Nurses Send An SOS Will Massachusetts Lawmakers Mandate Minimum Nurse-staffing Levels?

The numbers are alarming.
No one would argue that insufficient numbers of nurses in hospitals and other health care facilities is a good thing. But a recent survey reported by the Mass. Nurses Assoc. (MNA) puts the problem in stark relief.

Of the nurses surveyed earlier this year, 87{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} report having too many patients to care for. In addition, 67{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} said understaffing has led to medication errors, 64{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} said it has contributed to complications, 54{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} report readmissions due to understaffing, and 52{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} report injury and harm to patients as a result of the situation.
And, most alarmingly, 29{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} report patient deaths directly attributable to nurses having too many patients to care for.

“These shocking conditions exist right here in Massachusetts, a state that is known around the world as a medical Mecca,” said Karen Higgins, RN, president of the MNA. And the report explains why Higgins supports proposed legislation that would mandate a minimum nurse-to-patient ratio in medical facilities.

Not everyone agrees that a law is necessary, however, and even those who do aren’t all taking the same legislative strategy. What everyone can’t help but agree on is that there aren’t enough nurses to effectively treat a growing and aging population, in Massachusetts and nationwide.

But no law can produce nurses where there are none available, and therein, for some opponents of staffing mandates, lies the rub.

Strong Medicine

The legislation Higgins and the MNA support is a state House bill that would require all acute-care hospitals to adhere to minimum RN-to-patient ratios as a condition of licensure by the state Department of Public Health.

The proposed ratios are department-specific. For example, the proposal calls for one nurse for every four patients in medical/surgical units, where most patient care takes place. In emergency departments, the mandated ratios would be between 1-to-1 and 1-to-3 depending on the severity of patients’ conditions. The ratios would be 1-to-1 in labor and 1-to-2 for intensive care units, while other units range from 1-to-1 to 1-to-5.

“Given this understanding of the role of registered nurses, I’m sure you can begin to understand that the most important component of nursing is time — time that a nurse has to use his or her educated mind, trained eyes, and disciplined ears to monitor patients,” Higgins testified recently before the legislative Joint Committee on Health Care.

“When you’re a patient, anything that diminishes the time your nurse has to spend on your care makes it more likely something bad will happen to you. It’s that simple. And the most important determinant of how much time your nurse will have to devote to your care is the number of patients he or she is assigned.”

Not everyone agrees with the legislative approach being taken, however. The Massachusetts Organization of Nurse Executives (MONE), for example, has stated that mandated staffing ratios “will only serve to increase the stress on an already overburdened health care system and potentially create a greater public safety risk.”
MONE argues that mandated nurse-staffing ratios fail to factor in variables such as patients’ actual needs, the environment in which care is delivered, and the availability of adequate support services. Unintended consequences of these “arbitrary” ratios, the organization claims, could include cutbacks in services, bed closures, and emergency room diversions, resulting in decreased access to health care.

“Establishing mandatory staffing ratios is not the answer,” MONE argues. “Working together with policy makers in seeking solutions to ensure an adequate supply of nurses and other health care workers is a better approach to address the factors that contribute to the healthcare crisis in Massachusetts and across the country.”

California, as the first state to institute mandatory nurse staffing, has been closely watched by groups such as MNA and MONE, and held up as a positive example by supporters of staffing laws. But MONE pointed out that it’s possible that, in a nursing crunch, private hospitals could raid the ranks of state-employed nurses, paying them more, and leaving patients in state-run hospitals with worse care.

A Different Take

Sen. Richard T. Moore (D-Uxbridge), who chairs the Joint Committee on Health Care, has come up with a different sort of bill in what he calls “an act to promote improved patient outcomes through registered nurse staffing in licensed health care facilities.”

Moore says there’s little disagreement that adequate nurse staffing will result in improved patient outcomes. But he recognizes that, with the current nursing shortage affecting care facilities of all kinds, it would be difficult for institutions, particularly financially stressed ones, to comply with state-mandated ratios.

“The ratios themselves often fail to consider variations in nurse experience and ability, physical layout and availability of medical technology, or degree of sickness in patients,” he contends. “Furthermore, they utilize a punitive approach rather than incentives for compliance.”

Therefore, set-in-stone, mandated ratios are not the answer, he claims, but a more flexible approach, one that uses incentives by Medicaid and private insurers to reward hospitals and nursing homes that improve patient outcomes by providing adequate RN staffing.

The legislation would allow the Division of Health Care Finance and Policy to design a method of calculating a registered nurse ratio based on the average ability and experience of a facility’s nurses, along with the average case mix of patient conditions. By analyzing this data and the patient discharge data, the state could eventually show that facilities with more RNs have better patient outcomes.

“Over time, the data collected by the division might provide hard evidence that might help define more specific ratios or nurse-to-patient goals that could be set for providers to achieve,” Moore said.

Higgins prefers a stricter approach, however, citing research published in the Journal of the American Medical Association and the New England Journal of Medicine — not to mention her own organization’s striking survey — to support her position.

“These survey results are in line with the national studies. They underscore that RNs in Massachusetts are forced to care for too many patients at the same time and that the safety of all patients is seriously compromised as a result,” she said.

“These findings should be a wake-up call to hospital administrators, a warning to patients who seek care in our hospitals, and a call to action for legislators, who have in their hands the means to protect the public from the serious risks posed by current hospital conditions.”