Nursing Ratios – Is There a Better Way? - Institute of … · environment in California to push for job security. ... assignment will overlook certain aspects of care. ... Nursing

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Nursing Ratios Nursing Ratios ––Is There a Better Way?Is There a Better Way?

Nursing Ratios Nursing Ratios ––Is There a Better Way?Is There a Better Way?

A PANEL PRESENTATION ON THE A PANEL PRESENTATION ON THE PROS AND CONS OF USING PROS AND CONS OF USING NURSENURSE--TOTO--PATIENT RATIOS PATIENT RATIOS TO STAFF NURSING UNITSTO STAFF NURSING UNITS

February, 2004February, 2004


➊➊ Introduction of PanelIntroduction of Panel

➊➊ Patti Rogers, MBA, BSN, RNPatti Rogers, MBA, BSN, RN

➊➊ Frank Overfelt, MBA, FHIMSS, CHEFrank Overfelt, MBA, FHIMSS, CHE

➊➊ Cheryl McNally, LPNCheryl McNally, LPN

Nursing Ratios Nursing Ratios –– Is There a Better Way?Is There a Better Way?

Presentation FormatPresentation Format


Nursing Ratios Nursing Ratios –– Is There a Better Way?Is There a Better Way?Presentation Format, cont.Presentation Format, cont.

❂❂ PresentationPresentation FormatFormat

Background & History of Workload Background & History of Workload Measurement Systems for Nursing Measurement Systems for Nursing ––Frank OverfeltFrank Overfelt

Background and History of Nursing Background and History of Nursing Ratios Ratios –– Frank OverfeltFrank Overfelt


Nursing Ratios Nursing Ratios –– Is There a Better Way?Is There a Better Way?Presentation Format, cont.Presentation Format, cont.

❂❂ PresentationPresentation Format, Format, cont.cont.

Why Nursing Ratios?Why Nursing Ratios? –– Cheryl McNallyCheryl McNally

Other Alternatives Other Alternatives –– AcuityAcuity

Acuity (dependency) based staffingAcuity (dependency) based staffing

Patti RogersPatti Rogers

Conclusions & Discussion Conclusions & Discussion –– Frank Overfelt Frank Overfelt


Nursing Ratios Nursing Ratios –– Is There a Better Way?Is There a Better Way?Background and HistoryBackground and History

❂❂ Workload Measurement Systems Workload Measurement Systems for Nursingfor Nursing

1960’s/1970’s1960’s/1970’s –– Utilized Work Sampling to establish Utilized Work Sampling to establish hours of care requirementshours of care requirements

-- Not sensitive to variation in patient typeNot sensitive to variation in patient type-- Not sensitive enough to skill mixNot sensitive enough to skill mix-- No involvement of Nursing in the processNo involvement of Nursing in the process


Nursing Ratios Nursing Ratios –– Is There a Better Way?Is There a Better Way?Background and History, cont.Background and History, cont.

❂❂ Workload Measurement Systems Workload Measurement Systems for Nursing (cont.)for Nursing (cont.)

Mid 70’s to 90’sMid 70’s to 90’s –– Evolution of acuityEvolution of acuity--based staffingbased staffing

-- Complex Acuity systems which tried to capture workload Complex Acuity systems which tried to capture workload every shift (GRASP, Medicus)every shift (GRASP, Medicus)

-- Acuity systems which used limited criteria sets tied to oneAcuity systems which used limited criteria sets tied to one--time workload measurement activitiestime workload measurement activities


Nursing Ratios Nursing Ratios –– Is There a Better Way?Is There a Better Way?Background and History, cont.Background and History, cont.

❂❂ Background and History ofBackground and History ofNursing RatiosNursing Ratios

1990’s1990’s –– Benchmarking evolved as a means of Benchmarking evolved as a means of comparing performancecomparing performance

-- Management pushing to reduce costsManagement pushing to reduce costs

-- Late 90’s labor unions found a favorable Late 90’s labor unions found a favorable environment in California to push for job environment in California to push for job securitysecurity


Nursing Ratios Nursing Ratios –– Is There a Better Way?Is There a Better Way?Why Nursing Ratios??Why Nursing Ratios??

❂❂ Why Nursing Ratios??Why Nursing Ratios??Cheryl Mc Nally, LPNCheryl Mc Nally, LPN

•• Patient Safety?Patient Safety?

•• Nursing Job Satisfaction?Nursing Job Satisfaction?

•• Enhanced Outcomes?Enhanced Outcomes?



❂❂ Why Nursing Ratios?? (cont.)Why Nursing Ratios?? (cont.)

•• Patient Safety ?Patient Safety ?–– Major argument is that fixed ratios will Major argument is that fixed ratios will

improve patient safety.improve patient safety.

–– E.g., Aides forget to report issues of patient E.g., Aides forget to report issues of patient care/safety to the RN. RNs with too heavy an care/safety to the RN. RNs with too heavy an assignment will overlook certain aspects of care.assignment will overlook certain aspects of care.




•• Nursing Job Satisfaction? Nursing Job Satisfaction? –– According to a survey of nurses in According to a survey of nurses in

Pennsylvania hospitals, the lower the ratio of Pennsylvania hospitals, the lower the ratio of patients to nurses, the greater the job patients to nurses, the greater the job satisfaction.satisfaction.




•• Nursing Job Satisfaction? Nursing Job Satisfaction? –– According to the Pennsylvania survey, According to the Pennsylvania survey,

increasing the patient to nurse ratio by one increasing the patient to nurse ratio by one increased job dissatisfaction 15% to 23%.increased job dissatisfaction 15% to 23%.




•• Enhanced Outcomes? Enhanced Outcomes? –– The same Pennsylvania study “modeled” the The same Pennsylvania study “modeled” the

impact of staffing ratios on patient deathsimpact of staffing ratios on patient deaths




•• Enhanced Outcomes? Enhanced Outcomes? –– Additional deaths/1000 patientsAdditional deaths/1000 patients

6:1, not 4:1 2.30 8.70 8:1, not 6:1 2.60 9.50 8:1, not 4:1 5.00 18.20

Patient to Nurse Ratios All Patients

With Complications


Nursing Ratios Nursing Ratios –– Is There a Better Way?Is There a Better Way?DependencyDependency--based Optionsbased Options

❂❂ Dependency Based Staffing, an Dependency Based Staffing, an alternative to arbitrary ratiosalternative to arbitrary ratios ––Patti Rogers, MBA, RNPatti Rogers, MBA, RN

•• DefinitionDefinition

•• BenefitsBenefits

•• ShortcomingsShortcomings



❂❂ Dependency Dependency vs.vs. Acuity Acuity forfor Nurse StaffingNurse Staffing::

•• AcuitAcuityy –– Medical measure of a patient’s intensity of Medical measure of a patient’s intensity of illness illness -- not a workload measurenot a workload measure

•• DeDeppendencendencyy –– A workload measure of how reliant A workload measure of how reliant a patient is on nursing caregivers to meet care a patient is on nursing caregivers to meet care requirementsrequirements



❂❂ Essential Elements of a Valid Essential Elements of a Valid Dependency Classification System:Dependency Classification System:

•• ObjectiveObjective –– Not subject to individual interpretation Not subject to individual interpretation (high inter(high inter--rater reliability)rater reliability)

•• AuditableAuditable –– Traced back to patient chart/ordersTraced back to patient chart/orders

•• Discriminating Discriminating –– Must differentiate between Must differentiate between various patientsvarious patients



❂❂ Essential Elements of a Valid Essential Elements of a Valid Dependency Classification SystemDependency Classification System (cont.):(cont.):

•• Leadership & staff are:Leadership & staff are:–– Active participants in data collection and Active participants in data collection and

review, start to finishreview, start to finish–– Committed to using the staffing decisionCommitted to using the staffing decision--

making tool as createdmaking tool as created



❂❂ BenefitsBenefits::

•• MultiMulti--focal objectivity focal objectivity –– Accounts for patient Accounts for patient age, ADLs, family support on per patient basisage, ADLs, family support on per patient basis

•• Provides staffing level assessment per unit, Provides staffing level assessment per unit, per shift for central staffing officeper shift for central staffing office

•• Staff according to skill mix requirementsStaff according to skill mix requirements



❂❂ Benefits Benefits (cont.)(cont.)::

•• Enables equitable assignment to each nurseEnables equitable assignment to each nurse

•• Provides an objective agreedProvides an objective agreed--upon method for upon method for ongoing dialogue between staff and all levels ongoing dialogue between staff and all levels of staffing decisionof staffing decision--makersmakers



❂❂ BenefitsBenefits (cont.)(cont.)::

•• Objective means of determining required Objective means of determining required staffing for reporting to regulatory agencies staffing for reporting to regulatory agencies and risk management departmentand risk management department

•• Magnet Hospital Accreditation: Demonstrates Magnet Hospital Accreditation: Demonstrates an objective staffan objective staff--oriented structure in place to oriented structure in place to support nursing and quality patient care support nursing and quality patient care



❂❂ BenefitsBenefits (cont.)(cont.)::

•• Bridges the language gap between clinical Bridges the language gap between clinical care leaders and the finance departmentcare leaders and the finance department



❂❂ Shortcomings:Shortcomings:

•• It is a system of dataIt is a system of data--driven averages driven averages which cannot account forwhich cannot account for::

–– Accurate forecasting for unknown patientsAccurate forecasting for unknown patients»» Offset with KEANU classificationOffset with KEANU classification



❂❂ Shortcomings: (cont.)Shortcomings: (cont.)

•• It is a system of dataIt is a system of data--driven averages driven averages which cannot account forwhich cannot account for::

–– Unanticipated workload peaks and valleys Unanticipated workload peaks and valleys within a shiftwithin a shift

»» Offset with SWAT TeamOffset with SWAT Team

–– Classification Errors Classification Errors –– Accidental or intentionalAccidental or intentional»» Offset with QI AuditsOffset with QI Audits



❂❂ Shortcomings: (cont.)Shortcomings: (cont.)

•• Cannot replace nursing judgment Cannot replace nursing judgment

•• Cannot clone nursesCannot clone nurses

•• Cannot discriminate between a float nurse and Cannot discriminate between a float nurse and a regular unita regular unit--based staff memberbased staff member


Nursing Ratios Nursing Ratios –– Is There a Better Way?Is There a Better Way?..

❂❂ Conclusions and DiscussionConclusions and Discussion


Nursing Ratios Nursing Ratios –– Is There a Better Way?Is There a Better Way?DependencyDependency--based Systems vs. Nursing Ratiosbased Systems vs. Nursing Ratios

❂❂ Comparing DependencyComparing Dependency--based Systems based Systems with Nursing Ratioswith Nursing Ratios

•• Involves unit direct caregivers in the daily staffing Involves unit direct caregivers in the daily staffing decisionsdecisions

–– Ratios Ratios –– NONO Dependency Dependency –– YESYES

•• Matches patient care requirements to staff Matches patient care requirements to staff availabilityavailability




❂❂ Comparing DependencyComparing Dependency--based Systems based Systems with Nursing Ratios: (cont.)with Nursing Ratios: (cont.)

•• Budgets nursing resourcesBudgets nursing resources

–– RatiosRatios –– YESYES Dependency Dependency –– YESYES

•• Forecasts nursing resourcesForecasts nursing resources

–– RatiosRatios –– YESYES DependencyDependency –– YESYES




•• Correlates nursing resources to patient outcomesCorrelates nursing resources to patient outcomes

–– Ratios Ratios –– YESYES Dependency Dependency –– YESYES

•• Manages resources objectively within each unit Manages resources objectively within each unit and throughout the houseand throughout the house

–– Ratios Ratios –– YESYES Dependency Dependency –– YESYES


Nursing Ratios Nursing Ratios –– Is There a Better Way? Is There a Better Way? DependencyDependency--based Systems vs. Nursing Ratiosbased Systems vs. Nursing Ratios


•• Accounts for variability of patients within a unitAccounts for variability of patients within a unit


•• Accounts for variability among homogeneous unitsAccounts for variability among homogeneous units





•• Accounts for the variability of patients from Accounts for the variability of patients from hospital to hospitalhospital to hospital


•• Aids in resource management to ensure longAids in resource management to ensure long--term term viability of the institutionviability of the institution





•• Incorporates facility design into the staffing Incorporates facility design into the staffing requirementsrequirements


•• Helps resolves the nursing shortage issueHelps resolves the nursing shortage issue

–– Ratios Ratios –– NONO Dependency Dependency –– NONO


Nursing Ratios Nursing Ratios –– Is There a Better Way? Is There a Better Way? DependencyDependency--based Systems vs. Nursing Ratiosbased Systems vs. Nursing Ratios


•• Puts the nurse at the bedside more frequently (for Puts the nurse at the bedside more frequently (for those patients who need him/her)those patients who need him/her)

–– RatiosRatios –– NONO Dependency Dependency –– YESYES

•• Reduces RN time spent in nonReduces RN time spent in non--patient care patient care activitiesactivities

–– RatiosRatios –– NONO Dependency Dependency –– YESYES


Nursing Ratios Nursing Ratios ––Is there a better Way?Is there a better Way?

❂❂ Conclusions & DiscussionConclusions & Discussion

•• AA PATIENTPATIENT ISIS NOTNOT AA PATIENTPATIENT

–– Patients require different levels of care Patients require different levels of care throughout their staysthroughout their stays

–– Age is a factorAge is a factor–– Family support is a factorFamily support is a factor–– Teaching requirements are factorsTeaching requirements are factors–– ADL factors must be consideredADL factors must be considered


Nursing Ratios Nursing Ratios ––Is there a better Way? Is there a better Way?


•• AA HOSPITALHOSPITAL ISIS NOTNOT AA HOSPITALHOSPITAL

–– No two hospitals are alikeNo two hospitals are alike–– Specialty hospitals, tertiary care centers, and Specialty hospitals, tertiary care centers, and

community hospitals all differcommunity hospitals all differ




•• AA NURSINGNURSING UNITUNIT ISIS NOTNOT AA NURSINGNURSING UNITUNIT

–– Layout and design affect staffingLayout and design affect staffing–– Equipment affects staffingEquipment affects staffing–– Ancillary support affects staffingAncillary support affects staffing–– IT support affects staffingIT support affects staffing



❂❂ Cost Impact of California’s AB 394Cost Impact of California’s AB 394

•• Hospitals stateHospitals state--wide will need to hire a wide will need to hire a combined total of 5,000 additional nurses combined total of 5,000 additional nurses (keep in mind there is a nursing shortage)(keep in mind there is a nursing shortage)

•• Will add an additional cost of $900 million Will add an additional cost of $900 million to healthcareto healthcare



❂❂ Cost Impact of California’s AB 394Cost Impact of California’s AB 394

•• Cost of penalties for nonCost of penalties for non--compliancecompliance

•• Costly litigation (another full employment Costly litigation (another full employment act for lawyers)act for lawyers)



❂❂ Quote from Holly DeGroot, PhD, RN, FAAN, Quote from Holly DeGroot, PhD, RN, FAAN, in testimony given before thein testimony given before theCalifornia Legislature:California Legislature:

“AB 394 is antithetical to “real time” nursing decision making about meeting patient care needs, creating instead a set of fixed, cookbook style ratios that would stand regardless of what care patients really need. This should offend every nurse, because it takes away the most crucial and complex set of professional decisions and places it in the hands of legislators. …it violates the ethical responsibility of nurses.”



❂❂ BibliographyBibliography1)1) California NurseCalifornia Nurse--Patient Ratios. Patient Ratios. United Nurses United Nurses

Associations of California/Union of Health Care Associations of California/Union of Health Care Professionals. Professionals. http://www.unachttp://www.unac--ca.org/comp/pdf/ratios.pdfca.org/comp/pdf/ratios.pdf (9(9--55--03)03)

2)2) Substantial Changes Required in Nurses' Work Substantial Changes Required in Nurses' Work Environment To Protect Patients from Health Care Environment To Protect Patients from Health Care Errors. Errors. The National Academies.The National Academies.http://www4.nas.edu/news.nsf/isbn/0309090679?Ophttp://www4.nas.edu/news.nsf/isbn/0309090679?OpenDocumentenDocument (11(11--77--03)03)



❂❂ BibliographyBibliography3)3) Nurse staffing, mortality and burnout. Nurse staffing, mortality and burnout. Bandolier.Bandolier.

http://www.jr2.ox.ac.uk/bandolier/band106/b106http://www.jr2.ox.ac.uk/bandolier/band106/b106--5.html5.html (11(11--77--0303))

4)4) Update: New IOM Report Out & California NurseUpdate: New IOM Report Out & California Nurse--Patient Ratios. Patient Ratios. Texas Nurses Association.Texas Nurses Association.http://capwiz.com/txnurses/issues/alert/?alertid=4115http://capwiz.com/txnurses/issues/alert/?alertid=4115291291 (11(11--77--03)03)



❂❂ BibliographyBibliography5)5) DeGrootDeGroot, Holly A. Testimony on AB 394. , Holly A. Testimony on AB 394. Catalyst Catalyst

Systems.Systems. http://www.catsys.com/assets/PR_full_http://www.catsys.com/assets/PR_full_testimony.htmtestimony.htm (7(7--2222--03)03)

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Nursing Ratios – Is There a Better Way? - Institute of … · environment in California to push for job security. ... assignment will overlook certain aspects of care. ... Nursing