If you’ve been watching the news lately, you’ll notice that individual states are considering patient safety by proposing minimum patient/nurse ratios for healthcare systems. The research has been clear; the more patients a nurse has to care for, the worse the patient outcomes and the increased risk of mortality (Levins, 2023). This is not new. Healthcare systems have been wrestling with the patient/nurse ratio question for years. Nurses – especially since the pandemic – have been vocal about the need to address staffing so they are better equipped to provide safe patient care.
Should the state governments regulate safe staffing ratios? Let’s look at the issues.
The nursing workforce has an experience gap.
Today less experienced nurses outnumber nurses with greater experience at the bedside. We knew we would be facing a nursing shortage prior to the COVID pandemic simply because of the aging of the nursing workforce. Older nurses would be leaving the bedside and retiring due to age and the physical challenges of taking care of people. What was not anticipated was that nurses, especially younger nurses between the ages of 25 to 35 years of age, would also be leaving the bedside. Based on the latest data, 100,000 nurses have left the profession due to burnout and stress associated with the pandemic; however, even many more have moved from the bedside to other roles that do not deliver direct patient care (Martin et al., 2023). We’ve also seen nurses move to specialty areas where the patient/nurse ratio is more stable.
We need to address nursing education issues so we can fill the nursing pipeline.
Faculty are aging just as the those in active practice are aging. Nursing schools lack enough full-time and part-time faculty to address the over 78,000 of qualified applicants to undergraduate and graduate nursing programs that are turned away (AACN, 2023). There is a need to hire more adjunct faculty and teach them how to facilitate learning. The way we teach is evolving because our students and healthcare are evolving. There will be more emphasis on simulation to help solve the inadequate numbers of clinical sites. Equally important, simulation will help us facilitate learning and assessment of clinical judgement. Resources in nursing education must improve and that means we need to start paying faculty what they are worth. The last year has shown a decline in the enrollment in nursing programs AACN, 2023). There needs to be a culture change at the bedside so nurses and others will recommend the nursing profession to potential candidates.
New nurse graduates are not practice ready; so let’s stop treating them like they are.
The most recent research into the nursing workforce reveals new nurse graduates are not practice ready and they are not sufficiently supported by healthcare institutions when they graduate and start working. The NCLEX-RN pass rate has declined 10% over the past 3 years, and research involving educators and those in practice reveal that passing the NCLEX-RN exam doesn’t mean they are able to assume the role of a practice ready nurse upon graduation (NCSBN, 2023). According to Benner’s Model, From Novice to Expert, it takes 2 to 3 years for a nurse to be truly competent (Benner, 1982). That means we need to change our expectations of a graduate nurse and support them with training, mentoring, and precepting so they can become competent.
Health systems need to establish a safety net for new nurses by investing in in nurse residency programs and preceptor programs.
The experience gap impacts the number of quality preceptors and resource personnel who are available to support new nurse graduates. The movement of experienced nurses to other roles away from the bedside leaves new graduate nurses without a sufficient safety net, which includes experienced preceptors. The turnover rate for nurses with one year or less of tenure is 32.8% (NSI, 2023). Those institutions who have nurse residency programs tend to have lower turnover rates and improved return on investment because they have a better support system in place for new graduate nurses (Knighten, 2022).
Nurse retention should be a higher priority than nurse recruitment.
So often healthcare systems entice nurses to come work for them with bonuses and other perks. What they don’t realize is that bringing that talent in the door is not enough; they need to prioritize retaining that talent. There are many stories where nurses come to healthcare organizations following large sign-on bonuses just to find out what lies beyond the curtain is not at all what was promised. After a short time, the nurse wants to leave because the promise of being able to practice with adequate staffing, flexible scheduling, and the feeling of being valued just doesn’t exist. Many times, these nurses face paying back large amounts of money to leave their contracts. Investing in retention by providing adequate safe staffing with competent nurses and having flexible scheduling and benefits that people really need, can make all the difference. That means management needs to be up on the units to see what really is happening in patient care today. They need to ask the questions, “What do you need to practice safely? Why do you stay? What can the organization do so you feel valued?”
Nurses want to care for patients, and they want to do it safely.
So often we hear people say, “Nurses must not care about their patients if they go out on strike.” This is far from the truth. Nurses want to care for people; that’s who we are and what we do. However, we need to do it in an environment where we can provide the highest quality care. To provide quality care, we need a sufficient number of nurses who are competent. Strikes in healthcare are seldom about money alone; they are about the need to have sufficient numbers of nurses and resources to provide safe, quality care.
Staffing matters!
The research is clear; having the right number of competent nurses is necessary to deliver safe, quality care and improve patient outcomes. Staffing can no longer be about numbers because the numbers are not equitable. Healthcare institutions need to realize a nurse is not a nurse is not a nurse. Specialty knowledge, training, skills, and competency are different for each specialty unit. Patients are sicker and more complex than ever before. Therefore, while staffing ratios may be a first step, they are not the only step. Staffing needs to be determined by evaluating the number of patients, patient severity of illness, and competency of the nurse.
Quality healthcare costs money; providing unsafe care costs more.
Without a doubt, all the things listed above cost money. However, having insufficient, unsafe staffing levels or staffing with nurses who are not competent and experienced in the specialty area leads to more medical errors, increased patient dissatisfaction and increased staff dissatisfaction. Just look at quality measure scores, Leapfrog scores, and star ratings. Quality care suffers when there is an insufficient number of competent nurses caring for patients. Lower quality care leads to more lawsuits, increased patient bounce-backs, higher complication rates, and lower reimbursement. To be a successful healthcare organization today, one needs to invest in its workforce. The workforce is 50% of a healthcare organization cost and therefore can have the highest impact on whether the organization will be successful or not (Kaufman Hall, 2023). Investing in the workforce leads to a higher return on investment.
Back to the original question…Should the state governments regulate safe nurse staffing ratios?
If healthcare organizations won’t regulate themselves, someone needs to step in to protect the patients. Healthcare is about providing quality care to those in need in a safe manner. Staffing ratios are a first step in restoring quality patient care but it’s not the only step. In a better world, healthcare organizations would invest in their workforce, regulate themselves, and see the benefits to the patients and the community in which they serve. Isn’t it time for a better world?
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