What are the three general approaches recommended by the American Nurses Association (2017) to maintain sufficient staffing?

Case Study, Chapter 10, Mandatory Minimum Staffing Ratios

A nurse manager is attending a national convention and is attending a concurrent session on staffing ratios. Minimum staffing ratios are being discussed in the nurse manager’s own state. The nurse manager has a number of questions about staffing ratios that the session is covering. The nurse manager knows that evidence exists that increasing the number of RNs in the staffing mix leads to safer workplaces for nurses and higher quality of care for patients.

1. What are the three general approaches recommended by the American Nurses Association (2017) to maintain sufficient staffing?

2. Summarize the findings that are often cited as the seminal work in support of establishing minimum staffing ratio legislation at the federal or state level.

3. Analyze what proponents and critics say about whether mandatory minimum staffing ratios are needed.

Chapter 10 Mandatory Minimum Staffing Ratios

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RN Skill Mix

Economics as the driving concern for changes

Trend: reduction in RNs in staffing mix; replacement with less expensive personnel

Research: number of RNs in staffing mix directly affecting quality of care and patient outcomes

National movement to mandate minimum staffing ratios

As of 2017, 14 states addressed nurse staffing in hospitals in law/regulations

California is the only state that stipulates in law; regulations for required minimum nurse-to-patient ratios to be maintained at all times by unit

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Staffing Ratios and Patient Outcomes

Research findings (see Table 10.1)

Questions about cost-effectiveness of statewide mandatory nurse staffing ratios

Greater RN skill mix and fewer cases of sepsis and failure to rescue

Benchmark research

Needleman et al. (2002)

Aiken et al. (2002)

Direct link between nurse-to-patient ratios and mortality from preventable complications

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Mandatory Minimum Staffing Ratios: Needed? #1

ANA with concern related to effect of poor staffing on nurses’ health and safety and patient outcomes

Proponents

Absolutely essential for patient safety and outcomes

Use of standardized ratios for consistent approach

Critics

Exponentially increased cost with no guarantee of quality improvement or positive outcomes

AONE agrees and does not support mandated nurse staffing ratios

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Question #1

Is the following statement true or false?

Few states have enacted staffing laws.

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Answer to Question #1

False

As of 2017, 14 states addressed nurse staffing in hospitals in law/regulations.

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Mandatory Minimum Staffing Ratios: Needed? #2

Evidence of benefits mixed, contradictory

No accounting for education, experience, and skill level

Risk of actual decline in staffing—used as a ceiling or absolute criteria without accounting for patient acuity or RN skill level

Cost as the major deterrent—not financially attractive to hospitals

Mandate for specific staffing ratios and current shortage leading to reduction in hospital services, increased emergency room diversions, increased unit closures, increased expenses

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Mandatory Minimum Staffing Ratios: Needed? #3

Ohio Hospital Association: benefit of staffing ratios is mixed and sometimes contradictory

Corbridge (2017): argues that mandating inflexible nurse staffing ratios or stringent meal and rest break requirements do not improve patient care or outcomes

Silber et al (2016): better-staffed facilities had a formula for excellent value as well as better patient outcomes (see Box 10.2)

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California Prototype #1

First state to implement mandatory minimum staffing ratios

Maximum number of patients an RN could be assigned to care for under any circumstances (see Table 10.2)

Issues in determining appropriate ratios

Lack of data about nurse staffing distribution

Patient classification system (PCS) data problematic

Unknown cost

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California Prototype #2

Recommendation: 1 nurse to every 6 patients in med/surg units

Delays in implementation

Problems with interpreting the meaning and intent of language related to “licensed nurses”

Issues related to cutting nonlicensed staff

Questions if adequate number of RNs available to meet ratios

Emergency regulation in 2004; overturned in 2005

Hospitals and nursing unions’ responses

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California Prototype #3

Struggle to implement

Mandate effective 1/1/2004

Larger hospitals versus smaller hospitals to meet mandate

Need for legal clarification for “at all times” (i.e., breaks, lunches)

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Question #2

Is the following statement true or false?

California implemented mandatory minimum staffing ratios fairly quickly.

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Answer to Question #2

False

There were significant delays in implementing the California mandatory minimum staffing ratios.

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California Prototype #4

Improvement in RN staffing and patient outcomes?

Reduction in number of patients per licensed nurse

Increase in number of worked nursing hours per patient day in hospitals

No significant impact on measures of nursing quality and patient safety indicators

No increase in adverse outcomes despite increasing patient acuity

Lower risk-adjusted mortality (Aiken, 2010)

No improvement in quality of care (HC Pro, 2009)

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Similar Initiatives: Other States

Minimum standards for licensed nursing in certified nursing homes but not in acute care hospitals

Several attempts, but none enacted

Adequate numbers requirement for Medicare-certified hospitals

Many states actively pursuing minimum staffing ratio legislation

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Other Alternatives

Pursuit of alternatives to improve nurse staffing without legislated minimum staffing ratios

Lack of support for legislated minimum staffing ratios

The Joint Commission

ANA against fixed nurse–patient ratios; recommendation of three general approaches (see Box 10.3)

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Question #3

Is the following statement true or false?

The ANA supports legislation for fixed nurse–patient ratios.

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Answer to Question #3

False

The ANA does not support fixed nurse–patient ratios but advocates for a workload system that takes into account the many variables that exist to ensure safe staffing.

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End of Presentation

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