Ratios

TheCommuter, BSN, RN · Feb 21, 2008

Only California has legally-mandated nurse/patient ratios for acute care hospitals.

So the question should be worded the other way around: Why does California have ratio laws while the other 49 states do not?

It's all about money. Cash rules everyone around us, including politicians. Hospitals in the other states would have to hire more nurses if ratio laws were implemented, which would cost more money. Hence, hospital lobbyists work doggedly to prevent ratio laws from ever becoming realities in the other states.

Hospitals do not care about the medical outcomes or safety of their patients. Their primary concern is the long-term profitability of the facility. In other words, they are more concerned with the money-making capabilities of the hospital, and less concerned with the well-being of the patients.

CABG patch kid, BSN, RN · Feb 21, 2008

Hospitals do not care about the medical outcomes or safety of their patients. Their primary concern is the long-term profitability of the facility. In other words, they are more concerned with the money-making capabilities of the hospital, and less concerned with the well-being of the patients.

I'm sorry, but I had to comment on such a broad statement. I think that many hospitals DO care about the patient outcomes and their safety, even for monetary reasons. Hospitals these days are competing with each other for business, and one of the biggest ways they can compete amongst each other is by attracting patients. The best way to attract patients is by word-of-mouth, which will come about when patients are happy with the care they received. A patient will want to return or have other family members be a patient at a hospital if they feel that they received high quality care. In the long run, a hospital actually will make more money by being able to stay in business and being able to keep accredidation.

Maybe its just my optimism, but I do believe that there are caring healthcare facilities out there.

As far as the ratio question, I honestly don't know why more states don't have ratios. Healthcare is an ever-changing field, and a lot of things that didn't exist years ago are common place now. Maybe ratios will be one of those things in the future. A lot of regulations start at the state level before being implemented at the federal level; hopefully mandated ratios will be a federal mandate somewhere in the near future. I'm still learning a lot about politics, but this is definitely an issue I will be supporting in the future.

marie-francoise · Feb 21, 2008

I'm becoming increasingly cynical about how hospitals are run. In one hospital I was in, you could not comment about the silly public relations slogan posted everywhere because you could get hauled into HR. The monitors even have TV menus that look like hotel TV menus.

My guess is that hospital admin cares about patient well-being insofar as 1) patients don't sue and 2) patients keep coming back to that hospital to keep up its census. (Why the all-important "patient satisfaction" surveys! Or is it now "Customer satisfaction" surveys?)

Yep, the U.S. health care system revolves around money, and hospitals appear to institute their own nursing shortage by not hiring enough nurses in order to save $, which leads to burnout and a general nursing shortage.

I've also heard that even when a ratio law is in place, other services are cut, such as ancillary staff or aides. That doesn't surprise me.

I've also heard that some hospitals advertise nursing positions with no intention to staff them; but at least it shows they're "trying" to address staffing issues. I don't know if that's true, but that wouldn't surprise me, either.

If anyone has further info on these latter two practices, I'd be interested (i.e., hospitals cutting ancillary staff when ratios are lowered, and hospitals advertising nursing positions with no intention to hire).

classicdame, MSN, EdD · Feb 21, 2008

Actually, many states follow the guidelines of the Hospital Association which states simply that a safe ratio is required. California is the only state (of which I am aware) that has definite numbers. This resulted in many hospitals closing down because they could not pay for more staff. Texas has a law that is more in line with HA but also has meat behind it because of the safe harbor law. (www.texasnurses.com). I believe if more nurses were involved politically there would be better results. Waiting around for someone else to make your life better is not effective.

nursekatie22, RN · Feb 21, 2008

thanks everyone for your input. i realize that what works for one hospital (or unit, for that matter) won't work for everyone, but i want to do travel nursing and the things that really scare me are that i'll have a too-short orientation (which i understand is sometimes necessary d/t staffing, etc), and on top of that, i'll be trying to care for over twice the number of patients than i'm accustomed to.

maybe i just need to do it and see, but it's really terrifying to think of being in a situation like that as well as not knowing the hospital, staff, where things are, etc.

i'm a baby, i guess!

HealthyRN · Feb 21, 2008

There are very political reasons why most states don't have specific ratio guidelines, with the exception of California. Healthcare is a BIG business and anyone who thinks that it isn't about the bottom-line is naive. Yes, patients do matter, but keeping the doors open for patients and the community is even more important. Hospitals are very powerful and have a lot of money and hospitals do not support mandated staffing ratios. Nursing is the biggest cost to hospitals and mandated ratios mean that they must spend even more on this part of the budget.

On the other hand, not all nurses believe that ratios should be mandated. As Classicdame pointed out, the ratios in California have caused some problems. You also have to keep in mind that ratios do not necessarily address acuity. You may have a mandated ratio of 5 patients on a med-surg unit, but what happens if you get two of those patients that are waiting for an ICU bed to open up? Also, not all hospitals are equal. Five patients on a med-surg unit of a tertiary care center is a lot different from that of a small community hospital.

I also agree with Classicdame about nurses not being politically active. We like to complain about things, but we don't want to actually do anything to try to change it. We focus too much on our differences.

MA Nurse · Feb 21, 2008

Only California has legally-mandated nurse/patient ratios for acute care hospitals.
So the question should be worded the other way around: Why does California have ratio laws while the other 49 states do not?
It's all about money. Cash rules everyone around us, including politicians. Hospitals in the other states would have to hire more nurses if ratio laws were implemented, which would cost more money. Hence, hospital lobbyists work doggedly to prevent ratio laws from ever becoming realities in the other states.
Hospitals do not care about the medical outcomes or safety of their patients. Their primary concern is the long-term profitability of the facility. In other words, they are more concerned with the money-making capabilities of the hospital, and less concerned with the well-being of the patients.

Since Ca. has ratios, that's why a lot of travelers come here, for the $ and ratios, that's why some new grads are having a hard time getting jobs.

CABG patch kid, BSN, RN · Feb 21, 2008

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I've also heard that even when a ratio law is in place, other services are cut, such as ancillary staff or aides. That doesn't surprise me.

Yes it is true that if there are lower ratios, ancillary staff gets cut. Even where there was no mandate (VA system) if there was an LVN assigned to a group, the RNs would get more patients, say 8. If there was no LVN, then they would only get 6. Some of the nurses liked it better, some didn't. Where I work, we have a 4:1 ratio (telemetry) and we don't have any LVNs on that unit. At nights, there aren't very many aides either. I guess it is personal preference, but I actually prefer no LVNs because I like to do my own meds, finger sticks, insulins, etc. It's just easier for me to stay organized that way. With no CNA help, its hard to say if its harder that way or not, but everyone I work with seems willing to help each other out, so in the long run I don't think its an issue, because everyone is used to it that way. Like I said, I guess it is a matter of perception.

marie-francoise · Feb 22, 2008

I don't see what would stop money-minded hospitals from piling on too many patients on a nurse if we don't have madated ratios.

I just don't trust that, in a situation where the bottom line rules, hospitals would hire additional nurses simply for the quality of life of nurses. The only thing that I can see impelling them to consider better staffing is some sort of mandate; or, if they're facing too high a turnover due to nurses' frustrations that they can't ignore the staffing issue. But then there're always new grads to fill those positions (although the $ to re-train for a position is not negligible.)

And then there's the issue of total patient care of fewer patients without support staff versus more patients, with support staff.

Anyway, health care is indeed such a sticky morass of issues that no wonder the politicians won't face it head-on, in a systemic way. Here's hoping someday they will.

Daytonite, BSN, RN · Feb 22, 2008

i'm sorry if this has been covered before somewhere, but i've got a question....
why don't all states have laws regulating nurse-to-patient ratios. i mean, a monkey could see that a lot of the time, it's not safe practice, so what's the deal? i know that all states don't have unions to bargain for rights, etc, but it just seems like there should be a way to make things safer for everybody.
i'm a newish rn so i don't understand a lot of things still, but this just seems silly:o

yes, it does seem silly doesn't it. you need to understand that there is the clinical part of healthcare (that's us) and the business part. the business people are looking at dollars and cents and they don't understand the clinical component. it's not easy for nurses to unionize. i've worked in a hospital where the nurses were unionized and the story of how it came about would curl your hair. but, the union wasn't all that great either. i'm not exactly sure how the nurse patient ratio law came about in california, but it was done through the legislature. 45 hospitals in california immediately had to close their doors and cease operation because they couldn't meet the staffing ratios. california is a state where the citizens can get very political and work closely with their state legislators to get laws passed. the california nurses association played a big role. but you also have organizations like the american hospital association who have a very opposite view of these kinds of laws and have lobbyists who work very diligently against them. i know that they have been trying to get a "no lifting" law through the california legislature for nursing for 3 years now, but the governor has been vetoing it. it would require lifting equipment or lift teams and take the risk of lifting patients off the nursing staff in order to decrease back injuries. the fact is that no one really wants there to be laws mandating these things because they are very rigid. but, the other problem is that there are administrators out there who are money hungry and just won't spend a little more money to make things better for their staff or patients. and the rising costs of health care and how the insurance companies are dictating what they will and won't pay isn't helping either. every penny going into a hospital's till is precious. when i worked as a medical coder we had memos coming to us every day informing us of some new thing an insurance company wasn't going to pay for. it would spin your head to know what these medical insurance companies will and won't pay for and the hospitals and doctors have no say in it. keep your eye on this new movement to provide health insurance for everyone. it's going to be interesting in how it's going to be funded and paid for.

marie-francoise · Feb 22, 2008

I guess there's a problem in health care if hospitals truly can't afford adequate staffing.