Chapter 10: Mandatory Minimum Staffing Ratios
Chapter 10: Mandatory Minimum Staffing Ratios
Case Study
A nurse manager is attending a national convention and is attending a concurrent session on staffing ratios. Minimum staffing ratios are being discussed in the nurse manager’s own state. The nurse manager has a number of questions about staffing ratios that the session is covering. The nurse manager knows that evidence exists that increasing the number of RNs in the staffing mix leads to safer workplaces for nurses and higher quality of care for patients.
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1. What are the three general approaches recommended by the American Nurses Association (2017) to maintain sufficient staffing?
2. Summarize the findings that are often cited as the seminal work in support of establishing minimum staffing ratio legislation at the federal or state level.
3. Analyze what proponents and critics say about whether mandatory minimum staffing ratios are needed.
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Chapter_10.pptx
Chapter 10 Mandatory Minimum Staffing Ratios
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RN Skill Mix
Economics as the driving concern for changes
Trend: reduction in RNs in staffing mix; replacement with less expensive personnel
Research: number of RNs in staffing mix directly affecting quality of care and patient outcomes
National movement to mandate minimum staffing ratios
As of 2017, 14 states addressed nurse staffing in hospitals in law/regulations
California is the only state that stipulates in law; regulations for required minimum nurse-to-patient ratios to be maintained at all times by unit
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Staffing Ratios and Patient Outcomes
Research findings (see Table 10.1)
Questions about cost-effectiveness of statewide mandatory nurse staffing ratios
Greater RN skill mix and fewer cases of sepsis and failure to rescue
Benchmark research
Needleman et al. (2002)
Aiken et al. (2002)
Direct link between nurse-to-patient ratios and mortality from preventable complications
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Mandatory Minimum Staffing Ratios: Needed? #1
ANA with concern related to effect of poor staffing on nurses’ health and safety and patient outcomes
Proponents
Absolutely essential for patient safety and outcomes
Use of standardized ratios for consistent approach
Critics
Exponentially increased cost with no guarantee of quality improvement or positive outcomes
AONE agrees and does not support mandated nurse staffing ratios
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Question #1
Is the following statement true or false?
Few states have enacted staffing laws.
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Answer to Question #1
False
As of 2017, 14 states addressed nurse staffing in hospitals in law/regulations.
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Mandatory Minimum Staffing Ratios: Needed? #2
Evidence of benefits mixed, contradictory
No accounting for education, experience, and skill level
Risk of actual decline in staffing—used as a ceiling or absolute criteria without accounting for patient acuity or RN skill level
Cost as the major deterrent—not financially attractive to hospitals
Mandate for specific staffing ratios and current shortage leading to reduction in hospital services, increased emergency room diversions, increased unit closures, increased expenses
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Mandatory Minimum Staffing Ratios: Needed? #3
Ohio Hospital Association: benefit of staffing ratios is mixed and sometimes contradictory
Corbridge (2017): argues that mandating inflexible nurse staffing ratios or stringent meal and rest break requirements do not improve patient care or outcomes
Silber et al (2016): better-staffed facilities had a formula for excellent value as well as better patient outcomes (see Box 10.2)
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California Prototype #1
First state to implement mandatory minimum staffing ratios
Maximum number of patients an RN could be assigned to care for under any circumstances (see Table 10.2)
Issues in determining appropriate ratios
Lack of data about nurse staffing distribution
Patient classification system (PCS) data problematic
Unknown cost
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California Prototype #2
Recommendation: 1 nurse to every 6 patients in med/surg units
Delays in implementation
Problems with interpreting the meaning and intent of language related to “licensed nurses”
Issues related to cutting nonlicensed staff
Questions if adequate number of RNs available to meet ratios
Emergency regulation in 2004; overturned in 2005
Hospitals and nursing unions’ responses
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California Prototype #3
Struggle to implement
Mandate effective 1/1/2004
Larger hospitals versus smaller hospitals to meet mandate
Need for legal clarification for “at all times” (i.e., breaks, lunches)
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Question #2
Is the following statement true or false?
California implemented mandatory minimum staffing ratios fairly quickly.
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Answer to Question #2
False
There were significant delays in implementing the California mandatory minimum staffing ratios.
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California Prototype #4
Improvement in RN staffing and patient outcomes?
Reduction in number of patients per licensed nurse
Increase in number of worked nursing hours per patient day in hospitals
No significant impact on measures of nursing quality and patient safety indicators
No increase in adverse outcomes despite increasing patient acuity
Lower risk-adjusted mortality (Aiken, 2010)
No improvement in quality of care (HC Pro, 2009)
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Similar Initiatives: Other States
Minimum standards for licensed nursing in certified nursing homes but not in acute care hospitals
Several attempts, but none enacted
Adequate numbers requirement for Medicare-certified hospitals
Many states actively pursuing minimum staffing ratio legislation
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Other Alternatives
Pursuit of alternatives to improve nurse staffing without legislated minimum staffing ratios
Lack of support for legislated minimum staffing ratios
The Joint Commission
ANA against fixed nurse–patient ratios; recommendation of three general approaches (see Box 10.3)
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Question #3
Is the following statement true or false?
The ANA supports legislation for fixed nurse–patient ratios.
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Answer to Question #3
False
The ANA does not support fixed nurse–patient ratios but advocates for a workload system that takes into account the many variables that exist to ensure safe staffing.
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End of Presentation
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