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Patient limits for nurses: Who wins and who loses?

The election this November is an undeniably important one, as it will determine which party gains control over the House of Representatives. But there are also issues being decided on a state level that directly impact the health care system. In Massachusetts, voters will be deciding via ballot referendum on mandated staffing levels for nurses in hospitals. We dug deep into the research to better understand why this initiative is needed, and the potential outcomes of stricter patient-nurse ratios.

Why mandate patient ratios?

The Massachusetts Nurses Association (MNA), a powerful nurse’s union, has been fighting for limits on nurse/patient ratios for twenty years. Aside from the ICU, there is currently no state limit on the number of patients that can be assigned to a nurse at one time. As a result, many nurses report feeling unable to care for all the patients to which they are assigned. In a statewide survey of registered nurses conducted by the MNA, 77% said that they think nurses in Massachusetts hospitals are assigned too many patients at one time, and 61% of respondents reported that this was a challenge they faced themselves. 

Why is it so important to have the right number of nurses per patient? Nurses are the only people in the hospital directly responsible for patients 24/7, so it is their job to pick up on subtle changes in the patient’s condition that could mean the difference between life and death. If nurses are too busy to check in on every patient in their care, they could miss something important – and often do, as some nurses attest. 

If you’re a juggler and you can juggle 4 balls and then someone gives you 5 or 6, you’re going to drop some,” said MNA Communications Director David Schildmeier

Medical research supports the association between increased nurse staffing levels and patient outcomes, such as hospital-related mortality and failure to rescue. However, since all of these studies are observational, it’s difficult to tell whether better outcomes are due to greater nurse-patient ratios themselves or because the hospital may have a greater commitment to high-quality care in general. 

The ballot initiative is the MNA’s proposed solution to the problem of high nurse/patient ratios at Massachusetts hospitals. The initiative establishes mandated limits on the number of patients per registered nurse at a time, based on unit and level of care. Nurses would also be given an “acuity tool” to assess patients’ conditions, to determine if they need a lower patient limit. Hospitals would have to pass inspections to make sure they are abiding by the rules, and could be fined up to $25,000 for violations. Hospitals would not be allowed to fire clerical, professional, or maintenance staff to make up for hiring more nurses. 

Who wins?

The MNA has painted the nurse staffing issue as a win-win, but every policy has some winners and losers. 

Registered nurses

While not all registered nurses support ballot question 1, they arguably stand to gain the most from the initiative. Having an appropriate staffing ratio takes pressure off of nurses to juggle more and more patients, making their workload manageable and allowing them to provide better care for patients. Over the past few decades, American nurses have become less happy with their working conditions, citing understaffing as a key driver of job dissatisfaction. Unsurprisingly, higher nurse staffing levels are associated with lower levels of nurse burnout and job-related dissatisfaction. There’s a reason why the union has been fighting for this initiative for twenty years – nurses want to do what they love, and that’s taking good care of patients. Better nursing staff ratios will likely help that. 

Patients (maybe)

Advocates of the ballot initiative argue that the law will improve patient outcomes. While there is a demonstrated association between lower patient/nurse ratios and better outcomes, it is unclear whether mandated ratios will actually improve outcomes. California passed a law mandating nurse/patient ratios in 2004, making it the first state to do so, and giving researchers an opportunity to study the outcomes of such laws.

Studies comparing patient outcomes in California compared to states that do not have ratios found that CA had reduced adverse events, readmissions for heart failure, and lower mortality. However, studies comparing outcomes in California before and after the law are not as rosy. A 2007 study found no improvement in nurse-sensitive outcomes such as falls and pressure ulcers. A 2009 evaluation by the California Healthcare Foundation found no improvements in outcomes either. 

How could lowering patient ratios not improve outcomes? In California, some hospital administrators reported that the ratios lack of continuity of care because nurses had a lot of breaks and had to get coverage to meet the ratio requirement. Another theory is that patient ratios are just one element of the broader work environment of a hospital. One study of hospitals across the country found that increasing the number of nurses per patient decreased deaths and failure to rescue in hospitals with good work environments, but did not in hospitals with poor work environments.

Some have questioned whether the ratios would increase ER wait times at hospitals. Some hospitals in California reported longer ER wait times because they didn’t have enough staff. However, this is more likely due to a lack of beds rather than a lack of nurses. According to the CHF, the law did not impact patient satisfaction scores overall. 

Who loses?

Hospital administration

Hospital administrators have been largely against this initiative, claiming that the ratios are too inflexible and would bankrupt some hospitals. The experience of hospitals in California does not lend any support to these points. 

As health policy researcher Linda Aiken said in a 2013 interview: “None of the big unintended consequences nurses were worried about regarding the legislation actually happened… There is no evidence that hospitals closed as a result of the legislation.” The CHF evaluation similarly found that for California hospitals, “Staffing requirements likely had at most a marginal impact on financial stability.”

Are the rates too inflexible? Advocates say no. The law requires development of an acuity tool, which would allow hospitals to adjust the ratios down if necessary, depending on patients’ conditions. In this way, the law encourages flexibility in staffing. Of course, what administrators mean is they want the “flexibility” to hire fewer nurses than required by the law. However, that is currently what happens now, and nurses are increasingly being given workloads that they cannot safely manage. I’m sure many businesses would like the flexibility to pay their employees less than minimum wage, but that defeats the purpose of having a minimum wage. 

So if hospitals don’t suffer much financially, why do administrators oppose the law? Because the staffing requirements will likely force some hospitals to move money from areas like executive pay and administration to hiring more nurses. Boston College economist Judith Shidul-Rothschild recently estimated the cost of the law to hospitals statewide and found that it would cost $47 million (much less than the $1.3 billion estimated by the Massachusetts Hospital Association). 

“The majority of Massachusetts hospitals could easily meet the requirements of the law simply by shifting approximately 3 percent of the proportion of their budget currently allocated to non-direct care managers and hospital administrators, to RNs and hospital unit staff who provide direct patient care,” said Shindul-Rothschild.

Overall system outcomes

In general, it seems the law would have a positive impact for nurses, positive or neutral impact for patients (no study I found showed a negative impact of more nurses on patient outcomes), and a negative or neutral impact for hospital administrators (about half of MA hospitals already meet the ratio, so they would not need to hire more nurses). 

Given the current body of research, the benefits of mandated patient ratios on patient outcomes are not conclusive. Nevertheless, this law could be the start of a much-needed movement toward better working conditions for clinicians, a happier hospital workforce, and a stronger health care system for the state.