There is a flurry of state and national efforts to mandate safer nurse-to-patient ratios in healthcare, which could result in both lower infection rates and improved employee health. However, hospital associations and other groups are arguing against such laws, saying they need staffing flexibility and mandated nursing levels could undermine their economic stability and cause cuts in other areas.
“The staffing problem in our hospitals has gotten worse lately,” says Kathy Santoiemma, RN, a nurse at Montefiore Medical Center’s New Rochelle (NY) Hospital. “The hospital practice of understaffing is almost a daily problem for us and it must be addressed.”
Santoiemma was one of some 1,000 members of the New York State Nurses Association (NYSNA), who recently rallied at the state capitol in Albany to support a proposed state law that would mandate “safe” nurse-patient ratios to protect patients from healthcare-associated infections (HAIs) and other adverse events.
“Staffing is an issue across the board, not just for our nurses but for our patients,” says Tara Martin, senior communications manager for the NYSNA. “The primary function of a nurse is to be an advocate for the patients. When you’re understaffed you have a problem because you are not giving your full attention to every patient that needs it. So it creates an unsafe work environment for the nurses and also [endangers] patients. Our primary focus has always been to make sure our patients are safe. With the current staffing levels that are happening across the state -- patients are definitely at risk.”
The Safe Staffing for Quality Care Act would set enforceable nurse-to-patient ratios in New York healthcare facilities. The law would require minimum staffing levels ranging from one nurse per patient in trauma emergency, per two patients in ICUs, per three patients in the emergency department, per four patients on medical\surgical wards and per five patients in rehab\subacute.
The bill has passed one committee, but must go through another committee to reach the floor for a full vote, “We actually have momentum on this bill and we hope to have a vote by the end of the session, which is in June,” Martin says.
The nurses cite clinical studies that have consistently shown that safe staffing improves patient outcomes and even saves money.
“In study after study, unsafe staffing levels lead to worse health outcomes, including shock, cardiac arrest, and hospital-acquired pneumonia,” said Martha Wilcox, an RN at Sullivan County (NY) Public Health. “We know that a safe and reliable healthcare system of the future cannot be created unless we empower our frontline providers of care, and give them what they need to get the job done. We need hospital management to take safe staffing seriously.”
For example, a study published in the journal of the Association for Professionals in Infection control and Epidemiology (APIC) analyzed survey data from more than 7,000 registered nurses from 161 hospitals in Pennsylvania. The researchers linked nurse understaffing to burnout and increased rates of catheter-associated urinary tract infections (CAUTI) and surgical site infections (SSI).1 Job-related burnout was determined by analyzing nurse survey responses regarding the emotional exhaustion subscale from the Maslach Burnout Inventory-Human Services Survey (MBI-HSS). More than one-third of survey respondents got an emotional exhaustion score of 27 or greater, the MBI-HSS definition for healthcare personnel burnout.
Comparing CAUTI rates with nurses’ patient loads (5.7 patients on average), the researchers found that for each additional patient assigned to a nurse, there was roughly one additional infection per 1,000 patients (or 1,351 additional infections per year, calculated across the survey population). Additionally, each 10% increase in a hospital’s number of high-burnout nurses corresponded with nearly one additional CAUTI and two additional SSIs per 1,000 patients annually (average rate of CAUTIs across hospitals was 9 per 1,000 patients; for SSIs it was 5 per 1,000 patients).
Using the per-patient average costs associated with CAUTIs ($749 to $832 each) and SSIs ($11,087 to $29,443 each), the researchers estimate that if nurse burnout rates could be reduced to 10% from an average of 30%, Pennsylvania hospitals could prevent an estimated 4,160 infections annually with an associated savings of $41 million.
“Healthcare facilities can improve nurse staffing and other elements of the care environment and alleviate job-related burnout in nurses at a much lower cost than those associated with healthcare-associated infections,” the authors conclude. “By reducing nurse burnout, we can improve the well-being of nurses while improving the quality of patient care.”
Despite such evidence, hospital associations strongly oppose such bills, with the Greater New York Hospital Association (GNYHA) warning that staffing mandates will force hospitals to lay off other members of the care team and close nursing units because of a shortage of appropriately trained nursing staff. The nurses risk making their situation worse by “draining the resources necessary to provide support staff, licensed practical nurses, nurse assistants, and other types of professional staff, including physical therapists, clinical pharmacists, and phlebotomists,” the GNYHA said, adding that the extra work would then fall to nurses.
Several states have pursued legislation addressing safe-staffing concerns in nursing, but California remains the only state that stipulates a required minimum nurse-to-patient ratio.
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1. Cimiotti JP, Aiken LH, Sloane DM, et al. Nurse staffing, burnout, and health care associated infection. AJIC 2012;40:486-490
