On one side: Nurses point to evidence linking quality patient care to higher nurse-to-patient staffing ratios.
On the other: Hospital financial leaders are being asked to find ways to better manage costs in anticipation of declining payments under health reform. Moody's Investor Service predicts that even small increases in hospital costs could negatively impact the margins and credit ratings of Minneapolis-St. Paul hospital systems. (See related news item.)
The dispute is not new. Nursing and financial leaders have long debated how to staff efficiently and ensure the right number/mix of nurses to meet patient needs. Mass layoffs at hospitals hit a record high last April, according to the Bureau of Labor Statistics-and some of those layoffs have included nurses and other clinicians (Elliott, V.S., "Mass Layoffs at Hospitals Hit New Highs," AMA Medical News, June 14, 2010).
It's time to effectively address nurse-staffing issues, says Sanford, senior vice president and CNO, Catholic Health Initiatives. Otherwise, there will always be some dissatisfaction among nurses, she explained.
Do you think hospitals across the country will see more large-scale nursing strikes like the threatened Minnesota strike?
Sanford: Again, we need to take care of nurse staffing issues. It's the No. 1 issue that nurses cite when they leave hospitals. We must collaborate-work as a true team-to provide that proper balance and to ensure that the right nurse is providing the right care to every one of our patients.
Hospitals are facing financial challenges, and nursing is the most costly part of the room and board. Whenever times get hard, hospitals commonly look at how they can cut nursing costs.
However, there is a problem with how hospitals cut nursing expenses. One is that hospitals have never done cost accounting for nursing. So we do not know the true costs associated with nursing. If we don't know our true costs, we can't do a good job of managing those costs.
Hospitals are being shortsighted when they cut nurses, saying "We'll just have less of them on the floors." In the short term, costs may go down. But what is this going to cost down the line? What is the effect on patient care when you do that? Our research at Catholic Health Initiatives shows that patient mortality is higher in hospitals with lower nurse-to-patient ratios. We've also found that patients have a greater chance of getting a hospital-acquired condition (HAC) in a hospital with fewer nurses.
Hospital leaders must start asking: What is the cost of the turnover when you cut nurses? What is the cost of unhappy nurses? Dissatisfaction among nurses comes at a cost. For example, studies have shown that about 45 percent of new nurses leave their first hospital jobs within two years of graduating nursing school.
Many hospitals are in a tight spot financially right now. Is there a way to compromise on nurse-to-patient ratios?
Sanford: I agree there is a point where you can staff too many nurses, resulting in unnecessarily high labor costs. But I also think there is a proper, effective, and appropriate balance, where hospital units are not overstaffed or understaffed, and patients have the right number and mix of nurses available to provide quality care.
Hospitals have to get a handle on the business case for quality and the business case for nursing-and how these two are tied together. The business case for quality is becoming more and more transparent. Payment system changes, including value-based purchasing pilots, are beginning to tie revenue to quality.
Less transparent is the business case for nursing-or for ensuring the right number and mix of nurses to maintain quality.
Until this business case is made and understood, financially troubled hospitals will always look at nursing as one of their biggest costs. But reducing staff is an illogical choice because cutting nurses will end up costing the hospital more in terms of lost revenue and turnover.
How do you figure out the "business case for nursing" and "the business case for quality?"
Sanford: At Catholic Health Initiatives, we are doing two things. We are installing a software product that will help ensure that we are matching the right nurses with the right patients-so that more severely ill or complex patients are matched to nurses with the most advanced clinical skills. Not only will this software help us with daily patient assignments, it will give us data to understand typical nursing needs of patients according to their severity of illness. We will be better able to plan for the nursing needs associated with different diagnoses and comorbidities.
At the same time, we are doing some systemwide research related to nurse staffing ratios and patient outcomes. Eventually, we hope to put together a dashboard, which I think will be the first of its kind. The dashboard will predict a hospital's percentage risk of harming a patient (i.e, because of patient falls and HACs). For instance, "If your daily census is X and you choose to staff with X number of nurses, then you have X percent risk of harming a patient today."
We are still several years away from completing this project. It is complicated systems engineering work, and nurse researchers from University of Alabama in Huntsville are partnering with computer scientists and business operations experts to help us create this dashboard.
Once we have all the pieces in place, we will be able to mine data that helps us better understand our true cost of nursing care. Then, we will be able to find the appropriate level of staffing so that we don't overstaff or understaff, while ensuring the best patient outcomes.
Kathleen D. Sanford, RN, MA, DBA, FACHE, is senior vice president and chief nursing officer, Catholic Health Initiatives, Denver (firstname.lastname@example.org).
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