On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.99 n.8 Cape Town Aug. 2009
Legislating for nurse/patient ratios 'clumsy and costly' experts
Four hands-on nursing experts say legally enforceable nurse/patient ratios being lobbied for by South African nursing unions would be too costly and clumsy and could end up being detrimental to patient care.
Instead they say 'activity based' guidelines aimed at developing sufficient ward-appropriate competence levels, currently being developed by the national health department for 'discussion' by December, would make a more profound difference.
The experts are Netcare's Group Nursing Manager, Eileen Brannigan, her MediClinic counterpart, Estelle Jordaan, the Gauteng health department's standards compliance chief, Dr Sue Armstrong, and international patient/nurse ratio researcher, Christine Zondagh, of Charisma Nursing Solutions.
They were responding to the unions' attempt to relieve pressure cooker working conditions for a thin and increasingly ageing nursing population.
Veteran trade union, Solidarity, and the Democratic Nursing Organisation of South Africa (Denosa) are punting flexible but legally enforceable nurse/patient ratios to reduce 'burn-out' resignations, to reverse nurse emigration trends and to boost training outputs.
The unions differ in approach, both wanting legislation that would enable them to hold government more accountable, but with Denosa arguing that the country's disease profile was too dynamic for 'simplistic one size fits all' legislation.
In a report released to coincide with National Nursing Day (6 May) this year, Solidarity pleads for a pilot project for nursing ratios based on Australia's Victoria State model where ratios are individually tailored to hospitals.
It says the local combination of a high disease burden, higher population growth than nurse numbers growth, ageing nurses and 'possible maladministration' of public hospital funds leads to a vicious circle where disease burdens increase because of inadequate care.
As the disease burden increased more people became dependent on hospitals and the nurses' workload became heavier 'a reflexive cycle that has to be broken'.
Solidarity said that in Victoria flexible but legally enforced nurse/patient ratios were credited with bringing 6 000 nurses back to active practice.
'In South Africa we could do this based on relevant factors like location, population density and typical caseload.'
Legislation backfires in USA
The Victorian model of having the in-charge nurse 'floating' to be able to deal with emergent situations also led to better adaptability. A more rigid nurse/patient model introduced in California led to the closure of some private hospitals because they could not operate at the legally required levels, prompting fierce debate. It also led to perversities in emergency rooms where patients with immediate life-threatening conditions and/or trauma were turned away or told to wait because admitting them would cause a lapse in ratios. Solidarity conceded that more research was required on this, but emphasised that the number of active registered nurses in California increased by more than 10 000 per year as opposed to 3 000 per year before ratios became law.
The state recorded a 45% increase in new registered nurse graduates within 6 years of ratios becoming compulsory.
In both California and Victoria there has been a reversal of nursing shortages, emigration trends and nurses withdrawing from active practice.
Solidarity recommended that individual hospitals 'seriously consider' implementing their own ratios voluntarily.
Thembeka Gwagwa, General Secretary of Denosa, warned that any new law had to take into account disease patterns, especially since HIV/AIDS had reversed the nursing needs of medical wards when compared with traditionally higher care wards.
She blamed the SA Nursing Council's 'unreliable data' that overestimated the number of practising nurses for a historically lax government approach to training.
Christine Zondagh, whose international research on nurse/patient ratios forms the basis for much of Solidarity's proposal, told Izindaba that no legislative model could compensate for South Africa's current nurse shortage.
'We can only train, train, train, task shift and supervise with registered nurses the private sector has already dramatically increased training output and the public sector is starting to. Maybe we need to look at core minimum staffing levels,' she suggested.
She revealed that about 27 states in the USA had nurse/population ratio laws, with California's 'starting ratio' being 1 registered nurse for every 4 patients.
'We'd never be able to do that in South Africa. It's over the top. We have to take into consideration the shortage of registered nurses and look at task shifting, with registered nurses supervising.'
Zondagh considers a 'fair ratio' to be 1 nurse (not necessarily a registered nurse) for between 6 and 8 patients needing acute care.
She said there was incontrovertible evidence that, as soon as the ratio of nurses to patients increased, mortality rates declined. Her own research showed that private hospitals in South Africa generally checked their nurse to patient ratios 'about 2 - 3 times a day', but public sector practice remained hugely under-investigated.
Estelle Jordaan of MediClinic said her group worked on 1 nurse to 3.5 patients (medical wards) and 1 nurse to 3.2 patients (surgical wards), with about 1 registered nurse to 9 patients. The skills split was one-third registered nurses, one-third enrolled nurses and one-third nursing auxiliaries. All the key drivers of patient activity were loaded onto a software programme that produced a read-out of required staffing levels which were then subject to professional judgement. The most time-consuming tasks included admission, discharge, pre- and post-surgery tasks and transfers, with patients scored as 'major, moderate and minor' and weighting attached according to the ward or unit they were in and their actual condition.
After an ambitious recruiting foray in India, MediClinic was now about 20% short of desired nursing levels.
Sue Armstrong, who holds a doctorate in quality assurance (nursing) and serves on the national health department's nursing strategy task team, said every hospital unit manager should know how many nurses they need per shift.
'We (the national task team) are going about it the long way round but we think it's the right way to do it. We're hoping to have something for discussion by the end of the year so people can get their teeth into it and start shaking it.'
Brannigan said ratios should only be used as a guideline to determine shortages, training needs and what the cost of a service should be.
'You can't have one breaking the law because you can't implement it, just as you can't close a ward because you can't find a registered nurse.'
Rather focus on skills mix
She said the pragmatic debate was 'about the skills mix and staffing norms'.
'In other words how many hours of care do various patients need per day and what ratio of registered nurse to auxiliary nurse and auxiliary nurse assistant should that be?'
She said ratios were 'something one works towards'.
'We just don't have the nurses to indulge in this kind of luxury in South Africa. But we do need employers to commit themselves to try and achieve certain ratios.'
Brannigan, who also serves on the national nursing task team, said the team's work so far indicated that 'a lot of posts traditionally registered nurse could be done by others so they can get on with the real job you cannot allow patients to deteriorate just because you can't achieve some legislated norms'.
Around 44% of nurses work in the ailing public sector.
In public hospitals ratios range from as high as 1 nurse per 18 patients to as low as 1 in 44, with anecdotal evidence from the Eastern Cape suggesting that it has reached 1:50 in some general wards and 1:10 in some postnatal wards.
Solidarity's Research Institute says that at 1:18 a nurse has 3 minutes out of every hour to care for each patient, perform routine tasks and handle any possible emergency. This is excluding paperwork, stocktaking or other administrative jobs.
Another major stressor is the 'spike' in nurse/patient ratios near the end of shifts, caused by some nurses' dependency on public transport and their leaving up to an hour early to ensure they catch a taxi, bus or train.
Solidarity says this leads to those 'unfortunate enough' to possess their own transport having to take up the slack at the end of each shift.
Frustrated patients abusing nurses
The low staffing levels also mean that patient waiting times dramatically increase the chances of verbal abuse and violence towards nurses, especially with South Africa's high rate of injuries sustained in drunken brawls.
Latest (2008) South African Nursing Council population-based figures reveal a current ratio of 1 registered nurse for every 550 people (taking into account the 18% of nurses registered but not practising, reported by a 2004 HSRC study).
When one divides registered nurses by the country's refugee and illegal immigrant-boosted population (a conservative 55 million according to some international agencies, not the StatsSA population figure of 48.7 million), the ratio leaps to 1 registered nurse per 621 people.
Solidarity cited a 2008 study commissioned by the Critical Care Society of South Africa (CCSA), which revealed that three-quarters of the 448 ICU nursing managers, but only one-quarter of their subordinates, had ICU training. Just 3.8% of nurses had neonatal intensive care training. The CCSA says that nurses working in these understaffed wards have a higher probability of burnout and making fatigue-related mistakes. Inexperienced care workers often carry out tasks well beyond their scope of practice, meaning that when a mistake leads to a patient's death or impacts negatively on their health, the care worker or supervising nurse is often unfairly blamed.
When it comes to training, Solidarity said the 'best case scenario', using conservative official population estimates, put the number of registered nurses per capita at having increased by just 2.5% over the past decade.
It 'hardly inspired confidence' when a provincial health department (Gauteng) declared a 'hiring freeze' in public hospitals, while almost 9 000 positions for nurses remained unfilled. The Free State last year discharged all public sector patients except those in high care because of 'financial difficulties'.
The stressful working environment meant young nurses were leaving the profession in droves, as evidenced by 74% of the country's registered nurses now 40 or older and just 3% younger than 30.
With nursing college drop-out rates at around 75%, it was imperative that not just more people began studying nursing, but that prospective nurses were assessed competent enough to qualify.