Fight for mandated nurse-to-patient ratios heats up
Inside nurses' decades-long battle for better staffing ratios and why the healthcare industry has remained resistant.
There's a palpable air of excitement among nurses in Pennsylvania. For the first time in the state's history, a governor has voiced support for nurse-to-patient staffing rules that would set a maximum number of patients an individual nurse can care for at once.
On top of Democratic Gov. Tom Wolf's support, 49 state legislators in Pennsylvania have co-sponsored bills in the House and Senate that seek to establish mandated nurse-to-patient staffing ratios in hospitals.
"We are now further toward safe staffing ratio laws than anyone has ever been in Pennsylvania," Mick Power, an organizer with Nurses of PA, said on a conference call the organization hosted in June. "Three months ago, we were nowhere near this."
The fight for staffing ratio legislation in Pennsylvania is just one of many across the country, largely led by labor unions and nearly always met with steadfast resistance from the hospital industry.
Currently, 14 states have laws that address safe staffing, though California is the only state to implement a ratio mandate, at five patients to one nurse. Seven states pass the buck on to hospital committees responsible for setting ratios within their own facilities. Five states enforce a reporting mechanism for publicly disclosing staffing ratios.
Short-staffed and overworked nurses pose real risks to patient safety, health outcomes and workforce retention in hospitals. Kronos Incorporated polling shows 90% of nurses are considering leaving their hospital for another job, with burnout-related turnover rates among nurses already costing U.S. hospitals an estimated $9 billion per year. Recent research shows patient-heavy nurse staffing ratios are also costing patients their lives, especially in intensive care units.
The hospital industry has pushed back, arguing that there simply isn't enough research to support a front-loaded investment in nursing staff. They also contend there are not enough nurses to hire in the first place and say staffing mandates would force facilities to close.
Advocates, many of whom believe the nurse shortage to be an industry myth, argue that California's ratio mandate, which adjusts for acuity and hospital setting, has proven to be cost-effective, produce better health outcomes and open the floodgates for job-seeking nurses.
Backers of the ratios cite the rising number of nursing graduates per year and estimated increases in available nursing jobs. The advocates tout California as a model for curbing the threat of a shortage. In 2004, applications for nursing licenses in that state reportedly increased by more than 60%, with vacancies for RNs at hospitals having reduced by 69% by 2008.
"California hospitals are still open. The last thing we want is to see a hospital fail," Michelle Boyle, a nurse with SEIU Healthcare PA, told Healthcare Dive. "But we're on the ground. We're the ones doing the work day-to-day. We're the experts. Listen to us."
Opponents of nurse-to-patient ratio mandates, such as the American Hospital Association and the American Organization of Nursing Executives (AONE), argue mandatory ratios would make scheduling and staffing rigid, create unmanageable hiring costs and, above all, result in higher costs of care. AONE has maintained the same position on mandatory staffing ratios since 2003, before California's mandate was enacted.
Debate over research
In a 2007 paper funded by the nursing executives' group and published in the Online Journal of Issues in Nursing, nursing professor and researcher John Welton wrote that costs for an increase of one hour of care by a registered nurse per day in a medium-size hospital with an average of 100 adult medical-surgical patients would increase $1.4 million dollars annually.
Welton also dismissed two studies on staffing ratios from the 1990s in the New England Journal of Medicine and the Journal of the American Medical Association, both cited among safe staffing advocates.
The JAMA study, funded by the National Institute of Nursing Research and led by Linda Aiken, director for the Center for Health Outcomes and Policy Research at the University of Pennsylvania, found that the likelihood of mortality among patients increased 7% for each additional case assigned to a nurse.
Welton argued that both studies were outdated, and provided "no basis" for their methods, which he argued gloss over differences in nursing units and individual patients and do not account for the influence of surgeons and surgical environments.
Aiken told Healthcare Dive that her team has been tracking the rate of change in nurse staffing over the past decade. So far, they've found that hospitals have reduced their staffing ratio by about a half-patient per nurse. Most of that improvement, she said, has been made by a small group of hospitals that have pursued more balanced ratios.
"We estimated mortality after general surgery could be reduced by 13% if they staffed at California levels," she said. "California still has much better staffing than Pennsylvania, 15 years after passing that legislation. They have much better hospital outcomes as well."
In a statement to Healthcare Dive, AONE president Bob Dent acknowledged such studies showing nurse-staffing levels influence patient outcomes and satisfaction. But he said it's more complicated than that.
“However, patient care staffing is a decision based on a complex set of variables under the purview of the registered professional nurse," the statement reads. "Because staffing is an issue composed of multiple variables, mandated staffing ratios, which imply a ‘one size fits all’ approach, cannot guarantee that the health care environment is safe or that the quality level will be sufficient to prevent adverse patient outcomes.”
Even though acuity severity is increasing faster than hospitals are adding nurses, Aiken said, nurse-to-patient staffing is not a straightforward issue. In most states where staffing legislation exists, policymakers have forged compromise between nurses and hospitals.
The result has been a market-friendly approach to legislation that mandates hospitals and health systems address staffing ratios themselves via internal committees. The hospital industry and leadership have overwhelmingly supported this as a solution when faced with the possibility of ratio mandate legislation.
Aiken said this approach has worked in some hospitals, but executives need to be aware of research that shows hospitals get better patient health outcomes at a "significant savings" when safe staffing ratios are implemented. A study published in Health Affairs in 2013, for example, found hospitals with higher staffing were less likely to be penalized by Medicare for excessive readmissions.
"That's what researchers like me are trying to drive home, so that the largely business-focused people heading up these big consolidated health systems can understand that rationing nurse staffing is going to cost money, but using evidence to get it right will ultimately save the hospital millions of dollars and pay for itself."
Compromise for whom?
Nurses argue that many state-mandated committees are largely comprised of finance executives and management staff who don't necessarily know or have experience in the clinical side of the business. Gerard Brogan, lead nursing practice representative with National Nurses United, does not believe the committee solution is good enough.
"I haven't met a nurse yet who thinks that works," Brogan told Healthcare Dive. "[Business] people sit on these committees and bedside nurses don't have a real voice. It never worked."
Brogan pointed to Illinois, where the committee approach to staffing was enacted in 2008 as an alternative to a ratio mandate. That law, a compromise between the Illinois Nurses Association and the Illinois Hospital Association, requires each hospital to have a nursing care committee with at least 50% of sitting members registered nurses in practice.
Five years after passing the law, only 24.5% of committees reported improvement, with 45% of survey respondents saying staffing recommendations were made and 19% believing the committee had not made a difference.
Massachusetts passed a ratio mandate solely for ICUs in 2014, a compromise between the Massachusetts Health & Hospital Association and the Massachusetts Nurses Association. Much to the former's chagrin, a proposed ballot question in that state could have voters deciding on a staffing ratio mandate in all hospitals this fall.
Last year, MHA published a study asserting hospitals may be forced to close under a mandate.
Ratio mandate advocates like Brogan say the assertion that hospitals will close is "bulk standard" rhetoric commonly adopted by hospital associations when faced with staffing ratio regulations, as are claims that mandated ratios are too rigid and the nurse talent pool too shallow.
Boyle said the hospital industry made similar claims when the state banned mandatory overtime for nurses in 2009. "They said, 'Oh, the hospitals are going to shut down. The world is going to end,'" Boyle said. "They found better ways of staffing and filling those holes before it became a problem. It's the same thing with safe staffing."
According to Boyle, Nurses of PA is supporting Senate Bill 214, a ratio mandate bill modeled after California's law that has been idle in the Senate Health and Human Services Committee since January 2017. House Bill 1500, a similar piece of legislation that seeks to set staffing ratio mandates, has garnered a handful of Republican cosponsors.
"This is the most support we've had in, let's see, forever," Boyle said.
Getting bipartisan support for ratio mandate legislation has been tough for other states. The New York State Nurses Association, for example, is launching a $1 million ad campaign backing a ratio mandate bill that was shot down by the state's Republican-led Senate in 2016.
NNU has, unsuccessfully, helped mount such campaigns in Illinois, Ohio and Texas, among other states.
On a federal level, garnering Republican support for any safe staffing ratio has been difficult.
In addition to burnout rates, high turnover and an alarmingly high risk of experiencing workplace violence, many nurses believe there's a disconnect between business administrators driven by financial gain and clinicians driven by the ability to heal.
Aiken, for her part, will keep focusing on how nurse-to-patient ratios impact hospitals' bottom lines to get executives' attention.
While consolidating health systems have in many cases relied on staff cuts for financial preservation, she pointed to her own research finding that growing organizations such as Kaiser Permanente that invest in nursing staff while placing patient-centered care at the core of their mission can simultaneously achieve a healthy bottom line and produce healthy outcomes.
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