1. National Nurse to Patient Ratios

Nurse to patient ratios is one of the biggest issues facing nursing today and top of the list of the top 3 issues affecting nursing today.  Although some states have legislated nurse to patient ratios, many have not.   California, this country’s most populous state, was a pioneer in this issue. In 1999, California became the first state to pass legislation mandating minimum nurse-to-patient ratios. Regulations detailing specific ratios by type of hospital unit were released in 2002, with phased-in implementation beginning in 2004 and completed in 2008.  Here are the ratios:

• 6:1 patient-to-nurse workload in psychiatric facilities
• 5:1 patient-to-nurse in medical-surgical units, telemetry, and oncology;
• 4:1 in pediatrics;
• 3:1 in labor and delivery;
• 2:1 in intensive care units.

How does your state compare to California?  After instituting these laws, California nurse employment rose approximately 15 percent as a result of the law. The reason cited was because those nurses that left the field due to unsafe patient ratios returned.  The intent of the law was to improve care for patients but unexpectedly, occupational injury and illness rates of nurses dropped over 30 percent. In 2010, the University of Pennsylvania performed a study comparing California with New Jersey and Pennsylvania (two states with no nurse to patient ratio laws).

• California hospital nurses cared for one less patient on average than nurses in” Pennsylvania and New Jersey.
• California nurses cared for “two fewer patients on medical and surgical units” than nurses in Pennsylvania and New Jersey.
• Lower nurse-to-patient ratios significantly lowered the likelihood of a patient’s death.
• 29 percent of nurses in California experienced high burnout, compared with 34 percent of nurses in New Jersey and 36 percent of nurses in Pennsylvania, states without minimum staffing ratios during the period of research.
• 20 percent of nurses in California reported dissatisfaction with their jobs, compared with 26 percent and 29 percent in New Jersey and Pennsylvania.
• 13.9 percent fewer surgical deaths than New Jersey and 10 percent fewer surgical deaths than Pennsylvania.
• Wage growth for RNs in California after implementation of mandated minimum nurse staffing increased more than RN wage growth in other states.

Nurse to Patient Ratio benefits include;

• Decreased nurse fatigue, thus promoting increased safety as well as job satisfaction.
• Decreases nurse burnout, including irritability, insomnia, depression, weight gain, and other potential health risks that come from being overworked in a stressful environment.
• Regulated ratios allow nurses to give better value-based care while also maintaining their own health.
• Retention and recruitment rates also improve drastically with minimum nurse-to-patient ratios.
• Patient mortality and the number of preventable mistakes
• Fewer patient falls
• Fewer pressure ulcers
• Fewer central line infection
• Fewer healthcare-associated infections
• Fewer procedural mistakes such as medication errors
• Fewer patients suffered post-treatment complications that required them to return.  (makes you wonder if hospitals want this or not?)

Solution:

It is time to step up the dialogue on nurse to patient ratios becoming standardized nationally.  There is an overwhelming amount of data that supports better patient and nurse outcomes with lower ratios.  There appears to be a great disconnect between this evidenced-based practice and hospitals getting on board.  Some nursing organizations are also not on board with this depending on the state.  It amazes us that the same people who advocate for safer nursing conditions “over-look” this basic, very fixable aspect of nursing.  It is a simple matter of money for the hospitals and their bottom line.

Is it cheaper for hospitals to have patients die than have adequate staffing ratios?  Data shows that better patient outcomes and fewer hospital readmissions are achieved with lower ratios.  Are patients getting better effecting the hospital’s bottom line?  Do hospitals actually prefer return business and more readmissions over patients getting better?  Is it cheaper for the hospitals to load up a nurse with unsafe patient loads at the risk of losing nurses to unsafe conditions?  Do the boards realize that nurse burnout is a top reason nurses leave the field and therefore contributing to the shortages?  We think (yet have no hard data to support it) that the answer is YES!

We have to ask ourselves as nurses the reason this legislation is not at the forefront of priorities when it affects every person, not just nurses and why people fight against it. We are all patients at one point in our lives.  Through legislation, petitions, voting for candidates who support nurse and patient rights, lobbying, and protesting we can enact change.  We will go into this further in the conclusion of this article and give real solutions to this growing issue.

Get involved with National Nurses United’s National Nurse to Patient Ratio Initiative  https://www.nationalnursesunited.org/ratios

2. Mandatory Overtime Regulation

Mandatory overtime for nurses is one of the most pressing of the top 3 issues affecting nursing today.  It is a hot topic being addressed currently by various states individually.  18 States have already instituted some degree of mandatory overtime legislation, there is still a long way to go.  Ohio is beginning the process to institute their own mandatory overtime laws can take years.  National laws protecting nurses are nonexistent at this point and might never get enough traction to be enacted on their own.  Many have tried and were unsuccessful.

Mandatory overtime attributes to the general fatigue and dissatisfaction of nursing careers for some nurses. Not everyone dislikes mandatory overtime.  Some enjoy the extra money involved with working extra hours and rely on that money to balance flex hours and call offs.  Some nurses only enjoy working overtime if it is voluntary and on their own schedule, desire and fitness level at the end of their shift.  The facts regarding overtime in the nursing field are undeniable.  It’s simply not a safe practice.  Of course, there are those who can work days on end, 16 hours a day, without incident, however, the vast majority of data suggests that overtime nursing attributes to greater needle stick incidents, medication errors and adverse patient events.  More data suggests that nurse fatigue, burnout, and nurse health is also affected.

The Data of Safety

One study found that around 50% of nurses work more than 12 hours per day and 17% are required to work mandatory overtime. In Ohio, 35% of the nurses feared for their job by refusing mandatory overtime.  Ohio and other states nationwide threaten to terminate nurses who refuse to work overtime and often report them to the state licensing board for patient abandonment.

Federal laws prohibit the number of hours worked by pilots, train engineers, and truck drivers  to “protect the public from fatigue-related errors.”  Nursing is a similar profession with a duty to protect the public and nurses should be protected by not being forced to commit fatigue-related errors.   Here are some of the ways overworked nurses affect patient care and public safety:

1.  The proportion of needle sticks dramatically increase over 8 hours of work, as does the proportion of medication errors.
2.  Higher levels of overtime hours are associated with increased rates of infection, including skin ulcers and catheter-associated urinary tract infections. a hospital with overworked nurses.
3.  Increased rate in medication errors.  Errors in medication account for a large number of accidental deaths in hospitals. Next to hospital infections, errors in medication cause the most number of deaths.
4.  Nurse Fatigue leads to health issues.  Nurses in poorer health had a 26 to 71 percent higher likelihood of reporting medical errors than did their healthier peers. 
5.  The longer the shift, the greater the likelihood of adverse nurse outcomes such as burnout.
6.  Patients were less satisfied with their care when there were higher proportions of nurses working shifts of thirteen or more hours and were more satisfied when there were higher proportions of nurses working eleven or fewer hours.
7.  64% of nurses working 12 hours or more rarely get 7-8 hours of sleeping a night,  31% get 7-8 hours sleep only 2-3 nights weekly.
8.  One out of every five emergency department nurses meets the criteria for post-traumatic stress disorder, which can clearly be brought on by continual exhaustion and extended working hours.
9.  Seven out of 10 employees experiencing job stress said they frequently suffered health ailments.  Frequent mandatory overtime was one of the leading five factors that caused increased stress.
10. There are many more and the list goes on!

Why and How Much?

The infographic below shows two reasons why some people work overtime.  It is broken down by those who don’t want to let their coworkers down, and those that cannot get their work done in a standard shift and need that overtime to finish their work.

Solution:

A 12 hour work day is generally not recommended.  Couple the fact that working over 8 hours in a day increases the danger, working over 12 hours in a day is disastrous concoction attributing to nurse burnout, patient dissatisfaction, adverse events, declining nurse health, poor sleep and more.  I suppose we can make more money, but is it really worth it?  We have a duty to our patients to give them competent care.  It’s up to us as nurses to decide when enough is enough, yet our decisions can affect other people’s lives.  This should not be a hospital administrative decision and only mandated in emergency scenarios that are clearly defined.

What can we do as nurses to ensure we are not overworked?

1. Listen to your body and mind –  Recognizing when we are overstressed, tired and physically drained and declining overtime (when applicable) is one of the easiest fixes for this issue facing nurses today.
2. Become involved in legislation –  Although many bills have been drafted both locally and nationally, many have fallen short of support.  Write your congressmen and women, become involved with activism and sign petitions.
3. Before taking a job, ask the hospital if they require mandatory overtime – If you don’t agree, don’t take positions at hospitals which require mandatory overtime. In time, the nursing shortages caused by nurses refusal to work in unsafe conditions will filter down to management, forcing them to change policy on the hospital level.

3. Dangerous Work Conditions

It is estimated that 650,000 individuals injured each year in the healthcare industry alone. It is no wonder why dangerous work conditions are one of the top 3 issues affecting nursing today.  Patient ratios and mandatory overtime are both factors that help sustain dangerous work conditions.  It is no wonder why nursing is one of the most dangerous professions in the United States.  Becker’s Hospital Review states:

Between 2012 and 2014, workplace violence injury rates increased for all healthcare job classifications and nearly doubled for nurse assistants and nurses, according to data from the Occupational Health Safety Network. A total of 112 U.S. facilities in 19 states reported 10,680 Occupational Safety and Health Administration-recordable injuries occurring from January 1, 2012, to September 30, 2014. There were 4,674 patient handling and movement injuries; 3,972 slips, trips and falls; and 2,034 workplace violence injuries.

There are many factors that contribute to the statistics which include, needle sticks, bloodborne pathogens, infections from patient to nurse, increased mental health instability of patients, growing workplace stress, physical strain, hazardous chemicals, hand washing-related dermatitis and workplace violence.  We aren’t going to focus on all of them in this article, however, it is safe to say, we need to do more to reduce these incidences to make nursing a safer profession.

Workplace Violence

Workplace violence in health care is five to twelve times higher than the estimated rates of any other occupation according to a Government Accountability Office report.  Workplace violence is one of the most dangerous issues facing nurses across all disciplines and facilities.  Physical violence accounts for 45 percent of all workplace violence incidents in all industries in the United States. Medical and surgical hospitals, residential care facilities, and ambulatory health care settings were among the facilities with the highest prevalence of non-fatal occupational violence according to the U.S. Bureau of Labor Statistics.  Emergency room and psychiatric units carried the highest risks. In a national survey, researchers found that 78% of participants experienced at least one act of workplace violence in the last 12 months, with 75% reporting verbal threats and 21% reporting physical assaults, according to results published in 2011 by the Journal of Emergency Medicine.

A 2015 study of 5,385 workers polled, showed that only 19% of workplace violence is actually reported, yet 1,180 physical assaults, 2,260 physical threats, and 5,576 incidents of verbal abuse were reported.  Nurses, CNAs, and Doctors were at the greatest risk. The reasons: altered mental status, behavioral issues, pain/medication withdrawal, and dissatisfaction with care.  Fear for their safety was common among polled at 38%.

We believe the dissatisfaction with care is one of the only fixable reasons in this list.  Mental/behavioral status and pain medication withdrawal, are two reasons that are harder to assess and easily fix.  Nurses are the front-lines of healthcare, the customer service reps, and the patient advocates.  If the patient is unhappy with care, it is up to us as nurses and direct care workers (including doctors and CNA’s) to increase that satisfaction. Dissatisfaction with care also has a direct correlation between nurse to patient ratios and mandatory overtime.

Solution:

For too long nurses and administrators have said: “It’s just part of the job”.  Some local agencies will do little to file reports and prosecute offenders.  It is up to us as nurses to disseminate what is “part of the job” and what isn’t.  If an elderly dementia patient or low blood sugar patient freaks out and strikes a nurse, this is unintentional and realistically shouldn’t be prosecuted.  A patient who is angry about their care hitting a nurse is another story.  This should not be tolerated.

Congress needs to enact more laws protecting nurses, doctors and CNA’s from intentional workplace violence with strong penalties, jail time, and restitution.   With police officers, (also a high workplace violence job) it is a felony to physically harm an officer with stiffer laws for perpetrators.  Why is it a nurse, CNA or doctor is assaulted, the perpetrator isn’t held to those same standards?  We are every bit a part of the public service sector as police.

Again, California leads the charge on legislation holding the hospitals and facilities with some accountability with a law that will inevitably be a template for the rest of the country for violence against nurses. Illinois is already following suit.  Massachuset is also trying to enact a law protecting healthcare providers through State Bill S.765.  Albeit great that they are enacting laws to protect nurses, these laws don’t address stiffer penalties to those who perpetrate violence on healthcare staff.

Physical Strain

There are many causes of physical strain in the workplace for nurses and aides.  Some of these include; prolonged standing, patient handling activities, slip and falls, repetitive strain injury, and hand washing related dermatitis.   We will focus on prolonged standing and patient handling activities account for the majority of musculoskeletal injuries sustained by nurses due to its direct correlation with the other points in this article on patient ratios and mandatory overtime.

• Nurses are 48% more likely to have wrist, back and/or ankle sprains or strains on the job, compared to all other occupations
• They are 60% more likely to report chronic soreness and pain, especially in the feet and lower back
• 53% of all injuries while nursing was reported to be due to overexertion
• 83% injuries were musculoskeletal.
• The leading causes of MSIs (Musculoskeletal Injuries) were awkward posture (25%) and force (23%)

Nurses spend at times 12 hours or more (depending on overtime) on their feet.  A recent Canadian research study shows people who primarily stand at work are 232% more likely to develop heart disease than predominantly sitting occupations. There are other studies that show that people who are on their feet for extended periods of time are associated with a wide variety of lower extremity disorders including; tendonitis, plantar swelling, tiredness, cumulative muscle fatigue and body part discomfort.

Patient handling can be one of the most obvious and dangerous of nursing activities.  It is a task that also has a direct correlation with nurse to patient ratios and adequate staffing.  Data from the Bureau of Labor Statistics show that the rate of overexertion injury for hospital workers are twice the national average, and nursing home staff have three times the national average.  The BLS states the greatest risk factor is manual lifting, moving and repositioning of patients.  It can be a career-ending accident that compresses disks, lower lumbar strains and cervical compressions.  There is also a high incidence of rotator cuff and shoulder tears associated with patient handling as well.

Improper lifting and moving of patients are a huge liability for disability insurance with hospitals and why they spend so much money, time and training on ergonomic lifting and OSHA standards for safe patient handling.  This is one aspect of hospital safety that has gained traction and nurses are generally protected by hospital policies.  The addition of lift teams and mechanical lifts in facilities have decreased the incidence (debatably) yet not enough.  Why then are there still so many injuries related to patient lifting and maneuvering?  Some believe that nurse workload is to blame with little time setup and operate lifts.

One recent study suggests that the mechanical lifts aren’t effective enough to reduce significant strain to nurses and staff. The reality is there are few evidence-based studies that show a viable way to improve these outcomes and is truly “part of the job” until studies are conducted and evidence-based practice initiated. It is undeniable, however, that adequate staffing can help improve patient outcomes,  including patient handling.

Solution:

• Purchase shoes that are right for your line of work, they need to be worn properly, and replaces when fatigued. 2 times a year is the recommended time to replace footwear.
• Lose some weight. Losing weight will cause reduced stress on joints, lower back and especially your feet.  Even a small amount of weight will make a difference.
• Plantar fasciitis can be avoided by not walking barefoot often.   Stretching your arches and taking anti-inflammatories like ibuprofen can help with the pain.  Place your toes on a stair as if you are walking upstairs, then let your heel drop, you will feel the arch stretch as well as your calves.
• Body mechanics can help as well.  Proper posture and changing positions can make a huge difference in joint and tendon fatigue.
• Exercises that stretch and strengthen muscles and ligaments that support the back are an excellent preventive measure as well.
• Ask for help before you move somebody or something beyond safe limits.  Don’t every move anyone by yourself and the more the merrier to help prevent strain.
• Better nurse to patient ratios would also reduce the time you are on your feet in a given shift walking from room to room and standing.  You will be able to change postures and allow yourself to sit, stand, and walk.  Too much of any of the three will result in injury.
• Reduce the number of hours you are on your feet.  By reducing working hours through working 8-hour shifts or no more than 12 hours a day can significantly reduce the amount of time and persistent fatigue on your joints and ligaments.
• Use mechanical lifts, boards lift teams to move patients.  Never do so by yourself.
• Suggest a lift team be instituted in your facility if one isn’t already available.

Conclusion:

We work in the most dangerous profession in the nation.  Many of the dangers can be reduced with a lower nurse to patient ratio, reduction in mandatory overtime, and reduction in workplace violence and injuries.  How is this possible and how do the 3 top issues facing nursing today correlate with each other?   It all starts with a national nurse to patient ratio law.   By raising the amount of time a nurse can spend with a patient, a myriad of positive outcomes follow.

• Increased N2P ratios improve patient outcomes
• Increased N2P ratios decrease death rates in patients
• Increased N2P ratios provide less nurse fatigue allowing for more overtime (if the nurse feels they are able)
• Increased N2P ratios increase patient satisfaction which is inversely related to violence potential
• Increased N2P ratios in decrease the likelihood that a nurse will be overexerted and decrease sick days and injuries.

It is time to make hospitals safer for the nurses and more importantly the patients.  After all, isn’t this the reason we got into this profession, to begin with?  We are here to help make people better, provide a public service, provide compassionate care and be advocates for our patients.  It is time for nurses to band together and work for all of these changes in the nursing industry.   A law needs to be passed by Congress that makes nurse to patient ratios safe, eradicates mandatory overtime and makes workplace violence against healthcare professionals unacceptable and punishable by strict mandatory sentences, convictions, and fines.

A Safe Nursing Act is what will reduce the nursing shortage, minimize nurse burnout, make nursing safe, and provide more competent nursing care for everyone.   At one point in our lives, we will all be patients with a nurse taking care of us.  You can’t say that about many other professions.  The time is now to join the fight and bring this to the forefront of the public consciousness.

Nurse Nirvana is working to provide a campaign to help nurses come together to enact change through social media and a national hashtag of #WeAreAllPatients to bring public awareness and demand Congress pass safe nursing laws.  Together we can help eradicate the top 3 issues affecting nursing today.