1. Nurse-to-Patient Ratio Alexis Udelhoven – Viterbo University

2. PICO P: Hospital Nurses I: Use of nurse to patient ratio tool or patient acuity tool C: Standard practice O: Increased job satisfaction and less nurse “burnout”

3. Questions What is the best determinant for identifying appropriate nurse-to-patient ratio? How effective do you feel the use of a nurse-to-patient ratio tool or a patient acuity tool (such as MESH) is? Explain. California is the only state to have a law regarding nurse- to-patient ratio. Do you feel that all states should have this law? What might be the pros and cons?

4. Questions According to research, each additional patient per nurse is associated with a 23% increase in burnout, and a 15% increase in job dissatisfaction. Do you feel this way? And if so how do we address this? Are the nurse to patient ratios adequate in your practice? If not, what would be more appropriate ratios, and what type of skill mix?

5. Basic Education – RN’s Interviewed 3 year diploma: 1 Associate’s degree: 3 Bachelor’s degree: 3 Master’s degree: 2

6. Areas of Practice – RN’s Interviewed Medical/Surgical: 3 Obstetrics: 2 Emergency room: 1 Intensive Care: 2 Director/Charge nurse: 1

7. Years of Practice – RN’s Interviewed 0-5 years: 3 5-10 years: 4 10+ years: 2

8. What is the Best Determinant for Nurse-to Patient Ratio? Patient acuity/classification system “If filled out correctly” “Competency checks” Should consider other factors (family dynamics, psychosocial, etc.) “Some hospitals or nursing units use an established acuity tool. Others rely on charge nurses’ judgments of patient acuity” (Kidd et al., 2014, p. 1) Quality acuity tool Involves the nursing process, proves adaptable and flexible, and has credibility (Harper & McCully, 2007).

9. How Effective is a Nurse-to-Patient Ratio or Patient Acuity Tool? Nurse-to-patient ratio tool Not effective Patient acuity tool (MESH) “Most effective in a medical/surgical setting” Some felt this tool was not effective or minimally effective “Should be designed for each hospital/unit” Minimal research regarding acuity tools Safer Nursing Care Toolkit National Institute for Health and Care Excellence (Fenton & Ann, 2015)

10. Should All States Have Laws Regarding Nurse- to-Patient Ratios? Yes “Happier nurses with more job satisfaction which ultimately leads to quality patient care.” May be difficult to implement and inforce No “Too restrictive” Guidelines or Standards California’s law Effective January 1, 2004 Ratios specific to setting Ratios to be maintained at all times Must use patient classification system (Kasprak, 2004) Increased RN staffing in hospitals (McHugh et al., 2011)

11. Do you Feel “Burned Out” or Dissatisfied? How do we Address This? All 9 RN’s interviewed have felt “burned out” “It’s inevitable, but when it is consistent then something needs to be done.” “I do not feel burned out by nursing itself, sometimes hospital politics and issues have been more discouraging than patient care.” Addressing the issue Hire more staff, to decrease the workload of each nurse Use the patient acuity tool more accurately “Each additional patient per nurse is associated with a 23 percent increase in burnout and 15 percent increase in job dissatisfaction” (Knudson, 2013, p. C1)

12. Are the Nurse-to-Patient Ratios Accurate in your Practice? Appropriate Skill Mix? Dependent on the shift (Med/Surg, ER, ICU) Accurate most of the time (OB) Support staff are important LPNs can do more than CNAs

13. Question for You Do you feel that decreased job satisfaction and increased nurse “burnout” is directly related to high nurse to patient ratios? Yes, how do you think this should be addressed? No, what do you feel decreased job satisfaction and increased nurse “burnout” is related to and why?

14. References Fenton, K., & Ann, C. (2015). A tool to calculate safe nursingstaffing levels. Nursing Times, 111(3), 12-14. Harper, K., & McCully, C. (2007). Acuity systems dialogue andpatient classification system essentials. Nursing Administration Quarterly, 31(4), 284-299. Kasprak, J. (2004). California RN staffing ratio law. Retrieved from https://www.cga.ct.gov/2004/rpt/2004-R-0212.htm Kidd, M., Grove, K., Kaiser, M., Swoboda, B., & Taylor, A. (2014). A new patient acuity tool promotes equitable nurse-patientassignments. American Nurse Today, 9(3), 1-4. Knudson, L. (2013). Nurse staffing levels linked to patient outcomes, nurse retention. AORN Journal, 97(1), C1-C9. McHugh, M., Kelly, L., Sloane, D., & Aiken, L. (2011). Contradictingfears, California’s nurse-to-patient mandate did not reduce the skill level of the nursing workforce in hospitals. Health Affairs, 30(7), 1299-1306.