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How Many Patients Should a Nurse Care For?

Nurses are responsible for their patients. Should there be a maximum on how many they care for at once?

Several Illinois lawmakers want to improve patient outcomes through legislation that would limit the number of people nurses can care for at any given time

The Illinois Nursing Association said the bill will improve results for both  patients and nurses who are overworked.

Alice Johnson, the executive director for INA, said that the more patients nurses have, the less likely they are to catch mistakes, and the risks for patients experiencing complications increases.

“The body of evidence shows that safe patient-nurse ratios is better for patients,” she said.

A study done by the Illinois Health and Hospital Association, which is opposed to this legislation, estimates the staffing requirements would drive up healthcare costs by $2 billion per year.

Johnson said the staffing costs would be offset by long-term savings from reduced patient readmissions, lower nurse turnover, and fewer injuries to nurses.

Johnson also believes the legislation would help reduce the nursing shortage.  She said nurses who have left hospital positions would be more likely to return to the field with these kind of limits in place, and people would be more likely to consider nursing as a profession.

The limits set in the Safe Patient Limits Act vary by the type of care needed. A nurse working in pediatrics would have a maximum of  three patients, for example, while a nurse in an intensive care unit would only have two, and an acute rehabilitation nurse could have up to four, according to the proposed legislation.

Current law does not mandate how many patients a nurse can care for. Hospitals are required to have a nursing care committee that develops a staffing plan. Fifty percent of the members of those committees must be nurses who provide direct patient care. Hospitals are also required to have a plan that allows staffing to be adjusted based on the severity of patients.

But Johnson said surveys done by her organization show many nurses aren’t even aware these committees exist.

It’s also difficult to determine exactly how many patients the average nurse cares for because hospitals aren’t required to track patient ratios and they can vary widely from hospital to hospital.

“Currently, I’ve heard of nurses having as many of 12 patients assigned to them,” she said. “Which is very unsafe in a medical surgical unit.”

While sponsors of the legislation say it’s intended to help patients, the Illinois Health and Hospital Association opposes it, calling it unnecessary.

Danny Chun, a spokesperson for the organization, said hospitals need flexibility to assign nurses to different areas based on patient needs.

“It will not improve care or quality,” he said. “On the surface, it sounds good but when you actually look at the details of how it would work there are all kinds of problems.”

He pointed to the fact that hospital care teams include more than just registered nurses, and that other licensed professional nurses and certified nurses assistants also help provide care.

Chun added that implementing the bill would also be expensive, which could hit rural hospitals especially hard.

“It’s not feasible. It’s not necessary. Our quality is good with the nursing staff we have now,” said Randy Dauby, CEO of the Pinckneyville Community Hospital District, located in Southern Illinois.

He also noted that while hospitals are graduating nurses as quickly as they can, Illinois still can’t train enough nurses to meet demand. He worries  this law would lead to large hospitals raising salaries and offering bonuses to recruit nurses, at the expense of smaller, rural hospitals that would not be able to compete.

Dauby said nurse staffing needs to remain flexible, allowing nurses to move between areas as patient needs demand.

California is the only state that has mandated nurse staffing ratios. Chun pointed to several studies that indicate staffing mandates don’t result in improved outcomes.

However, other studies do show a link, including those conducted by the Agency on Healthcare Research and Quality, the federal agency tasked with examining the nation’s healthcare systems. Those studies conclude that patients are at greater risk of death and other complications as the number of patients per nurse increases.

A report from the Illinois Economic Policy Institute suggests the ratios proposed in the bill would improve patient outcomes and help retain nurses. Insufficient staffing levels and high patient to nurse ratios, in addition to workplace violence, are cited in the report as factors that lead to an estimated 30% to 50% of all new registered nurses changing positions or leaving the field within the first three years of their practice.

Lawmakers have until the end of this month to vote on the bill.

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