Numbers Game Two Sides Sharply Divided On Nurse- Staffing Ratios

Dr. Charles Cavagnaro calls it “cook-book legislation.” 

By that, he means that those who support proposed legislation that would implement minimum nurse-to-patient ratios in the state’s hospitals are of the opinion that patient care quality comes down to a formula, or recipe, that centers around the number of nurses on a given floor at a given time.

“It’s just not that simple,” said Cavagnaro, president and CEO of Wing Memorial Hospital and Medical Center in Palmer and an outspoken opponent of nurse staffing ratios, and one of many hospital administrators certainly glad that a pilot program that would have implemented minimum ratios at 10 Bay State hospitals was rejected this month by a House-Senate conference committee preparing a budget for fiscal ’05.

But while pleased with the conference committee’s vote, Cavagnaro, like other hospital administrators, knows the fight on minimum ratios is far from over. “The MNA is a very powerful organization,” said Cavagnaro, referring to the Mass. Nurses Assoc., which strongly supports minimum ratios. “They’re going to keep coming at is on this.”

State Sen. Marc Pacheco (D-Taunton), who spoke to The Healthcare News prior to the conference committee’s actions, has been fighting for minimum staffing ratios for more than a dozen years now, and agrees that the matter is one that will be debated in the Commonwealth for some time to come.

Pacheco, who proposed the pilot program, said it would have provided the answers to questions that many have nurse-staffing ratios and whether they will improve patient care — the matter he and other supporters say is at the heart of the discussion.

Pacheco said the pilot program, as proposed, would have phased in the ratios, and only for the hospitals that can afford them. He wants to use such an initiative to show individual hospital administrators and the Mass. Hospital Assoc. that the ratios won’t bankrupt hospitals and that enough nurses can and will be found to fill the positions. He told The Healthcare News that, for years now, he has heard hospital administrators say that the state must first resolve the fiscal crisis facing all care providers, and also address the current nurse shortage, before even thinking about putting in place nurse staffing ratios.

He doesn’t buy into that argument, and he believes hospitals are using those issues to continually put off something they simply don’t want.

“We have ratios for staffing in day care centers and at summer camp — why shouldn’t we have them for the intensive care unit?” he said, adding that he believes the MHA is opposed to the pilot program because it will likely validate the argument that minimum ratios are necessary.

“We need to see what will happen in terms of the economics and the nurse staffing,” he said, noting that the pilot would provide an effective laboratory. “If it doesn’t work, then it can’t continue, but I’m confident it will work; 27 hospitals already meet the standards set down for the pilot.”

Yes, the emotions — and the arguments — are quite heated when it comes to the subject of nurse staffing ratios. The Healthcare News takes a detailed look at why those on both sides of the issue are so passionate in their arguments.

Down to a Science?

Scanning the landscape of the nurse-staffing ratio debate, it would appear that there is little middle ground in this fight. Proponents and opponents are far apart in their views on how the concept impacts hospital finances, the supply of nurses, and, first and foremost, patient care.

The two sides are even far apart on how they view preliminary results in the nation’s first testing ground on nurse staff rations, California, where a measure went into affect in January. “It’s been a total failure … from the reports we’ve seen, none of the hospitals have been able to meet the requirements,” said Smith. Pacheco sees things differently. “I think California is showing everyone that ratios are necessary — and that they work.”

The different attitudes can even be seen in the language used to describe the issue in general, and the pilot program in specific. Proponents call the latter a “safe staffing” measure, while opponents, call it an “end-around,” and describe the concept of ratios as “bad public policy.”

Indeed, when they talk about nurse-staffing ratios, opponents of the concept come back time and again to the word flexibility, or, in this case, the lack thereof. They say the measure, as proposed, would tie the hands of hospital administrators and essentially tell them how — and on whom — to spend their resources.

“Hospitals would be held prisoner by ratios,” said Smith, adding that, in his opinion, the proposed program was overly rigid in its dictates — ‘draconian’ was the term he used — and predicted that if it became reality, some units of hospitals or entire facilities might be forced to close because the mandates couldn’t be met.

Dr. James Fanale, COO of Mercy Medical Center and chief medical officer of the Sisters of Providence Health System, agreed. “I think it’s hard, if not impossible, to say just what the right number of nurses is,” he said, adding that the proposed measure put all the emphasis on nurses, while hospital administrators, in general, choose to look at the broader picture and all health care professionals working as a unit.

And by effectively dictating how many nurses a hospital must hire, nurse-staffing ratios would remove a large measure of flexibility in hospital spending, he explained. “Even if we had all the money in the world to pay for these nurses, which we don’t, there are other areas where hospitals might want to spend that money, like technology,” he said. “I’d like to bring our technology up to date with all the other industries in the free world.”

Like Cavagnaro, Deborah Morrissey, interim vice president of Patient Care Services at Baystate Health System, believes nurse-staffing ratios are being touted as a simple answer to a complex problem. “It’s not the solution that’s being made out to be,” she told The Healthcare News, adding that, like other hospitals and health care systems, Baystate is devoting its time and energy to programs to increase the flow of nurses into the system rather than putting in place strict mandates on staffing.

And like Fanale, she said there are too many variables involved to link patient care outcomes directly to nurse-staffing ratios. “Hospitals are different and patient situations are different,” she said. “But under this proposed pilot program, everyone would be mandated to do the same things; this will have a devastating effect on small hospitals.”

But proponents of the nurse staffing ratios say this is a matter of patient safety — not money or the supply of nurses or administrative flexibility. MNA leaders and legislative supporters cite several recent studies they say show a strong, consistent link between nurse staffing levels and patient outcomes.

An often-cited Journal of American Medical Association study, for example, shows that the higher the patient-to nurse ratio, the more likely there will be a death or serious complication. Each additional patient above four that a nurse is caring for produced a 7{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} increase in mortality. If a nurse is caring for eight patients instead of four, there is a 31{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} increase in mortality.

As proposed, the pilot program would have established minimum ratios for different types of units or departments in a hospital. The proposed law calls for one nurse for every four patients in medical/surgical units, where most patient care takes place. In emergency departments, the proposed regulations would require a 1-to-1 and a 1-to-3 ratio depending on the severity of the patients’ conditions. Ratios would be 1-to-1 in labor and 1-to-2 for intensive care units, while other units would range from 1-to-1 to 1-to-5.

Those ratios would ensure adequate staffing and generate better patient outcomes in the state, said Karen Higgens, RN, president of the MNA, who told The Healthcare News that minimum nurse staffing ratios are supported by eight out of 10 voters in the Commonwealth and nine out of 10 frontline nurses.

The Bottom Line

While proponents of the nurse staffing ratios bill put patient care at the center of their argument, they also say its passage will go a long way toward alleviating the nurse shortage in Massachusetts. Indeed, Pacheco and the MNA both cite an independent study, conducted by Opinion Dynamics Corp. (ODC), which reveals that many RNs believe nurse understaffing is a serious problem and that the situation would be improved with minimum staffing ratios. And if such ratios were put into effect, more nurses would stay in the profession — and some who have left it would be prompted to return.

“The consequences of understaffing appear to be two-fold and self-compounding,” the study’s authors, John Gorman and Chris Anderson write in an executive summary to their report. “The direct effect is a decreased quality of patient care leading to more medical complications, longer hospital stays and, in some instances, mortality. The secondary effect is a stressed workforce that is burning out and feeling that their own livelihood is increasingly at risk due to possible legal liabilities resulting from mistakes caused by high patient loads.

“The compounding effect is that stress and risk associated with high patient loads is further decreasing the number of RNs willing to work in acute situations,” they continue. “In fact, it appears that many RNs would consider returning to acute care from other settings if ratios are established. Among RNs who do not currently provide direct patient care, a majority would consider returning to the bedside if legislation was passed to regulate RN-to-patient ratios.”

Not surprisingly, opponents of nurse staffing ratios take a different view of how the measure might impact the nursing shortage. They don’t believe it will attract more individuals to the field, and will, in the meantime, succeed only in inflating salaries and benefits as hospitals compete amongst themselves — and with other health care providers such as nursing homes and home health agencies — for a limited supply of nurses.

Cavagnaro said that nurse-staffing ratios could bring an additional $1 million to $2 million burden to the hospital. He predicts a bidding war if nurse staffing ratios become reality, one that can only hurt smaller facilities like Wing.

In the worst-case scenario, Wing would be so financially hamstrung by the nurse staffing measure that it would have to close its doors, said Cavagnaro. This wouldn’t impact the RNs, other nurses, or any of the other health care professionals at the hospital, he explained, because they could all easily find work. But it would impact the people in Wing’s service area, located roughly half-way between Springfield and Worcester. Residents of those towns would face a much longer drive and significantly more headaches to receive care.

“This bill will end the kind of service that people have become accustomed to,” he said of the pilot program. “The MNA is trying to paint the picture that you’re either for this bill or you’re against patients. And that just isn’t the case.”

The Right Ingredients?

Pacheco told The Healthcare News that he and other supporters of nurse-staffing ratios are in this fight for the long haul because they consider the concept crucial to improving patient outcomes in the Commonwealth.

Cavagnaro plans to continue fighting as well, because while the nurses union sees staffing ratios as a logical solution to a recognized problem, he and other hospital administrators firmly believe this cook-book legislation, as they call it, is a recipe for disaster.

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