Rationale
It is apparent that the entire healthcare system is grappling with nursing shortages-a phenomenon that is characterized by improper nurse-patient ratios. This has adamantly hampered the quality of care provided and adversely affecting patient outcomes and satisfaction. According to the American Nurses Association, proper staffing and hence patient-nurse ratios is an integral aspect in improving the quality of healthcare provided. High nurse-patient ratios means that nurse have to deal with huge numbers of patients leading to clinical errors, clinically acquired infections or premature discharges from hospital. This leads to high readmission rates and increased hospital costs due to recurrence of diseases and illnesses.
Literature Review
Nurse-patient ratios have historically been tied or influenced by various social and cultural factors that range from organizational cultures to staffing policies. Organizational culture affects various vital aspects of health institutions, ranging from managerial and trickling down to other aspects such as staffing. Organizational culture influences the thinking of the policy developers and subsequently the staffing policies adopted by an organization. For instance a patient safety oriented organizational culture will focus on provision of quality care and as such pursue policies that ensure nurse satisfaction and reduced work related stress and fatigue. On the other hand, organizations whose cultures are financial-oriented will tend to dismiss or ignore nurse satisfaction, adopting staffing models that minimize costs as a way of increasing profit margins. According to Clancy (2011), the condition in which nurses render their services have a huge impact on the quality of care provided. Increased workload wears out nurses and this may translate to numerous clinical errors .Apart from work hours and work flow designs, nurse-patient ratio determines the level of motivation for nurses. It is human nature that whenever conditions are favorable, productivity and accuracy increases. Clancy (2011) asserts that if at all patient safety has to be attained, there should be joint efforts between hospital managers and other stakeholders such as the government, in terms of laying strategies aimed at increasing supply for nurses and consequently ensuring that nurse-patient ratios are friendly and safety-oriented. A sizeable research-based literature has established an indisputable link between patient safety and nurse-patient ratios.
While patient safety has predominantly focused on environmental and infrastructural aspects, staffing issues significantly contribute to patient safety. As demystified by Shekelle (2013), in a study done of Pennsylvania hospitals for 232,342 discharges from the surgical unit, it was established that 2% (4,535) of the patients discharged died within the first 30 days after discharge. In a comparative study of 1:4 and 1:8 patient-to-nurse ratios, it was found that the difference between the two ratios was tentatively 1000 deaths. This study underscores the importance of reducing the number of patients that a single nurse is serving at any given time.
According to a report by IOM IN 1999 (To Err is Human), there was great emphasis on reviewing organizational culture at the institutional level as a way of ensuring clinical errors are reduced. According to the report, up to 97,000 deaths occurred very years in the United States as a result of clinical errors (Altman, Clancy & Blendon, 2004)). However, according to the report, the deaths could be significantly reduced by revising the patient safety policies that were in place. Among the recommendations offered by the institute include; reviewing of nurse staffing issues and reducing the nurse-to-patient ratio. A significant amount of clinical errors in the report were associated with work related stress and fatigue that leads to mental interruptions during delivery of care. Although worthy strides have been made by various states in the US in line with the IOM recommendations, the nurse- patient ratios continue to be a major cause of deteriorated quality of care. California was the first state to impose minimum nurse-patient ratios and as indicated by Aiken et al. (2010), California has managed to significantly reduce work related stress and fatigue. Compared to other states, nurses in California reportedly enjoy high levels of motivations and satisfaction as a result of reduced workloads-something that translates to improved quality of care and patient outcomes.
Wallace, B., (2013) views the patient/nurse ratio as one that has not been addressed appropriately especially in terms of policies that can overcome the ever-present challenge in healthcare institutions. Beyond the influence that the understaffing has on the patient outcomes, there lies the psychological and mental problems that the nurses undergo when striving to provide care to patient who not only require physical attention but also sympathy. When the work place environment does to adequately support the role of the nurse, then this psychological and mental strain tends to overwhelm the nurses and further compromise the quality of care and the expected outcomes. The Nurse Managers should thus focus on creating a safe patient-care environment by ensuring the availability of supportive infrastructure, equipments, supplies and other resources to facilitate the nurse workflow. This should be accompanied by a mix of experience, skill and competency within the workforce to ensure critical thinking and effective decision making within the limited resources available. Policies and regulations are effective only when the environment for working of the nurses is supportive.
Analysis and Interpretation
Rothberg et al. (2005) in their study sought to establish the cost-effectiveness of high and low patient to nurse ratios. In this study, the patient to nurse ratio was adjusted and issues such as safe care, positive outcomes, nurse satisfaction and patient satisfaction were analyzed against the cost of maintaining the workforce at each particular level. The results indicated that with an increased patient to nurse ratio, the overall expenditures decreased significantly but the quality of care and the safety were highly compromised. At eight patients per nurse, was identified as the least expensive ratio while the four patients-per-nurse ratio was considered the safe and cost effective ratio. With increasing or high patients to nurse ratio, mortality rates and costs increased and the trend was seen as progressively less-effective along this incremental trend. The low patient to nurse ratios had an influence on reduced hourly wages and decreased mortality rates. The ability to influence the resources to support the nurses in their delivery of care even at the most cost-effective levels always has an impact on the cost and outcomes. And thus, a combination of resource management and supportive environments play a crucial role in handling the challenges that encompass nurses working in strained environments.
Understaffing is not a disputed issue within the healthcare institutions today. Current trends at demographic level as well as trends in recruitment of nurses show that the problem will consistently increase within the next decade. As acuity care continues to become the norm of the day, and patient-centered care being advocated amidst an increasing population and less enrollment rates in nursing colleges, the situation is expected to become less manageable tin o the future if the right policies are not implemented early enough. Staff planning processes and staffing models that focus on patient turnover issues such as admissions, transfers and discharges have been proven effective in helping nurse managers meet their staffing needs amidst the limited allocation of resources. In this view, the policies should focus on the trends which indicate a worsening situation in the future and this will be based on how well the nursing profession is viewed by the general public in terms of choice as a rewarding career (Clancy, 2011). Nurse satisfaction, career advancement planning and supportive work environment all pay a crucial role in encouraging enrollment in nursing colleges. Without these incentives, there is a likelihood that the nurse workforce will continue to grapple in the same or worse situation than it is now as demographic trends continue to show increment which would mean increased number of patients and a more strained workforce. The quality of care will automatically be compromised not to mention the effect on the overall health of the community.
Conclusion
Arguably, nurse-patient ratios influence the quality of care received by the patients. It is important to acknowledge that nurses are human beings prone to fatigue and work stress. Whenever a nurse is overworked, stress sets in-an aspect that drains their energy and motivation to work. Lack of motivation as a result of unfriendly work environments leads to failures in terms of provision of care and chiefly compromises the patient outcomes. Therefore, there is the need to address nurse-to-patient ratios and go the California way that has seen major improvements in nurses’ satisfaction and consequently the quality of care provided.
References
Aiken, L. H., Sloane, D. M., Cimiotti, J. P., Clarke, S. P., Flynn, L., Seago, J. A., & Smith, H. L. (2010). Implications of the California nurse staffing mandate for other states. Health services research, 45(4), 904-921.
Altman, D. E., Clancy, C., & Blendon, R. J. (2004). Improving patient safety—five years after the IOM report. N Engl J Med, 351(20), 2041-2043.
Clancy, C. M. (2011). AHRQ Commentary: Working Conditions That Support Patient Safety. Heart Failure.
Rothberg, M. B., Abraham, I., Lindenauer, P. K., & Rose, D. N. (2005). Improving nurse-to-patient staffing ratios as a cost-effective safety intervention.Medical care, 43(8), 785-791.
Shekelle, P. G. (2013). Effect of Nurse-to-Patient Staffing Ratios on Patient Morbidity and Mortality.
Wallace, B., (2013). Nurse staffing and patient safety: What’s your perspective? Nursing Management, 44(6), 49-51.doi: 10.1097/01.NUMA.0000430406.50335.51
