IMPROVING THE QUALITY OF CARE: THE CONTINUING DEBATE OVER NURSE-PATIENT RATIOS

Volume 30, Issue 535                                                        March 16, 2009

Matthew Gever

How many nurses are enough? That is the question in states that are debating whether or not to mandate nurse staffing standards at hospitals.

Such standards are not the newest aspect of quality of care deliberations, but the issue may grow in importance as baby boomers age. By 2025, the United States may need 500,000 more registered nurses than it has, according to a March 2008 report from experts at Vanderbilt University and others.

 Nurse staffing standards are needed to protect patient safety, say some lawmakers. "Ratios greatly reduce costly medical errors, hospital infections and the significant expense of replacing the increasing numbers of RNs who leave the bedside due to unsafe staffing conditions," said Senator Daylin Leach of Pennsylvania, where HB 147 is currently being debated.

However, some recent studies of California's policy have come to less sanguine conclusions.  "Most of the quality measures do not appear to have been directly affected by the increase in RN staffing," said a study published in February by the California HealthCare Foundation (CHCF).

This year, at least nine states and Congress are considering legislation that would require hospitals to meet specific nurse-to-patient ratios. Advocates want to follow the lead of California, which in 1999 became the first—and so far the only—state to mandate specific nurse-to-patient ratios in hospitals when it passed AB 394.

Most of the bills now under consideration would base nurse staffing on the numbers of patients in a ward. For example, the regulations that detail how California's law should be carried out require one nurse for every four patients in an emergency department; every five patients in medical-surgical units; every two patients in maternity wards; and for every six in behavioral health units. The state's Department of Health Services developed these ratios through its own analysis of the existing literature on the topic, visits to state hospitals and meetings with professional groups.

Pro and Con

A number of studies have found a relationship between lower staff ratios and certain improved health outcomes. For example, a series of studies from the Agency for Healthcare Research and Quality found "significant associations between lower levels of nurse staffing and higher rates of pneumonia, upper gastrointestinal bleeding, shock/cardiac arrest, urinary tract infections, and failure to rescue."

Many of the health-care leaders interviewed for the CHCF study said they expected that the ratios would eventually improve the quality of care by increasing the interaction between nurses and patients. However, the CHCF found that since the California law went into effect, the average length of patient stay has remained the same, and other nursing-sensitive measures such as pressure ulcers, post-surgery sepsis and pneumonia mortality showed minimal or no improvement.

The authors of another study, in the journal Health Affairs, suggested that mandating nurse-staffing ratios could raise hospital costs more than previously anticipated. The study found that the real wages for nurses in California cities increased by an average of 7.8 percent more than the wages for nurses in other metropolitan areas across the nation.

Nurses themselves are divided on the issue. While most favor lower staffing ratios, some don't want lawmakers to get involved. For example, the Arizona Nurses Association "feels strongly that these ratios must be set, not by legislators or government officials, but in the workplace in direct coordination with nurses themselves," according to a spokesperson for the group. The Grand Canyon State is currently considering HB 2186, which sets a series of nurse-patient ratios similar to California's.

Some nurses, however, see legislation as essential protection from staffing cuts by hospital management. "These are the same administrators who have spent the last two decades cutting corners and dangerously increasing nurses’ patient loads," said a statement from the Massachusetts Nurses Association. Last session, lawmakers in the Bay State considered but did not pass SB 2816, which originally included a ratio provision.

Others think that the real issue is not ratios but rather developing policies to address the shortage of nurses. “Demand for full-time registered nurses in Texas in 2008 exceeds supply by 22,000," said Dan Stultz of the Texas Hospital Association, who added that this gap in demand for nurses will grow to 70,000 by 2020. The Lone Star State is now considering a ratio bill in SB 1000.

Other states currently considering nurse-patient ratio bills are Florida (HB 241), Illinois (HB 485), Nevada (AB 121), New York (AB 2264), New Jersey (AB 1531), Oregon (SB 564) and West Virginia (HB 2949).  Congress is considering S 54, which would mandate ratios for hospitals that serve Medicare patients. These bills would implement ratios similar to those of California.

© Copyright 2009, State Health Notes