Evidence-Based Legislation and Continual Reassessment as Solutions to Inadequate Nurse Staffing

Evidence-Based Legislation and Continual Reassessment as

Solutions to Inadequate Nurse Staffing

Theresia Barnett

Marian University, Leighton School of Nursing

Author Note

This paper was prepared for NSG 343, Section B, on April 15, 2019, under the guidance of Professor Friedman.

Abstract

Insufficient nurse staffing has been connected to a higher incidence of morbidity and mortality in hospitalized patients. Recent research has shown the many adverse events that can occur when patient to nurse ratios are too high. These three studies show that dangers of inadequate nurse staffing and provide evidence to create new methods of nurse staffing to meet evolving patient needs. This information indicates that nurse staffing should have its basis in legislation, with systematic reassessments being performed to make within-shift changes as necessary.

Keywords: nurse-to-patient rations, nurse staffing, in-hospital morbidity, adverse events, legislation

Literature Review of Evidence-Based Nurse Staffing: History and Controversy

Introduction

The necessity of legally mandated nurse to patient staffing ratios for inpatient medical centers was questioned during the election cycle of 2018, when the citizens of Massachusetts voted on a ballot referendum concerning nurse to patient ratios in Massachusetts hospitals (American Journal of Nursing, 2019, p. 12). The nurse to patient ratio is the number of patients that a nurse is responsible for at a time. This issue was discussed as early as 1961, when a rehabilitation center in California examined its own staffing system in preparation for certification by the State Department of Public Health as an institution that received public funds for patient care (Affeldt, 1961, p. 243).

Rancho Los Amigos Hospital reviewed its own staffing ratios as a guide to other facilities when determining appropriate staffing (Affeldt, 1961, p. 243). Even in 1961, this issue was controversial; Affeldt said the following regarding the attitude of administrators regarding staffing ratios:

Administrators, whether of hospital or medical background, have varying opinions of

the value of staffing ratios or formulae. Some consider them useful in developing

work loads and budgets, and for planning programs. Others, believing they are

arbitrary, prefer not to use them (p. 243).

The ratios in place at the Rancho Los Amigos Hospital in 1961 were not the product of legislation, but were inspired by a desire to be a certified facility that provided acceptable care to its patients (Affeldt, 1961, p. 243). What can be learned from 1961 and applied to modern issues is that the way hospitals are staffed has, if nothing else, a perceived impact on patient care, and therefore warrants closer inspection.

Just like some of the administrators at Rancho Los Amigos Hospital in 1961 (Affeldt, 1961, p. 243), some national and Massachusetts-based nursing administrators in 2018 saw no need for legislation requiring what was believed to be appropriate staffing of nurses (American Journal of Nursing, 2019, p. 12). Arguments by nurse administrators against what was known as Question 1 on the Massachusetts ballot in 2018 were varied (American Journal of Nursing, 2019, p. 12). Nancy Gaden, chief nursing officer at Boston Medical Center, told the public that the emergency department would be forced to see fewer patients per day and that 62 medical-surgical beds would not be used because of an inability to staff nurses in accordance with the law (American Journal of Nursing, 2019, p. 12). The former president of the American Nurses Association, Pamela Cipriano, believed that the law would encroach upon the rights of nursing to create its own guidelines as a profession (American Journal of Nursing, 2019, p. 12). These arguments—directed towards both the public and Massachusetts nurses—were effective, as the referendum did not pass (American Journal of Nursing, 2019, p. 12).

However, one prominent nursing researcher, Linda Aiken, disagrees with the agendas of the aforementioned Massachusetts nursing administrators (American Journal of Nursing, 2019, p. 12). In a commentary on the position statement of the International Council of Nurses, Aiken and her colleague Claire Fagin believe that the numerous studies highlighting the correlation between higher nurse to patient ratios and improved outcomes are cause for the implementation of what they call evidence-based staffing (2018, p. 469). Aiken and Fagin focus on both patient safety (2018, p. 469) and the job satisfaction of bedside nurses (American Journal of Nursing, 2019, p. 12). In the spirit of nurse administrators, who must be concerned with the cost of hiring and paying more nurses, Aiken also believes that evidence-based staffing is fiscally desirable (2018, p. 469).

If Question 1 had passed in November of 2018, Massachusetts would have been the second state to begin legally mandating the staffing of nurses. In 1999, California passed Assembly Bill No. 394 as a part of the state’s Health and Safety Code (California Legislature, 1999). This is fortunate, as it provides data within the United States about the efficacy of mandated staffing in healthcare facilities. California implemented the law because of a concern for the safety of patients (California Legislature, 1999). It is easy to see how proponents of legislated nurse to patient ratios have held patient safety as a main goal—nurses are the only members of the healthcare team constantly with the patient and are legally responsible for continual assessments of the patient (Sloane, Smith, McHugh, & Aiken, 2018, p. 1001).

When considering the feasibility of nurse to patient ratios being legislated at the state or national level, there are a variety beliefs and potential outcomes to be examined. The International Council of Nurses released a position statement in 2018 that clarified a belief that nurse to patient staffing ratios have the potential to influence the following: patient safety and outcomes, such as morbidity and mortality; the welfare of nurses who attend to patients at the bedside; and the amount of money spent by hospital systems when dealing with the financial consequences of inadequate nurse to patient ratios (p. 1).

Different arguments are used by those who believe that mandated staffing requirements would negatively impact the healthcare system and the well-being of patients. In Massachusetts, it was estimated that the passage of Question 1 would require the hiring of between 1,809 and 2,624 new nurses (American Journal of Nursing, 2019, p. 12). This process would cost an enormous amount of money, which was estimated to be between $676 million and $949 million annually to be in compliance with the proposed staffing ratios (American Journal of Nursing, 2019, p. 12). An argument used by the American Nurses Association against the referendum is that it would impact the integrity of the profession (American Journal of Nursing, 2019, p. 12).

This paper will examine the plethora of research available regarding the various beliefs and outcomes associated with the legislation of nurse to patient ratios. It will consider whether existing laws have had an impact on the primary goals of patient safety and nurse satisfaction. Cost effectiveness of existing and potential legislation will be examined as a secondary factor.

Research Analysis

Introduction

Many approaches have been taken when analyzing the effect of nurse staffing ratios on patient outcomes. It is difficult to do randomized control trials on this topic because of the huge amount of effort that would be required, and because researchers would have no real way of controlling the staff available on the units in question. It may also be seen as unethical to randomize some patients to be on units with higher nurse to patient ratios because of the known negative effect it has on morbidity and mortality. The following three studies each evaluated the effect of different staffing levels using unique metrics to measure outcomes.

McHugh, M. D., Rochman, M. F., Sloane, D. M., Berg, R. A., Mancini, M. E., Nadkarni,

V. M.,...Aiken, L. H. (2016, January). Better nurse staffing and nurse work

environments associated with increased survival of in-hospital cardiac arrest

patients. Medical Care, 54(1), 74-79.

Background: This study was produced primarily by researchers from the Department of Nursing at the University of Pennsylvania and its Center for Health Outcomes and Policy Research in conjunction with the American Heart Association’s Get With the Guidelines-Resuscitation ongoing research. The goal of this study was to expand on prior research that had been done regarding the effect of nurse staffing on survival of in-hospital cardiac arrests (p. 75). Unlike previous similar studies, McHugh et al. distinguished registered nurses at the bedside from registered nurses who do not provide direct patient care (p. 75).

The researchers were motivated to expand upon previous research that has shown a decreased prevalence of failure to rescue in hospitals with better nurse staffing (p. 75). The researchers also wanted to determine the unexplored link between the work environment of nurses and the survival of patients following an in-hospital cardiac arrest (p. 75). These links are studied because of the evidence demonstrating the necessity of sufficient levels of nurses to provide adequate assessment, monitoring, and intervention for patients who are at risk of cardiac arrest while hospitalized (p. 75). The researchers acknowledge that nurses, not physicians, are the providers that assess and evaluate hospitalized patients and are often the initiators of treatment in the event of a cardiac arrest (p. 74).

Study design: This cross-sectional study combined data from three sources:

AHA’s Get with the Guidelines In-Hospital Cardiac Arrest-Resuscitation database: provided details in the events preceding and following the cardiac arrest; the characteristics of the patients who had arrested; and the outcomes of the cardiac arrests.University of Pennsylvania Multi-State nursing Care and Patient Safety Survey: provided details on the nurse staffing at the hospitals studied.AHA’s annual hospital survey: provided hospital information

The investigators were blind to which hospital had provided the data, and nurse selection was random.

Measurement tools: The researchers measured nurse staffing simply by asking each nurse how many patients they had cared for on the previous shift (p. 76). This data was collected randomly via survey that was mailed to nurses in California, Pennsylvania, Florida, and New Jersey (p. 75). Details on the in-hospital cardiac arrests were acquired from the AHA’s ongoing Get With the Guidelines-Resuscitation survey (p. 75). Hospitals that choose to participate in this survey provide the program with a plethora of information surrounding a cardiac arrest event, including code flow sheets, page logs, and drugs used during the event (p. 75).

Sample: The final sample included 75 hospitals and 11,160 patients (p. 75). The AHA’s Get With the Guidelines-Resuscitation program collects data on all cardiac arrests in participating hospitals. The researchers in this study had several criteria to narrow down the sample size of cardiac arrests; inclusion criteria included inpatients who presented with any of the following rhythms: pulseless electrical activity, asystole, ventricular tachycardia, and ventricular fibrillation (p. 75). Exclusion criteria included: being less than eighteen years old; the presence of an implantable cardioverter-defibrillator; and being on an obstetrics, pediatrics, psychiatry, or rehabilitation unit, or being in the emergency department or a procedural area (p. 75). Inclusion criteria for hospitals was having more than ten cardiac arrests between 2005 and 2007 (p. 75).

Results: One interesting finding of the study was that staffing on medical-surgical units (mean=seven patients per each nurse, with a standard deviation of 2.8) was much more variable than staffing on intensive care units (mean of 2.3 patients per nurse, with a standard deviation of 0.6) (p. 77). Two nursing-related factors were found to influence survival: (1) patients with witnessed cardiac arrests were twice as likely to survive to discharge; and (2) on medical-surgical units, chances of survival until discharge following an in-hospital cardiac arrest decreased by 5% with each additional patient per nurse (p. 78). Another notable finding was the staffing levels on intensive care units did not impact the patient’s chance of survival to discharge (p. 78). This may be because ICUs are recognized as being very high acuity and may be given priority when it comes to appropriate staffing.

Discussion: The researchers reflected on previous research that has been done regarding the importance of witnessing and/or monitoring of a cardiac arrest to the survival of the patient; since fewer patients per nurse allows the nurse to spend more time with each patient, the amount of cardiac arrests that are witnessed increases, and therefore survival increases (p. 79). The researchers believed that an increased nurse to patient ratio would decrease the number of deaths following an in-hospital cardiac arrest, and would also reduce the incidence of other adverse events (p. 79).

The researchers acknowledge that this study, since it was cross-sectional, cannot establish causality. The generalizability of this study is also questionable; hospitals that participate in the AHA’s Get With the Guidelines-Resuscitation program tend to be larger and have more advanced technology (p. 77).

Personal analysis: This study is another example of the growing body of evidence that recommends an increase in nurse staffing on medical-surgical units. One interesting thing learned from this study is that almost half of in-hospital cardiac arrests occur on medical-surgical units, and not in the ICU (p. 79). This study sheds light on the essential role that the bedside nurse plays in assessment and the initiation of interventions in the event of an in-hospital cardiac arrest.

One article that helped to inspire this paper, which covered the failure of Question 1 in Massachusetts in 2018, ended its report by saying that previously established nurse staffing in ICUs had not shown an improvement in patient outcomes (Sofer, 2019, p. 12). This study came to the same conclusion; the explanation for this, provided by this study, is that ICU staffing tends to be more consistent than staffing on medical-surgical floors (p. 77). This finding could potentially be used to refute the argument that legal mandates do not improve outcomes; medical-surgical units and ICUs are not the same, and a finding in one setting may not be applicable to the other.

I believe that the findings of this study should be respected and viewed as sound; the critics of mandated nurse to patient ratios do not tend to question the legitimacy of the research that suggests their efficacy. Criticisms seem to be based upon the cost of complying with the law or critics may apply findings from the ICU to medical-surgical units.

Lee, A., Cheung, Y. S. L., Joynt, G. M., Leung, C. C. H., Wong, W., & Gomersall, C. D.

(2017). Are high nurse workload/staffing ratios associated with decreased

survival in critically ill patients? A cohort study. Annals of Intensive Care, 7(46),

p. 1-9. doi: 10.1186/s13613-017-0269-2.

Background: This study was done because research regarding the effect of nurse staffing on mortality in the ICU has been conflicting (p. 1). However, the researchers believe that there are flaws in previous studies including: (1) the average of nurse staffing over a period of time may not be a sufficiently sensitive measure, and (2) workload varies between days in ICUs, and decompensating patients may, as a nature of their condition, already have more nursing care devoted to them (p. 2). The researchers wanted to determine if there is a threshold at which increased nurse staffing in the ICU ceases to improve outcomes, and that the distribution of workload rather than patients in the ICU may be associated with differences in mortality (p. 2).

Study design: Researchers at the Chinese University of Hong Kong performed a cohort study which retrospectively analyzed prospective data collected via audit over a period of five months at two ICUs in Hong Kong (p. 2). It does not appear that there was any randomization, control group, of blinding used to perform the study.

Measurement tools: This study not only measured nurse to patient ratios, but also measured the nursing workload that each patient required. The measurement of workload presented by each patient was the Therapeutic Intervention Scoring System-76 (TISS-76), where an increasing number of points indicates an increase in workload (p. 2). This data was collected by an audit nurse each day of the study, and the total TISS-76 score per day was divided by the number of bedside nurses on the unit that day (p. 3). TISS-76 score was used because it is valid, and because it does not include nursing activities that can be performed by unlicensed assistive personnel (p. 6).

Using the TISS-76 scoring system, the following hypothetical patient earns a score of 38: two vasoactive drug infusions; controlled ventilations with muscle relaxants; hemodialysis for an unstable patient; continuous dysrhythmia infusion; chest tube; anticoagulation; more than two IV antibiotics; treatment for metabolic acidosis; hourly vital and neuro checks; two peripheral IVs; parenteral feedings; continuous ECG monitoring; intermittent schedule IV medications; intake and output monitoring; urinary catheter; and uncomplicated dressing changes.

The measure of patient acuity was the Acute Physiology and Chronic Health Evaluation III (APACHE III) (p. 3). It is unclear how the number of nurses per shift was calculated, but differences in staffing between shifts in one day was accounted for (p. 3). The primary outcome of interest was mortality, and other adverse outcomes (i.e. nosocomial infections) were not included in the data (p. 3).

Sample: Two ICUs in Hong Kong were included in the study, one with twelve beds and the other with 22 (p. 2). Both were the only adult ICU in the hospital (p. 2). Ultimately, 894 admissions and 845 patients were included in the study (p. 4). Exclusion criteria for patients included a primary diagnosis of burns, age of less than sixteen, transfer to another hospital’s ICU, or a stay in the ICU of less than four hours (p. 2).

Results: The results of the study suggest a workload threshold per nurse, based on the TISS-76, of less than 40 (p. 4). The 275 admissions that took place entirely with a workload-to-nurse ratio of less than 40 had a 95% greater chance of survival to hospital discharge; conversely, the 27 admissions that occurred when the workload to staffing ratio was greater than 52 for one day or more of the admission were less likely to survive than patients who were in the ICU with a workload to staffing ratio of less than 52 (p. 5). The results also showed that units did not intentionally increase their staffing when TISS-76 scores increased (p. 5).

Discussion: Since this study is observational, it cannot establish causality between workload/staffing in the ICU and mortality before discharge (p. 7).

This study is not very generalizable to the greater population because the sample size of hospitals is small (n=2) and the configuration of Chinese ICUs is unique (p. 7); the units tend to be open and work is shared between nurses (p. 6). The recommendation of these researchers would be a workload ratio of 50 TISS-76 points per nurse; at greater than 52 points, all patients appear to be at an increased risk of death (p. 6). This study suggests that ICU staffing may be more appropriate if based upon the workload generated by patients and not on the number of patients on the unit (p. 6).

Personal analysis: The study presented previously in this literature review found that staffing differences had not significant effect on mortality in ICUs. The Lee et al. study featured in this section proposes a new way to consider staffing in the ICU, and suggests that it could be more appropriate if based off of workload rather than absolute number of patients or beds. If this evidence was to be accepted and translated into a legal mandate, it would have broad implications for hospital administration. The work involved in staffing a unit would increase, because constant re-assessments would need to be made to determine the workload in the ICU at any given time. When problems such as this are posed, it must be determined if the worth of the lives saved by more appropriate staffing is worth the administrative and salary expenses related to providing appropriate nurse staffing.

Liu, Y. & Aungsuroch, Y. (2017, October 19). Factors influencing nurse-assessed

quality nursing care: A cross-sectional study in hospitals. Journal of Advanced

Nursing, 74, 935-941. doi: 10.1111/jan.13507.

Background: It has been established internationally that the provision of quality nursing care should be a priority of healthcare systems (p. 936). One way to measure the quality of nursing care is the nurse-assessed quality nursing care (NAQNC) measurement tool (p. 936). NAQNC is a way to measure how nurses feel about the quality of care they are providing to their patients (p. 936). Self-assessment by registered nurses of the care that they provide is supposed to lead to a greater understanding among nurses of the factors influencing nursing care (p. 936).

Study authors Ying Liu and Yupin Aungsuroch at the Dalian Medical University in China decided to examine the influence of several factors on NAQNC in Chinese hospitals (p. 937-938). Some of the potentially influential factors examined were low nurse to patient ratios, the experience of burnout, undesirable work environments, and dissatisfaction with one’s job (p. 937). In this study, it is understood that the nurse to patient ratio on a particular unit has the potential to influence the other three factors (burnout, work environment, and job dissatisfaction), and therefore can indirectly affect the NAQNC (p. 937). While the influence of each individual factor on NAQNC and patient outcomes have been measured previously, the interaction of the various aforementioned factors were measured for the first time in this study (p. 936).

The ultimate goal of this study was to provide hospital administrators with the evidence needed to create work environments for their nurses that decrease burnout and increase job satisfaction with the ultimate goal of improving NAQNC and patient outcomes (p. 936).

Study design: This study was designed as a cross-sectional survey (p. 938). For this study, the researchers developed multiple hypotheses which were then tested with multiple surveys. The hypotheses most relevant to this literature review are a) a higher patient to nurse ratio directly and negatively influences NAQNC and job satisfaction but directly and positively influences burnout and intention to leave, and b) a higher patient to nurse ratio indirectly and negatively influences NAQNC but indirectly and positively influences intention to leave through job satisfaction and burnout (p. 937). Four general hospitals from six administrative regions were selected with simple randomization, and the nurses were selected from those hospitals through stratified random sampling (p. 938). No blinding nor masking was involved.

Measurement tools: Many measurement tools were needed in order to measure various factors and how they related to NAQNC. Packets of all of the surveys were distributed to random nurses by research assistants and the primary investigators, which were then returned to the head nurse; the number of surveys provided to a particular unit was proportional to the number of nurses on that unit (p. 939). Satisfaction with work environment was measured with a Chinese language version of the Practice Environment Scale (C-PES), which has been found to be reliable and valid (p. 938). The C-PES is a four-point Likert Scale that measures 28 items. Because of the way the finished surveys were collected, some underreporting may have occurred due to fear of retaliation by management.

Nurse to patient ratios were measured by the Nurse Staffing Form, developed by Linda Aiken, which asks nurses to self-report the average number of patients that they had cared for each shift within the past thirty days (p. 938). The tool used to measure job satisfaction, the Chinese Nurse Job Satisfaction Scale, was developed by the primary investigator, and is simply the Nurse Job Satisfaction Scale translated into Chinese (p. 938). It is a 34 item, five-point Likert Scale (p. 938). A Chinese version of the Maslach Burnout Inventory Human Service Survey was used to measure burnout (p. 938). Intention to leave was measured by the Anticipated Turnover Scale, which is a five item, seven-point Likert Scale (p. 938). All measurement scales were determined to be valid and reliable (p. 939).

Sample: When considering the possibility of attrition of nurses from the study group, it was decided that a minimum 550 participants would be needed in order to make reliable claims regarding the test hypotheses (p. 938). Participants were selected using proportional stratified random sampling; the final group was composed of 566 nurses (p. 938). Criteria to be included in the study was: employment at that hospital for a minimum of three months; having a Chinese Registered Nurse license; being in a position that provided direct patient care; and willingness to participate in the study (p. 938).

Results: Multiple hypotheses that were tested are not directly relevant to the discussion in this paper, and will therefore not be included. However, the researchers did find that NAQNC was influenced directly by patient to nurse ratio (p. 940). Work environment, of which patient to nurse ratio is a component, directly influences job satisfaction and indirectly influences NAQNC (p. 940). Job satisfaction was found to directly influence burnout, and burnout was found to directly influence NAQNC (p. 940).

Discussion: As has already been established, one of the main goals of this research study was the desire to inform hospital administrators and nurse managers about how to retain nursing staff. The researchers are confident in their findings that a work environment perceived as positive had a direct, positive effect on NAQNC (p. 940). This suggests to hospital administrators that adequate resources, adequate nurse to patient ratios, and the ability to participate in hospital governance motivates nurses to provide high quality nursing care (p. 940). The study also found that Chinese nurses rated the quality of nursing care provided (NAQNC) as lower as a direct result of high patient to nurse ratios (p. 941). However, patient to nurse ratios were not found to directly influence job satisfaction or burnout, which suggests that nurse to patient ratios are seen as part of the nurse’s work environment (p. 941).

Personal analysis: The predominant focus of this literature review has been on the impact of nurse to patient ratios on patient outcomes and safety. However, the experience of nurses in their careers is also important. Nurses have a duty and, hopefully, a desire to provide high quality nursing care to their patients. This study shows that requiring nurses to overextend themselves affects the nurse’s perception of the care that they provide. It also directly, negatively affects work environment, which affects burnout and intention to leave the position or the profession. These findings are relevant because they can help hospital administrators and nurse managers to understand why nurses are leaving bedside nursing. Mandated staffing ratios could potentially force unwilling administrators to provide the work environments necessary to produce quality nursing care.

Summary

These studies support the belief that higher patient to nurse ratios leads to poorer outcomes. The Liu and Aungsuroch study also assessed the impact that ratios have on the job satisfaction of nurses. A shared limitation of the studies is that not all type of hospital units are studied, so the external validity of the studies may be questionable. Unfortunately, I do not think that enough evidence has been provided in these studies to create legislation that mandates nurse to patient ratios, because the laws proposed thus far have suggested absolute levels of staff rather than an approach that can evolve to satisfy increased or decreased demands of patient acuity.

Recommendations

Registered nurses are highly trained medical professionals who have a great impact on patient improvement and safety. Nurses are responsible for assessing for status changes, assisting with or performing ADLs, administering medications, and making recommendations to the provider. It is also the responsibility of the nurse to prevent the possible harms of hospitalization- catheter and central line acquired infections, pneumonia, pressure ulcers, and medication errors. In order to function most effectively, nurses need to have the support of their management and the law, and not be overburdened with patients.

The evidence is clearly in favor of appropriate staffing on inpatient acute care units. Insufficient staffing has been connected to higher morbidity and mortality rates. In addition to these studies, a meta-analysis was conducted that shows the potential relationship between nurse to patient ratios and nurse sensitive patient outcomes. Reductions in the following events were experienced when there was a decrease in nursing hours per patient bed days: decubitus ulcers, ventilator-associated pneumonia, central line infections, and urinary catheter associated infections (Driscoll et al., 2018). Most notably, there was a 14% decrease in the likelihood of in-hospital mortality (Driscoll et al., 2018).

California is the only state in the United States that has passed legislation mandating nurse to patient ratios. The law covers inpatient acute care settings. California State Legislature Assembly Bill No. 394 requires a patient to nurse ratio of 5:1 on medical-surgical units and 2:1 on intensive care units (1999). The bill introduced in Massachusetts in 2018 took the same approach to staffing- it would require a firm limit on the number of patients a nurse could be responsible for at a time, but did not account for a potential change in patient acuity (Sofer, 2019).

The aforementioned laws take a rigid approach to mandated nurse staffing. This may be a step in the right direction- the current situation in some areas of the United States are seen as intolerable by nurses. In New York, nurses viewed the staffing ratios as unsafe and voted almost unanimously to strike, which would have occurred on April 2nd if negotiations had not been extended (Brusie, 2019). A nurse at Mt. Sinai Hospital in New York said the following regarding the planned strike:

Nurses are mentally and physically exhausted. We are overworked. We need management to acknowledge that we are at the bedside 24/7, 365 days a year and we know what is required to provide quality care. As nurses, we joined this profession to heal and provide compassion to those who are ill. Our working conditions do not allow us to fulfill our purpose (Brusie, 2019).

The New York State Nurses Association, which also serves as the union for New York nurses, says that registered nurses are sometimes being assigned to nine, ten, or more patients in an acute care setting (New York State Nurses Association, n.d.)

Two potential solutions to unsafe nurse staffing have been explored. The existing law in California, and the proposed laws in other states, set a mandatory minimum nurse to patient ratio. However, the research done by Lee, Cheung, Joynt, Leung, Wong, and Gomersall suggests that staffing levels may need to change within a shift to accommodate for changes in patient acuity (2017). These models do not have to be mutually exclusive; Current recommendations believe that the two systems must be combined to be effective.

The National Institute for Health and Care Excellence has created a guideline for nurse staffing on adult inpatient wards (2014). This guideline focuses on continual assessment of patient acuity through the use of a standardized tool that considers factors like ADLs, mobilization, types of medications and routes of administration, feeding, hygiene care, and the nursing time that must be devoted to activities like post-mortem care and teaching (National Institute for Health and Care Excellence, 2014).

The American Nurses Association has changed its tune since the Massachusetts Referendum of 2018. It now supports a legislative model that sets minimum nurse to patient ratios (American Nurses Association, n.d.). However, the ANA also recommends that within shift changes be made with respect to changing acuity (n.d.).

One healthcare system that has been lauded for exceptional patient outcomes is Kaiser Permanente in California; This has been attributed to investment in nursing staff (McHugh, Aiken, Eckenhoff, & Burns, 2016b, p. 178). A cross-sectional analysis comparing the Kaiser system to Magnet and non-Magnet status hospitals found that the Kaiser model produced better outcomes and had higher rates of nurse satisfaction (McHugh et al., 2016b, p. 185). What can be learned from this study is that manipulation of the following factors should be the focus of administrators that wish to improve patient outcomes and nurse retention: Appropriate nurse workloads; greater proportion of RNs among all nursing staff, with the largest group being BSN-prepared; empowered nurses in executive positions; support for professional nursing practice; and provision of sufficient resources and education (McHugh et al., 2016b, p. 185-186). These changes will require support from administration, national organizations, and legislation.

We should not expect a change to occur instantaneously; the entire history of nursing has been filled with struggles for recognition of our profession and improvement of the care that we provide to our patients. The proposed changes will be difficult and will need to come with education and patience. It is the duty of modern nurses to advocate for ourselves and for our patients, and to strive to constantly improve healthcare quality and decrease adverse events.

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