You’ve worked on a busy Med Surg unit for almost a year now. You were so excited to be hired right out of nursing school to the day shift, but it’s been so much harder than you ever thought it could, and so different from what you expected. It only took a few days to discover that no one does anything like they taught you in nursing school, there’s just no time. Recently you’ve been cringing every time your phone buzzes, worried it’s the nurse manager asking you to come in for an extra shift. It’s so hard to say no. You want to be a team player, but you’re just so tired. You’ve been wondering if you’re cut out to be a nurse, but maybe this is just how it is. Today is your fourth day in a row. You arrive on the unit to discover that not one, but two nurses have called in sick, and one of your nurses is a floater from labor and delivery. Normally you have five patients, but today you see with a sinking heart that you’ve been assigned seven. You sit at the computer next to your nursing mentor, trying to wrap your brain around your day, trying not to cry. He’s a good nurse and seems to notice everything. He turns to you and says, “Are you okay?”
You point at the seven patients on your computer screen and reply, “How can this be safe? How can they do this to us…to our patients?”
He says, “It’s a right to work state, and the hospital can do whatever they want.”
You say in disbelief, “So there’s no law against this? There’s no maximum number of patients we can be assigned? They could give us twenty next time?”
He shakes his head ruefully and says, “Medicare has guidelines for patient ratios, but this hospital has never followed them and we’re still running.” He looks over his shoulder before he turns back to you and says under his breath, “We shouldn’t talk about this at work, but there’s a group you can join to fight for safe staffing laws. Check it out when you get home, it’s called NursesTakeDC. It’s a dot org. But don’t talk about it here, you could get in big trouble.”
Mandated Nurse-to-Patient Ratios
Does this conversation seem familiar? Have you ever felt like you were working in unsafe conditions and wondered, “Isn’t there a better way?”
As a patient safety specialist, I’ve always been a huge advocate for safe staffing laws as a solution to so many of the problems nurses face. But, then I read a recent article, Why mandated nurse-to-patient ratios have become one of the most controversial ideas in health care and I had to give my position a second look.1
How Can There be Controversy Over Something So ... Obvious?
Opponents say ratio laws would exacerbate nursing shortages across the country, limit access to care, and take important staffing decisions out of the hands of nurses. Danny Chun is a spokesperson for the Illinois Health and Hospital Association (IHHA), a leading advocacy group for hospitals. He states that safe staffing laws are “a deeply flawed, inflexible, rigid approach to setting staffing levels that do not improve quality, safety or outcomes, but in fact would adversely affect patients.”1
The IHHA is against the Safe Patient Limits Act, a bill recently introduced in Illinois (House Bill 2604, Senate Bill 1908). Under the Safe Patient Limits Act, no nurse working in a hospital could be responsible for more than four patients at a time. The ratio would be even lower for special units like L&D, ICU and the ER. If passed, any facility that fails to comply could receive a fine of up to $25,000 per day.
Critics of the bill say that the consequences could be catastrophic, causing shortages of nurses and money. There may be increased wait times for patients in the ER, and hospitals may have to turn away patients because they don’t have enough nurses to meet the ratios. In addition, an unexpected influx of patients due to epidemics, mass shootings or other disasters could make it impossible to meet the ratios. Small hospitals operating in regional areas could be forced out of business. Chun says in Illinois, “more than 40% of hospitals across the state are losing money or barely surviving.” The cost to the hospital could be passed on in the form of higher healthcare costs.
The biggest criticism being offered is that mandated ratios don’t work. Chun says, “The evidence is not conclusive that ratios improved quality, safety or outcomes,”1
The Evidence
Here is where I get excited. I went to Google Scholar and typed in “Safe Staffing Laws, nursing” and got 44,400 hits. I love digging into the research to find the truth (like the X-files, the truth is out there…) I found multiple review articles that speak to the state of the science on safe staffing ratios. One by Olley (2017) suggests that there is a significant research gap to support claims of increased patient safety in the acute hospital setting with improved ratios (for all the REST of the evidence, check out my Just say "YES" article on this topic).2
California is the only state in the union with a safe staffing law. AB 394 was passed back in 2004 after a massive effort by the California Nurses Union. The result of the bill is that nurses in California have approximately one less patient than the national average. Multiple studies have shown that the standard mortality rate decreased by more than 33% after the enactment of the bill.3
This seems like pretty good evidence…evidence that the law that California enacted is working in California. See where I am going here? The biggest criticism of bills in other states (and this comes from organizations like the American Nurses Association) is that there is no empirical evidence supporting specific ratio numbers. Passing legislation without sufficient evidence is potentially dangerous since legislation is difficult to change. Critics say the laws currently proposed also don’t take into account nurse education, skills, knowledge and years of experience. In Bill 394, only 50% of the mandated nurses must be RNs. Some say these laws ignore patient acuity, required treatments, length of stay, team dynamics, environmental limitations, variations in technology and availability of ancillary staff. And last but not least, these laws are inflexible and don’t allow for the changing needs of patients.4
The Bottom Line $$$
The mortality rate may have decreased, but the finances are problematic. To meet mandatory staffing ratios, hospitals in California have had to cut funding for supplies, upgrades and education and holding patients longer in the ER. The result is increased economic costs for employers, with the unanticipated side effect of an increased workload for nurses in non-patient tasks as ancillary staff are dismissed. 4 & 5
The PRO Side
I’m not actually telling you to say “NO” to mandatory staffing laws. I want to get a conversation going, so please comment! To learn more about Nurses Take DC and what you can do to make a difference, take a look at my second article on the topic. Most importantly, before you speak up about safe staffing laws, make sure you are knowledgeable on the topic. We must be well educated on all sides of a topic if we want to weigh in on shaping the future of patient care.
References
Why mandated nurse-to-patient ratios have become one of the most controversial ideas in health care
Systematic review of the evidence related to mandated nurse staffing ratios in acute hospitals.
Statewide and National Impact of California’s Staffing Law on Pediatric Cardiac Surgery Outcomes
Effects of Public Reporting Legislation of Nurse Staffing: A Trend Analysis
Mandatory Nurse-Patient Ratios
