mandated nurse–patient ratios - British Columbia Nurses' Union

BCNU PositioN statemeNt oN
mandated nurse–PatIent ratIOs
604.433.2268 | 1.800.663.9991
www.bcnu.org
August 2011

BCNU PositioN statemeNt oN
maNdated NUrse–PatieNt ratios
BCNU BELIEVES THAT:
• British Columbians expect and deserve safe,
competent care from nurses in hospitals,
residential care facilities and the community.
Fewer patients per nurse and more direct nursing
care hours are associated with better care and
improved outcomes.While hospitals cannot
control patient severity and complexity, nurse
staffing can be better planned and a mechanism to
improve it is urgently needed.
• Mandated nurse-patient ratios resolve patient
safety concerns and excessive workloads for
nurses.They represent minimum requirements
for nurse staffing and are flexible with respect
to patient acuity, nursing expertise and other
workload variables.
• Mandated nurse-patient ratios create safer care,
more satisfied nurses and save healthcare dollars–
as we know from California, Japan and Australia. i
Saskatchewan successfully completed a pilot project
so we know this approach can work in Canada.
i California’s legislation was passed in 1999 and implemented in
2004. In 2006, Japan put MNPR in place.Victoria,Australia has
had MNPR since 2001 and New SouthWales,Australia passed
legislation for MNPR in 2011.
BACKGROUND: Why Mandated
Nurse–Patient Ratios? (MNPR)
Current workloads for nurses are untenable.
BC nurses are striving to provide high quality care
despite excessive demands and workloads based
on greater numbers of patients with more complex
needs. An important part of a larger approach towards
increased quality of care, MNPR are a simple and
transparent way of setting minimum safe working
conditions. Besides MNPR, BCNU recognizes that
nursing workplaces require other appropriate resources
including clerical support, allied healthcare providers
and equipment.We also call for effective front-line
nursing leadership and prohibition of mandatory
overtime. Collecting data on nurse-sensitive patient
outcomes will be a useful way to evaluate MNPR once
they are established.The public has the right to know
nurse staffing levels in each workplace and to demand
safe ratios.
Peer-reviewed literature on MNPR is divided.While
critics of MNPR identify problems with this approach,
alternatives they propose are not being implemented.
Studies show that administrators experience difficulty
ensuring that ratios are in effect “at all times” but
creative scheduling resolves this. Rarely mentioned in
the literature are key social issues related to the value
of nurses.When nurses are valued, patients and the
healthcare system benefit.
Richer staffing of regulated nurses produces lower
failure to rescue ii rates among surgical patients, lower
inpatient mortality rates (by 10 to 14%) and shorter
hospital stays for medical patients. 1,2
MNPR are designated minimum staffing standards and
are flexible; more nursing staff may be required based
on these and other factors:
• Patient/resident/client clinical acuity
• Nursing expertise
• Nature and complexity of care needed
• Skill mix (RNs, LPNs, Care Aides etc)
• Available support staff
• Physical layout
Regulated nurses require enough time to: assess
those under their care; develop, evaluate, revise
and implement care plans; educate their patients,
families, caregivers; and plan for discharge.A workload
measurement tool, which takes into account a
variety of factors related to those above, is a useful
instrument in assessing appropriate staffing numbers
and skill mix. Synergy is one such tool that has been
successfully used by BC and Saskatchewan nurses.
Enforceable MNPR put quality of service and working
life on centre stage.They are an important part of
a larger approach to improving patient outcomes,
nurses’ work life and saving healthcare dollars.
ii Failure to rescue is a nurse-sensitive measure that points to
hospitalized patient outcomes.When regulated nurses have
enough time at the bedside to observe patient deteriorations,
FTR rates are lower, as regulated nurses take remedial action for
patients who need interventions.

PATIENT OUTCOMES:
Safe Staffing Saves Lives
Higher levels of regulated nurses (LPNs, RNs, RPNs)
are associated with better outcomes, including lower:
mortality, rates of failure to rescue, urinary tract
infections, upper gastrointestinal bleeding, hospitalacquired
pneumonia, shock and cardiac arrest, and shorter
length of stay for medical patients. 3
Surgical patients with pneumonia exhibit an average of
74% increase in total length of stay, costing between
$22,390 to 28,505 (US) per patient. 4 With more RNs
on the job, recovering surgical patients have a lower
likelihood of pneumonia (2.17% to 1.33%). Furthermore,
greater levels of education amongst nurses have been
shown to improve outcomes. 5
Patient satisfaction surveys before and after MNPR
indicate significant improvements in patients’ perceptions
of their care, particularly the attention they received from
nursing staff. 6
NURSE OUTCOMES:
Safe Staffing is Sustainable
Despite robust evidence that points to the need for
implementation of formal staffing plans, nurse staffing
decisions are often made on an ad-hoc basis. 7 Extreme
workload pressures on nurses have resulted in
overworked, injured and ill nurses with low rates of job
satisfaction. In 2008, $320m was paid for BC nurses who
required long term disability support; in 2010 this figure
rose to $427m. 8 An injured nursing workforce creates
suffering for nurses and their families while adding to
spiraling healthcare costs.
Addressing these concerns requires a comprehensive
approach.With MNPR, California nurses feel empowered
and consistently report that their workloads are
reasonable; they have substantial support and enough
regulated nurses to complete their work so they feel
that they provide quality care and have time to take
their breaks. 9 Six thousand nurses came back into the
workforce in Victoria,Australia when MNPR were
instituted.They would leave the workplace and possibly
the profession were ratios abolished. 10
COST OUTCOMES:
Safe Staffing Saves Money
Comprehensive and long term economic analyses of MNPR
have proven the cost effectiveness of this approach. 11 Most
importantly, however, saving lives and reducing human
suffering are ethical issues that can never be reduced to
dollars and cents: people’s lives come before money.
Investigating a 1:4 (nurse-patient) model, a Michigan study
found that net cost savings occurred through shorter
patient length of stay, fewer readmissions and adverse
events. Hospital operating costs increased by only 1.7%.
Furthermore, reduced nursing staff turnover led to lower
costs of replacing nursing staff and less overtime costs. 4
Besides this, nosocomial infection rates decrease when
adequate nurse staffing is in place; estimated cost savings
are between 5 to 6%, approximately $24,629 to $31,356
(US) per patient. 12
Low retention of nurses is very costly, with replacement
costs ranging from $21,514 to $67,100 per nurse. 13
Finally, a noteworthy study of 11 US states concluded that
increasing RN hours and raising the proportion of RNs
would save 6700 lives, $5.7 billion and 4 million days of
patient care in hospitals each year. Increasing RN staffing
would produce net short-term cost savings of $242
million. 14
BCNU’S Ratio Guidelines
Determining safe staffing levels requires constant
evaluation. Numbers will fluctuate according to the needs
of patients, clients and residents.The ratios outlined
below are based on ratios successfully implemented in
other jurisdictions and reflect minimum requirements
which will require adjustment upward for patient acuity
and other factors.These nurse-patient ratios apply 24
hours a day, 7 days a week.
The following ratios do not include many areas in which
nurses work, such as psychiatry, ambulatory care, dialysis,
tertiary facilities, residential care, rural settings and
community worksites.These areas will require further
consideration and research due to their uniqueness.
• Antepartum 1:4
• Dialysis 1:2
• Emergency Room iii 1:3
- ICU Patients in ER 1:1
- Triage 1:1
• Intensive/Critical Care 1:2
- Ventilated 1:1
• Labour and Delivery
- During delivery 1:1
- During labour: active 1 st to 4 th stage) 1:1
• Medical/Surgical 1:4
• Neo-natal Intensive Care 1:1
• Operating Room 2:1
• Pediatrics—General Medical Ward iv 1:4
- Pediatric Oncology 1:2
- Pediatric Surgery 1:3
• Post-Anesthesia Recovery (conscious) 1:2
• Post-Anesthesia Recovery (unconscious) 1:1

BCNU PositioN statemeNt oN
mandated nurse–PatIent ratIOs
• Postpartum v 1:4
• Step Down and Telemetry 1:3
iii In some cases, such as extreme trauma, ratios of 3:1 are
required.
iv With higher acuity, 1:3 is the standard for a regional facility.
v The mother is one patient and the baby is another patient.
Furthermore, more regulated nursing staff are required to
care for high-needs newborns such as twins, triplets and
premature infants.
Residential Care
For residential care facilities, BCNU recommends that
a minimum of one full-time RN director of nursing
and one RN supervisor is on site, providing direct care
supervision, at all times (24 hours per day, 7 days per
week). In facilities with 100 or more beds, a full-time RN
assistant director of nursing and a full time RN director of
in-service education are mandatory. In facilities with less
than 100 beds, these positions are to be proportionally
adjusted for size.
Total nursing staff hours are to be 4.55 per resident day. 15
Mandated minimum staffing levels are 1 regulated nurse
for every 25 residents. BCNU recognizes and underscores
the high value of direct care provided by regulated nursing
staff, given the benefits to health status.When regulated
nurses have increased resident contact, failure to rescue
rates decrease—as deteriorations in health status are
easier to detect. BCNU calls for more bedside nursing as
a means of improving residents’ outcomes.
COMMUNITY NURSING: (Home Care
Nursing, Public Health and so forth)
Staffing requirements for home care nursing and public
health, unfortunately, are not well documented in
retrievable literature. Some health units in BC use a
point system to allocate workload which might provide
a foundation for determining ratios. Further exploration
is required but given the complex needs of clients who
are quickly discharged from hospital and still require
treatments and close monitoring, it’s imperative to set
safe staffing levels.
BCNU:Taking Action to
Improve BC’s Health
BCNU is aware of problems with half-measures: no public
disclosure; no enforcement; no rights for the nurse as
patient advocate; no whistle-blower protection; RN and
other staff interchangeability; and staffing based solely
on patient classification systems without ratios as a
minimum safety standard. MNPR, when carried out in a
comprehensive manner, will set a new standard in BC.
Patient advocacy is an important part of the nursing role.
Simple, transparent and enforceable MNPR are a vital step
towards excellence in patient care. Our healthcare system
will improve when front line care improves.The cost of
not implementing ratios is far too great. In the interests
of patients, the public, nurses and employers, it is time to
bring about MNPR.
For more information
Please contact a BCNU Regional Chair to discuss these
issues; contact details are at: bcnu.org/about_bcnu/
leadership/council.htm and in Update magazine.
Bibliography
1 Lang,T., Hodge, M., Olson,V., et al. 2004. Nurse-Patient Ratios:A Systematic
Review. JONA 34(7-8) July/Aug: 326-37.
2 CHSRF (2006). Implement Nurse Staffing Plans for Better Quality of Care.
www. chsrf.ca
3 White, K. (2006). Staffing plans and ratios:What is the latest U.S.
perspective? Nursing Management. 37 (4): 18-24.
4 Public Policy Associates (2004).The Business Case for Reducing
Patient-to-Nursing Staff Ratios and Eliminating Mandatory Overtime.
5 Tourangeau,A., Doran, D., McGillis Hall, L., et al. (2007). Impact of hospital
nursing care on 30-day mortality for acute medical patients. JAN 57(1) 32-44.
6 Michell, P., Mount, J. (2008). Nurse Staffing—A Summary of Current
Research, Opinion and Policy. Ruckelshaus Centre,Washington, US.
7 LeMoal, L. (2009). Nurse-patient ratios in the Canadian context.
Saskatchewan Union of Nurses.
8 Health Sector Compensation Information System report (2010).
9 Gordan, S., Buchanan, J., Bretherton,T. (2008). Safety in Numbers: Nurse-to-
Patient Ratios and the Future of Health Care. Cornell University Press, USA.
10 Wise, S. (2007). Undermining the Ratios.Workplace Research Centre,
University of Sydney,Australia.
11 Needleman, J., Buerhaus, P., Stewart, M., et al. (2006). Nurse Staffing in
Hospitals: Is There a Business Case for Quality? Health Affairs 23 Jan
(1):204-11.
12 Stokowski, L. (2009). Nurse Staffing For Safety. Medscape Nursing
Perspectives: Oct.
13 Tschannen, D., Kalisch, B., Hee Lee, K. (2010). Missed Nursing Care. CJNR
42(4):22-39.
14 Aiken, L., Sloane, D., Cimiotti, J., et al. (2010). Implications of the California
Nurse Staffing Mandate for Other States. H Serv Res 45(4): 904-21.
15 Zhang, N., Unruh, L., Lin, R., et al. (2006). Minimum Nurse-Staffing Ratios for
Nursing Homes. Nurs Econ 24(2):78-85.