Debate over nurse-patient ratios heats up

Ratios are back in the news—and no, not because celebrities are embarrassing themselves on social media. So-called safe staffing, a policy that sets ratios for the number of patients a nurse or other health provider can care for at one time, is gaining newfound attention in the wake of the Covid-19 pandemic.

A key factor in the recent New York City nurse strike, nurse-patient ratios are expected to remain a top issue as hospitals struggle to fill health worker shortages.

Unfamiliar with the concept or how we got here? Fear not, Healthcare Brew has got you covered.

State(s) of play

More than a dozen states have implemented hospital safe staffing standards—which often vary among facility units and/or license types—since California became the first state to adopt nurse-to-patient ratios in 1999. (They took effect in 2004.)

Most states require hospitals to have a committee of nurses and other staff that determine minimum care requirements for their facility, but some simply mandate disclosure of staffing levels, according to the American Nurses Association (ANA), a professional association that advocates for the committee approach. Other states require both approaches.

Today, California is still the only state to have set nurse-to-patient ratios in state law—although a Massachusetts law also sets ratios just for ICU patient assignments.

There are no federal standards, but advocates, like National Nurses United (NNU), are pushing for them.

Why it matters

Debate over hospital safe staffing has percolated in the US for years, sparking headlines amid high-profile ballot fights (think Massachusetts in 2018). But it’s escalated as more nurses leave the field, due in part to the pandemic. Many nurses who stay argue that they have fewer resources and must care for too many patients at once—even in places with safe staffing policies.

“There is not a nursing shortage. There [are] close to 5 million nurses in this country, and they have had it,” said Gerard Brogan, director of nursing practice for NNU, a union and professional association with almost 225,000 members.

In California, nurses pushed back against Covid-era emergency rules that they argued allowed facilities to skirt staffing requirements. Colorado and New York, meanwhile, passed safe staffing legislation for the first time in 2022 and 2021, respectively, as the pandemic brought these issues to the fore.

More recently, nurses unions in Washington and Oregon relaunched legislative campaigns to beef up enforcement of staffing guidelines set by hospital-based committees—rules that, critics argue, are not always followed. (Illinois updated enforcement of its law in 2022.)

• Zoom in: The issue came to a head as New York State Nurses Association nurses went on strike in early January after failed talks with two New York City hospitals over pay, benefits, and patient loads. The three-day strike ended after the union secured what it called “concrete enforceable safe staffing ratios,” among other concessions. (Nurses at the city’s public hospitals have since reportedly called for similar safe staffing standards.)

“In any state, especially under these circumstances, you’re going to see issues,” Jason Richie, associate director of state advocacy at ANA, told Healthcare Brew.

But Brogan argued that even pushing for enforcement of hospital committee-backed standards “is a false fight” since “the ratios agreed to are never adequate anyway.”

“It’s a faux staffing committee,” he said, noting that NNU is at odds with ANA on the issue.

The ratio debate

Critics—primarily hospital leaders and groups like the American Hospital Association (AHA) and American Organization for Nursing Leadership (AONL)—cast safe staffing ratios as an expensive, “one-size-fits-all” approach to healthcare.

AHA, in conjunction with AONL, argued that mandated staffing ratios “are a static and ineffective tool that cannot guarantee a safe health care environment or quality level to achieve optimum patient outcomes.” And they “increase stress on a healthcare system already facing an escalating shortage of educated nurses,” the organizations contended in a policy statement.

The Massachusetts Health and Hospital Association argued that the 2018 ballot measure to set nursing ratios would’ve cost hospitals (and ultimately patients) an estimated $1.3 billion in the first year and $900 million annually thereafter. (The ballot’s defeat came after industry lobbying efforts outspent the Massachusetts Nurses Association, Brogan noted.)

But supporters like Brogan argue that claims of outsized costs are unfounded and that investing in staff will lower system costs in the long run. They also tout mandated ratios as a key to improving patient outcomes and preventing nurse burnout—saving health systems from turnover-related costs.

“The thrust of the ratios is not to make every nurse extremely happy about life, but it does lead to more satisfaction from nurses, which in turn keeps them at the bedside and keeps them loyal to both the employer and the patients,” Brogan said.