Depending on who you ask, the state of Massachusetts is either: a) close to; or b) seriously considering following California's lead and limiting the number of patients who can be assigned to nurses. Potential legislation have been working its bearing, in a series of fits and starts, through the state legislature.
The sooner, the better, say Julie Pinkham, RN, MS, executive director of the Massachusetts Nurses Association (MNA), a strong proponent of such limits, who say it has be clearly demonstrated that assigning too many patients to nurses can hold a direct impact on patient sanctuary.
"Every piece of research we have see says that the number of patients a nurse have is directly related to morbidity and mortality," she says. "Linda Aiken be the first one to quantify that." (Aiken's article in the October 2002 Journal of the American Medical Association found that "surrounded by hospitals with soaring patient-to-nurse ratios, surgical patients experience difficult risk-adjusted 30-day mortality and failure-to-rescue rates, and nurses are more likely to experience burnout and assignment dissatisfaction." (1)) "This research validated what nurses own been wise saying to us."
Pinkham adds that "another broadsheet by Jack Needleman found a direct correlation between patient outcomes and the number of patients per nurse." (2)
Because of these findings, say Pinkham, nurse-patient ratios must be looked at within terms of assignment of care. "Registered nurse assignment of patients is not unlike any other type of effort we do--like cancer screenings, for example," she asserts. "Look at it this way: Insurance companies, after doing their research, establish whether or not the money they are investing in a treatment is worthwhile--if it is efficacious. If it is, we expect it to be covered. But in nursing care, even though we hold a direct correlation between a nurse having more than four patients and increased risk, one hospital will dispense you 8-to-1 and another 4-to-1."
She notes that research also shows that on an upward curve nurse-to-patient ratios can be cost-effective, as in good health as safer. (3) "This last one finally puts it in perspective," she say. "Imagine going to a hospital, having a stroke, but the hospital is aphorism that even though research shows you should be treated with a abiding protocol, they are not going to do it?" she poses. "That's why we're saying we want to have a shorten in place--and that it desires to be directly linked to lenient outcomes. Patients also need to grasp what the limit is, and that, for example, their nurse should individual have three auxiliary patients."
Easier said than done
While the issues are clear to Pinkham's organization, and the Massachusetts Hospital Association (MHA) is undeniably supportive of improving lenient safety, incorporating those goal into legislation that both groups can support is not that easy.
"Essentially, everyone agreed nearby should be a limit on the number of patients assigned to an RN," say Pinkham. "We have be negotiating a waiver for financially strapped hospitals [who vote they cannot afford additional staff], and what the 'just the thing' number should be."
But, counters Daniel P. Moen, president and CEO at Heywood Hospital in Gardner, MA, and board chairman--elect of the MHA, "There have not really been any in-depth discussion on waivers [for financial concerns]. Before we take to that point, we have primary concerns as to whether these guidelines are based on research and evidence."
Pinkham say the state Department of Public Health will have public hearing and set standards and limits, and that within would be an acuity system to adjust those limits up and down. "The final regulations will be developed over a spell of 12 months, once the legislation passes," she reports.
"Our biggest concern right presently is that this is still a piece of legislation that addresses RNs solely," says Moen. "Our board feel strongly that any type of legislative guidelines on staffing need to include the unharmed direct care team--LPNs, CNAs, and probably other types of providers like mental strength and rehab units that want to be counted in the staffing guide."
The target issue of the MNA, says Pinkham, is retention, while supply be the key concern of hospitalists. This latter concern is untaught in lantern of the current nursing shortage, but it may not be as big a challenge within Massachusetts, she notes.
"We own the highest ratio of nurses per capita within the nation, and every single [nursing] school is full," Pinkham concedes. "But after three years, these nurses tend to give up the bedside; if we do not set a limit on working conditions, we will verbs to lose these people."
She go on to report that a number of nurses who own left the bedside "hold told us they would return if the situation changed."
The numbers game
What exactly are the appropriate standards that should be established? "The limits surrounded by our bill for the ICU were no more than two patients per RN, which is also the opinion of the Institute of Medicine and hard to negotiate around--and that's almost 50% of adjectives beds," say Pinkham. "In med/surg, we say it should be 4-to-1." The bottom strip, Pinkham says, is that "we enjoy to have some leap of dependence that the Department of Public Health will not abandon adjectives scientific recommendation out of hand."
But Moen is not comfortable beside hard-and-fast numbers. "We are very strong on the point that if nearby are going to be guidelines there requirements to be flexibility around them," he shares. "What we're saying is, clearly hospitals and patients differ, and a one-size-fits-all approach ties management's hand as far as using the resources of the organization."
For example, Moen action, when there is a huge influx of patients and conditions translation rapidly, a hospital desires to maintain flexibility. "Or, for example, if you enjoy a patient who is in recent times about to be discharged, they may require lone minimal staffing.
"We are not agreeing to something that's a hard-and-fast ratio by another name," he continues. "In sincerity, you will probably find that most ICUs are staffed that way [with two patients per nurse], but you can enjoy an ICU where within are four patients but two are boarders--they are there for other reason. In that case, should you own to adhere to that same stratum?"
Other states following suit?
The legislative moves in Massachusetts may only be the initiation of a developing national trend, says Pinkham. "I believe in that are 14 states working on similar legislation," she reports. "And New York's may be even more aggressive than ours."
The states that pushed this type of legislation, she explains, were those that saw the untouchable penetration of manage care. "They saw big pressure to muffle LOS [length of stay], there be a lot of hospital closures and they really consolidated patients into little beds," Pinkham say. "Since then, we've see an increase in acuity. Now, we have the sickest of patients and an exodus of nurses from the bedside; it's a best storm."
As for whether the legislation becomes trueness in Massachusetts, the jury is still out. "Everybody requirements to see mandatory overtime go away, but one and only if it's done in some instrument that gives hospitals the flexibility they stipulation to protect patients," insists Moen. "We've made a commitment to stay at the table, but we have secure lines we just won't cross; short of that, we are initiate for discussion."
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