerical help or an IV team.


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Christine Guercio, BSN, RN, nurse staffing manager at Carroll Hospital Center, Westminster, MD: Yes. If a matrix with nurse-to-patient ratios is used in conjunction with effective communication and understanding of variables, it works quite well.

Olivia Prebus, BSN, BA, RN, staff nurse at the Magnet-designated Children's Hospital of Philadelphia: Yes and no. While safety demands that nurses have a sensible limit to the number of patients they care for, nurse-to-patient ratios come in a variety of models. The model of fixed nurse-to-patient ratios carries risks. Fixed ratios do not account for changes in the acuity of patients and in nurse experience. In my experience, these changes occur rapidly from shift to shift, so flexibility is key to successful staffing plans. I worry that any mandated minimum-staffing ratio would become the standard ratio as hospitals seek to save money. In cases where hospitals would need to hire extra nurses to comply with a law-mandated ratio that does not fit their needs, I worry that vital ancillary staff would lose their jobs, thus increasing the responsibilities falling to the nurse. This would reduce the nurse's ability to provide quality care.

Staffing plans that allow for flexible standards are safer. I believe staffing standards should be set with the input of nurses at the bedside, as well as administrators, and be based upon the acuity and unique needs of the patients. Safe staffing plans should be based in the care models of each hospital. For example, a medical floor in an adult hospital may have nurses care for 5-7 patients at a time, but on a pediatric medical floor nurses would care for four patients at a time. This is a necessary difference because pediatric patients often require more face time with their nurses because they are dependent on adults for help with basic activities of daily living. Flexible safe staffing models allow for necessary differences in nurse-to-patient standards on an institutional level and, within hospitals, on a unit level as well.

ADVANCE: Is increased nurse staffing cost effective?

Poduska: Yes. You have to always evaluate it, but where you're going to save costs, especially with a good skill mix of RNs, is your nurse-sensitive indicators will improve, and you'll have fewer falls, fewer pressure ulcers and fewer medical errors.

Guercio: Increased nurse staffing is cost effective when compared to the costs of increased patient risk and untoward events. When looking at the overall cost of increased nurse staffing, it is imperative that all variables are assessed and the focus remains on evidenced-based data to promote staffing for quality care.

Prebus: Research continues to show that many of the factors that play into healthcare error are a result of inadequate nurse staffing. These include too little time spent with patients, too few nurses and stress related to fatigue. Increased nurse staffing addresses these issues and creates an environment for safer and higher quality care. Increased nurse staffing is certainly cost-effective because it reduces preventable errors paid for by hospitals.

ADVANCE: Are there laws in your state that address nurse-to-patient ratios? What is your hospital's policy on nurse-to-patient ratios?

Poduska: There are no laws on nurse-to-patient ratios in Colorado. Our hospital looks at patient acuity, and we go from there. There's no set "everybody has this amount" or "everybody has that." There's always a guideline, and acuity trumps everything. We use matrixes depending on the number of patients, and then we evaluate additional considerations, such as do they need one-to-one care, whether they're in isolation and whether they're demanding lots of physical care.

Guercio: Maryland does not have a law that dictates nurse-to-patient ratios. However, all nurses are required to perform within the Nurse Practice Act. Our hospital staffs according to a set matrix unique to each floor. The matrix is based on hours of care for that population of patients. The matrix and staffing patterns are frequently analyzed and are modified shift by shift with relation to acuity needs.

Prebus: There are no laws in Pennsylvania that address nurse-to-patient ratios. The Pennsylvania State Nurses Association is working to pass safe staffing legislation (HB 1880) that would mandate safe staffing plans created by each hospital with the input of bedside nurses. There are no fixed nurse-to-patient ratios at my hospital. We use an acuity index to assess staffing needs on each unit on a shift-by-shift basis to ensure safe, high-quality care. This system works well and allows nurses at the bedside and the unit managers to determine the necessary skill mix and staffing that best serves the patients.

ADVANCE: What is the status of mandatory overtime? Is it allowed in your state? Does it occur in your facility?

Poduska: Mandatory overtime is allowed in Colorado, depending on the hospital. But we barely ever use it. We have incentive plans that encourage nurses to come in for additional hours.

Guercio: I believe mandatory overtime is allowed in the state of Maryland. However, our facility does not regularly institute it. We use other opportunities such as rotations of shifts, internal contracts and incentivized shifts to meet our staffing needs. The only time it would be potentially used is in emergency operations, but that is rare.

Prebus: Mandatory overtime is legal in Pennsylvania but has not been employed by my hospital for several years. Studies show mandatory overtime decreases workplace satisfaction and increases nurse fatigue and fatigue-related mistakes that lead to poor outcomes. My hospital places patient safety at the center of everything we do, so it has eliminated mandatory overtime.


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ADVANCE: How does your hospital keep nurses safe on the job?

Poduska: We use lots of portable lifts for moving patients and are also installing ceiling lifts. To avoid needlestick injuries, we use a lot of needleless systems. We also offer education on topics like safe patient lifting and needle sticks, and we recently offered active shooter training because you never know what may come through the doors anymore. Our employees in high-risk areas undergo training on how to de-escalate patients and how to do takedowns, if necessary.

Guercio: We have an associate safety committee as well as a safety reporting system that encourages staff to report safety issues and potential issues as well. All issues are followed up on, and preventive measures are instituted. We have a robust safe-lifting initiative and recently installed overhead lifting equipment as well as improved mobile devices to assist nurses. We also are providing increased education and strategies related to workplace violence prevention.

Prebus: My hospital provides a lot of education on safety from the moment a new nurse is hired through to annual staff education modules. We are encouraged to report unsafe conditions when we see them, and we have methods to do so anonymously if we are not comfortable going up the chain of command on our units. The hospital promotes safe patient handling and provides trainings periodically to reinforce the concept and remind us to ask for help if patients are too heavy to be moved by one or two people. We use patient lifts and roller boards as well as weight-based metrics to help guide the number of people required for patient movement.

Jolynn Tumolo is a frequent contributor to ADVANCE.

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I agree that the healthcare setting continues to get more and more challenging. I often feel the "number crunching" is difficult in settings where one spends time consoling patients/ families yet the acuity may be perceived as low but the intensity of the work remains high. There are times when the numbers fail to reflect the policy -ie in administering conscious sedation, the nurse should be one to one. Do we look more at "scores"/fiscal rsesponsibility than outcomes ie- what are the number of med errors,staff injuries etc. in determining staffing? I think it is difficult to manage the ebb and flow of daily practice...some days are reasonable and others feel like you are skating on thin ice. As an older nurse, I have concerns with being utilized as a tech and there is much evidence to support the need to protect healthcare workers from unsafe working conditions.As always, there is a degree of risk associated with staffing and the balance of fiscal responsibilty and good outcomes remains challenging.

Marguerite December 24, 2012

I also agree w/Jim. Over nearly 40 yrs experince which includes Ambulatory Center Care, ICU, and ED - acuity has only rarely been addressed by management. Nurses ARE increasingly being asked to do more with less - more productivity with less staff. This now includes not just nurse managers but (inexperienced) Medical Directors who "have no clue and NO ppl skills" and, do not respect nurses enough to even ask for their input. While Residents, and some Attendings, are not held accountable for their actions or to even follow hospital policy. You think its bad now? Wait until nurses like myself retire, and believe me I am out the door as soon as I am able in the next few years. Unless this toxic attitude of "save-a-buck, let's pile more work on nurses" changes soon... my heart CRIES for the patients we as nurses swore to give our all for (and have done so). Goodness help us all.

Sue  HosiptalDecember 20, 2012

I work In a busy ICU. They staff us based on how many patients we have. They never look at acuity. If pt census goes down, they want us to send someone home. If pt census goes up, it is the rare day you get the extra nurse. Management thinks it is fine that each nurse takes 3 pts apiece and then wonder why HCAP scores remain so low. I've worked as a nurse for over 25 years and it just gets harder and harder. Longer hours, less help, larger patients and no adjustment on managements part for any of that.

Jean ,  RNDecember 19, 2012

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