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Does Florida Need Staffing Ratios?

Monday April 21, 2003
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With studies documenting that more RNs mean improved patient outcomes, it might seem that mandatory nurse-patient ratios ensure better working conditions, greater job satisfaction, and fewer medical missteps. But legislating a minimum number of nurses per unit may not be everyone's Rx for relief.
"Ideally, there would be lower staffing ratios to assure the highest-quality care and to make certain the nurse has time to understand what matters most to those we're privileged to serve," says Anne Boykin, RN, PhD, dean of the Christine E. Lynn College of Nursing at Florida Atlantic University, Boca Raton. "I support lower ratios as appropriate. This should not be prescribed, but rather based on an understanding of the complexity of nursing situations."
Last year, Florida lawmakers looked at the Safe Staffing for Quality Care Act, which died in committee. If it had passed, the bill would have barred hospitals from mandating overtime and excessive work hours. It also would have required that facilities provide one nurse for every two patients in critical care areas and one nurse for every four patients in med/surg units. Similar legislation was reintroduced this session, however, by State Sen. Mandy Dawson (D-Fort Lauderdale), and lawmakers in 28 other states are considering nurse-staffing measures this year, as well. In 1999, California passed a mandatory staffing ratio law, but it has yet to take effect.
The Florida Nurses Association reported in late 2002 that 97% of RNs responding to a survey indicated they were dissatisfied with the time they had available for direct patient care.1 Lower staffing ratios, the argument goes, are likely to give nurses more opportunity for bedside teaching and comforting. Supporters focus on quality of care and patient safety aspects, likening ratios to minimum safe-staffing standards set for airlines and day care centers. Also, they say, several studies show a link between better outcomes and the amount of care provided by RNs.2, 3, 4, 5, 6 There are, however, no research studies to date that link mandatory staffing levels with better patient outcomes.
Making Ends Meet
Most hospitals already meet proposed critical care ratios, says Joan Clark, RN, MSN, CNAA, vice president for patient care and chief nursing executive at Baptist Hospital of Miami. Clark, who is also president of the Orlando-based Florida Organization of Nurse Executives, cites "areas like critical care, [where there's] a 1:2 ratio - a standard pretty much across the nation." She also notes that ratios are in place in the OR (1:1 during surgical procedures) and in labor and delivery units (1:2). "I think where [the problem] comes into play is with the ratios in med/surg areas."
In California, proponents of mandated ratios say that maintaining good nurse-to-patient ratios could result in cost savings by relying less on temporary and travel nurses, reducing overtime, improving outcomes, and limiting nurse turnover. Ratio supporters also believe better staffing may lure back some nurses who've left the acute care fold.
But Barbara Lumpkin, RN, associate executive director of the Florida Nurses Association in Orlando, doubts that that will occur. "According to the data we have," she says, "80% of the nurses are already working."
Mary Lou Brunell, RN, MSN, executive director of the Florida Center for Nursing, says that historically, refresher courses and reentry initiatives have not been successful because nursing has changed so much in the past decade. Moreover, some former nurses who've become established in other careers may not want to return to the hospital setting, she says, adding that some RNs have reached a point financially where they don't have to work. The center, based on the campus of the University of Central Florida in Orlando, hasn't taken an official position on mandatory staffing ratios.
Opponents of ratios also worry that hospitals may cut the number of ancillary staff to free up funds to pay for more nurses. They fear this could backfire, ending up forcing RNs to perform unskilled tasks like delivering trays. Should Lawmakers Stir the Pot?
Florida's 2002 ratio legislation ranked RNs and LPNs equally. It also failed to differentiate by shift, location of facility, or type of facilty - which raises questions about the wisdom of lawmakers' dictating numbers to the healthcare industry. Facilities caring for more acutely ill patients, for example, may require higher staffing levels than, say, community or rural hospitals that transfer their more complicated cases to other institutions.
Here's another pitfall with staffing ratios: If a hospital doesn't have enough nurses to satisfy the newly legislated requirement, it may have to close units, decreasing access to care.
"All of us in the state have experienced a dramatic increase in ER volume," says Clark. "If we can't move patients that need to be admitted into beds because of a mandated ratio, that could further compound the emergency department crowding problem." Many nurse leaders, including Lumpkin and Brunell, fear minimum staffing ratios could become maximum levels. When patient acuity indicates the need for more RNs, nurse executives may experience difficulty securing the additional staff.
"We're against ratios that have numbers in them because that's too prescriptive and takes away the right of professional nurses to make professional judgments," says Lumpkin.
She believes hospitals should be required to have a staffing plan based on acuity and nurse skill mix and that staff nurses should monitor the plan. The Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations has identified such plans as a way to transform the hos-pital workplace.6
Direct-care providers and nurse executives recognize the dangers of understaffing. As patients become more astute consumers, they may learn to ask about staffing ratios and choose facilities accordingly. On the other hand, that presumes a market-driven economy; in Florida, most hospitals stay busy, so choosy healthcare consumers are unlikely to cause facilities to bring more nurses to the bedside.
"There are difficulties and challenges with trying to put in this kind of a mandate," says Brunell. "We need to spend more time looking at bringing people together to discuss issues and options. That's part of the role of the center - being a collaborator and looking for alternatives as to how we can improve things."