THE DESCRIPTION OF THE ISSUE
The focus on patient safety and quality of care has placed many demands on the healthcare system. One of the pertinent issues that have been explored as having an impact on the quality of care and patient safety is the nurse staffing ratios. The Joint Commission identifies that staffing levels have a profound impact on the occurrence of sentinel adverse events, injuries, deaths as well as permanent functional losses in patients undergoing care (American Nurses Association, 2016). With low staffing levels, the workload on the nurses and the healthcare personnel is heavy amidst the need satisfy all aspects of patient care without compromise. Like any other human being or any other profession, nurses do experience fatigue and exhaustion as well as burnout and may need rest at some point (Juraschek, Zhang, Ranganathan & Lin, 2012; 256).
Ideally, in the absence of rest, the ability of nurses to function optimally cannot be assured and the impact is on patient safety and several or many compromises on the quality of care afforded to patients. The chances of errors in the care process, such as medication errors, partial diagnosis and misses in processes and procedures increase with such burnout (Ford, 2013; 26). In such circumstances, they have to thrive under such conditions as there are no nurses to replace them. When nurses work beyond eight hours in a single day and particularly for those in acute care and intensive care units, the level of burn out and exhaustion is extreme. This is even in the consideration that the level of precision and accuracy required within these units calls for high alertness at all times which could be compromised in the event of burn out and fatigue (Stanton, 2004; 11).
WHY NURSE STAFFING LEVELS ARE IMPORTANT
When the nurse patient ratios do not meet the minimum staffing levels, there is a parallel increase in the number of hours per patient per day and thus these two must be managed in tandem. One of the important approaches to the management of nurse staffing ratios is to understand the actual causes of this problem. While recruitment of new nurses has been significantly achieved, this has not helped resolve the problem (Stanton & Rutherford, 2004; 19). On one hand, the increase in patient populations and the low retention of experienced nurses have played a key role in magnifying the problem and making it a chronic issue. Nurse are being forced to quit due to the pressure of their work environment and the need to seek career growth considering the historical perception that nurses can only work in bedside related roles (Robbins, 2015; par.8).
The Registered Nurse Staffing Act was formulated to provide states with a framework on which they can implement safe staffing levels for their care facilities. Despite this legislation, the Joint Commission emphasizes on the need to have each healthcare organization assessing their staffing needs through regular review of potential issues that may lead to ineffective and inadequate staffing levels (Juraschek, Zhang, Ranganathan & Lin, 2012; 246). This is in the knowledge that while the legislation caters for issues that specifically address staffing levels, other aspects such as ancillary support staff, skill mix and nurse competency are not addressed. Their impact on patient safety and quality care could be equal in magnitude to that posed by the low staffing levels; an issue that has been explored significantly through the Quality and Safety Education for Nurses (QSEN) project competencies (American Nurses Association, 2016).
OPPOSING VIEWS ON THE IMPORTANCE OF NURSE STAFFING LEVELS
There is however divergent views on increasing nurse staffing levels within the opponents on this stance indicating that the staffing ratios should not be based on ratios rather it should be based on patient dependency. This implies that there are units that may have large patient numbers but still may not require the same level of care and may not pose many demands to the attending nurses and these cannot be equated to the more intensive and involving units and facilities where nurses are required to afford continuous and precise monitoring of the patient population (Ford, 2013; 34). The National League of Nurses (NLN) holds a radical stand that even as healthcare facilities seek to recruit more a responsive formula that includes determining the needs and tailoring the staffing to the needs within each unit are necessary. In such units, the numbers may be smaller but the level of work may be high.
Secondly these opponents are of the view that such legislation is setting an unrealistic demand for nurse recruitment while already the problem exists and therefore the legislation is skewed in its formation (Stanton, 2004). The American Association of Registered Nurses (AARN) for instance has raised it objection of the importance and value of closing down hospitals that do not meet the minimum staffing levels. In their argument, the AARN identifies that such legislation only shifts the problem from one care facility to the other as patients who have previously depended on the facility will have to seek new options. The AARN proposal is that the federal and state authorities have to partner and formulate a framework that eliminates the very strict licensure and certification issues which limit nurses from practicing in some states. The Compact Licensure format for instance would help nurses move from those states that are adequately rich in nurse workforce and help reduce the gap in the understaffed states.
Further, the legislation requires that all those healthcare facilities that do not meet these requirements even when they indicate that they cannot sustain such demands should be closed. This in itself imposes a new problem by overpopulation the available care facilities with new patients and undoing the patient ratios in those facilities. Other demands such as the requirement to initiate Emergency department diversions by denying access to patient because a facility cannot meet the minimum staffing levels with any additional nurses poses the question of timely care for patients in need and the risk of delaying care (American Nurses Association, 2016).
A chasm thus exists as to which approach should be taken because in any case these demands by the opponents are legitimate and cannot be ignored. There has to be a compromise at some point and that means balancing the demands of the legislations, policies and regulations with the specifics such as patient dependency and sustainability of higher recruitment for nurses. However, there is no doubt as to the importance of increased recruitment of nurses at least to meet the minimum staffing levels and then the specifics can be introduced at this point (Robbins, 2015;73). The primary focus is on the patient safety and therefore with this goal, there is a need to determine the primary areas on which patient safety could be compromised. That implies looking at nurse staffing in two perspectives; on one hand the nurse to patient ratio and on the other hand the nurse-hours per patient per day. This specific way of looking at the issue can afford a more agreeable format on which nurse shortage and nurse staffing can be managed (Juraschek, Zhang, Ranganathan & Lin, 2012; 251).
STRATEGIES TO SOLVE THE PROBLEM OF NURSE STAFFING LEVELS
There are several approaches that need be adopted to help resolve the nurse staffing levels. Each stakeholder has a role to play to assist in achieving the desirable and effective nurse staffing levels. On one hand, the managers and leadership through the government should recognize that it is imperative that the stakeholders have to afford nurses more opportunities for professional and personal growth and that implies improving their salaries, wages and remunerations while also providing opportunities for growth such as continue education. This method offers an indirect approach that seeks to increase retention rates and assure on sustainability since the costs of retaining nurses is significantly lower than the costs of replacing experienced nurses with new recruits (Stanton & Rutherford, 2004; 41). The idea is to have the new nurses in helping achieve the minimum staffing levels as opposed to acting as a replacement to those nurses who quit for pursuance of personal goals.
The second approach is at the lobbying and legislative levels which imply that politicians and nurse advocacy groups have to come together and develop policies that impact on the workforce wellness as a strategy to improving staffing levels. With a stable nurse workforce, the focus can now be turned to having more responsive legislation and approaches at the state level such as the need to have healthcare facilities posting their staffing ratios in a regular basis (American Nurses Association, 2011). The strategy means that the consumers and healthcare stakeholders can apply pressure on respective organizations and facilities to attain the minimum staffing levels. On the other hand, patients are afforded the chance to make a choice and for safety purposes they are likely to choose those facilities that have attained the minimum staffing levels (American Nurses Association, 2015). For those that have not attained the staffing levels, the commercial value of losing out on clients due to the staffing levels can endear them to satisfy the demands and reach out to clients.
Within such a competitive framework, where staffing levels are used to market services and as indicators of quality of care, many healthcare facilities will want to drive their revenues even higher by ensuring viable and appealing nurse-patient ratios. This strategy will help eliminate the traditional approach to cut costs and increase revenue by nurse managers by reducing staffing ratios at the expense of quality care (Manojlovich, 2009;18). The primary driver for profits will be patient volumes and this will be achieved when patients are assured of quality services.
Thirdly, the professional organizations such as the ANA and the NLN have to collaboratively work with the State Boards of Nursing and the Centre for Medicare and Medicaid Services (CMS) to increase the pressure on healthcare facilities on matters pertaining to never events and hospital acquired infections (HAIs). That includes but is not limited to cutting down and withdrawal of the reimbursements but also imposing fines and penalties for those healthcare facilities that report extremely high rates of HAIs and never events (American Nurses Association, 2011). The purpose of these penalties is to ensure that managers take a lead role in improving the quality of care by investing on the nurse workforce. By attaining the minimum nurse staffing levels, managers are assured of a vibrant workforce that is not burned and overworked. Nurse scheduling for shifts can be cut down to allow nurses enough time to rest or to have enough personal time especially in this era where professionals do not want to be subjected to a situation of choosing to be active between home and work because they want both (Daggett, 2014; 141). With viable nurse staffing levels, the nurses can be afforded the personal time that they need rather than being subjected to choosing between financial compensation and personal time (Ghebrehiwet, 2005; 83).
The other strategy that is viable within the context of the nursing workforce is for care facilities to take a lead role in utilizing their Health Records and Information Systems to develop trends and patterns which can inform supervisors on appropriate nurse scheduling techniques. This approach would seek to help supervisors and nurse managers to recognize the periods of the week or the times of the day when they experience a high influx of patients or when patient volumes are high (Stanton & Rutherford, 2004). This information would be used to provide temporary backups by hiring part-time nurses who can be called upon to fill the staffing levels at the periods that are characterized by high patient volumes. While the American Nurses Association has reservations on this method, other professional bodies such as the AARN as well as the Joint Commission and the Kaiser Foundation have proposed that such temporary solutions stand a high chance of improving quality care.
CONCLUSION
It is my view that nurses have to network more aggressively and the professional nursing organizations such as the American Nurses Association and the National League of Nurses have to voice the needs of the nurses and demand that these needs be met within specific timelines (Daggett, 2014; 149). I think each nurse in their role needs to be vocal on matters of nurse staffing as they affect all aspects of care and this is the role that I will have to play even in my future stations as a nurse; to advocate on the importance of nurse staffing levels being met as required or as needed within the organization (Juraschek, Zhang, Ranganathan & Lin, 2012; 247).
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