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Best Practices: Staffing Levels
The single most important policy for solving the problem of overworked and understaffed hospitals is the establishment of staffing ratios, mandating both a minimum ratio of RNs to patients and controlling the ratio of RNs to lesser-trained hospital staff. While management generally opposes staffing ratios, evidence suggests that they have proven effective in the recruitment and retention of nurses. Linda Aiken, founder of the magnet hospital program and perhaps the most widely respected author in the field, argues that unless "a floor for staffing is established, we are not going to be able to stop the flight of nurses from hospitals."169 Similarly, JCAHO President Dennis O'Leary notes, "While mandated ratios are controversial among health professionals, there are established relationships between nurse staffing levels and patient outcomes." He also stresses "achievement of mandated ratios will be meaningless until controls are placed on the numbers of non-nursing tasks that nurses are required to perform."170
Management in hospitals that have adopted such ratios has come to appreciate them. Cape Cod Hospital in Massachusetts, which signed a collective bargaining agreement in 1997 mandating a 1:5 staffing ratio for medical/surgical units (with a skill mix of 85 percent RNs), initially resisted the proposal but now hails it as a cornerstone of recruitment strategies. "It definitely does help with recruitment," stated Human Resources Director Molly O'Connor. "I've won some candidates over that way." As of 2002, the hospital — in a relatively isolated part of the state — had achieved a vacancy rate of just 8.9 percent.171
Similarly, the Nursing Executive Center points to Hackensack University Medical Center in New Jersey as the hospital with the best track record for recruitment and retention of nurses. Standing alone even among the other hospitals trumpeted as national models, Hackensack has committed to "alleviating intensity" among RNs, and with this policy it has established an RN turnover rate of only 3 percent and a vacancy rate of virtually zero.172 Indeed, the attraction of mandated staffing ratios is so powerful that in the aftermath of California's staffing legislation, one Nevada legislator bemoaned the likelihood that that state would see a mass exodus of nurses heading across the border for the promise of a more adequately staffed hospital unit.173
In some cases, staffing ratios seem like the elephant in the corner of nursing research. Many reports — particularly those funded by management — define the problem in terms that seem to intentionally skirt the central issue of staffing. One typical study surveyed nurses regarding their perception of
(a) autonomy, control, and physician relationships;
(b) faith and confidence in peers and managers;
(c) emotional exhaustion;
(d) job satisfaction; and
(e) the quality of patient care.174
Every one of these five aspects is significantly dependent on hospitals' staffing ratios. However, this study, like so many others, seems engrossed in measuring the symptoms of staffing levels rather than the root cause. In this sense, establishing adequate staffing ratios is the prerequisite to pursuing best practices in the other areas.
Specific Proposals for Staffing Levels
Staffing levels may be mandated either in an individual hospital's contract or through state or federal legislation. While staffing ratios have proven effective at the individual hospital level, legislated ratios may be preferable where politically feasible. The Massachusetts Nurses Association, which negotiated the Cape Cod Hospital contract, has misgivings over the strategy of negotiating staffing ratios with individual hospitals. While the staffing mandate is effective for the hospital that adopts it, its success often comes at the expense of other area hospitals — in some cases, hospitals represented by the same union. For this reason, the union has stopped concentrating on winning such clauses in contracts and is aiming instead at advancing state legislation similar to that adopted in California.175
In January 2002, California Governor Gray Davis announced the long-awaited nurse-patient ratios required for by legislation. Davis released the ratios for 12 acute care hospital units, including an initial 1:6 ratio for general medical/surgical units, moving to 1:5 in 12 to 18 months after the 1:6 introduction (see table at right). That represents half the number of patients that the hospital industry proposed in their recommendations to the state. The new ratios also limit emergency room nurses to one trauma patient, pediatric nurses to four child patients, and OB nurses to two mothers in labor. Given the need for public comment and the development of final regulations, Davis stated that the ratios will not take effect until January 2004.
The California ratios have been commended by nursing organizations, including the AFSCME affiliate United Nurses Associations of California. UNAC's president, Kathy Sackman, RN, applauded the state's move to safer staffing levels, stating, "These ratios move us much closer to ensuring that all California citizens get the level of nursing care they are demanding and deserve."176 At the same time, Sackman, who is also an AFSCME International vice president, criticized the ratios for not going far enough to address the problems of overworked nurses and quality care, and she reiterated her group's commitment to working for further improvement in ratios.177
|
Nurse-to-Patient Ratios in California |
| ICU/CCU/Neo-natal intensive care |
1:2 |
| Burn unit |
1:2 |
| |
|
| OR/PACU |
|
| Under anesthesia |
1:1 |
| Post anesthesia |
1:2 |
| |
|
ER (triage RNs not counted in ratios)
|
|
| General |
1:4 |
| Critical care |
1:2 |
| Trauma |
1:1 |
| |
|
| Medical and surgical (initial ratio) |
1:6 |
| 12 to 18 months phase-in |
1:5 |
|
Step-down/intermediate care/DOU |
1:4 |
| Step-down/telemetry |
1:4 |
| Telemetry |
1:5 |
| Oncology/speciality care |
1:5 |
| Labor and delivery |
1:2 |
| |
|
| Post Partum* |
|
| Couplets |
1:4 |
| Mothers only |
1:6 |
| Pediatrics |
1:4 |
| Intermediate care nursery |
1:4 |
| Well baby nursery |
1:8 |
| Psychiatric/behavioral health |
1:6 |
| Mixed units (initial ratio) |
1:6 |
| 12 to 18 months phase-in |
1:5 |
| |
|
| If maternal child has ante-partum and post-partum |
1:3 |
| |
|
| Notes: Ratios subject to upward adjustment based on patient acuity. Hospitals must get state’s agreement on plan for staffing acuity. |
Source: California Department of Health Services. Proposed Regulations. California
Code of Regulations. Title 22, Section 70001 et seq. |
Even if one is convinced of the importance of staffing ratios, several key issues make it difficult to determine exactly how the mandate should be framed. First, clearly, is the debate over the proper ratio of RNs to patients. The California legislation mandates both specific nurse-to-patient ratios and limits use of unlicensed assistive personnel.178 The state's initial ratio of one nurse for every six patients in medical/surgical units has been criticized by nurse unions as insufficient. One union proposal, for instance, included alternative ratios based on a massive study that examined 22 million patient discharge records from 1993 to 1998. Employing an expert panel of 25 experienced RNs who categorized patients into one of 500 diagnosis-related groups, the union assigned each diagnosis related group to one of seven hospital units where the nurses expected such a diagnosis would most likely be treated. It then compared the diagnosis related groups in each unit to develop ratios of the relative acuity level each unit was responsible for treating. Since California already had (for two decades) a legislative mandate requiring a ratio of one nurse for every two patients in the ICU, the ICU's acuity level was used as a baseline of comparison for establishing reasonable staffing ratios for other departments. Using this method, the staffing ratio in medical/surgical units should be 1:3 — twice as intensive as the standard set by state regulation.179
The research to date shows that better staffing levels do, in fact, improve both the nurse work environment and patient outcomes.180 But both scholars and nurses themselves have pointed to the limitations of staffing ratios. First, there is a danger of accomplishing RN-patient ratios but failing to secure adequate staffing levels for support staff whose work is essential to freeing RNs to concentrate on their highest-skilled work. Beyond this, staffing ratios inevitably provide only a crude measure of the quality of care needed: They do not take into account patient acuity, size and physical layout of units, or other factors that influence the demand for nursing in a given unit. For this reason, several scholars have attempted to develop models that go beyond simple nurse-patient ratios to develop a more sophisticated staffing formula that accounts for both patient acuity and the organization of work in a given hospital.
A recent Harvard study advocates use of a numerical model to account for patient acuity when determining RN staffing levels. It recommends using nursing intensity weights (NIW) to control for differences in nurse staffing driven by severity of patient illness. Designed to adjust hospital Medicaid payments based on differences in patient need for nursing care, NIWs are determined by an expert panel charged with estimating the relative nursing intensity of each diagnosis-related group's category over the average length of stay. Because the effort of nurses tends to be higher immediately after admission, the first days of a patient's hospital stay are typically accorded a higher score. The average of all scores represent the NIW for the respective diagnosis-related groups. To determine appropriate staffing levels, the Harvard researchers adjust the nursing hours per patient day by the NIW weight.181 However, this remains a painstaking, difficult and only roughly accurate yardstick for determining staffing needs.
Jean Seago, a highly respected nursing scholar, has developed a formula that attempts to account for the full range of factors affecting staffing levels. The table on page 47 outlines both her list of factors and the means by which these may be measured. Seago has collected this data for a sample of 100 California hospitals, and suggests that similar data be collected from all hospitals. Such data could be used to evaluate the findings and adjust the staffing formula. While the formula remains tentative for now, Seago argues that it constitutes "a beginning attempt at a conceptualization of nurse workload for an acute care medical/surgical nursing unit that goes beyond ratios, nursing hours per patient day, and beyond PCS scores."182
While sophisticated formulas such as Seago's or the NIW may become more feasible over time, in the short term the most effective means for developing appropriate staffing levels may be to combine mandated minimum ratios with truly joint committees in which nurses in each hospital unit could use their knowledge to adjust the staffing levels above the minimum as needed. This strategy has precedent. One of the original magnet hospitals reported having a nursing department committee that "conducts a patient acuity study that results in a redistribution of patients in the units of the hospital so that nursing needs are better met."183 Another "ICU head nurse has the authority to close beds in the unit when staffing is not adequate to render safe care."184 Clearly, any such committee proposal can work only if nurses are truly granted at least equal say over the ultimate staffing levels.
Where true labor-management partnerships have been undertaken, agreements on staffing levels are impressive. Kaiser Permanente, among the largest of California's health care employers, has agreed to a staffing ratio proposed by UNAC and SEIU of one medical/surgical nurse to four patients — a goal more stringent than the California state mandate. Kaiser Permanente anticipates that the additional staffing cost will range from $140 million to $200 million per year; however, the organization also expects to achieve savings through reduced nursing turnover and improved patient outcomes.185 Similarly, nurses at St. Vincent Hospital in Santa Fe (affiliated with AFSCME 1199NM) negotiated an agreement to launch an ongoing labor-management process aimed at establishing adequate staffing levels. Joint labor-management committees examine each floor of the hospital and establish mutually agreed upon staffing levels. Importantly, the agreement also established a penalty for violations. If staffing on any floor falls below the agreed level, all staff on that floor, including the unit secretaries, are paid time and a half.186
As an initial step, it might prove useful simply to require hospitals to collect and publicize data on staffing levels. The American Hospital Association recommends that hospitals "monitor and measure the number and mix of qualified staff to ensure there are enough workers for safe, timely care that is satisfying to patients and staff."187 If these data — plus measures of vacancy and turnover — were shared with a union or distributed to the general public, this in and of itself might provide some hedge against the worst sort of hospital practices. In this spirit, New York State Assembly Bill 2581, requires hospitals to publicize extensive information regarding nurse staffing and patient outcomes. Similarly, better data are one of the immediate benefits of hospitals attaining magnet status: Just the process of applying for magnet recognition forces a hospital to collect more extensive staffing data than is normally tracked. Indeed, a 2002 nurses strike against the Oregon Health Sciences University was settled, in part, because of the hospital's agreement to apply for magnet status and to share the information gathered in the process with the union.188
The following are among the most useful examples regarding staffing levels:189
- Establish specific staffing levels (UAN/ANA, Sparrow Hospital, Michigan; SEIU, Liberty Medical Center, Maryland; MNA,
- Cape Cod Hospital, Massachusetts; Wisconsin Federation of Nurses and Health Professionals, St. Francis Hospital, Wisconsin;
- SEIU, San Francisco General Hospital, California; SEIU, Crouse Hospital, New York).
- Joint labor-management committees establish enforceable staffing levels (AFSCME 1199NM, St. Vincent Hospital, New Mexico).
- Allow nurses to set nurse-to-patient ratios on a unit-by-unit or clinical specialty basis (UAN/ANA, several New York hospitals).
- Require hospitals to collect nursing-sensitive data.
- Institute union-management committees to review staffing standards and/or develop staffing standards for each unit in the hospital (UNAC/UHCP/AFSCME, Kaiser, California; Oregon Federation of Nurses and Health Professionals (OFNHP), Kaiser, Oregon; NYSNA, Mt. Sinai Hospital, New York).
- Permit self-scheduling — allowing the nurses in a unit to create the schedule (SEIU, Beth Israel Hospital, New York).
- Have a "no floating" policy — use a special group of nurses trained to float to various units (University of California-Davis).
- Have a policy of no cancelled shifts (Poudre Valley Hospital, Colorado).
- Provide premium pay when short staffed (SEIU, Crouse Hospital, New York).
- Do not use agency nurses (University of California-Davis).
- Offer flexible schedules.
- Have a permanent supplemental staffing pool (SEIU, Liberty Medical Center, Maryland).
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