How many nurses does it take to run a hospital?
Legislatures in at least seven states and the District of Columbia are trying to answer that question as they debate bills that would require hospitals to have a minimum number of nurses on staff at all times.
California’s Legislature passed a minimum nurse staffing law in 1999. While no other state has done so since then, the nursing unions backing the bills have grown increasingly powerful in statehouses across the country.
Hospital administrators are vehemently opposed. They argue that the bills would strip them of their ability to make basic staffing decisions and would be a financial burden. Many nurses and nursing unions counter that the legislation is needed to prevent cost-conscious hospitals from endangering patients by putting too large a workload on too few nurses.
"Hospitals right now are run like businesses, and they’re focused on the short-term bottom line," said Jeff Breslin, the president of the Michigan Nurses Association, a union that supports a minimum staffing bill in the Michigan Legislature. If the bill becomes law, he said, "it doesn’t matter what part of the state you’re in, you can be assured you’re going to have adequate nursing care whatever place you’re going into."
Lawmakers in D.C., New York, Texas, Florida, New Jersey, Iowa and Minnesota also are considering legislation. While the language differs across the states, a minimum nurse-to-patient ratio is at the heart of all the bills.
The measures call for different ratios in different parts of a hospital. For example, the proposed law in Michigan would require hospitals to maintain a 1-to-1 ratio – no fewer than one nurse for every patient – in all operating rooms across the state. In pediatric units, that ratio may go as high as one nurse for every four patients.
A 2004 survey of research conducted by the U.S. Agency for Healthcare Research and Quality, part of the Department of Health and Human Services, found that patients at hospitals with low nurse-to-patient ratios fared worse than those at hospitals with higher ratios. But nursing and hospital advocates say there’s scant research on what the ideal ratios should be, and studies conflict on whether mandating a ratio by law improves patients’ health, according to hospital and nurses’ groups.
Joyce Young, a nursing administrator with St. Joseph Mercy Health System in the Detroit area, said many hospitals were creating minimum staffing levels on their own and didn’t need laws to tell them what to do.
"Hospital nursing leaders are in positions such that they can be able to determine staffing levels," Young said. It shouldn’t be "based upon a legislator who mandates a number. It should be left to the nurses."
Hospital administrators also worry that minimum nurse staffing laws would force them to hire more nurses than they need, adding costs that aren’t reimbursed by insurers. Robert Malson, the president of the District of Columbia Hospital Association, said passage of the bill now before the D.C. Council would lead directly to bankruptcies. "The most precarious would be the first ones to go down," he said.
Today, only California requires all of its hospitals to maintain a minimum nurse-to-patient ratio. If a hospital has a surge of patients because of something unexpected, such as a car crash or an outbreak, it still must meet the minimum ratio. The only time it may go under the minimum ratio is during what the statute calls a "health care emergency."
Jolee Cochran, a registered oncology nurse who’s been working at Cedars-Sinai Medical Center in Los Angeles for 26 years, said the law had made her job more manageable. Before, she said, it wasn’t uncommon for a nurse to be responsible for seven patients at a time. Now it would be a violation of the law for her to have more than five patients under her care.
Cochran said patients in her hospital were much sicker than they used to be and required much more complex care. "I can’t imagine having more than five patients with one nurse, with the type of patients we have now," she said.
She also said the law had made scheduling shifts more challenging. Because the staffing ratios in California apply at all times, if a nurse goes on a break, "there has to be someone there to cover you," Cochran said. "By law, you can’t fudge that or else you get fined."
Jan Emerson-Shea, a vice president at the California Hospital Association, agreed with Cochran that the law’s rigidity – its "at all times" clause – is a major problem. She also said the ratios written into the state’s law were a political compromise that had no basis in scientific evidence.
Despite the challenges posed by the law, hospitals have slowly learned to live with it, Emerson-Shea said.
"We don’t fight this issue now," she said. "It’s the law of the state. . . . It’s over. It’s done."
What was a major victory for nurses in the Golden State 14 years ago has been followed by a string of defeats elsewhere. "Hospitals go to holy war to prevent it," said Chuck Idelson, a spokesman for National Nurses United, a 185,000-member labor union founded four years ago in California.
National Nurses United is the primary supporter of the staffing ratio bills that are working their way through various state capitols. However, not all nurses back the union’s legislative push.
The American Nurses Association, a professional trade group that advocates on behalf of both unionized and non-unionized nurses, opposes staffing ratio bills. Janet Haebler, the association’s director of state government affairs, said she didn’t expect any others to pass this year.
Haebler said understaffing was a major problem, but that calcifying a nurse-to-patient ratio into law wasn’t the right way to solve it. The association instead favors laws that require hospitals to set up committees made up of nurses and administrators who work together to create staffing plans.
"We’re respectful of all approaches as long as nurses have input," she said. "In California, there’s no input. It’s just . . . ‘This is what it will be at all times.’ "
Clarification: This version of the story deletes the following comment from Jan Emerson-Shea of the California Hospital Association, as she and the reporter dispute the context in which it was made: "Many had to rely on temporary nurses for the first few years, she said, but ultimately the hospitals didn't suffer financially 'to any significant degree.' "