nurse staffing issues - nursing shortage
Many registered nurses (RNs) believe that low nurse staffing
levels in acute care hospitals are jeopardizing the quality of
patient care and prompting RNs to leave the profession. While 18
other States have considered legislation regarding nurse staffing
in hospitals, in 1999 California became the first State to mandate
minimum nurse-to-patient ratios in acute care hospitals, which
will begin to be implemented by July 2003.
A study supported by the Agency for Healthcare Research and
Quality (National Research Service Award training grant T32
HS00086) suggests that these mandatory nurse-to-patient ratios
could generate opportunity costs that are not easily measured and
that may outweigh their benefits. A second AHRQ-supported study
(HS09958) suggests that long overdue improvements in the hospital
workplace and 40 percent increased enrollment in nurse education
programs are needed to avoid the projected shortage of more than
400,000 RNs by the year 2020. The two studies are summarized here.
Coffman, J.M., Seago, J.A., and Spetz, J. (2002). "Minimum
nurse-to-patient ratios in acute care hospitals in California."
Health Affairs 21(5), pp. 53-64.
The minimum nurse-to-patient ratios proposed by the California
Department of Health Services (DHS) range from one nurse per
patient in operating rooms to one nurse per eight infants in
newborn nurseries. DHS also proposes that minimum ratios for
medical-surgical and rehabilitation units be phased in, moving
from an initial one nurse (RN or licensed vocational nurse, LVN)
per six patients to one nurse per five patients within 12 to 18
months of enactment. These proposed minimum ratios generally call
for fewer patients per nurse than hospitals recommend and more
patients per nurse than unions recommend.
Implementation of the initial ratios proposed by the California
DHS would result in an increase of $143,836, or 1 percent on
average, in expenditures for nursing wages per hospital per year
(not including costs for employee benefits and employment taxes).
Phasing in minimum nurse-to-patient ratios for medical-surgical
and rehabilitation care units from 1:6 to 1:5 would result in an
increase of $217,210, or 1.7 percent per hospital per year. The
estimated total annual cost of implementing the ratios at
California's 400 acute care hospitals would be about $87 million.
This approach may exact opportunity costs that could outweigh
its benefits, assert the researchers. They point out that there
are no data showing that mandatory minimum nursing ratios will
improve patient outcomes. Also, hospitals may compensate for
increased costs for nurses by cutting spending for housekeepers,
ward clerks, and other support staff, since many of their tasks
could be performed by RNs and LVNs. Such an approach could make
hospital jobs even less attractive to nurses. Furthermore, higher
personnel costs may compel hospitals to defer investments in
medical technology and facilities that could improve the quality
of care. The researchers suggest that a well-designed acuity-based
ratio system may be a more flexible alternative to minimum
nurse-to-patient ratios.
Buerhaus, P.I., Needleman, J., Mattke, S., and Stewart, M.
(2002, September). "Strengthening hospital nursing." Health
Affairs 21(5), pp. 123-132.
Enrollment in nursing education programs, which has declined
each year since 1995, would have to increase immediately by 40
percent to offset the projected shortage of more than 400,000 RNs
by 2020. Long overdue improvements in the hospital workplace are
also needed to recruit and retain registered nurses, according to
these authors. They suggest that health policymakers focus on
redesigning the work content and organization of hospital-based
nursing care and improving the education of RNs, including support
of nontraditional educational programs that enable licensed
practical nurses, nurse aids, and others to become RNs.
For instance, hospital-based nursing care should be redesigned
to reduce the inordinate amount of time RNs spend in functions
other than providing patient care. Excessive paperwork,
inefficient communication systems, outdated patterns of care
delivery, and other difficulties contribute to low job
satisfaction and a frustrating work environment. They are also
major barriers to providing efficient and appropriate nursing
care. Efforts also are needed to improve the relationship between
the nursing profession and hospitals. AHRQ and other agencies and
organizations should continue to fund redesign efforts and
knowledge about best care practices.
The education of RNs must also be improved to better prepare
for the future. For example, only 23 percent of baccalaureate
nursing education programs have a required course in geriatric
nursing, despite the rapidly aging population. Also, nursing
schools need to offer more courses in clinical management, so that
RNs are better able to delegate nursing functions to others and
oversee the larger non-RN workforce. Policymakers should develop
programs that offer financial support for continuing education and
formal course work designed to help RNs more capably use
technology and computer information systems and apply quality
improvement methods to clinical and administrative processes.
Finally, the quality of care associated with nurse staffing should
be monitored.
Reprints available from the AHRQ Publications Clearinghouse.
These are excerpts from the AHRQ Research Activities,
you can read the full report at
http://www.ahrq.gov/research/nov02/1102RA4.htm |