Runninghead:NURSINGSTAFFLAW

NeedforNursingStaffRegulatedlaw
MelanieDavis
WesternWashingtonUniversity

NURSINGSTAFFLAW

MelanieDavis
NURS301
November30,2015

DearReader,
Pleaseletmeknowifmypaperflows,andifmyparagraphsareinlinewithmythesisand
supportingevidence.Isthereenoughinformationtoconvincethereaderthatnursesneedtohave
asetnumberofpatients(orless)assignedtothem?
Thankyouforreviewingmypaper,
MelanieDavis

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NeedforNursingStaffRegulatedlaw
Introduction

Thewidelyspreadissueofnurseshavingtoohighpatientworkloads,needstobe
addressed.Itisagrowingconcernthatimpactsthedeliveryofhealthcare.Becausenurseshave
toohighpatientnumbers,theyarehavingtoworkforanextendedamountofhoursthroughan
entireshiftwithouttakingabreak.Nursesaregivenathirtyminuteunpaidmandatorylunch
breakthatisintendedforthenursetotake,eventhoughmanyarentableto.Asanursemyself,
thereweremanytimesIwasunabletositdownonashift,andevenmorefrequentlyunableto
usetherestroomfrombeingassignedtoomanypatients.Themainreasonnursesarentableto
takeabreakhastodowiththeamountofpatientsnursesareassigned.Ahighnumberofpatients
doesntallowmandatorybreakstobetaken,anddoesntallowthenursetogivetheproper
amountofcarethepatientsneed.Thiscontinuouscycleofinabilitytofulfillobligationsona
shift,isacontributingfactortonurseburnoutaswellasotherissues.Alawthatspecifiesa
numberofpatientseachnurseisresponsibleforonthemedicalsurgical(medsurg)floorin
hospitalswouldimprovethequalityofhealthcarebyincreasingnurseandpatientsatisfaction,
reducingmishapsandpatientmortality,anddecreasingnurseburnout.
WhyIChoseTheseArticles
Thearticlesinthispaperprovideinformationthatsupportmyviewontheneedforalaw
thatregulatesthenumberofpatientsnursesareresponsiblefor.Thearticlesgatheredforthis
paperconsistofacademicscholarlyjournalswhichareconsideredcrediblesources.Therewere
manyarticlesonthenursingstaffshortage,andthevastamountofconsequencesithasonthe

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deliveryofhealthcare.Nursesareundeniablyaffectedaswellasotherswhoareinvolvedinthe
healthcaresystem.
Manycomplaintshadbeenfiledregardingnurseshavinganunsafenumberofpatients
pershiftwhichpromptedtheCaliforniaNursesAssociationtoconductresearch.Theywere
determinedtofindtheunderlyingcauseastowhyanumberofnursesdidnttaketheirbreaks,
andwhyasteadynumberofnursingerrorsandpatientincidenceswereontherise.Another
problemthatwasuncoveredwastheretentionratefornurseswasatanalltimelow.According
toTellez(2013),theCANursesAssociationuncoveredreportsfromtheInstituteofMedicine
(IOM)thatcoincidedwiththeirownresearch,thatnursesinthemedsurgandacutecaresettings
wereoverworked.Thepatientworkloadpernursewashigh,andtheworkenvironmentswerenot
idealtodeliverqualitymedicalcare.In1999,Californiapassedalawthatrequiredaminimum
numberofnursestopatientsinresponsetotheincreasingamountofincidents,whichwas
officiallyimplementedin2004.CaliforniaistheonlyUSstatetoadoptastatewidelawthat
regulatesnursestaffing.TheCAlawinthemedsurgsettingisaminimumofonenursetofive
patients,andonenursetotwopatientsinintensivecareunits,oronetooneifthepatientis
unconscious.Thewaytocalculatethenursetopatientratioistotakethenumberofnursesonthe
unitanddividebythenumberofpatients.Theimplementationofthelawwassuccessfulinthe
aidofdecreasingtheimpactandamountofnegativeoutcomesrelatedtoformerlyundefinedand
poorlyoutlinednursingstaffpolicies.Aconcernsomehadwiththeimplementationofthislaw
wasthatpotentialnursestobehiredontofulfilltherequirementmightbelessskilledLicensed
PracticalNurses(LPNs)tosavetheagencymoney.HoweverMcHugh,Kelly,Sloane,&
Aiken(2011)foundtheskilllevelwasnotreduced,andmedicalfacilitiesmettheincreased

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demandfornurseswithhighlyskilledRegisteredNurses(RNs).Therewasnotadecreasein
skilledRNshowever,Martin(2015)foundthatwhenmoreRNswerehired,theUnlicensed
AssistivePersonnel(UAP)becameless.MoreRNswereneededwithoutadecreaseinthe
amountofUAPs,sothenursescouldimplementthetrainingandeducationtheyreceivedto
performthedutiestheywerehiredtodo.WithlessornoUAPs,nursesfoundthemselveshaving
toworkmoreandcompletethenecessarybutbusytasksUAPusuallyperformed,ontopoftheir
ownrequiredduties.Aswithanynewlaworpolicy,problemsareidentifiedandimprovedvia
trialanderror.Martin(2015)pointedouttheresultwestriveforinthedeliveryofquality
healthcareispatientsatisfaction.Sincethelawwasimplementedtherehavebeenmixedfeelings
onthedetailsofthelaw,butwithconstantresearch,therehasbeenapositivecorrelation
betweenthenewlawandanincreaseinpatientandnursesatisfaction.McHugh,Kelly,Sloane,
&Aiken(2011)notedduetotheprovenpositiveoutcomesoftheCAlaw,policymakersin
otherstatescanlooktoCAsexperiencewhenconsideringsimilarapproachestoimproving
patientcare(p.1).WithevidencethatsupportedCaliforniasminimumnursetopatientratio
lawthatdisplayedpositivechangeswithanincreaseinbothnurseandpatientsatisfaction,other
statessoonfollowedwithproposedwaystofocusonandadjusttheirstaffingissues.
PatientSatisfaction

Asnotedabove,withouttheimplementationofalaw,accordingtoMartin(2015)

hospitalswithtoomanypatientsandnotenoughnurses(lownursestaffing),canexpecttohave
patientsunsatisfiedwiththeinadequatecaretheyreceive.WiththeincreaseinRNs,Tevington
(2011)notedtheincreasedimprovementinqualitycare,patientsatisfaction,andpatientsafety.
EvidencehasshownthathospitalswithagreateramountofRNstaffhavepatientsthataremore

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comfortableandpleasedwiththeoverallcarereceived.Hospitalacquiredillnesseswerealso
decreased.Themainobjectiveinimplementingachangeistoensurequalitycareisgivenina
safehospitalenvironment.Patientsandnursesshouldbesatisfiedwiththequalityandfair
treatmenttheyreceive.Alternativestostateregulatedratios,asidentifiedbytheANA,arestate
regulatedreporting/publicdisclosure,andfacilitymandatedstaffingcommittees(Tevington,
2011).Ifafacilityisgoingtoregulatetheirownstaffing,facilitymanagementneedstocometo
anagreementonasafeandcomfortablepatientamountthatsuitsthepatient'sneedsandis
reasonabletothenurse.Financialneedstoimplementchangeisafactor,butiffacilitiescan
implementachange,thencreatingtheirownsafepolicywouldbelessexpensiveandmore
beneficialforthem.

MishapsandPatientMortality
Whilemoneyisalargecontributingfactortoimplementingsuchchange,thenumberone
concernistomaintainthesafetyofthepatientandnurse.Martin(2015)statedthathospitalized
patientswhoacquirednosocomialinfectionssuchaspneumonia,urinarytractinfections(UTIs),
orhaveexperiencedtragiceventssuchasshockorcardiacarrestwhileseekingcareinthe
hospital,isthedirectresultoflowstaffing.Thereisadirectcorrelationbetweenoverworked
nursingstaffandpoorpatientoutcomes.Fromtheextensiveresearchthathasbeenconducted,
theresproofthatidentifiesthatwithadecreaseinpatientspernurse,thepatientmortalityrate
wasloweredbymorethan50%(Martin,2015).Thehealtheffectsonpatientsthatcouldhave
beenpreventedwithanadequateamountofstaff,coststhehospitalalotofmoneytheyare
monetarilyresponsiblefor.MartinwroteAccordingtoStanton(2004),pneumoniaandpressure

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ulcersalonecosthospitalsmorethan$9billionayear.Whilehospitalsbelieveshortstaffingis
makingthebottomlinebetter,itispossiblycreatingamuchgreaterbudgetaryproblem(2015,
p.5).Hiringadditionalnursesmaycosttheagencymoremoneyupfront,butinthelongrun
wouldsavethemmoneybyhavinglesspatientmishaps.

AdverseHealthEffectsandNurseBurnout
Notonlyisthereagreaterriskforpatientmishapsandpatientdissatisfaction,nursesare
atriskofbecomingoverworkedbyhavingtoomanypatientsassignedtothem.Forinstance,
overworkingcanhaveadversehealtheffectsonthenurse.Workinginahospitalthatisunder
staffedordoesnothaveafacilityguidelinethatspecifiesasafeamountofpatientspernurse,has
notonlydisplayedanincreaseinnurseburnoutbuthashadadversehealtheffectsonnursessuch
aschronicfatigue,sleepdeprivation,andadeclineinworkperformance(Martin,2015).Nurses
whoareconsistentlyoverworkedbyhavingtoomanypatientsarenotgoingtobesatisfiedwith
theirjobs.Asanurse,wewanttofeelgoodaboutthecarewedeliver,butifwearentgiventhe
opportunity,wearentgoingtofeelsatisfiedwithourjobwhichwillleadtojobdissatisfaction.
Nurseswouldnotwanttocontinuewiththesamejobknowingtheywouldbeunhappyfrom
beingconstantlyoverworked.Whennursesareoverworked,theyareawaretheirpatientsarent
gettingtheattentionfromthemthattheyneed.Whiletheytrytodeliverthebestcarepossible,in
thebackoftheirmindliesthefearthatsomethingadversecouldhappenfromeitheranerrorwith
therushedcaretheyhadtogiveorbecauseofthecaretheydidntgivebecausetheydidnthave
time.Anursedoesnotwanttohaveontheirmindtheworrythatherpatientshealthisdeclining

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becausetheyarentgettingthenursingcaretheyneed.AccordingtoDouglas(2010),a
nationwidesurveyrevealedthat60%ofnursesseetheneedforimplementationofanurseto
patientratio.Whetheritshouldbemandatedbylaworthroughcollaborationoftheagencywith
thenursingstaff,theyacknowledgetheneedforasafenumberofpatientspernurse.Nursesare
directlyaffectedbytheirworkingenvironmentandbythenumberofpatientsassignedtothem,
thereforetheiropinionshouldbeconsideredinthefinaldecision.
AsMartin(2015)pointedout,ahighnursetopatientratioisdirectlyresponsiblefor
nursesjobrelatedburnoutandjobdissatisfaction.Healthcarefacilitiescanavoidpreventable
patientmortalityandlownurseretentionratesbyinvestinginRNstaffing(p.1).AsDouglas
(2010)statedtherearemanyfactorssuchasfinancial,availablenursingstaff,patientacuity,
etc...thatneedstobeconsideredbeforeimplementing.
Healthcarelaw
Anotherviewthatcouldbeconsiderediswhythestateshouldgetinvolvedinfacility
policychangesatall.Nursingstaffandadministrationcouldcollaboratetogethertodecideon
safenursingratiosthatworkforthespecificfacilities.Ifafacilityfailstomeetacommonground
however,thereshouldstillbeanationwidelawinplacetoensureissuesrelatedtohighnumber
ofpatientspernursewillnotoccur.
Therearemanyaspectsthatneedtobeconsideredwhenachangeisrecognizedand
decided.Factorsthatneedtobeconsideredarethenumberofpatients,numberofnurses,facility
settingandconditions,patientacuity,staffexperience,amountandskillmixofstaff,nurse
fatigue,patientandnursesatisfaction,safety,andfacilitybudgettoallowforsuchchanges.
Douglass(2010)pointedoutthebiggestissuewiththeselawsisbeingabletomeetthesetatall

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timesrequirement.Thehealthandphysicalandmentalneedsofpatientsareunpredictableand
constantlychanging,whichmaketherequirementunrealistic.Foralawtogovernanentirestate,
itwouldbemoreappropriatetorestateinawaythatallowsroomforcircumstancesthatdont
allowtheatalltimesapproach.
Amandatorylawwouldbeapositivemove,butasstatedabove,manyfactorsneedtobe
consideredfirst.Withthenumerousamountoffactorsthatarepartofthedecisionprocess,
Douglas(2010)foundthatmostnursesareagainstthelawmandatedratiopropositionbecause
theyfeelitshouldbeafacilitydecision.Theymaybeagainstastateenforcedlawbuttheyare
eagertoimplementafacilityregulatedpolicytoachievesafeandeffectivestaffing.Forexample,
a51ratiocannotbeexpectedtobeachievedsafelywhenapatienthasahighacuity.Therefore
apatientthatrequiresahigherlevelofcareneedstobeassignedanursewithadecreased
amountofpatientsforthatshift.Thisisanexampleofwhenafacilityisabletocometoa
decisiononastaffingpolicythatfitstheparticularinstitution,butastategovernedlawshould
stillbeinplaceforfacilitiesthatfailtocometoaunanimousdecision.
Conclusion
Thisissuchaprevalentissueinourhospitalstodaythatneedstoaddressedsotrained
nursesandhealthcareprofessionalscanbeproudofthecaretheydeliver.Poorstaffingdoesnt
onlyaffectthenurse,itaffectsallinvolvedinthehealthcaredeliveryprocess.Evidencesupports
theutilizationofanursingstafflaw,asevidencedbytheCAminimumnursingstafflaw,and
thereforeshouldbeadoptedbyallstatesnationwideforallhospitalstofollow.Thenumberof
patientsassignedtomedsurghospitalnursesneedstobecollectivelydecidedandmadea
mandatorylaw.Theutilizationofsuchstaffingpolicieswouldimprovethequalityofhealthcare

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byincreasingnurseandpatientsatisfaction,reducemishapsandpatientmortality,anddecrease
nurseburnout.

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