Do nurse/patient ratios work? Nurse/patient ratios have always been contentious. But the experience of two states--one Australian, one American--which have legislated nurse/patient ratios shows they have a positive impact on nurses' professional esteem and ability to give the patient care they want to provide, and on nurses' political savvy.

Nurse/patient ratios are not the panacea to all staffing woes but they do make a considerable difference to both patient safety and nursing morale. Nurse/patient ratios have always been driven by nurses' unions whose members have been committed to easing their workloads and thus improving patient safety. The Australian state of Victoria has had mandated nurse/patient ratios since 2001, thanks to intense industrial and political campaigning by the Victorian branch of the Australian Nursing Federation (ANF).

California's nurse/patient ratios have had a stormy passage from statute books to application. The California Nurses' Association (CNA) fought for nurse/patient ratios for a decade and the legislation introducing them was signed in 1999 but did not come into effect until 2004. They then survived an attempt to roll them back by Governor of California Arnold Schwarzenegger, thanks to a year-long, nationwide campaign mounted by the CNA.

NZNO has considered nurse patient ratios. In 2003, members at regional conventions throughout the country endorsed a staffing model which included nurse/patient ratios and the establishment of associate charge nurse positions. This was based on the Victorian model. In 2004 NZNO published a booklet, Nursing the System Back to Health, which outlined the case for nurse/patient ratios. (1) But hoped-for funding for a safe staffing pilot did not materialise, with the then Minister of Health Annette King opting to support a magnet hospital project instead.

Committee of Inquiry established

Subsequently, negotiations in 2004 for a multi-employer collective agreement coveting nurses and midwives in the country's 21 district health boards (DHB), explored the issue of nurses' workloads. But because of the enormity of the issue, NZNO and DHB New Zealand agreed to the establishment of a Committee of Inquiry into safe staffing and healthy workplaces. Its report is due out late next month.

Last month the 25,000 strong British Columbia Nurses' Union (BCNU) began wage negotiations and the union's claim included a nurse/patient ratio framework based on the work done in Victoria and California. Campaign officer with the BCNU Shirely Ross said nurse/patient ratios would be a "very sticky issue" at the bargaining table. There is considerable international evidence that nurse/patient ratios improve patient safety. Large scale research by renowned nursing workforce researcher Linda Aiken found that in a given unit the optimal workload for a nurse was four patients. Increasing the workload to six resulted in patients being 14 percent more likely to die within 30 days of admission. A workload of eight patients vs four patients was associated with a 31 percent increase in mortality. (2)

Another study showed that higher nurse staffing levels resulted in reduced numbers of urinary tract infections, pneumonia, upper gastrointestinal bleeding and shock in medical patients, and lower rates of "failure to rescue" and urinary tract infection in major surgery patients. (3)

Lower registered nurse (RN) staffing levels and poor organisational climate have been found to put nurses at greater risk of needle stick injuries. (3) So what is the experience of the two states that have mandated nurse/patient ratios? Victoria introduced ratios into public hospitals in 2001, a move credited with bringing around 6000 nurses back into the nursing workforce. But ratios were only introduced after a hard-fought battle, waged by the ANF against the Victoria State Government. The ratios formed part of the ANF's industrial claim in 2000 to the State Government. The campaign included the ANF being held in contempt of the Industrial Relations Commission, with the threat of imprisonment hanging over its then general secretary Belinda Morieson. The Government, wanting to avoid a major showdown with the State's 30,000 nurses, agreed to arbitration with a single Commissioner, a process in which parties could not appeal In August 2000 the Commissioner endorsed nurse/ patient ratios, which were phased in from January 2001. The Government funded an advertising campaign to attract nurses back to nursing, and funded nursing refresher and re-entry programmes--keys to the success of the ratios, according to state secretary for the ANF in Victoria, Lisa Fitzpatrick. She believes New South Wales' unsuccessful attempt at introducing ratios foundered because no attention was paid to these aspects.

Flexibility within ratios

Victoria's ratios were decided on by charge nurses. Within the ratios, charge nurses have flexibility in allocating workloads, taking into account skill mix and patient acuity. In large metropolitan and country base hospitals, the ratios in general and medical/surgical wards are 1: 4 plus the charge nurse on morning shifts; 1: 5 plus the charge nurse on afternoon shifts and 1: 8 on night shifts.

But the ANF has had to be vigilant in maintaining the legislated ratios. 2004 was devoted to retaining the ratios after the State Government launched a bid to remove them. "You'd think the State Government would have got the message by now that nurses want to keep the ratios," Fitzpatrick said.

The ANF's subsequent industrial campaign in support of ratios featured 13,000 bed closures in the public health system over two weeks. The ANF also commissioned research from Sydney University in 2004, which revealed that removing the mandated nurse/patient ratios in hospitals in Victoria would lead to an exodus of nurses from the health system. The study by the Australian Centre for Industrial Relations Research and Training found that more than half of Victoria's aging nursing workforce would consider quitting, retiring early or cutting hours if the ratios were abolished. Ninety percent of nurses were convinced ratios were essential for managing their workloads. (4)

But independent research from Monash University on a patient dependency system (PDS) pilot, agreed to at the 2001 negotiations, was challenged by the ANF. Among the findings of this research were that the ability of the piloted PDS to adequately capture the acuity of particular patent groups was rated as "sometimes" to "most of the time" by around two thirds of the respondents. (5) It was reported to reflect the staffing needs of nurses' patient care area "sometimes" to "most of the time" by 63 percent of the respondents. (5) The PDS was TrendCare. Fitzpatrick described the executive summary of the Monash research as "a very hot potato" and said that a rating of "sometimes" in the crucial areas of acuity and staffing needs was "as every nurse knows, simply not good enough". ANF, after studying the research, published its own executive summary. This pointed out that 77.1 percent of respondents said Trendcare consistently suggested less time than needed in practice, and that 81.6 percent of respondents said Trendcare "never" or "rarely" or "sometimes" reflected staffing needs. Close to 81 percent of respondents did not believe Trendcare measured their workload accurately "often" or "most of the time". (6) The ANF believed any trial of Trendcare should include comparisons with nurse/patient ratios but the State Government's Department of Health Services refused to allow this. (6) "But in the trial, nurses made it clear they were not going to accept a PDS and that they wanted ratios," Fitzpatrick said.

Ratios not improved

The ANF's campaign was successful in retaining the ratios for another three years, ie until the next round of bargaining in 2007. But many nurses were disappointed the ratios had not improved, particularly in post-natal areas and that other aspects of the ratios had not been addressed, Fitzpatrick said.

There was no doubt ratios had eased "crushing nursing workloads" and improved recruitment and retention. "Government figures show that in the five years since the introduction of ratios, there are 6000 more nurses in the system. At major metropolitan hospitals, vacancies have dropped from between 150 to 200 full-time equivalents (FTEs) to 50-60 FTEs, and retention rates have been very impressive across the state," Fitzpatrick said.

Research was about to begin on patient morbidity and mortality rates before and after the introduction of ratios, she said.

There was no doubt that ratios had improved nurses' professional self esteem. "Nurses feel better because they can give better care. A number of nurses who left private hospitals--where the ratios do not apply--when the ratios were introduced have spoken out favourably on ratios," Fitzpatrick said.

Australian research released last year showed hospitals could save money, improve patient care and allocate fairer nursing workloads if they fostered nurses according to patients' needs instead of by ratios. (7) Monash University researcher, Virginia Plummer, from the School of Nursing and Midwifery, completed a study of almost two million nursing hours in Australia and overseas. The study involved measuring the allocation of nursing resources in hospitals and found that, in many instances, TrendCare, an Australian computer system that allocates nurses across wards depending on patient needs, better met the needs of hospitals. "Under the TrendCare system there is a closer correlation between the needs of a patient and the care provided," Plummer said.

But Plummer said the introduction of nurse patient ratios in Victoria had allowed nurses to regain confidence and control over their working conditions and this had resulted in a stabilisation of the Victorian public hospital system.

Fitzpatrick dismisses this research, saying it deliberately excluded nurses in Victoria, with Queensland the only Australian state involved. Some New Zealand and some Thai hospitals were included in the research, she said.

Fitzpatrick rebutted claims by employers that there was no flexibility within the ratios and that ratios provided nurses when they were not needed. "The bean counters have no appreciation of the care required for the patient in the bed. They think that unless a nurse is busy doing physical tasks, she is not nursing and should not be on the ward. It is important to understand that in a 20-bed unit with five nurses, it doesn't mean that each nurse will be caring for four patients. One nurse may be caring for two acutely ill patients, while another cares for six who are not so sick. There is flexibility according to acuity," she said.

The ratios had played a part in boosting ANF membership, she said, which over the last decade had increased by 1500 every year and now stood at 42,000.

California's nurse/patient ratio legislation was signed into law in 1999, to come into effect on January 1, 2001. Subsequent legislation extended the deadline to January 1, 2002. The Department of Health Services (DHS) was charged with developing the actual ratios and they finally became effective on January 1, 2004. The ratios vary by unit but examples include: 1:5 for medical and surgical units; 1:4 for paediatric units; 1: 4 for step down units, dropping to 1:3 in 2008; 1: 5 in telemetry, dropping to 1: 4 in 2008; 1: 4 in emergency rooms (ER) but 1: 2 for intensive care patients in the ER and 1: 1 for trauma patients.

The ratios apply in all hospitals, both public and private, but there are a few exceptions for small rural facilities. As CNA president Deborah Berger states "all hospitals, all shifts, at all times, including meal and break times". A competent charge nurse, RN manager or break RN must relieve an RN during their breaks. The ratios are enforced by nurses themselves and by the DHS.

In November 2004, just two days after President' Bush's re-election, the Republican Scharwzenegger, signed an emergency order suspending key portions of the ratio law. When nurses protested he described them as "special interests"--and galvanized an army of nurses into opposing him. Berger was not surprised at the intensity of nurses' response to Schwarzenegger's comments--"they were irate"--but the reaction of patients did surprise her. "They were even more irate than the RNs."

Between November 2004 and November 2005, a total of 10,000 nurses attended more than 107 rallies in California, Ohio, Massachusetts, Washington DC and New York, protesting at almost all of Schwarzenegger's fund raisers, eventually derailing his plans to roll back ratios. The nurses' protests also halved Schwarzenegger's approval ratings which stood at 70 percent before the campaign." Nurses stood up to Schwarzenegger because they were shocked and outraged that they'd worked for ten years to be able to finally provide good nursing care to all their patients and he took it away on a whim," Berger said.

The key to the success of the campaign to maintain ratios in the face of the Governor's attack was keeping nurses and communities involved, and being very creative in the themes of the various rallies in order to capture the attention of the media and the public. "I think nurses knew who they were and what their value was--they were just despondent or depressed over the value corporations placed on the nursing profession. They finally became angry and ready for action. That was never more evident than at the rallies," Berger said.

The nurses also formed alliances with other workers, notably teachers and firefighters, as Schwarzenegger attempted to erode public employees' rights.

Berger believes there will be further attempts to roll back the ratios "but now that nurses have experienced the way things should be, they will always fight to keep them. We are even including ratios in our contract negotiations".

Berger said nurses had returned to the workforce with the introduction of the ratios. "We have exceeded the projections by the DHS in terms of numbers of nurses needed to fulfill the ratios mandate. Hospitals that had been staffing to the ratios, even before the mandate, have experienced a dramatic decrease in turnover and have improved recruitment.

It would be interesting to do a study to see if workplace injuries had decreased as well."

Nurses' political awareness has also increased. "At each of the 107 rallies we didn't just highlight that Schwarzenegger was rolling back ratios but also who he was taking money from. Large hospital corporations are among his biggest political donors."

The CNA, with a membership of 65,000 in California and Illinois, is now working with nurses in other states to get ratios in place nationwide. Berger, an RN with 32 years' experience, has been CNA president for three years. Her involvement with CNA began after her husband died unexpectedly. "I had requested some time off and it was denied, with the employer stating I needed a better reason. The CNA stood up for me to make sure I got the time off I needed to deal with my loss."

She pays tribute to CNA's executive director of 20 years, Rose Ann DeMoro. "Without Rose Ann, at the helm our very successful journey would not have been possible. People are committed to CNA and Rose Ann because she does truly talk the talk and walk the walk. Not many union leaders do this today. Most want to work more with the employer, than on behalf of the employee and the community," she said.

DeMoro had, over the last 20 years, attracted the "most creative, talented and progressively committed staff to work for CNA".

In the last decade, the time of the fight for ratios, CNA membership has almost quadrupled from 17,000 to 65,000. Both a union and professional organisation, the CNA is by far the biggest nurses' organisation in California, which has around 297,000 licensed nurses.

Nurses' political awareness, honed during the ratios fight, is now being harnessed for the CNA's next major campaign, a clean money initiative, calling for publicly funded political campaigns and single payer health care, first in California and then nationally. And the CNA is working towards becoming a US-wide organisation.

References

(1) NZNO (2003) Nursing the system back to health: Nurse to patient ratios. Wellington: NZNO.

(2) Aiken, L., Clarke, S., Sloane, D., Sochalski, J. & Silber, J. (2002) Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction. JAMA; 2002; 288: 1987-1993.

(3) International Council of Nurses. Fact Sheet--Nurse: Patient Ratios. http://www.icn.ch/matters_rnpratio.htm. Retrieved 9/03/06.

(4) Medical News Today (2004) Nurse exodus warning over patient ratios. http://www.medicalnewstoday.com/medicalnews.php?newsid=6853. Retrieved 09/03/06.

(5) School of Nursing, Monash University (2004) Patient Dependency System Pilot Evaluation: A report prepared for the Department of Human Services, Victoria. Melbourne: Monash University.

(6) Australian Nursing Federation (Victoria Branch) (2004) Patient DependencE System Pilot Evaluation: A report prepared for the Department of Human Services, Victoria. An ANF (Vic Branch) Alternative Executive summary. Melbourne: ANF.

(7) Medical News Today (2005) Making the most of our most precious nursing resources. http://www.medicalnewstoday.com/medicalnews.php?newsid=34663. Retrieved 09/03/06.