Staffing Ratios and a little about APRN scope

1. Staffing Ratios & APRN Practice
Mohamad Ata, MS RN
Rush University Medical Center
02/01/2015

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 S. 1257- PTN in New Jersey
• Synopsis: New Jersey state assembly bill, introduced January 30,
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
• (S. 1257, 2012)

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
• (S. 382, 2013)

9. Reference List
A bill to amend title XVIII of the social security act to allow physician assistants, nurse practitioners,
and clinical nurse specialists to supervise cardiac, intensive cardiac, and pulmonary
rehabilitation programs, S. 382, 113th
Cong. § 1 (2013)
Aiken, L., Clarke, S., Sloane, D., Sochalski, J., & Silber, J. (2002). Hospital Nurse Staffing and
Patient Mortality, Nurse Burnout, and Job Dissatisfaction. JAMA: The Journal of the
American Medical Association, 288(16), 1987-1993.
Aiken, L., Sloane, D., Cimiotti, J., Clarke, S., Flynn, L., Seago, J., ... Smith, H. (2010). Implications Of
The California Nurse Staffing Mandate For Other States. Health Services Research, 904-
921.
Establishes minimum registered professional nurse staffing standards for hospitals and ambulatory
surgery facilities and certain DHS facilities. S. 1257, 112th
Cong. (2012)
Nurse Staffing Plans & Ratios. (2014, December 1). Retrieved February 1, 2015, from
http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/State/Legislative- Agenda-
Reports/State-StaffingPlansRatios
Rothberg, M., Abraham, I., Lindenauer, P., & Rose, D. (2005). Improving Nurse-to-Patient Staffing
Ratios As A Cost-Effective Safety Intervention. Medical Care, 43(8), 785-791.

10. Reference List
A bill to amend title XVIII of the social security act to allow physician assistants, nurse practitioners,
and clinical nurse specialists to supervise cardiac, intensive cardiac, and pulmonary
rehabilitation programs, S. 382, 113th
Cong. § 1 (2013)
Aiken, L., Clarke, S., Sloane, D., Sochalski, J., & Silber, J. (2002). Hospital Nurse Staffing and
Patient Mortality, Nurse Burnout, and Job Dissatisfaction. JAMA: The Journal of the
American Medical Association, 288(16), 1987-1993.
Aiken, L., Sloane, D., Cimiotti, J., Clarke, S., Flynn, L., Seago, J., ... Smith, H. (2010). Implications Of
The California Nurse Staffing Mandate For Other States. Health Services Research, 904-
921.
Establishes minimum registered professional nurse staffing standards for hospitals and ambulatory
surgery facilities and certain DHS facilities. S. 1257, 112th
Cong. (2012)
Nurse Staffing Plans & Ratios. (2014, December 1). Retrieved February 1, 2015, from
http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/State/Legislative- Agenda-
Reports/State-StaffingPlansRatios
Rothberg, M., Abraham, I., Lindenauer, P., & Rose, D. (2005). Improving Nurse-to-Patient Staffing
Ratios As A Cost-Effective Safety Intervention. Medical Care, 43(8), 785-791.