Nurses, hospitals continue national battle over staffing ratios

The Massachusetts Nurses Association is attempting to get a referendum to voters that would create staffing ratios in the state’s hospitals. The initiative would establish maximum safe patient limits for nurses according to their units.

The association has backed the referendum as steadfastly as hospital groups have railed against it. The only other state to have such a referendum is California, and Massachusetts hospitals could see into their future by understanding how it has impacted their counterparts in the Golden State.

Creating nurse staffing ratios is needed because of dramatic changes in the hospital industry, according to the MNA. The group’s Web site said health reform and hospital consolidation has caused staffing cuts and reduction of hospital services. The group said the lack of staffing laws has made it common for nurses to care for up to eight patients at a time, when a safe limit might be only four.

[See also: Nurse staffing, burnout linked to HAIs.]

The proposed legislation would allow one nurse to care for no more than four patients at a time in medical/surgical units, no more than three patients per nurse in emergency departments, and critical care nurses could have no more than two patients at once. It would also allow for nurses to treat fewer patients based on an acuity system. Hospitals in violation could be fined $25,000 for every day they don’t comply.

Studies have shown, and most experts agree, that more nurses can provide better care. But there is no evidence that nursing ratios, specifically, improve quality. 

Tim Gens, executive vice president of the Massachusetts Hospital Association, said the legislation would be “poor public policy.” His concern is that other providers’ jobs, and in turn the community, would be negatively affected.

“Hospitals are preparing to express concerns and their views on how to provide excellent patient care,” he said of the referendum. “This arcane idea was a bad idea when it was first proposed in the 1990s and far worse today as we look at the goals of healthcare reform.”

Joanne Spetz, professor at the institute for health policy studies at the University of California, San Francisco, said the research on the issue in California has limitations, but overall, has shown that ratios don’t decrease rates of mortality, pressure ulcers, falls or death following complications. 

What ratios did do was cause some unexpected challenges for hospitals, particularly during the first year after implementation in 2004. California ratios are one nurse for no more than two patients in critical care, one nurse for five patients in medical/surgical units and one to four in emergency departments.

Factors that weren’t considered were covering meal or restroom breaks or the backup that could occur if an emergency room gets overwhelmed by a car accident, or what to do if the staff gets the flu and nurses can’t come in.

Hospitals were not happy about the legislation, but nurses were. Studies showed thier job satisfaction improved and turnover was reduced. This could be, in part, because their salaries also rose.

[See also: Staff scheduling tools can improve the bottom line.]

“It’s classic union,” Spetz said. “Unions are intended to take profits that might be retained by an organization and redistribute them to workers. If demand rises faster than supply wages go up. Analysis has indicated that wages went up more rapidly in California than elsewhere after this was put in place.”

According to data from the Bureau of Labor Statistics from 2011, California has more nurses than any other state – and they are the best paid in the country. The mean annual wage for registered nurses in California is $90,860, with Massachusetts second at $86,810 and Hawaii at $83,950. Emerson-Shea said they run closer to $135,000 in the Bay Area.

To make up for the increase in staffing costs, Spetz said some hospitals reduced charity care spending and nursing assistants.

Jan Emerson-Shea, vice president of external affairs for the California Hospital Association, said positive affects of the legislation were the re-opening of nursing schools that had previously closed. Before the new graduates were able to get into the workforce, Emerson-Shea said travelling nurses were used to fill the void – and many hospitals were unable to fully comply.

The organization surveyed California hospitals during the first five months after enactment in January 2004. What they found was: approximately 85 percent of responding hospitals were unable to meet the ratios for every shift in every unit during this time; 35 percent took beds out of service or closed units due to the requirements; more than a third went on or requested diversion and reported longer waiting times; and nearly 50 percent couldn’t transfer patients from the emergency department because the receiving hospital was unable to meet requirements.

“Every day, I would venture to say there are hospitals that are in violation of it,” Emerson-Shea said. “But the enforcement of it has been relatively reasonable. And now, day-to-day, hospitals have learned to live with it.”