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| “Handle with Care”- The Issue of Nurse Staffing for Safe Care |
| by Senator Richard T. Moore |
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Safe staffing and its relation to patient outcomes is a major topic in the field of health care today. We may hear people talk about “nurse-patient ratios” or “safe staffing” or “appropriate staffing” or “quality of care” or “adverse patient outcomes” or a number of other terms. All of these terms are used often and to some extent, mistakenly. “Nurse patient ratios” refers to the number of patients each nurse has to care for. For instance, in intensive care units the nurse-patient ratio is usually 1:1 or 1:2, one nurse for one patient or one nurse for two patients. Different ratios may apply to different units based upon patient need. “Safe or appropriate staffing” is used to indicate whether there are enough nurses and the correct mix of nurses in the patient care team to care for the number of patients and their care needs. “Adverse outcomes” is a term to describe the “quality” of patient care. For instance, adverse outcomes seen very commonly in the research are: pressure ulcers, falls, pneumonia, failure to rescue, medication errors and many more. Currently, many, if not most, of the outcomes (i.e. indicators) being measured are negative----failures. There are some researchers arguing that “positive outcomes/indicators” are needed because they will reflect adverse outcomes avoided. Research has been trying to identify indicators which have meaning to health care professionals as well as to patients. While there have been numerous science-based studies indicating that having more nurses with adequate support of their care team and technology will improve patient care and safety, no study findings support a specific nurse to patient ratio. The problem in developing a specific ratio, and then, passing a law or regulations to mandate hospitals to follow is that conditions vary greatly from hospital to hospital, shift to shift. The nurses differ in physical ability, education and experience. Patient care needs can literally change in a heart-beat, and staff support can also vary in number and quality. The appropriate staffing needs must be based on the professional judgment of nurse managers and nurses and those staffing needs then must be evaluated based on patient outcomes, not whether some arbitrary staffing ratio was in place. The American Nurses Association has worked with others to develop nursing sensitive indicators (i.e., indicators sensitive to nursing input). The American Nurses Association National Database for Nursing Quality Indicators (NDNQI) developed and maintains a database of these nursing-sensitive indicators. All hospitals participating through placement of their hospital and unit-specific data into NDNQI currently do so voluntarily. As mandatory overtime plus the use of voluntary overtime became an issue for practicing nurses, the question arose for researchers as to the effect that prolonged nursing work hours and fatigue “might” have an adverse impact on patients and the nurses themselves. Groundbreaking research has demonstrated that as worked hours increase past 8 hours, but most dramatically past 12.5 hours, the probability of errors and near misses harming patients rise. In addition, the rate of the nurses having accidents or near misses increases when nurses are driving home from work. These findings are consistent with previous research done with airline pilots, truck drivers, boat pilots, and physicians. Clearly, human physiology decreases the individual’s ability to make critical decisions, attend to details and to problem solve when the person is overly tired. From these studies we have learned nurses working overtime, whether voluntary or mandatory, endangers patients and themselves; and nursing managers should not demand or allow nurses to work greater than 12.5 hours in a day because it endangers patients and nurses. One of the great challenges for nursing is to convince the government, health systems, patients and others that nurses’ contributions to patient care are so significant that collection of nursing-sensitive indicators should become mandatory and the re-evaluation of staffing habits are imperative. For that reason, I have sponsored Senate Bill No. 1260, An Act to promote safe patient care and support the nursing profession. My bill addresses the current, and growing, nursing shortage by providing funds for more nursing faculty and for nursing scholarships, addresses the issue of nurse fatigue by limiting regular and overtime hours of nurses, recognizes the importance of the entire patient care team rather than focusing only on Registered Nurses, evaluates hospital nurse staffing plans using evidence-based, nurse sensitive measures, publishes nurse staffing plans and evaluates plan changes using nurse-sensitive tools to determine if staffing affected safe patient outcomes. My legislation has been thoroughly and independently evaluated by health care research experts at the University of Massachusetts Medical School, and is endorsed by the American Nursing Association, the Massachusetts Association of Registered Nurses, the Massachusetts Organization of Nurse Executives, the Federation of Licensed Practical Nurses, and several other professional nursing groups. My plan for promoting safe patient care has also been independently endorsed over the nurse’s union plan by The Boston Globe, the Boston Herald, the Worcester Telegram & Gazette, the Springfield Republican and nearly every major newspaper in the state. |
