Nurse staffing has been a hot-button issue in hospital management for years, with no consensus on the optimal ratio of nurses to patients and vast heterogeneity in staffing patterns worldwide.
A study published in JAMA in 2002 was one of the first to show a connection between high nurse-to-patient ratios and worse outcomes after surgery. Specifically, each additional patient a nurse was assigned was associated with a 7% increase in mortality at 30 days, as well as in failure to rescue.
Other research on the question has found mixed results, however.
A study which looked at ICU nurse staffing in Massachusetts before and after the state legislated a maximum 1:2 ICU nurse-to-patient ratio in 2016 found no association between higher nurse staffing and better patient outcomes, according to results published in Critical Care Medicine in October 2018. Another study, published in December 2018 by BMJ Quality and Safety, found a link between lower nurse staffing and higher in-hospital mortality among patients admitted to general wards in the United Kingdom.
Such evidence of potential risks to patients should be concerning to hospitalists, even though their role in nurse staffing decisions may be limited.
“We rely on nurses to be our eyes and ears for our patients and if they are spread too thin, that can be a big problem,” said Anica C. Law, MD, a critical care physician at Beth Israel Deaconess Hospital in Boston and author of the Critical Care Medicine study of the Massachusetts law.
The factors that typically guide nurse staffing decisions include patient acuity, nurse education and training, and time of day, experts said. Additionally, those in charge of these decisions differ by institution, with regulation, legislation, and sometimes union agreements dictating who works and when.
Hunting for optimal
The ideal number of nurses working in the wards or the ICU is still unknown, even among experts.
“It is actually very difficult to directly conclude that any particular level is optimal,” said Peter Griffiths, PhD, chair of health services research at the University of Southampton in England and lead author of the BMJ Quality and Safety study. “We've got a general push that says when staffing is relatively low, the outcomes are substantially and significantly worse, so you can see the benefits from investment in nurse staffing from that point of view. Quite where the ‘optimal’ lies is, I think, a more elusive question.”
At the University of Pennsylvania Hospital in Philadelphia, most non-ICU wards are staffed at a 1:4 or 1:6 nurse-to-patient ratio, according to Rachel Kohn, MD, MSCE, a pulmonology and critical care physician who researches ward capacity strain. “Other hospitals, including community hospitals, have 1:8 nurse-to-patient ratios, and 1:10 has been proposed by several health systems and organizations,” she said.
A good ratio of nurses to patients on the wards is likely 1:4, unless the patients are extraordinarily sick, said Diana Mason, PhD, RN, senior policy service professor at the Center for Health Policy and Media Engagement at George Washington University School of Nursing.
If a nurse were tasked with caring for eight or 10 patients, Dr. Mason said she would tell him or her to stop working at that institution. “When that nurse makes an error because they just don't have time to do all the double checks, they do workarounds to try to get their work done, and they violate safety precautions as they're doing that, the hospital is not going to back them up,” she explained.
Dr. Law noted that ICU staffing was fairly consistent in Massachusetts, even before the legislation she studied was enacted. “There does seem to sort of be a uniform belief that if a patient is sick enough to be in an intensive care unit, they probably shouldn't be staffed at a patient-to-nurse ratio greater than 2:1,” she said.
Dr. Griffiths was not too surprised that the study found no change in outcomes under the new law. “Here we've got a setting where staffing tends to be at a very high level anyway. . . . For a lot of patients the staffing ratio starts off at 1:1 as the norm,” he said. “The effect of any mandate is really to stop an erosion of staffing under certain circumstances more than actually requiring a very substantial uplift.”
Rules and regulations
Like the Massachusetts law, most state legislation regarding minimum nurse staffing ratios has targeted the ICU, where there is more agreement that patients need a certain level of individual attention, experts said.
Dr. Griffiths noted that despite the lack of effect observed in the Critical Care Medicine study, the new law may still have provided benefit, by preventing hospitals from ever dipping below the mandated threshold. “It becomes much harder to see [benefit] because you're not actually seeing massive changes in the overall staffing levels,” he said.
In the United Kingdom, there has been a “huge resistance” to putting a legally mandated number on nurse staffing, Dr. Griffiths noted. Hospital staffing in general is “very grounded in historical norms” and often affected by budgetary concerns, he explained.
California was the first state in the U.S. to enact legislation of minimum nurse-to-patient ratios across the board in 1999, and feedback since then has been mixed. “Most nurse managers do not want minimum staffing ratios. Most nurses at the bedside do,” Dr. Mason said. “The nurse managers will argue that it gives them no flexibility.”
Often, hospitals facing legal minimums have eliminated nurses' aides in order to pay for the mandated nurse staffing, she said. That strategy can then add those aides' responsibilities to the list of tasks already facing nurses.
Legislation is not the best solution to these challenges, according to Michael A. Rie, MD, FACP, professor emeritus at the University of Kentucky, Lexington, and the author of an editorial accompanying the Massachusetts study.
“Once you try to do that for all patients in all locations under all circumstances, you miss the point about what nursing as a profession or medicine as a profession or even pharmacy as a profession is all about,” he said. “There has to be a give and take.”
Dr. Law also cautioned against any additional laws mandating nurse staffing until more research has determined what level of nurse staffing is both cost effective and safe and what outcomes could measure the effectiveness of such regulation. “One takeaway from our study is that any proposed legislation needs to really clearly delineate the problem, or legislation is only going to add bureaucracy and cost,” she said.
The patient-to-nurse ratio may not even be the best measure of staffing, according to Dr. Law. “Some people might argue that a workload-to-nurse ratio is a more effective way to measure how much a nurse is doing,” she said. “But even so, there is not a magic number for what that ratio should be on the floor, in the ICU, in the ED, and moreover, that number probably varies, not only from hospital to hospital but even from nurse to nurse.”
This issue is hard to study, due to variability in settings and training, Dr. Law added. “It's a really difficult question to answer,” she said.
Dr. Griffiths thinks researchers may also need to expand their focus to different outcomes. “If you look at the range of things nurses get involved in, mortality as an outcome is only really reflecting a small part of it,” he said. “So there's a lot more to be done in that area to demonstrate value.”
He'd also like to see research finding the optimal nurse staffing level, not just the minimum that could be required by law. “While there's a lot of interest in mandatory minimum staffing levels, a mandatory minimum staffing level doesn't actually give you the optimum staffing level either. So I think that tools to help identify the nurse staffing requirements [would help]. Although there are a lot of such tools out there, the evidence base for them is not very good,” Dr. Griffiths said.
In addition, given that most of the research in this field has been retrospective, Dr. Kohn would like to see prospective, experimental trials on nurse staffing. “We can see that there are associations, but we don't know if these are true causal relationships or which components of nurse staffing truly matter. I think having more randomized controlled trials or more of an innovative, quality-improvement approach . . . would be very informative to help to start to answer some of these questions,” she said.
Dr. Rie agreed about the need for improved research. “You have to show that the deployments of nursing and the acuity level of the patients reflect themselves in the outcomes,” he said. “Most of the kind of research that is lacking has to do with outcomes of the process. That has been a boondoggle for decades, and the reason is nobody likes to report their negative outcomes.”
Hospitalists' role in the equation
As to where hospitalists fit in with all of this, the experts had differing opinions.
“Clearly having adequate nurse staffing is incredibly important for the work of hospitalists, and therefore they have a very strong interest in getting nurse staffing levels right. And they're actually in a very good position to observe the consequences of inadequate nurse staffing,” said Dr. Griffiths.
Dr. Mason agreed. “Hospitalists spend their life at that bedside with these patients, and they are able to see what happens when there aren't enough nurses. And if they haven't figured that out already, then they are not paying attention,” she said.
While hospitalists will probably not want to be involved in nurse staffing decisions as “a regular thing,” it's important for them to alert those in charge of nurse staffing when more nurses are needed to treat a higher level of patient acuity, according to Dr. Rie.
“The informational interchange needs to be between the hospitalist and the nurse supervisor or persons responsible for deploying the nursing personnel around the hospital as needed,” he said. “The hospitalist is well-suited to understand that from the medical perspective, but I don't think the hospitalist should be the person to determine nurse staffing around the hospital.”
Dr. Mason argued that because hospitalists have a major stake in getting good care for their patients, they should recognize the power they wield within hospital systems.
“Adding their voices to the importance of adequate nurse staffing is crucial. It's not just staffed nurses saying we don't have enough nurses. When a hospitalist confirms this floor is understaffed, people are going to pay more attention,” she said. “I would encourage [hospitalists] to pay attention to staffing and know that they can be a voice and a partner with the nurses in saying we need safe staffing on this floor. And the nurses should be able to provide the hospitalists with the evidence if they need the evidence to take to their superiors.”
Dr. Rie agreed that hospitalists should assert themselves when patient care could be compromised by staffing levels.
“The focus has to always be: ‘Are the patients getting the standard of care or not?’” he said. “When it becomes apparent, whether it's to the hospitalist or somebody else, that they're not, one has a professional duty to speak up, at which time, other people running the budget and the finance and the administrators get really upset with you. . . . I think the hospitalists are very good in seeing when the general cycle of how the hospital operates is being pushed out of kilter for whatever reason.”