May 22, 2018
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Keeping patient-to-nurse ratios low

By Judith E. Brown, Special to the BDN

Over the last several weeks, nurses at Eastern Maine Medical Center in Bangor have been negotiating for a new contract. We are now working without a contract while talks continue. Since the success of our negotiations not only affects the nurses but the patients and the community, we feel the public should now be part of the dialogue.

Nurse staffing is one of the major sticking points in these talks. We are always concerned about staffing and patient safety. In 2002, The New England Journal of Medicine published a study of 799 hospitals that said more hours of care by registered nurses per day are associated with better care for hospitalized patients. According to research funded by the Agency for Healthcare Research and Quality, AHRQ, hospitals with low nurse staffing levels tend to have higher rates of poor patient outcomes such as pneumonia, shock, cardiac arrest and urinary tract infections.

In 2003, Linda Aiken published a study that found that for each additional patient over four in a nurse’s workload, the risk of death increases by 7 percent for surgical patients. Patients in hospitals with the highest patient-to-nurse ratio (eight patients per nurse) have a 31 percent greater risk of dying than those in hospitals with four patients per nurse.

Earlier this year, Aiken updated this study. She concluded that the hospital nurse staffing ratios mandated in California are associated with lower mortality. When nurses’ workloads were in line with California-mandated ratios, nurses’ burnout and job dissatisfaction were lower, and nurses reported consistently better quality of care for their patients.

The Maine State Nurses’ Association is attempting to bargain for similar ratios at EMMC. While EMMC staffing plans seem to be in line with many of the ratios of the Aiken study, the reality is that unless the ratios are explicitly stated in a format such as a contract, the plans are easily ignored.

A staffing plan may state that the typical staffing is 1-4 or 1-5, however, that ratio may not be the staffing on any given shift. Nurses who cannot come in because of illness are not replaced, new patient admissions occur and suddenly you have an assignment of six patients (or more) to one nurse. Recently, a charge nurse on one of the night shifts had an assignment of seven patients plus the responsibility of running the floor and being the resource for other nurses. This is just too much.

It is important to point out that the ratios we are proposing are intended to be flexible according to patient needs and acuity. Nurses should be assigned fewer patients if the overall condition of their patients requires more care. However, as Aiken and others have pointed out, an assignment of more than four patients per nurse on a medical-surgical floor carries great risks.

There is a direct relationship between nurse staffing and patient well-being. Nurses serve as an around-the-clock surveillance system in hospitals for early detection and prompt intervention when patients’ conditions deteriorate.

According to Aiken, registered nurses with the highest patient-to-nurse ratio are twice as likely to be dissatisfied with their position and experience job-related injuries and burnout. Estimates indicate that the cost of replacing a hospital medical and surgical nurse is $42,000. By increasing RN staffing levels and lowering the patient-to-nurse ratio, hospitals can save money as well as saving lives and decreasing RN turnover.

So many things are now part of the daily job of a nurse. Electronic charting alone takes up much of a nurse’s day. The Professional Practice Committee at EMMC did time studies and found that eight hours out of 12 were consumed with electronic charting in the ICU. Earlier this year, additional patient teaching responsibilities were added to the telemetry nurses’ already full plate. On-call hours have increased for many nurses at the medical center. All of this adds up to an increasingly overworked staff.

Nurses want to go home each day knowing they have made a difference. Instead, many are going home in tears wondering if they made a mistake and inadvertently harmed the very people they were trying to help most.

Judith E. Brown of Bangor is a registered nurse and president of Unit 1 of the Maine State Nurses’ Association.

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