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Better Nurse-to-Patient Ratios a Must for Psychiatric Hospitals

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Minnesota could be the next state to enact legislation that would ensure adequate nurse staffing in hospitals. Washington, D.C. is also making gains, if legislation introduced last week by D.C. Council Chairperson Phil Mendelson passes.

A recent article in the Washington Post recounts cheers when Mendelson's legislation was unveiled, largely due to the ongoing frustration and concern expressed by many nurses who work in D.C.-area hospitals. Mendelson's bill would mandate nurse-to-patient ratios (a certain number of nurses needed for a certain number of patients), which would increase quality of care for hospitalized patients, and improve the retention of nurses.

Illinois should pay attention to what is going on in Minnesota and D.C.

Mental health funding cuts in Illinois have not been good for state residents who seek help in hospitals or other institutional settings. The latest cuts coincide with the announcement that the U.S. Department of Justice is currently investigating Chicago-area psychiatric hospitals. Inpatient psychiatric units need to be adequately staffed with knowledgeable and experienced registered nurses and other mental health workers. Increasingly, they aren't, and this is cause for great concern.

I'm a psychiatric nurse who has worked when understaffed. I've tried to maintain a safe and effective environment when there were too few people at hand, and too many patients to care for. Persons who were depressed were left with no one to talk to; persons experiencing severe anxiety had to wait for requested medications, and persons experiencing frightening voices were forced to go through it alone. Too many psychiatric settings across the country have tried to cut costs by cutting nursing staff. Clearly, this is the wrong way to go. A further decrease in quality of care will only lead to an increase in adverse events -- inpatient suicides and suicide attempts, and violence.

In psychiatric hospitals, registered nurses are responsible for the safety and care of patients on a unit. Keeping patients from harming themselves or others is the basic responsibility, but actually providing care and treatment is what we have been educated and trained to do (and what is right).

Often, our time is simply spent monitoring and maintaining, and even that proves difficult when there are too few of us. In one example when I was working understaffed, a patient tried to hang herself by wrapping a shoelace around her neck and then tying it to the springs under her bed. Luckily, this person was found before it was too late. The fear of incidents like this will collectively resonate with inpatient psychiatric mental health nurses because, like me, they know that with fewer nurses on a shift, and with the overall acuity of today's inpatient psychiatric unit, these incidents are hard to prevent. But in trying, which all inpatient psychiatric nurses do, comes chronic worry and stress.

There are strikingly few safeguards in place to ensure that there are enough nurses to care for patients in inpatient acute care psychiatric units. Some states do a much better job with nurse-to-patient ratios. Most states do not have mandates or laws to ensure adequate staffing in hospitals. Unfortunately for nurses, hospital associations have strong lobbying groups that have fought hard against these mandates. Hospitals, squeezed by decreasing revenues from Medicaid, Medicare, and private insurance companies, try to recoup some of these losses by cutting nurses like me.

This does not happen in states that have mandatory staffing levels for nurses.

Some nurses are opposed to nurse-patient ratios because there are more variables to consider than number of nurses working and number of patients to be cared for. I agree that we should take into account more aspects of the work, such as how sick patients are, the number of projected admissions and discharges (which are time-consuming and take nurses away from the patients already on the unit), and the skill mix (number of RNs versus mental health workers). The educational level of RNs is also important -- hospitals that employ more nurses with a baccalaureate degree or higher have fewer adverse outcomes.

Psychiatric hospitals have staffing plans that are supposed to take these variables into consideration, but in all my years in psychiatric nursing, I have never seen one that actually worked. Few plans accurately reflect nurses' work and patients' needs.

Maybe a standard nurse-to-patient ratio is the way to go. It would certainly be better than what we have now. Patients on our inpatient psychiatric units deserve better than what we, given staffing cuts, are able to give. Psychiatric nurses want to provide quality care. They are often in positions that make this nearly impossible.

But in states such as California, where legislated nurse-patient ratios (California RN Staffing Ratio Law) have been in existence since 2004, studies show there is better job satisfaction and retention, lower patient mortality, and better quality of care.

California nurses are not in the clear. The California Hospital Association, with their longstanding disapproval of the law, is trying to chip away at the law to eventually overturn it.

I hope they do not succeed.

More patients and fewer nurses leads to poor(er) patient outcomes. Nursing professional organizations such as the American Psychiatric Nurses Association and others agree.

I hope that more states mandate safe nurse staffing levels, which means a minimum of one nurse to six patients on psychiatric units in California.

I wonder what the staffing ratio is on the psychiatric hospitals in the Chicagoland area that are currently under investigation. Probably not very good.

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