Nurse to patient ratios: lies, damned lies, and statistics.

The data is in. The fewer patients assigned to nurses, the better the patient outcomes. So why does Nevada, particularly Southern Nevada, have high nurse-to-patient ratios?

Some argue that it's all about the money. After all, it is logical that fewer nurses caring for more patients could yield higher revenue for hospitals. It can also ensure a cycle of repeat business by way of "frequent flyers." For example, a male patient is hospitalized to get a knee replacement. Because his nurse has ten other patients, the nurse is unable to adequately protect him from acquiring an infection. Thus, the patient must stay an extra few days for antibiotic therapy. He is rushed out of the hospital because of the HMO factor and receives little to no discharge teaching because the nurse is putting out fires for the other nine patients. The patient returns a week later with a bowel obstruction because he didn't understand that the pain killers he took home could cause constipation. So much agony could have been avoided if a nurse had had the time to adequately address his needs during his first admission.

So are high nurse-to-patient ratios about the money? Or is it unavoidable because of the highly publicized nursing shortage? Let's get right down to the stats.

The American Hospital Association (AHA) reported in April 2006 a national registered nurse deficit of 118,000 RNs "to fill vacant positions nationwide." (1) In the December 2003 issue of Health Affairs, distinguished nurse researcher, Peter Buerhaus, published interesting statistics supporting our nation's increased dependence on "foreign born" nurses. (2) However, this same data appeared to indicate a surplus of 600,000 registered nurses in the U.S., not working as nurses. A surplus of 600,000 nurses could well eliminate the AHA's reported 118,000 deficit.

When questioned by email about this surplus, Buerhaus responded, "There are roughly 500,000 individuals who are licensed to practice as an RN in the U.S. today, but who are not currently working." He then speculated that perhaps many of these nurses are retired, too old to work, independently wealthy, or have chosen to stay home with children. But nurses working in the hospital trenches of Nevada, where some of the highest ratios in the country exist, need not speculate why Nevada has the worst shortage of nurses in the country. To them the reason is: burnout.

Another argument challenging ratio enforcement is the hypothesis that ratios would be impossible to meet and would therefore cause hospitals to shut down. But according to Deborah Burger, President of the California Nurses Association, where mandatory ratios are in full force, "After many dire predictions about closing hospitals and wards by the California Hospital Association, there were in fact NO hospital closures let alone unit closures in California due to the ratios law. It is not just my wishful thinking but actual facts reported to the Department of Health Services."

Did California have an abundance of nurses to support mandated ratios? Before ratios were imposed, California ranked last in numbers of nurses per capita and Nevada ranked second to last. Today, California has increased its numbers of nurses per capita, now leaving Nevada in last place.

The California Nurses Association has embraced nurses is Texas and other States to help them achieve mandated ratios as well. In a report by The Texas Observer, "Even Schwarzenegger's office has acknowledged that California's law has produced some benefits. For one thing, it's lured thousands of nurses back to work, easing that state's shortage." (3)

How did the California Nurses Association manage to beat the odds and attain ratio legislation? Ms. Burger reports, "Since we left the ANA [American Nurses Association], we have accomplished more in the last 12 years than in the previous 50 years with ANA. Since then we have put forward safe staffing legislation (ratios and whistle blower protections) in Illinois, Maine and Texas. In all states, ANA has opposed the bill, but we are moving forward because nurses (just ask any traveler who has worked in California recently) know this will make a difference."

California has set the standard for hospital nursing care. There, medical-surgical nurses are assigned a maximum of five patients, while here in Nevada it is customary for nurses to have twice as many.

So the next time someone offers statistics supporting a particular view, recall what Mark Twain said, "There are three kinds of lies: lies, damned lies, and statistics."

(1) http://www.aacn.nche.edu/Media/FactSheets/NursingShortage.htm

(2) http://content.healthaffairs.org/cgi/content/abstract/22/6/191

(3) http://www.texasobserver.org/article.php?aid=2495

Lillian Gonzalez, BSN, RN

Las Vegas Agency Nurse

NurseLily@AnAmericanRN.com