This year, nurses across a few states, including Pennsylvania and Ohio, led the charge for patient safety legislation — mandates at the state-level that would require minimum nurse-to-patient ratios in patient care facilities in an effort to increase the safety of both hospital staff and the patients they treat. Early adopters of state-level legislation for nurse-to-patient staffing ratios include Massachusetts, California, and most recently, Oregon. On a federal level, bills mandating nurse-to-patient staffing ratios have also been introduced and considered, but the question remains: is this the only solution needed to ensure safe staffing at the bedside?
Mixed Opinions on Nurse-to-Patient Ratios
As a result of the pandemic, we’ve seen an increase in burnout and stress levels for nurses across the U.S. With patient acuity rising, and a growing number of experienced nurses leaving the workforce, nurses have struggled to safely provide quality care amidst their growing caseloads.
Researchers from the University of Pennsylvania have found that adding one additional medical patient to a nurse’s workload increased mortality by 7% and one additional surgical patient increased mortality by 8%. Hospital readmissions increase too if there is not an adequate number of nurses caring for patients. The researchers concluded that by instituting minimum nurse-to-patient ratios in Pennsylvania, it would reduce length of stay, prevent hospital deaths, and decrease hospital readmissions.
However, recent approaches to legislating nurse-to-patient ratios do not address other key factors impacting the nursing workforce. For one, many nurses in the 25 to 35 age group, which health systems should be relying on over the next few decades, have already left the profession due to burnout, exhaustion, and feeling undervalued based on a myriad of factors — including pay. As a result, we’ve reached a point where many nurses in care settings are now new to the profession, meaning they have limited experience at the bedside. While having enough nurses should improve patient outcomes, numbers alone don’t make up for insufficient expertise. Experience is necessary for quality patient care.
While ratios are a strong start, they are not the sole solution to building an environment where nurses feel supported in their careers and empowered to provide the best care possible. The right number of competent and qualified nurses is necessary to deliver safe, quality care and improve patient outcomes. Staffing can no longer be only about numbers when factors including specialty knowledge, training, skills, and competency come into play for each specialty unit.
Keeping Our Nurses Safe, Supported, and Engaged
Developing a physically and psychologically safe environment for nurses requires a multi-pronged approach, with a focus on initiatives like fortifying our nursing education pipeline, implementing a team-based model of care, and improving communication and visibility from the leadership level.
Nursing school enrollment numbers have continued to drop in recent years, adding to the growing shortage of nurses. At the same time, passing the NCLEX-RN exam doesn’t necessarily mean nurses are prepared to assume the role of a practice-ready nurse upon graduation. With these educational challenges in mind, we need to reinforce the recruitment, training, and retention of new nurses. This means implementing best practices to increase competency and reduce turnover in settings beyond academia to support and further train new nurses for practice. Approaches to this include extended orientation programs, bolstered nurse residency programs, and providing ongoing mentorship.
Team & Competency-Based Staffing Ensures Safety
Beyond fortifying the nursing education pipeline, pursuing a team-based model allows for a more agile nursing workforce and plays to the qualifications and strengths of each staff member. While implementation requires investment in re-educating staff to facilitate appropriate delegation of patient care, these efforts can help account for a lack of experienced RNs at the bedside. Investment from leadership is also a critical aspect of the equation. Ensuring a competent nursing workforce can practice safely will require leaders to do their due diligence — by actively listening to feedback and providing the appropriate resources for continued learning. When leadership adequately supports nurses, patients can trust their care team is staffed with engaged, well-equipped professionals who will provide the best care possible.
We need to remember the nursing care shortage is the result of many factors; however, in many cases it is not due to nurses not wanting to “nurse” anymore. Nurses want to take care of patients, but they want to do so in an environment where they are safe to practice and can deliver safe, quality care to their patients. The reality of nurse-to-patient ratios today is that when nurses have limited support and capacity, they burn out and decide to leave the bedside altogether.
With the number of newer, less experienced nurses rising, we must consider the competency and skill set of the individual nurse and the acuity of the patients they serve. While legislation may be a start, health systems and the nursing community as a whole need to invest in building an environment where nurses feel safe to practice and confident they can deliver excellent care to their patients.
Anne Dabrow Woods, DNP, RN, is a practicing nurse practitioner in critical care for Penn Medicine, Chester County Hospital, and adjunct faculty for Drexel University in Philadelphia and Neumann University in Aston, Pennsylvania. She currently serves as chief nurse of Health Learning, Research & Practice, Wolters Kluwer.