All RNs All the Time: Wave of the Future?

February 11th, 2012


By , BSN, RN

When I was a traveling nurse, whenever I started a new assignment, one of the first things I judged at my new hospital was the quality and quantity of the nursing assistants. They could make or break my assignment. It was the CNAs, PNAs, or simply NAs who knew all the stuff I needed to know, where everything was kept, and who to avoid. I valued their assistance and their knowledge. Facing facts, RNs were usually in short supply and the NAs made all the difference in a successful day. What would you do without them?

Well, one hospital in Pennsylvania is in the process of finding out how it works without nursing assistants. Hahnemann University Hospital, in Philadelphia, is going to an all RN nursing staff; no more nursing assistants.

In an article in the Philadelphia inquirer, the hospital’s chief executive officer, Michael Halter, has said he thinks the long term results of going to an RN only nursing staff will net the hospital more money, more clients and create a more loyal staff. Halter noted a pilot study from just one of the hospital’s nursing units found that using all RNs, instead of a combination of nurses and nursing assistants, produced results showing higher-quality care and improved patient and nurse satisfaction.”


This really is merely an echo of study after study that has proven the relationship between nurse staffing and quality of patient care. In fact even the U.S. government backs Halter’s assertions with studies of its own. In March of 2007 the Department of Health and Human Services surveyed published research across the nursing spectrum to assess how nurse/patient ratios were associated with outcomes in acute care hospitals.

Researchers found that hospitals with higher RN staffing were associated with lower hospital-related mortality, less failure to rescue, cardiac arrest, hospital-acquired pneumonia, and other adverse events. Another result of having more registered nurses was better a higher level of patient safety particularly in intensive care units (ICUs) and in surgical patients. Also, more direct patient care performed by RNs instead of NAs was associated with decreased risk of hospital-related death and shorter lengths of stay.

Similar studies have been done in other countries with the same results. Last year, in Great Britain, researchers surveyed 400 wards across more than 46 hospitals showing the impact of reducing numbers of registered nurses and substituting healthcare assistants. RNs taking part in the reduction of nursing workforce reported more falls, more urinary tract infections, and more pneumonia in patients on the wards.

Peter Griffiths, Southampton University professor of health services said, commenting on the study, “This shows there are consequences for reducing the registered nurse workforce. It strongly suggests that the push to substitute nursing aides for registered nurses as a cost saving measure is unlikely to achieve adequate quality of care.”

And this is not a new conclusion, either. In 1978 in the journal Hospitals a research study was published that began with this abstract: “The emphasis on cost containment and consumer satisfaction has spurred a new upsurge in interest in all-RN nursing. Data are mounting that show that an all-RN staff doesn't necessarily cost more and that its use markedly improves the quality of patient care. Although obstacles to implementation exist, they are not insurmountable, and nurse leaders are asking, "Why not?"

Sound familiar?

What About the Bottom Line?

So, research has shown greater patient and nursing satisfaction when units or facilities go to an all RN approach to patient care. And, research shows better health and greater patient safety in units and facilities that employee an all RN nursing staff. On top of that there is the bottom line. Nurses may be more expensive than nursing assistants but if patients are getting better care and staying healthier that is cost effective. Particularly since Medicare and Medicaid stopped paying for hospital acquired illnesses and infections.

Beginning in October 2008, Medicare began a program where they would no longer pay for treatment of certain hospital acquired conditions (HACs). The changes surround the identification of certain conditions that can be “reasonably prevented” in the acute care setting. Therefore, if any of these conditions are acquired or in certain cases exacerbated during a hospital stay, the hospital will not receive payment for the care and treatment of that condition. The Centers for Medicare and Medicaid Services (CMS) selected 10 categories of conditions that fall under the HAC payment provision. Included in those 10 conditions were:

  1. Foreign object retained after surgery
  2. Air embolism
  3. Stage III and IV Pressure Ulcers
  4. Blood incompatibility
  5. Falls and trauma
  6. Manifestations of poor glycemic control
  7. Catheter associated urinary tract infection
  8. Vascular catheter associated infection
  9. Surgical site infections following specific surgeries
  10. Deep vein thrombosis (DVT)/Pulmonary Embolism (PE)

CMS specifically looked at conditions that are:

  1. High cost, high volume, or both
  2. Result in a higher payment when diagnosis presents itself as a secondary diagnosis
  3. Could have been reasonably prevented through the application of evidence-based 

As a result of all this evidence, Halter may be on to something. Halter thinks the move will pay off financially as insurance companies change reimbursement policies to reward quality.

Hahnemann’s CEO says it will take about six months to a year to transition the whole hospital to an all RN care model. The facility currently employees 600 registered nurses and is looking to hire 50-60 more.

I have never worked in a hospital that had only registered nurses on the nursing staff but I did work in an OR once that only employed one scrub tech. It was fun to get to scrub so much and there was a level of camaraderie and communication that was easy to access. I think the patients got great care. I don’t know if it really made a difference in the patients’ outcomes. It will be an interesting phenomenon to continue to watch.

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