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Beyond Nurse-to-Patient Ratios

Emerging Research Consensus Eyes a More Complex Set of Variables

PHILADELPHIA -- Two years ago, on International Nurses Day and the 190th birthday of Florence Nightingale, the AFL-CIO-affiliated National Nurses Union (NNU) took over a sizable chunk of lawn in the shadow of the U.S. Capitol to anchor its legislative lobbying efforts and rally
NNU on Capitol Hll
Images: Kucinich Campaign
Brandishing signs that way "Safe Patient Ratios Save Lives" and "I'm a Patient Advocate," members of the National Nurses Union demonstrate outside the U.S. Capitol on May 12, 2010.
members around two key agenda points. It was easy to know what those points where because many in the sea of red shirts brandished two-sided signs that read "Union Nurses = Quality Care" and "Safe Patient Ratios Save Lives."

Labor disputes
That latter slogan about nurse-to-patient ratios has been a central focus of nursing labor disputes for decades and, in particular, since the launch of California's mandated nurse-to-patient ratio law.

"If you ask any nurse in any part of the country about staffing, they'll tell you, if they're not from California, that they're always understaffed," says Deborah Burger, a veteran nurse who heads both NNU and the California Nurses Association. She believes the 2004 implementation of California's minimum nurse-to-patient ratio law saved lives and prevented many nurses from leaving the profession, and makes no bones about her group's push for similar laws throughout the rest of the country.

Issue and conflict
That push presents mandated ratios as the solution to two of health care's most pressing problems: low job satisfaction among nurses and the need to improve the quality of patient care. Nurses, who are among the country's most trusted professionals, have garnered much public and press sympathy for their argument and picket lines. But the same actions put them in conflict with hospital administrators who are wary of the financial implications of mandated ratios and who point to the lack of hard evidence
Matthew McHugh
Photo: Penn
Matthew McHugh, Assistant Professor of Nursing at the University of Pennsylvania School of Nursing, led one of the latest studies of the nursing practice environment.
that, in isolation, mandated ratios can solve either problem.

Meanwhile, the strikers' claim that they are motivated by concerns for patient welfare has been challenged by a recent MIT study that analyzed 20 years of nursing walkouts at 43 New York hospitals. It documents a 19.4 percent rise in in-patient mortality during those job actions.

Overall, the nursing-ratio imbroglio appears to be a significant barrier to achieving the levels of workforce stability, fiscal efficiency, staffing morale and patient-care outcomes demanded by a new era of health care reform and reorganization.

Ongoing research
The prominence of the conflict has made the issue a focus of numerous academic studies over the last twenty years. Virtually all investigators acknowledge that adequate nurse staffing is a crucial element of hospital care. But study findings in recent years have also emphasized that staffing is only one of a complex array of elements within the "practice environment" that ultimately determines the quality of patient outcomes and nurses' job satisfaction.

The most recent of those works was conducted by a team at the Center for Health Outcomes and Policy Research within the University of Pennsylvania School of Nursing. Led by professor Matthew McHugh, the study of nearly 100,000 nurses found 34 percent of hospital nurses felt "burned out in their current jobs."

Burnout and work environment
The investigators reported that "nurses' assessments of the overall quality of their work environments -- including factors such as managerial support for nursing, responsiveness of management to correcting problems in care at the bedside identified by nurses, and doctor-nurse relations -- were significantly associated with burnout and job satisfaction."

Although "mandated nursing ratios" is the phrase most associated with hospital strikes, the nursing community does not unanimously support the concept. A 2009
Peter Buerhaus
Photo: Vanderbilt
Peter Buerhaus is a Professor of Nursing at Vanderbilt University Medical Center and director of the Center for Interdisciplinary Health Workforce Studies.
survey published in the journal, Nursing Economics, found that 38 percent of RNs were not in favor of mandated ratios and only 34 percent supported the idea of a national law requiring them.

Local nursing committees
The approach endorsed by the 180,000-member American Nurses Association (ANA) envisions a national law establishing local hospital committees dominated by nurses that craft unit-specific staffing plans for their own facilities.

"We don't have a number in our legislation," says Katie Brewer, an RN and ANA senior policy analyst.

Peter Buerhaus, Vanderbilt University Medical Center nursing professor and director of the Center for Interdisciplinary Health Workforce Studies says there's no scientific evidence supporting a "magic number" for nurse staffing.

No hard, scientific evidence
In fact, in 2003, when the California Department of Public Health was developing the rules for its new law, it ran up against that same problem and noted that "essentially there was not hard, scientific evidence in the literature indicating the number of patients nurses can safely and effectively handle while providing quality patient care." Subsequent studies of California's ongoing experiment have provided noteworthy insights but not the hard data required to define an industry standard for ratios.

Building on earlier research linking better staffing to better outcomes, studies conducted so far indicate
Maja Djukic
Photo: NYU
Maja Djukic is Assistant Professor at the NYU College of Nursing and has been researching nursing workforce issues on a grant from the Robert Wood Johnson Foundation.
California's mandated ratio experience has been at least partially successful and, importantly, hasn't inadvertently harmed patients. Research suggests the ratios -- which range from 2:1 in intensive care units to 6:1 in psychiatric departments -- have translated into better care and more satisfied nurses, but experts await more data.

California's improved staffing
"My sense is that, as a policy option, (the California ratio law) worked in terms of improving staffing," said Penn's McHugh. Researchers now must establish whether the law actually improved patient outcomes, he noted.

"I don't profess that this is the only or the right policy option," McHugh says, adding that the policy is one approach to improve patient safety and nurses' work environment.

Vanderbilt's Buerhaus, who has studied the issue extensively, says by focusing so tightly on staffing to the exclusion of the other elements in the practice environment that "you never fix the underlying problems."

'Other solutions'
"There's no question that in some hospitals, increasing staffing will on average lead to better outcomes," Buerhaus says, "but not in every hospital, not on every unit and not in every place." The situations in some hospitals might need another solution, he says.

For instance, a 2011 study Buerhaus co-authored, published in the New England Journal of Medicine, found an association between high patient turnover and higher patient mortality. The high turnover requires more work for nurses, a problem that can be fixed by changing patient flow so nurses aren't slammed, he says.

That study also notes that "additional research is needed to understand the complex interplay among nurse staffing, patient preferences, and other factors, including staffing levels of physicians and other non-nursing personnel, technology, work processes and clinical outcomes."

Another recent study led by Maja Djukic of New York University's College of Nursing and funded by the Robert
Linda Aiken
Photo: Penn
Linda Aiken is a professor at the University of Pennsylania's School of Nursing and Director of the Center for Health Outcomes and Policy.
Wood Johnson Foundation surveyed more than 1,200 RNs about staffing, workgroup cohesion, physical work environment and job satisfaction in relation to RN-rated patient-care quality.

Factors other than staffing
It found that the ratings RNs gave to their units' overall working environment correlated with the ratings they gave the quality of patient care. Slight increases in the practice environment ratings were associated with dramatic increases in the quality of care ratings. The authors concluded that "our evidence demonstrates the importance of considering RN work environment factors other than staffing when planning improvements in patient care quality."

Similarly in December, 2011, a new study led by Linda Aiken provided further evidence of how critical the understanding -- and proper management -- of the totality of the nursing practice environment is to the quality of patient care. Aiken is a professor at the University of Pennsylvania School of Nursing and director of its Center for Health Outcomes and Policy. Her conclusion reports that investigators found that lowering nurse-to-patient ratios "markedly improves patient outcomes in hospitals with good work environments, slightly improves them in hospitals with average working environments, and has no effect in hospitals with poor environments."

Future research
Such findings suggest that an emphasis on nursing ratios alone may offer too narrow a focus for achieving either organized nursing's actual goals or lawmakers' effective health care policy formulation. They also point to a need for continuing research to define and quantify all elements that make up the complex matrix of a nursing practice environment.

It's not too hard to imagine that in the near future, data from that research will be fed into a computer system that enables administrators and nurses to visualize, track, manage and document the moving parts of that environment in a way that best serves the interests of their patients as well as the teams responsible for their care and well-being.

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Dinah Wisenberg Brin is a journalist and former staff reporter for Dow Jones Newswires, the Associated Press and Congressional Quarterly. Hoag Levins is the Managing Editor of the LDI Health Economist. HoagL@wharton.upenn.edu

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