State mandated safe staffing ratios are a mechanism designed to improve safety for patients and nurses.  Inadequate staffing endangers patients and contributes to employee turnover. As health care demands grow, adequate staffing will become increasingly important.
Sufficient staffing directly contributes to improved treatment outcomes and decreased operational costs. In addition, high-performing care facilities foster an ongoing culture based on improving services. As a result, safe staffing ratios have grown in popularity.
Safe Staffing in California
In 2004, California became the first state to enact nursing safe staffing ratio legislation. Prior to this, nearly a third of all nurses employed in the state experienced routine mental and physical exhaustion. As a result, many nurses were unsatisfied with their jobs.
After legislators enacted California safe staffing ratios, patient mortality events within thirty days of hospital admission decreased notably, and nurse-patient rapport improved significantly. Deaths during surgeries also decreased. Additionally, for each nurse added to the staffing pool, patients spent 24 percent less time in intensive care units and 31 percent less time in surgical units.
The safe staffing ratio law produced improvements in California long-term care facilities as well. Patients in these facilities experienced positive outcomes such as:
● Decreased urinary tract infections
● Fewer ulcers
● Reduced critical hospitalizations
● Reduced need for catheters
Clients who lived in these facilities also experienced less deterioration in their abilities to perform daily activities of living.
Safe staffing ratio laws could particularly benefit low-income populations. Care facilities that serve client populations consisting mostly of Medicaid recipients and uninsured consumers are more likely to exceed safe staffing ratios. These facilities expose consumers to increased risk.
Budget cuts and the growing medical personnel shortage force nurses employed at some facilities to work long hours and care for more clients, critically deteriorating patient outcomes. This circumstance compromises the recovery process and promotes employee turnover.
Health care facilities that maintain poor safe staffing ratios contribute to nursing work related sicknesses. Nurses working at understaffed facilities are at increased risk for:
● Cardiovascular disease
● Musculoskeletal injuries and disorders
In the United States, nearly 70,000 nurses suffer from nonfatal work injuries every year.
Some nurses must work three to four extra hours each day at understaffed care facilities. The long hours place tremendous strain on the heart. Over time, these circumstances lead to fatigue and burnout. The conditions might cause symptoms such as:
● Bad temper
● Increased blood pressure
● Increased weight
Each additional patient in excess of four per nurse increases these risks by an average of 20 percent.
Mandated Nurse Ratios
High burnout rates present among many working nurses in the United States. Unsafe staffing ratios result in diminished services and negative outcomes that might include:
● Heart attacks
● Medical errors
● Unintentional deaths
Each patient that a nurse cares for over the safe staffing ratio limit increases the chance of mortality by 7 percent. The most severely understaffed facilities report outcomes such as:
● Electrolyte imbalances
● Heart failures
● Respiratory infections
● Urinary tract infections
At these facilities, health aides might spend less than three hours per day with clients, and registered nurses might deliver services less than an hour a day, resulting in poor patient outcomes such as skin disorders, weight loss, and ulcers.
Researchers have not yet conducted complex studies regarding whether safe staffing ratios improve patient outcomes.  Additionally, some health care professionals share mixed feelings about the regulation. California Nurses Association representatives report that the law does improve conditions for patients and nurses. Furthermore, some health advocates share this opinion. However, representatives from the California Hospital Association report the safe staffing ratio laws place an unfair burden on employers.
The most difficult challenge for employers is maintaining regulatory ratios twenty-four hours per day with unpredictable patient volumes. In addition, if a nurse so much as takes a five minute break and available nurses fall below the mandated minimum, current regulations consider a facility out of compliance.
Further complicating the issue is that current California safe staffing ratio regulations require a minimum of one nurse for every four patients. Hospitals can only exceed this ratio during emergencies. Such restrictions contribute to excessive consumer waits, such as when unexpected patient surges occur.
For now, hospital administrators do their best to estimate safe staffing ratios based on historical patient volume. The way that legislators have structured the law offers no flexibility for emergencies. Despite these issues, most nurses support the legislation unequivocally, because it improves patient outcomes and working conditions. At facilities that do not implement safe staffing ratios, surveys have revealed significantly lower patient satisfaction compared to hospitals that do.
An Alternative to Mandatory Nurse-Patient Ratios
Health care advocates worry that a national safe staffing ratio law similar to California’s would spell disaster for the United States health care system.  As an alternative, they propose the nursing intensity billing model.
The payment model works with standard, existing medical financial coding. Using the codes, care provider organizations would request reimbursements based on the actual cost of delivering services rather than enterprise retail cost, a practice that would save insurers such as Medicaid significant expenses.
The nursing intensity billing model could transform billing practices from a system that calculates costs based on departmental pricing to one that tallies expenses based on the actual resources used to care for patients. This would also eliminate the practice of offsetting losses by charging paying consumers higher fees. Moreover, the new model would align care costs more closely with the most used health care resource in medicine – nursing staff.
Health care facilities have started to realize that safe staffing ratios can reduce treatment costs.  The savings in recovery time for injured nurses would save care provider organizations hundreds of millions of dollars every year. Ultimately, safe staffing ratios just might improve working conditions for all practicing nurses in the United States.
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