National Nurses United

best effort, one out of every four patient deaths happens unnecessarily. Just like the family of that fourth patient, we think it���s wrong to double the workload of RNs when you know that���s going to happen. Replications of Dr. Aiken���s initial study in Canada, England, and Belgium have produced similar findings. Other studies by the nation���s most respected scientific and medical researchers affirm the significance of California���s RN-to-patient ratios for patient safety. A meta-analysis of 90 studies commissioned by the Agency for Healthcare Research and Quality (AHRQ) in 2007 has subsequently concluded ���there is an evident association between nurse staffing and patient outcomes.��� As the Institute of Medicine���s 2003 study put it, ���research now documents what physicians, patients, other healthcare providers and nurses themselves have long known: How well we are cared for by nurses affects our health and sometimes can be a matter of life and death.��� In 2010, researchers Aiken, Sloan, Cimiotti, Clarke, Flynn, Seago, Spetz, and Smith released the results of their much-anticipated study on the ���Implications of the California Nurse Staffing Mandate for other States.��� Their findings show that hospital nurse staffing ratios are associated with lower mortality and nurse outcomes predictive of better nurse retention in California. Dr. Aiken is the director of the Center for Health Outcomes and Policy Research at the University Of Pennsylvania School Of Nursing. Dr. Aiken���s research studies have focused on the impact of modifiable organizational attributes on patient outcomes and workplace stability in hospitals. The researchers in this study surveyed more than 22,000 RNs in California, Pennsylvania, and New Jersey. Had New Jersey hospitals and Pennsylvania hospitals matched California���s 1:5 ratios in surgical units, they would have had 14 percent and 11 percent fewer patient deaths respectively. Far fewer California RNs miss changes in their patients��� conditions because of their workload than New Jersey or Pennsylvania RNs. California RNs are more likely to stay at the bedside and less likely to report burnout or intent to leave the profession than nurses in Pennsylvania or New Jersey. Their findings appear to justify the trust the public invests in RNs. The researchers stated RNs��� reports of workloads and staffing have shown them to have considerable reliability and have better predictive validity than the American Hospital Association measures of nurse staffing. According to Aiken, et al., the California mandates can be viewed as a benchmark against which to compare hospitals within California and between California and other states: ���From a policy perspective, our findings are revealing. The California experience may inform other states that are currently debating nurse ratio legislation including Massachusetts (Coalition to Protect Massachusetts Patients 2008) and Minnesota (Ostberg 2008), or other strategies for improving nurse staffing, such as mandatory reporting of nurse staffing, as enacted in New Jersey (New Jersey Revision of Statutes 2005; Rainer 2005) and Illinois (Kevin and Stickler 2007), and mandating the process by which hospitals determine staffing as in Oregon (Oregon Revision of Statutes 2005).��� She further asserts, ���Our results suggest that the California hospital nurse staffing legislation represents a credible approach to reducing mortality and increasing nurse retention in hospital practice.��� Social, Economic, and Political Patient Advocacy research has demonstrated that legislated, transparent, numeric, minimum RN-to-patient staffing ratios, with staffing up based on the acuity and severity of illness of the patient, is a credible, evidence-based approach to improving nurse and patient outcomes. 30 N AT I O N A L N U R S E Rather than decreasing the number of RNs, hospitals should increase the ratios of RNs to patients, because RNs��� higher level of knowledge and experience has been shown to reduce patient mortality and reduce the overall costs of care. From a hospital and business perspective, improved RN-topatient ratios have a synergistic and demonstrated economic value for hospitals in terms of lower liability and improved reputation by reducing adverse outcomes such as decreased blood-borne infection rates, patient falls, decubitus ulcers, ventilator-acquired pneumonia, and medication errors. In instances where there is not a clear business case for increased nurse-to-patient ratios, there is a compelling social case that can be made due to the reduced adverse outcomes and avoided additional hospital days. From a patient and social advocacy perspective, improved RNto-patient ratios have economic and non-economic benefits for patients and their families in terms of decreased pain and suffering from preventable complications, decreased lengths of stay, lost days from work, and increased patient satisfaction. Increasing nurse staffing is associated with fewer in-hospital deaths under all options. Needleman (2006) and his colleagues concluded that 70,000 deaths could be avoided by raising the hospital nurse staffing threshold to the 75th percentile overall. Rather than weakening or lowering safe staffing standards, a more appropriate strategy would be for government, i.e., Centers for Medicare and Medicaid Services (CMS), and other payers to increase reimbursement rates to hospitals that comply with the safe staffing standards, instead of tying reimbursement to unproven customer satisfaction surveys. Under current reimbursement systems, the incentive and financial reality for hospitals is for them to staff at levels below where the benefit to society equals the cost to employ the additional nurses. A strong reason for employers to oppose an RN-led comprehensive healthcare delivery models and safe staffing ratios is to retain unfettered control of the practice environment for their own benefit. Such employers exercise coercive and punitive power to influence the development of behaviors and skills that reflect business strategy and organizational design. Salary and pay-for-performance schemes are designed to communicate these messages of strategy and control to generate compliance with organizational policies. Scripting, rounding, shared governance, pursuit of ���magnet��� status, and patient satisfaction schemes are methods by which healthcare organizations can push industry-aligned, performance-based competencies as a substitute for professional clinical nurses��� skills, expertise, and practice-based competencies. End of Part I. References AB 394, Chapter 945, Statutes of 1999. California, (1999). Aiken, L. H., Clarke, S. P. & Sloane, D. M. (2002). Hospital Staffing, Organizational Support and Quality of Care: Cross-National Findings. International Journal of Quality in Health Care 14 (1): 5���13. Aiken, L. H., Clarke, S. P., Sloane, D. M. , Lake, E. T. & Cheney, T. (2008). Effects of Hospital Care Environments on Patient Mortality and Nurse Outcomes. Journal of Nursing Administration. 38 (5): 220���6. Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J. , Busse, R., Clarke, H. , Giovannetti, P., Hunt, J. , Rafferty, A. M., & Shamian, J. (2001). Nurses��� reports of hospital quality of care and working conditions in five countries. Health Affairs. 20 (3): 43���53. Aiken, L.H., Clarke, S.P., Sloan, D.M., Sochalski, J. , Silber, J.H. (2002) Hospital nursing staffing and patient mortality. Nurse burnout, and job dissatisfaction. 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 SEPTEMBER 2012

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