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Researchers examine nurse staffing and shortages

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.

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