By: Adam C. Abrahms and Stephanie R. Carrington

Since California’s implementation of legislation setting minimum nurse-to-patient staffing ratios in 2004, the issue of nurse staffing has been slowly but surely creeping its way into other states’ legislation, attempts at federal legislation, and of course, into more union contracts.

When it comes to requirements for hospital staffing ratios, federal regulations provide only that hospitals participating in Medicare have “adequate numbers” of nurses and other personnel to provide nursing care.  But some states have gone further in regulating nurse-to-patient staffing ratios, either requiring that minimum nurse-to-patient ratios be maintained at all times, mandating that hospitals have staffing committees develop and implement staffing policies; or requiring some form of disclosure or public reporting of staffing policies.

Current Status of Staffing Restrictions

To date, California is the only state requiring that a minimum nurse-to-patient ratio be maintained in hospitals at all times, varying by unit.  Although Maine and Washington, D.C. initially implemented similar staffing ratio legislation, D.C. later waived enactment of staffing ratios due to the nursing shortage, and Maine removed required minimum ratios after finding there was no reliable scientific evidence that mandated ratios were a guarantor of quality and safety of care.  Taking a different legislative approach, seven states require hospitals to utilize staffing committees responsible for staffing policies (CT, IL, NV, OH, OR, TX, WA), and five states require hospitals to publicly disclose or report their staffing policies and/or practices (IL, NJ, NY, RI, VT).

The New York State Nurses’ Association has been actively pushing for New York’s adoption of the “Safe Staffing Quality Care Act,” introduced in April of the past year.  Not only does the bill set mandatory nurse-to-patient ratios – it also mandates public disclosure of staffing ratios, restricts use of “float” nurses, and specifies that hospitals cannot consider assistive personnel in counting ratios.  In other words, the law, if passed, would rob hospitals of their discretion to adjust nurse-to-patient ratios based on their use of more cost-effective ratios combining, for example, RNs and nurses’ aides, respiratory therapists, technicians, or other assistive personnel.

Hospitals in the 49 states without mandatory nurse-to-patient ratios are not off the hook, however, as more nursing unions bargain for minimum staffing ratios in the absence of legislation requiring the same.  National Nurses United continues to aggressively promote minimum staffing ratios through legislation and bargaining efforts across the country.  Most recently, the Massachusetts Nurses Association contracted for limitations on the number of patients nurses could care for at a time, and National Nurses Organizing Committee – Florida bargained for acuity staffing grids in its nurses’ contracts.

What’s All the Fuss About?

Unions argue better nurse staffing brings about more favorable outcomes for nurses and patients, but there is no evidence proving that minimum nurse-to-patient ratios, with their crippling costs and rigid requirements, are the best way to bring about better staffing.  Minimum nurse-to-patient ratios are not only difficult for hospitals to enforce because of their complete lack of flexibility, but they also increase costs without proper justification.  As the American Nurses Association explains, there are also “real concerns about the establishment of fixed nurse-to-patient ratio numbers,” because many variables are key to establishing the best staffing for any one unit.  These variables include the intensity of patient need (or acuity), level of the nursing staff’s experience, layout of the unit, and level of support from ancillary personnel – factors that hospitals, not legislators and unions, are best able to consider.  There is no magic number staffing ratio that will ensure enough quality care in one case without stepping overboard in another instance.

Contrary to any stated altruism, nursing unions aggressively promote mandatory staffing ratios because they increase the number of nurses that must be hired, which in turn increases union membership.  Nurses often favor the staffing provisions because they think it will guarantee a reduced workload, despite the fact that mandatory ratios are likely to have the exact opposite effect.  Notwithstanding the initial allure staffing ratios might present to practicing nurses, their rigidity and failure to address the less-than-predictable nature of hospital staffing requirements at any given time may pose major difficulties going forward, including inability to meet staffing needs, expanding cost of healthcare, and lack of flexibility to accommodate all of the variables that should be considered in meeting staffing needs.

Management Missives

  • Hospitals should carefully track staffing issues that come up, in order to be able to articulate (whether to the legislature or at the bargaining table) that current staffing models are adequate.
  • It is important to be aware of nurses frequently discussing staffing ratios because it may be an indication that they are organizing and pushing for fixed ratios, in which case it is best to be prepared with the facts.
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