April 9, 2013

Stewart: How to understand the staffing ratio debate

Daily Briefing

The Daily Briefing's Dan Diamond spoke with Jennifer Stewart, the Nursing Executive Center's managing director, about new staffing ratio legislation and the state of the debate.

Q: Before we get to why staffing ratios are back in the news again, can you explain how—and whether—they work?

JS: Staffing ratios remain a top issue for many unions and patient safety advocates. The underlying theory is that by specifying the exact number of patients each registered nurse can care for, nurse-to-patient ratios set an upward cap on registered nurse work intensity.

Basically, it's an effort to try and prevent registered nurses from being assigned too many patients at once, in hopes of increasing patient safety. 

Some hospitals have essentially adopted the ratios on their own, and California enacted a statewide law about a decade ago that mandates hospitals maintain specific nurse staffing levels.

However, there’s vigorous debate—and quasi-competing studies—regarding if California’s mandated staffing ratios have had the desired impact on nurse burnout and patient care outcomes. 

Q: How closely are you following lawmakers' efforts to enact mandated ratios in Michigan, Minnesota, and Washington, D.C.?

JS: It's certainly news, but it's important to remember that staffing legislation has been bubbling around for years—it's often introduced in state legislatures, but doesn't always make it out of committee.

It's also key to remember that with mandated ratios, there's another way you get there: Through a union, with collective bargaining arrangements.

So we advise hospital leaders: You can't think of mandated ratios as only a legislative matter, even if bills in front of your state legislature tend to get more press.

Your nursing union could independently push for mandated ratios, too.

Q: Where are the hot zones of union activity?

JS: About one-fifth of hospitals are unionized, but whether a hospital's nursing staff is unionized tends to vary state-by-state—California has very strong unions, which helped lead to the passage of the statewide law on ratios.

The coasts are heavily unionized, too.      

Q: Returning to the ratios debate, what have we learned from the organizations that have instituted ratios?

JS: So ratios presume that all nurses are the same—that a nurse is a nurse is a nurse.

But if you think about it, there are different paths to becoming a nurse. Some have bachelor's degrees, some don't. Some are going to have specialty certification, some are just out of school.

And instituting ratios also presumes that all the support around a nurse is going to remain constant. But if you look at California, one of the lesser-known findings from a study conducted by Dr. Linda Aiken is that the amount of support staff went down.

Essentially, there's a fixed amount of money that hospitals have to spend on labor.

It's interesting because there's been a push toward nurses practicing at the top of their license.  But if the support staff get stripped out, that means nurses are doing everything from performing clinical assessments to giving medication and even emptying out waste baskets. Some of that work, in theory, could be performed by staff with a lower level of education and training.

Q: Based on your description, it sounds like the law of unintended consequences may apply here: The effort to solve concerns over burnout and patient safety may be creating another issue entirely.

JS: You know, there's kind of an epic battle shaping up for the future of nursing.

On the one hand, there's a push for every nurse to have a bachelor's degree. But at the same time, the fight for ratios may make it hard to achieve top-of-license practice.

And we're looking at this right now—we're surveying nurse managers on not only the nurse-to-patient ratios on their units, but also the level of support staff, nurse education, experience, and more. In addition to publishing national results, we’ll analyze the data by region, unionization status, and other hospital characteristics. I'm hoping that will give us more perspective on this.

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