Nurse-to-Patient Staffing Ratios: The Case for State Mandates

Introduction

As of now, at least fourteen states across the country have legislation on safe staffing. Although California is among those fourteen jurisdictions, it is unique in the sense that its legislation includes a nurse-to-patient ratio clause. The allowed ratio is five patients per nurse. Half of the remaining states mandate hospital boards and committees to set nurse-to-patient ratios within their own hospitals, while five other states require hospitals to disclose their staffing ratios publicly (Abraham). Staffing ratios are especially important when they are set by the state, as is the case in California.

When states do not set standards — as is the case in most states across the country — facilities usually become short-staffed. In other cases, nurses become overworked and exhausted, leading to high staff turnover in health facilities, poor health outcomes, and compromised patient safety. A recent survey by Kronos Incorporated showed that nearly ninety percent of nursing staff want to leave their current positions because they feel overworked (Abraham). Other surveys and studies show that in places where nurses are far fewer than patients, patients are losing their lives, especially in ICU wards.

Despite the clear risks and dangers of having more patients than available nurses can handle, hospitals and other health facilities are pushing back, claiming that not enough studies support the need to employ more nurses. They also argue that not enough nursing staff are available for hiring, so even if they decided to hire more people, they would not find enough qualified candidates (Abraham). However, states are not relenting. More states have expressed their intention to set a standard ratio, or at least to require hospitals to disclose their nurse-to-patient ratios publicly. It is the argument of this paper that all states should use the California law as a model to set official nurse-to-patient ratios that should be strictly adhered to, in order to avoid the many ills of having far fewer nurses than patients.

Proponents' Arguments for Mandated Staffing Ratios

California enacted state legislation in 2004 that, in brief, stated that for every five patients there should be one nurse. This law effectively set the minimum limit and necessitated the employment of more nurses to ensure that sufficient numbers were available to provide patients with the quality healthcare they need. Different limits were set for different health facility settings. For example, in an operating room, the ratio was set at one nursing staff member per patient, while for psychiatric wards the ratio was set at one nursing staff member for every six patients. For emergency rooms and pediatric rooms, the limit was four patients per nursing staff member (Terasawa).

It has been argued that the California state legislation improves health outcomes, is cost-effective, and has led to increased opportunities for nurses. Those who support the inclusion of ratios in law also argue that the annually increasing number of graduates will fill open positions. In other words, highly skilled nurse graduates are helped to find work by the legislation, while shortages are simultaneously addressed. Between 2004 and 2008, vacancies for registered nurses reduced by sixty-nine percent. This demonstrates that no significant shortages were experienced after the enactment of the law and that vacancies have decreased because more nurses are filling open positions more quickly (Abraham).

Proper staffing is important for the delivery of quality healthcare. Staffing levels should be flexible and should take into account additional factors including resource availability, unit layouts, experience levels of available staff, transfers during shifts, admission numbers, and patient needs. Laws like California's have set standards for optimal staffing; however, new legislation can improve upon them to make them more comprehensive, accounting for factors such as availability of support resources, nursing unit layout, physical design of health facilities, expertise of available staff, number of admissions, number of discharges, and patient condition (Lippincott Solutions). As more jurisdictions focus on quality and value-based care, proper nurse staffing is expected to be central to the implementation of related policies, since nurses are often at the forefront of delivering healthcare services. Optimal nursing levels can achieve not only better healthcare but also better patient outcomes and higher job satisfaction.

Those who support the setting of nurse-to-patient ratios in legislation argue that such laws improve the quality of care provided. They argue that this was the effect observed in California hospitals. Furthermore, many studies have revealed that higher staffing levels often mean better health outcomes for patients (Livanos, 68–70). Advocates of nurse-to-patient laws also argue that low nursing levels put patients at risk and that only the establishment of minimum patient-to-nurse ratio limits can help guarantee quality standards below which hospitals should not fall, or risk penalties. Proponents are also of the opinion that patient categorization methods based on acuity — as found in the California statute — are not sufficient, since they make it difficult to determine which health facilities are complying. Their recommendation is that simpler minimum ratios be required and publicly disclosed, making it easier for all stakeholders to quickly identify and report hospitals not complying with the law.

Advocates for the setting of nurse-to-patient ratios in statutes also contend that establishing ratios will eliminate or reduce nursing shortages. Their belief is that qualified nurses are refusing to work in certain institutions because of poor working conditions in many hospitals, including chronic overwork and negative patient outcomes. Proponents argue that when ratios are written into law, working conditions will automatically improve: overworking will become a thing of the past and negative outcomes will decrease (Nantsupawat et al., 91–98). This, they believe, will help reduce nursing shortages, as those who have left the profession due to poor conditions will be more likely to return when conditions improve.

When California passed its nurse-to-patient ratio legislation, the number of registered nurses in the state's hospitals increased significantly over the following years. While it is not entirely clear that the increase in registered nurse numbers was driven solely by better working conditions, it is generally expected that more nurses would help reduce negative outcomes in hospitals. Conditions did improve in California hospitals following the legislation, including better wage rates and stronger wage growth than in other states during the same period. This is widely regarded as part of the reason for the increase in nurse numbers in the state's healthcare system (Terasawa).

California's optimal staffing mandates are also thought to have improved working conditions in other ways. Hospitals whose nurse-to-patient ratios met the state's recommendations showed higher job satisfaction scores, lower nurse burnout numbers, better work environments, and lower turnover rates (Terasawa; Nantsupawat et al., 91–98). It was also found that nurses in hospitals with optimal registered nurse staffing levels were less likely to report poor care quality, abuse by patients or staff, or complaints from families or patients. From these findings, it can be stated that California's nurse staffing mandates helped improve conditions for nurses and that this attracted more nurses to work in the state's hospitals, reducing the previously existing shortage.

A final point made by proponents of California's nursing staff mandates is that they help improve the quality of care. Nurses exist to provide care; while they fulfill other roles in hospital settings, their primary duty is to care for patients. Institutions with poor nurse staffing cannot provide good quality care because their nurses are constantly overworked. That overwork and resulting exhaustion can increase the length of hospital stays, result in medical errors, increase patient mortality, increase the number of patient falls, and lead to a rise in hospital-acquired infections (Nantsupawat et al., 91–98). Lowering the limit of patients each nurse is expected to handle at any given time ensures that nurses are not overworked and are capable of delivering good quality care. It also ensures that nurses can fulfill other nursing roles, such as discharge planning and case management, more effectively. A recent survey by the American Nurses Association revealed that more than fifty percent of nurses felt they did not spend enough time with their patients ("Mandated nurse-to-patient staffing…"). This clearly affects care quality and is often a direct consequence of poor nurse staffing — a situation that mandated nurse-to-patient staffing numbers can help reverse.

Conclusion

As is evident in the arguments presented in this paper, states across the country should use the California model to establish statutes setting minimum patient-to-nurse ratios. Since California enacted its minimum patient-to-nurse ratios for various hospital units and scenarios, the state has recorded better healthcare outcomes and higher staff job satisfaction scores. It is clear from the opponents' arguments that not everyone agrees that minimum nursing ratios should be codified in law. Some believe it is unnecessary, while others believe there are better ways of addressing the challenges that minimum mandated staffing ratios are intended to solve.

However, these arguments do not directly address the actual problems that minimum nurse staffing ratios aim to cure: nursing shortages and lower patient outcomes resulting from those shortages. Ensuring that optimal numbers of staff are available in hospitals nationwide will help significantly improve patient outcomes, improve the quality of healthcare, and prevent avoidable negative outcomes such as patient falls and dissatisfaction. It will also improve the work environment for nurses and reduce the alarming turnover rates that result from overworking.

Works Cited

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