Issue link: https://nnumagazine.uberflip.com/i/117858
the assigned patients, regardless of how the LVN/LPN is used within the assignment. Direct-care RNs cannot assign nursing/patient care tasks to subordinates such as LVNs/LPNs, unlicensed assistive personnel/nurses aides, and medical assistants in the acute-care hospital setting when there is no statutory or legal authorization allowing them to do such tasks. The direct-care RN retains accountability for the competent provision of all nursing care provided to a patient. Safe Staffing Essentials only licensed nurses providing direct patient care are included in the ratios because the intent of the statute is to ensure that nurses are ���accessible and available to meet the needs of the patient.��� While nurse administrators, nurse managers, and nurse supervisors have vital supportive, supervisory, and oversight responsibilities, it is not their role to be readily accessible and available to directly meet the needs of the patients when they are functioning in their administrative or supervisory positions. The ratios are the same minimum standard for every shift. They represent the leanest staffing the California Department of Health Services (DHS) believes is compatible with safe, quality patient care in the acute-care setting. Because of the pressures of managed care and the increasing complexity of acute-care services, people who are hospitalized now tend to require more intense and sophisticated care for fewer days. When combined with the flexible shift scheduling in hospitals (i.e. eight-, 10-, and 12-hour shifts may be available on the same unit), it is no longer feasible to reduce nursing staff during evening, night, or weekend hours. The ratios represent the maximum number of patients assigned to any one nurse at any one time. It is DHS��� intent not to permit averaging the numbers of patients and nurses during a single shift, nor averaging over time. This prohibition of averaging is consistent with the way existing ICU and NICU nurse-to-patient ratios have been interpreted and enforced since they were put in place over 26 years ago. The 1:2 ratios in those units have historically been interpreted to mean that an individual nurse in an ICU may not have a patient assignment that exceeds two patients at any time. RNs have a duty to recognize circumstances that cause harm to their patients and activities and decisions that in their professional judgment are against the interest of their patients. RNs have the right to advocate in the exclusive interest of their patients and must be able to do so without fear of retaliation or reprisal. Direct-care RNs are inseparably linked to patient safety. Safe staffing standards based on the patient���s acuity allows the direct care RN to observe subtle changes in the patient condition, recognizing the early signs and symptoms of the beginning of a patient���s decline. These can only be detectible through the direct-care RN���s physical presence and her/his ability to directly observe the changes in the patient���s physical and cognitive status. Decisions about nurse staffing levels should be based on sound evidence and health policy science to reduce the risk of preventable complications and ensure optimum patient outcomes. The strength of the empirical, peer-reviewed research findings of Dr. Linda Aiken and her colleagues��� 2010 study supports the immediate implementation on a national scale of California���s landmark RN-to-patient ratio law as a benchmark in order to protect the public. The evidence is clear and convincing that minimum RN-to-patient ratios, with staffing-up based on the patient���s acuity and severity of illness, is the most important and cost-effective safety measure for ensuring therapeutic and effective patient outcomes. SEPTEMBER 2012 Selected Overview of the Scientific Evidence for Safe Staffing Ratios in 2002, dr. linda aiken and her associates published a study that proved the relationship between patient-to-nurse ratios, patient mortality, failure to rescue (deaths following complications) among surgical patients, and factors related to nurse retention and burnout. Dr. Aiken stated, ���Because of the importance of the nurse-patient relationship various entities have, over time, advanced proposals designed to ensure that there are sufficient numbers of nurses to meet patient needs. One such proposal has been and is minimum staffing ratios.��� The 2002 Aiken study was published in the Journal of the American Medical Association, a widely respected, peer-reviewed journal which contributed to its credibility and acceptance by medical and nursing professionals. The study estimated the probability of death and ���failure to rescue��� for each patient under various patient-tonurse ratios. The odds of patient mortality increased by 7 percent for every additional patient beyond four in the average nurse���s workload in the hospital; the difference from four to six patients per nurse and from four to eight patients per nurse would be accompanied by 14 percent and 31 percent increases in mortality respectively. Their findings at the time suggested that officials in California���s Department of Health Services were wise to reject ratios of 10 patients per one nurse in medical and surgical units proposed by the hospital industry stakeholder groups, including the California Healthcare Association, the American Nurses Association-California, and the California Association Nurse Leaders. The outlandish recommendation by hospital industry trade groups was surprising only in the fact that the Department of Health services had already determined that the appropriate ratio, based on Office of Statewide Health Planning and Development (OSHPD) data, showed that 75 percent of California���s hospitals were already staffed at a level of 1:5.6 or higher for medical/surgical units. That same study showed that approximately 50 percent of all hospitals were meeting the 1:5 ratios in their medical/surgical units. However, the fact that the administrative and executive nursing leaders aligned themselves with the bottom-line business interests of their institutional employers, thereby putting profits above patient needs, was shocking. Many of these administrators retain RN licensure, but they have no direct line of accountability for the provision of patient care or patient outcomes. Their intellectual dishonesty, coupled with a failure to advocate in the exclusive interests of patients, would appear to constitute unprofessional behavior by any reasonable standard. Dr. Linda Aiken and her colleagues have noted that RNs constitute an ���around-the-clock��� surveillance system in hospitals for early detection and prompt intervention when patients��� conditions deteriorate. ���The effectiveness of nurse surveillance is influenced by the numbers of RNs available to assess patients on an ongoing basis.��� ���The association of nurse staffing levels with the rescue of patients with life-threatening conditions suggests that nurses contribute importantly to surveillance, early detection, and timely interventions that save lives.��� According to the Institute of Medicine���s 2003 study, cutting RN-to-patient ratios to 1:4 nationally could save as many as 72,000 lives annually! Another plain way to illustrate the significance of that statistic is to consider that when a hospital imposes a workload of eight patients per RN, we know that by refusing to accept the scientifically recommended ratio of four patients per RN, then, despite the staff RN���s W W W. N A T I O N A L N U R S E S U N I T E D . O R G N AT I O N A L N U R S E 29