Patient to Nurse Ratio legislation and a little bit on APRN scope of practice

1. Staffing Ratios & APRN Practice

2. Does this Sound Familiar?
• “Bob is low-censused, but Jane just called
in sick. Now we’re expecting three new
admissions and that patient is coding.”
– You, the RN, are forced to put in extra work
– You fall behind, leave late, or make a mistake
– Then you’re blamed for not being efficient
• Before long, the RN is written up and is
looking for a new job… where the same
thing happens

3. US Legislation
• California is the only state with
comprehensive patient to nurse (PTN)
staffing laws that apply to all units
• Other states require hospitals to have
staffing committees responsible for
staffing
– IL, CT, NV, OH, OR, TX, WA
• Others considering legislation: DC, NY,
TX, FL, IA, MN
• (Nurse Staffing Plans & Ratios, 2014)

4. Significance of the Issue
• Reports showed that each patient added to RN workload
led to an increase in mortality by 7%, following common
surgeries
• Research also shows that increased RN levels led to a
decrease in mortality in patients who had an acute MI
• Mortality reductions associated with increased PTN were
most significant in hospitals that were already severely
understaffed
• Reduced workload led to higher staff retention and lower
turnover
– Leads to decrease in overhead and training costs
• (Aiken, et al. 2010)

5. Is it Cost-Effective Legislation?
• Hospitals complain about being already squeezed and adding another nurse
increases costs
• 8:1 PTN was associated with the lowest cost, but highest in mortality. Every
decrease in patient increment by one, led to lower mortality, but higher costs
• Cost associated with saving one life when PTN reduced to 7:1 was over
$45,000. Cost associated with saving one life when PTN reduced to 4:1 was
over $140,000.
• Research shows that lower PTN ratios does NOT save money, but costs
less than any other patient safety intervention
– For example, thrombolytic therapy or a PAP testing costs exorbitantly more
($180,000 per life saved and $430,000 per life saved, respectively) than reducing
staffing costs
– If a hospital decided, for economic reasons, to stop providing thrombolytic
therapy or PAP testing, physicians would never refer to that hospital.
– Lower PTN is a patient safety intervention, and when compared to other safety
interventions is actually still more cost effective.
• (Rothberg, et al. 2005)

6. The Quality of Care
• Physicians agree that deficient nursing staffing results in
decreased quality of care
• Staffing shortages led to RN burnout in 40% of hospitals
– Job dissatisfaction in hospitals is 4x higher than the average US
worker
– 1/5 nurses intend to leave their job
• Increased emotional exhaustion and increased job
dissatisfaction in nurses correlated with increased PTN
• 168 hospitals in Pennsylvania found:
– RNs in hospitals with 8:1 PTN were 2.29x more likely than 4:1
ratio to show emotional exhaustion and 1.75x more likely to be
dissatisfied
• (Aiken, et al. 2002)

7. NJ A2548
• Synopsis: New Jersey state assembly bill, introduced February 21,
2012, which institutes minimum RN staff standards for hospitals
and other healthcare facilities
• Highlights:
– 5:1 PTN medical-surgical units
– 4:1 PTN stepdown, telemetry, or immediate care
– 1:1 PTN for trauma services in the ED
– 1:6 PTN psychiatry units
– Facilities must utilize a staffing system to ensure appropriate staffing
• Desired outcome:
– Improved quality of care and improved patient safety via improved PTN
ratios
– This bill would be associated with improving access to care and the
costs mentioned earlier that are associated with PTN issues

8. S. 382- Improving Access to Care:
APRN Scope
• Synopsis: Senate bill, introduced February 26, 2013,
amends title XVIII (Medicare) to broaden PA, NP, & CNS
scope of practice
• Highlights:
– These clinicians can supervise cardiac, intensive cardiac, and
pulmonary rehabilitation programs
• Desired outcome:
– This bill would increase access to care for all patients, but
especially in rural areas, and addresses primary care shortage
– The bill would widen the scope of APRNs, giving them more
knowledge, more autonomy, and more respect in the healthcare
industry