After a victory in California and pitched battles in states such as Massachusetts and Texas, nurse unions supporting mandatory nurse-patient ratios in hospitals are gearing up to bring their issue to the national stage. The California Nurses Association (CNA) and a few like-minded nurses unions are hoping that Congress will mandate minimum ratios for nurses in hospitals throughout the country with legislation introduced by Sen. Barbara Boxer (D-CA) on May 13.
Hospital associations and nurse executives can be expected to fight the proposal, arguing that mandated ratios leave too little flexibility for the ebb and flow of patients and their varying acuity levels. Even nurses are divided about the concept: mandated ratios have been one of the philosophical dividing lines that have separated the CNA from the American Nurses Association (ANA), which went their separate ways in the 1990s. The ANA argues that safe staffing is indeed a problem and that hospitals should be required to ensure that enough nursing help is available, but stops short of backing ratios.
For emergency departments (EDs), the issue is particularly vexing. Anecdotally, ED directors complain that fixed staffing requirements tie their hands, making it more difficult to treat a surge of high-need patients. If a nurse hits her maximum number of patients, the argument goes, she would be restricted from caring for any more, and cause a backup in the waiting room. There's also concern about limitations on nurse patient loads in the units to which admitted patients would be sent, potentially adding to the problem of boarding in ED hallways.
Robert Derlet, MD, and John Richards, MD, emergency physicians at the University of California, Davis, complained that the rigid 4:1 patient-to-nurse ratio in the ED has resulted in more patients being placed in hallways with no direct nursing observation during crowded times. “We believe this rule should be relaxed when applied to the ED to allow for flexibility during periods of crowding,” the pair wrote in a January 2008 article in the Western Journal of Emergency Medicine.1
Rigid Ratios
Debra Berger, RN, president of CNA, acknowledges that the ED has a particularly variable acuity and census. But she says hospitals around the state, including those run by Kaiser Permanente, have found ways to manage that variability, such as by maintaining a resource nurse who gives meal and lunch breaks and fills in.
Besides, Berger says, hospitals always have the option to exceed the minimum staffing level. “The reality is they can always staff up, but they need to have that bare minimum safety net,” she says.
Of course, that assumes they can make the argument within their hospitals to spend the money increasingly difficult as hospital bottom lines feel the effect of the economic downturn along with state and federal government cutbacks.
Most research on the impact of California's nurse ratio law has examined effects on patient care hospital-wide, with minimal attention to the ED. A couple of research projects have honed in on emergency patients. Lori Weichenthal, MD, and colleagues in the UC San Francisco medical education program at Community Regional Medical Center in Fresno carried out an observational study comparing indictors of quality care in 2003, before the California ratios took effect, with the following year. They found that wait times, throughput times and admission times went up significantly, while time to antibiotics in pneumonia patients went down. There were no statistically significant differences in medication errors or administration of aspirin in acute coronary syndrome patients. Their review was published in the April 2009 Journal of Emergency Medicine.2
A study at another UC campus further south had different results. Emergency physicians at UC San Diego's hospital carried out a prospective study of 2 EDs using an electronic medical record to track patients during times “in ratio” and “out of ratio.” They wanted to find out whether a 4:1 ratio would improve patient care in the ED by allowing nurses to focus on fewer patients and get tasks done more quickly, or whether it would force more patients to wait longer for nursing care, explains Ted Chan, MD, lead author on their report in the October 2008 Annals of Emergency Medicine Research Forum Abstracts.3
Apparently the low ratio was allowing nurses to be more focused in their work, Chan says. “Being in ratio did not appear to result in longer delays in care,” he says. “We found that maintaining ratios even had a shorter length of stay.” However, the study did not look at boarding and whether patients were slower getting into medical units of the hospital.
Impact of California Law Unclear
When the California ratios went into effect in 2004, hospital representatives predicted it would result in the shuttering of EDs and hospitals because of the cost of hiring adequate staff to meet the 6:1 ratio for medical/surgical units, which would bump down to 5:1 in 2005. As of 2008, the required ratio for California EDs has been 4:1, going down to 2:1 for ICU patients in the ED and 1:1 for trauma patients in the ED.
So what has been the impact of the ratios 5 years later? EDs and hospitals have indeed closed, but there are plenty of economic and other factors playing into those closures, says Joanne Spetz, PhD, who has been studying the impact of ratios since before they were enacted.
“Was it good for California or California's patients?” asks Spetz, associate adjunct professor at UCSF's School of Nursing. “That's really hard to pin down. There's no one study where people say, ‘Aha, that's it.’”
Among the stronger findings so far have been about nurses' well-being. Nurse satisfaction in California is up, studies show, and so are their incomes. There are also about 100,000 more nurses working in California than before the regulations went into effect, the CNA says.4
“There's some evidence that if the nurses are happy and less stressed you get better patient outcomes,” Spetz says.
And certainly in general, more nursing care results in better medical outcomes, says University of Nebraska associate professor of nursing Mary Cramer, PhD, RN. “That's not debatable,” she says. “The more RN care provided to patients, there are improved outcomes.” But whether a mandated ratio is the best way to ensure adequate nursing coverage is debatable, she says.5
Other academics have looked at the issue and offered alternatives to ratios, such as reform of the billing system to pay hospitals directly for nursing care rather than bundling the reimbursement with other services.6 Another incentive approach would be to include nurse staffing in pay-for-performance systems.7 Everyone, from hospital lobbyists to nurse unions, seems to agree that the nurse shortage must be addressed through a focus on churning more nursing students through the educational system, which is hampered by a lack of instructors.
A 2008 study of 12 California hospitals, chosen to be representative of the state's 410 acute-care hospitals, concluded that since the regulation was put in place, more RNs and fewer unlicensed nurse aides were employed. There was no clear connection between financial problems of hospitals and the nurse ratios – changes in Medicare and Medi-Cal rates, along with new seismic safety requirements, had much greater impacts, the researchers concluded.8
In the study, sponsored by the California HealthCare Foundation, hospital administrators told researchers that it was difficult to meet the ratios and ensure staffing at all times. At the same time, they said that they expect having stricter nurse staffing will ultimately result in better patient care through greater interaction with patients, even if there are no data yet proving it.
Spetz, who led the California HealthCare Foundation research, said the ratio law was passed with no requirement that it be studied to see whether it improved patient safety or working conditions for RNs, the stated goals of proponents. Research has been spotty and hampered by a lack of intended outcomes to measure whether the law did what it was supposed to do, Spetz says. “What you learn from the California experience is that it's hard to establish a fixed ratio,” says Spetz. “Nobody really knows what the right ratio might be. In the end it's a political and economic decision.”
State Legislation
The California Nurses Association/National Nurses Organizing Committee (CNA/NNOC) has been advocating strenuously for mandated ratios in a number of states, with a particularly long-running saga in Massachusetts. Other states where the issue has been debated include Texas, Maine and Pennsylvania; a new nurse staffing plan requirement was signed by Texas' governor in June, while a similar law was approved by Nevada's legislature in June, overriding a governor's veto in the process.
Meanwhile, other organizations such as ANA are pursuing less-drastic options at the state level to promote nurse staffing levels. ANA proposes that hospitals be required to write staffing plans for each unit, examining local needs and other factors, and choosing an appropriate nurse-patient ratio for each situation. This process should include involvement by nurses, ANA argues.
According to an ANA listing of state legislation on nurse staffing plans and ratios as of June 2009, there are 12 states and the District of Columbia that have approved some kind of legislation or regulations; 17 states have had rules proposed during 2008 and 2009.
CNA argues staffing plan legislation has little value, since hospitals are already required to maintain such documents to meet the requirements for accreditation. “The ANA model is that you let acuity and nursing judgment decide, but the reality is that we've had that for hundreds of years already, and they totally ignore the nurse at the bedside,” says CNA's Berger.
The 2 nurses unions are also offering alternative visions of appropriate nurse staffing at the federal level. The ANA promotes the “Safe Staffing Act” in Congress. The legislation would require hospitals to create staffing plans, with input from nurses, based on patient acuity, census and resources available in each unit. It would also require hospitals to make public the number of licensed and unlicensed staff on each shift.
Meanwhile, the bill introduced by Barbara Boxer and supported by CNA and its allies would extend the nurse-patient ratios that have been in force in California since 2005 to the entire nation. It would also provide whistleblower protection to nurses, create standards for lifting patients to avoid injury, and provide assistance to nursing students who agree to work for 3 years for a safety-net hospital and to RNs who agree to serve as nurse educators.
Ratio foes such as the California Hospital Association argue that the main motivation behind state and federal ratio laws is simply the CNA's effort to promote itself as the leading nurses union in a high-stakes competition with other labor groups such as the ANA and Service Employees International Union. In February CNA merged with the Massachusetts Nurses Association and United American Nurses to create a new, 150,000-member organization to be called the United American Nurses-National Nurses Organizing Committee.
But Cramer says the support CNA is seeing in many states is a sign that this issue does resonate with the public and with legislators. “People continue to be worried about” the level of nurse staffing in hospitals, she says. “When something rises to the level of policy it's because people don't feel confident that an issue is being dealt with adequately.”
Graphic note: There is an American Nurses Association map of state legislation on nurse staffing plans and ratios dated March 2009 at http://www.safestaffingsaveslives.com/WhatisANADoing/StateLegislation.aspx.
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