Hospitals over-crowded, under-staffed

Research has demonstrated a clear relationship between inadequate nurse staffing and poor patient outcomes

The premiers health care innovation working group released its first report last week to polite applause. Baby steps, low-hanging fruit, motherhood and apple pie are all words that have been used to describe the initial efforts of premiers to collaborate on health care without Ottawa herding the cats.

Those of us clapping loudly are trying to blow some air on this spark of pan-Canadian collaboration so that health care improvements do catch fire across the country.

Nurses know changes are needed. Hospitals across the country are at overcapacity. A generally accepted standard of safe hospital occupancy is 85 per cent yet most hospitals are working at a 100 per cent or more. The results of overcrowding include compromised care, high rates of hospital acquired infections and unnecessary rates of hospital readmission. Another result is dangerous levels of workload, and the resulting vicious circle of working short.

Nurses are twice as likely to be ill or injured than workers in any other occupation. Public sector nurses worked the equivalent of 11,400 full-time equivalent positions in paid and unpaid overtime in 2010. Twenty per cent of nurses in the hospital sector leave their jobs annually, costing a minimum of $25,000 per nurse as a result of the transition. Workload is often cited as a key factor in turnover.

Two decades of national and international research have consistently demonstrated a clear relationship between inadequate nurse staffing and poor patient outcomes, including increases in mortality rates, hospital acquired pneumonia, urinary tract infections, sepsis, hospital acquired infections, pressure ulcers, upper gastrointestinal bleeding, shock and cardiac arrest, medication errors, falls, failure to rescue and longer than expected length of hospital stay.

The link between nursing workloads and patient safety is as clear in long-term care as it is in acute care. The more direct nursing care the better the resident outcomes, including lower mortality rates, improved nutritional status, better physical and cognitive functioning, lower urinary tract infection rates, fewer incidents of pressure sores, and fewer hospital admissions.

This evidence linking working conditions to care conditions can no longer be ignored. Safe staffing must be made one of the Premiers’ guiding principles for health human resource management. Sadly, the word patient does not appear in the health human resources section of the innovation working group’s first report, but it is patient safety that must drive staffing decisions.

Three decades of a "silo" approach to health human resources planning has left health care workers and health care budgets on a roller coaster. Safe staffing goes beyond scopes of practice and team-based care — although both are part of addressing dangerous workload. The premiers health care innovation working group must work with provider associations, unions and employers in its next phase of its consultation. Saskatchewan Premier Brad Wall, co-chair of the working group, has a home-grown model to share — a partnership agreement between the Saskatchewan Union of Nurses and the government of Saskatchewan with the addition of regional health authorities, aimed at achieving safe levels of staffing for patients.

Some jurisdictions, notably California and Australia, have legislated mandated staffing ratios as a way of addressing nursing workload. Emerging research has associated mandated nurse patient ratios with improved patient outcomes and even financial savings to the health system by decreased lengths of stay, adverse events and reduced turnover.

Governments should commit to achieve safe staffing across the continuum of care. Data on adverse events should be linked with data on workload and staff mix to assist decision-makers to improve working and caring conditions.

Safe staffing as a guiding principle and a measurable outcome in health care would be a bold step for governments, and a giant step for Canadians.

Linda Silas is President of the Canadian Federation of Nurses Unions.