1. Nurse Staffing: National Policy Perspective
Pamela F. Cipriano, PhD, RN, FAAN, NEA-BC
Chief Clinical Officer and Chief Nursing Officer

2. The Impacts of Nurse Staffing
Patient Safety
Patient Satisfaction
Nurse Satisfaction and Retention
Financial Outcomes

3. Patient Safety
Research shows an association between higher levels of RN staffing and fewer adverse events, such as:
Increased complications
Shock
Urinary tract infections
Increased LOS
Failure to rescue
Pressure ulcers
Mortality
Every additional patient assigned to an RN is associated with a:
53% increase in respiratory failure
17% increase in medical complications
7% increase in the likelihood of failure to rescue
7% increase in the risk of hospital-acquired pneumonia
Hospital-acquired infections
Pneumonia
Cardiac arrest
Upper GI bleeds
Medication error rates
Falls
Central line infections

4. Patient Safety Results from Alberta, Canada Education Correlation
Nearly 1/3 of the variation in hospital death rates in Alberta were associated with hospital nursing characteristics
Four hospital nursing characteristics significantly associated with lower mortality rates:
Employment status
Education
Skill mix
Nurse/physician relationships
Education Correlation
A 10% increase in the proportion of nurses holding a BSN was associated with a 5% decrease in both likelihood of patients dying within 30 days of admission and the odds of failure to rescue.
With higher proportions of nurses educated at the
baccalaureate level or higher, surgical patients
experienced lower mortality and failure-to-rescue
rates.

5. Patient Safety
If a nurse has 8 patients instead of 4, the risk of death for all those patients increases by 31%
Adding one full-time RN per patient day eliminated 16% of hospital-related deaths
There is a 3% to 6% shorter length of stay for patients in hospitals with a high percentage of RNs
Caring for >2 ICU patients led to 49% increase in LOS and increased risk of medical complications
Excessive nurse workload is a key factor in safety in ICUs
There are 17 errors per patient day in ICUs
For every patient >4 assigned in acute care
areas, risk of mortality could rise 7%

6. Patient Safety Heavy workload leads to: Decreased patient supervision
Incorrect ventilator/equipment set-up
Drug administration problems
Insufficient time for clinical procedures to be done properly
Inadequate training or supervision
Errors

7. All options reduce hospital days and patient mortality
Patient Safety
Option
Outcome
Raise the proportion of hours provided by RNs to 75% of total nursing care hours
Reduce LOS by 1.5 million days
Increase the number of licensed (RN & LPN) hours per day to 75% percent (without changing the proportion)
Reduce LOS by 2.6 million days
Raise both staffing hours and percentage of nursing care provided by RNs to 75% nationwide
Reduce LOS by 4.1 Million days
Reduce adverse outcomes by 70,000
All options reduce hospital days and patient mortality

8. Patient Satisfaction
“Nursing care should receive universal recognition as the principal factor in determining the inpatient acute care experience” (Clark, Leddy, Drain, & Kaldenberg, 2007, p. 124).
Greater patient satisfaction is associated with more total nurse hours of care per patient day and with more RNs in the staffing mix
Patients’ perception of nurse staffing influences patients’ perception of nursing care, which influences their overall satisfaction with the entire hospital experience

9. Patient Satisfaction
When the ratio of working RNs to state population increases, perceived nursing care quality increases, and vice versa. (e.g. California and Texas report lower than average patient satisfaction while also having the lowest RN supply per patient.)
Improved Nurse Staffing
Greater Nurse Satisfaction
Improved Quality of Care
Higher Patient Satisfaction

10. Nurse Satisfaction and Retention
Inadequate nurse staffing leads to job dissatisfaction, burnout, injury and illness, as well as high job turnover
Results of an ongoing ANA survey:
40% report job dissatisfaction, and more than 43% demonstrated high levels of burnout
23% plan to quit their current jobs within the next year; for nurses under 30 years of age, that figure rose to 33%
60% said they knew of someone who left direct care nursing due to concerns about safe staffing
73% don’t believe the staffing on their unit of shift is sufficient
52% said they thought the quality of nursing on their unit has declined in the past year

11. Nurse Satisfaction and Retention
“If you overburden nurses with too many patients who are as sick as they are in hospitals today, patients will become a problem, an undesirable, and not a challenge to them…and challenge is the reason why they became nurses in the first place. Nurses will want to flee their patients and their workplaces, not embrace patient care and their work” (Suzanne Gordon, quoted in Massachusetts Nurse, 2008).

12. Nurse Satisfaction and Retention
The average age of an RN is increasing more than twice as fast as all other occupations in the workforce (average age of a clinical nurse is 46.8)
By 2020, 44 states are expected to have RN shortages
50% of the workforce will reach retirement age by 2015
National Projections
Virginia Projections
Year
Demand
Shortage %
2005
52,777
-7,698
15%
2010
57,643
-11,927
21%
2015
63,157
-18,446
29%
2020
68,945
-25,111
36%

13. Financial Outcomes
Cost-effectiveness: Based on value patients and payers assign to avoided death and complications
Does improving quality increase or decrease the cost to patients, hospitals and payers?

14. Financial Outcomes
Hospitals with better staffing are more profitable and have a lower cost-per-patient discharge than understaffed hospitals.
Reports show that minimum RN staffing levels are more cost-effective than common lifesaving practices such as clot-busting medications for heart attack and stroke, and cancer screenings.
Nurses prevent adverse events
Increased nurse hours = decreased complications
Pneumonia adds days and $23,000-28,000
Adverse drug reaction adds days and $2,000-3,500

15. Financial Outcomes
Complications connected to higher nurse-to-patient ratios increase the unreimbursed hospital costs by an average of $1,248 per patient.
The cost for advertising, training and loss in productivity associated with recruiting new nurses to a facility is a minimum of $37,000 per nurse.

16. Financial Outcomes
Mortality is most affected (72,000 lives can be saved per year with 1:4 ratio)
Moving from 1:7 to 1:6 staffing saves 1.4 additional lives at $64,000 per life
Moving from 1:5 to 1:4 saves additional lives at $136,000 per life saved

17. What’s going on around the country?
Legislation
What’s going on around the country?

18. Federal Legislation - Pending
The Registered Nurse Safe Staffing Act (S. 73/H.R. 4138)
Sponsored by:
Sen. Daniel Inouye (D-HI)
Rep. Ginny Brown-Waite (R-FL)
Rep. Lois Capps (D-CA)
Proposes:
Hospital staffing plans, developed in coordination with direct care registered nurses
Public reporting of staffing information
No specified staffing ratios

19. State Legislation OverviewSC VA NM CO TX OK WA OR CA ID NV UT MT WY ND MN KS NE MO IA AR MS IL IN OH KY TN wv WI MI PA NJ NY AK HI MD DE MA CT NH VT RI NC GA AL FL LA ME SD AZ DC
Enacted legislation to date: CT, IL, OH, OR, WA, TX, RI, CA, FL, NJ, VT, NV, NY, PA
Defeated/reversed legislation to date: AK, CO, FL, MA, NM, ME, DC
As of October 21, 2008
Pending legislation: AZ, HI, IL, IA, MI, MN, NY, OR, WV

20. State Legislation - Adopted
Staffing Plans - Every hospital must have a committee who will develop, oversee and evaluate a nurse staffing plan
Hospital staffing committee must include direct care staff nurses
Connecticut (50%)
Illinois (50%)
Ohio (50%)
Oregon (50%)
Washington (50%)
Texas (% not specified)
Involvement of direct care nurses not specified
Rhode Island – Hospitals must annually submit a core-staffing plan to the Department of Health

21. State Legislation – Adopted
Staffing Ratios – State-mandated unit-specific nurse-to-patient ratios
California - Defines the same minimum unit-specific nurse-to-patient ratios to be utilized in all nursing units in all hospitals. The nurse-to-patient ratio may be adjusted based upon patient acuity and is enhanced by the continuation of the mandated use of a patient classification system.
Florida - Minimum staffing requirements for nursing homes.

22. State Legislation – Adopted
Public Reporting of Nurse Staffing
Illinois - Instituted a Hospital Report Card, which in addition to reporting patient outcomes reports on nurse staffing plans, orientation & training.
New Jersey - Hospital must complete and post daily staffing information for each unit and each shift. Made available to the public on a quarterly basis.
Vermont - Requires public access to information related to nurse staffing ratios.

23. Other Actions Taken
Nevada – In 2003, required the Legislative Committee on Health to appoint a subcommittee to conduct an interim study on nurse staffing
New York – Ban on mandatory overtime
Pennsylvania – Ban on mandatory overtime

24. State Legislation/Regulations - Defeated or Reversed
REJECT
Defeated
Alaska – Limits on mandatory overtime
Colorado – Staffing plan legislation
Florida – Public reporting and staffing ratio legislation
Massachusetts – Staffing ratio legislation
New Mexico – Public reporting legislation
Reversed
Maine - Removed established staffing systems consisting of required minimum nurse-to-patient staffing ratios. Maine Quality Forum Advisory Council recommended standardization of staffing plans and acuity tools instead of mandated ratios.
Washington DC - Waived enactment of staffing ratios previously legislated in 2002

25. State Legislation - Pending
Arizona – Staffing ratios
Hawaii – Staffing ratios
Illinois – Staffing ratios
Iowa – Hospital staffing committee (50% direct care RNs)
Michigan – Hospital staffing committee (50% direct care RNs), staffing ratios
Minnesota – Hospital staffing committee and staffing ratios
Missouri – Public reporting
New York – Staffing ratios
Oregon – Staffing ratios
Pennsylvania – Limits on mandatory overtime
West Virginia – Staffing ratios