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Running head: HEALTHCARE ISSUE

Healthcare Issue Analysis Paper: Mandatory Nurse-To-Patient Ratios


Kiel Reidenbach
Ferris State University

HEALTHCARE ISSUE

Mandatory Nurse-To-Patient Ratios


Nurses are the primary providers of direct patient care in United States hospitals. Due to
many factors, such as the aging nursing population nearing retirement, as well as the aging
population in general needing care, staffing nurses adequately can be a challenge. Nurse to
patient ratios vary considerably depending on what hospital a nurse works for, what patient
population a nurse works with, and can also vary from shift to shift. In most states, there is no
government mandated staffing level which accounts for this wide variation. However, this is not
to say that much legislation has not been proposed. This paper looks to explore the issue of nurse
staffing, the effects that it has on all parties involved, and show why legislation in this area
should not be supported, despite its good intentions.
Description of Current Health Care Issue and Importance to Healthcare
Currently, with the exception of California, nurse to patient ratios are decided largely
within the hospital or institutions in which a nurse practices. Due to lack of formalized ratios,
nurses in similar units, caring for similar patients, may have much heavier, or much lighter
patient assignments than their peers. This inconsistency has been shown to create issues with job
satisfaction, patient safety, and patient outcomes. With the current nursing shortage, estimated to
reach 20% vacancy by 2020 coupled with a 40% increase in demand, healthcare will need to
address issues with unsafe staffing (Duvall, Andrews, 2010).
Current research on safe nurse-to-patient ratios is largely based on observational studies.
Statistics from these studies show that as staffing increases, positive patient outcomes,
recruitment, and overall job satisfaction will also increase, and nursing shortages will decrease
(Tevington, 2011). However, much of these findings are also found to be overstated. The Institute
of Medicine indicated a lack of evidence to link staffing ratios directly with patients outcomes
and did not recommend basing public policy and staffing decisions off of existing literature
(Bolton et al., 2001).
Importance to Patient Care

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Increased nurse staffing has been shown through observational studies to improve many
aspects of patient care. An increase in nurse staffing showed a decrease in hospital related
mortality, failure to rescue, cardiac arrest, hospital acquired pneumonia, as well as other adverse
events (Kane, Shamliyan, Mueller, Duval, & Wilt, 2007). Cho et al. (2015) looked more closely
at what increasing a nurses workload does to patient care and found that each additional patient
added to a nurses assignment was associated with an increase of 5% in the odds of patient death
within 30 days of admission. In addition, the odds of patient mortality are nearly 50% lower in
hospitals with better nurse work environments (Cho et al., 2015). However, some of this data
needs more probing.
The Institute of Medicine put out a report titled Keeping Patients Safe: Transforming the
Work Environment for Nurses that warned against putting full stock in observational studies
that use patient mortality as an outcome measure. Patient death is not a common occurrence and
its relatively low frequency makes unearthing statistically significant data difficult. In addition,
not all of these deaths can be directly attributable to injuries related to healthcare. Some just die
as a result of overwhelming disease (Institute of Medicine, 2004). Studies of nurse staffing
using patient mortality as an outcome measure have lacked the methods for separating
preventable and non-preventable deaths (Institute of Medicine, 2004).
Importance to Nursing
The issue of nurse staffing affects more than just the safety and quality of patient care.
The nurses who work within the constraints of the staffing models imposed on them are heavily
affected. Job satisfaction, retention, and burnout are all variables that must be considered.
Models that do not provide the resources for nurses to provide necessary care to their patients or
create an environment that fosters frustration and overworking of nursing staff can have negative
consequences.

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Retention has been shown to stem from a nurses lack of satisfaction with staffing. Hairr
et al. (2014) reported that many nurses are simply staying with their current employer because
of the current economic environment. As the economy improves, nurse staffing may become a
major issue in the effort for institutions to retain their nursing work force. The current nursing
shortage will also play a role in addition to retention issues. This shortage is especially
troublesome when one considers that 46% of the current nursing workforce is over the age of 50
(Nursing Shortage, 2015). This shortage is expected to reach 300,000 to 1 million nurses by the
year 2030 (Mason, Gardner, Hopkins-Outlaw, OGrady, 2014). This issue has two points of
interest as it pertains to the staffing crisis. First, this shortage makes adequate staffing levels
difficult in general, and the shortage negatively effects job satisfaction leading to turnover.
Identification of Actual or Proposed Legislation
Currently there is legislation addressing possible solutions to the issue of nurse staffing.
According to an interview with James Chip Falahee, who is the Senior Vice President of
Bronson Methodist Hospital as well as a registered lobbyist, this type of legislation comes up
every couple of years (J. Falahee, personal communication, March 04, 2016). At present, there is
legislation pertaining to staffing of nurses in both the federal and Michigan governments. These
include Michigan Senate Bill 574, Michigan house bill 5013, Senate Bill 864, and House Bill
2083. All of these bills, with the exception of House Bill 2083, look to mandate minimum
staffing levels, by unit, for nurses. For these three bills, it would be up to hospitals to assess
acuity of patients served, provide adequate staffing levels that adhere to the ratios described in
the bill, and keep record of staffing levels both for public as well as regulatory review.
House Bill 2083 is unique from the other three bills as it does not look to mandate
staffing levels across the board. It provides a mandate for hospitals to form a staffing committee
that must consist of 55% staff RNs that is responsible for initiating a hospital wide staffing plan.
This could prove problematic as this committee will carry a majority vote over senior leadership

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and management. Therefore, staffing plans have potential to prove costly for hospitals depending
on the outcome, as well as levying stiff financial penalties for non-adherence.
Although these bills look to solve some of the issues within our healthcare system such as
nurse burnout and patient safety concerns, this tactic may not be the solution that it appears to be.
Lack of data, monetary constraints, and ability of hospitals to follow through are all
considerations. There is research that finds that lower nurse to patient ratios ensure safer patient
care, however, there is also research that finds otherwise. For this reason, these bills should not
be supported and would be considered over-stepping by the government entity involved.
Implications and Consequences of Legislation on Nursing and the Public
Legislation mandating nurse staffing levels would have wide-spread effects on the public,
nurses, and employing hospitals. One of the best sources for information on the effect that
mandated nurse staffing levels can have is the state of California. In 1999, California passed
legislation, Assembly Bill 394, that mandated minimum nurse-to-patient ratios (Donaldson &
Shapiro, 2010). These mandated ratios were then implemented in 2004. Interestingly, the bill
acknowledged in its preamble that there was insufficient empirical evidence to guide public
policy efforts to prescribe safe staffing (Donaldson & Shapiro, 2010). The bill was passed
anyway.
Implications for Hospitals
Hospital operations have potential to change, as with any mandate from the government
that changes current practice. Many studies found that wait times in emergency departments
increased following mandated staffing ratios in California hospitals (Donaldson, Shapiro, 2010).
This is best explained by the rippling effects of operational changes to accommodate staffing
ratios at all times. A patient often will end up waiting in the ER bed because there is no nurse to
staff the bed on the unit per the staffing model. In order to avoid being penalized financially for
non-adherence to mandated ratios, the hospital must now find a nurse to staff that bed before
placing the patient (Donaldson & Shapiro, 2010).

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Hospitals facing mandated staffing levels may also have to completely restructure current
staffing practices. Chapman, Spetz, Seago, Kaiser, Dower, and Herrera (2009) found that most
hospitals found it extremely difficult as well as expensive to find more RNs for their positions.
In addition, the money used to expand the nursing pool must come from a variety of other areas.
Many hospitals in California reported cutting or laying off ancillary staff positions, reducing
other patient services such as outpatient clinics, and reduction in costs from non-nursing areas
(Chapman et al., 2009). Additional costs to the hospital were also incurred from bonuses to
recruit experienced nurses for specialty units, increased use of agency nurses, and increased
training for graduate nurses (Chapman et al., 2009).
One other major criticism of mandated nurse to patient ratios from the perspective of
hospitals is that it completely removes the critical thinking and human aspect inherent in
healthcare. Denise Neely, Chief Nursing Officer at Bronson Methodist Hospital stated
mandating staffing levels takes away the critical thinking involved in staffing. We dont make
widgets. We deal with people (D. Neely, personal communication, March 03, 2016). It is
difficult to objectively measure acuity of all patients at any one time and also to objectively
measure the nursing dose needed to care for patients. Donaldson et al. (2010) stated that the
quantity and quality of nursing care that captures the content of nursing interventions as well as
the frequency, is not considered at all in the head count approach to staffing ratios.
Implications for Nurses
Mandated staffing legislation has a large effect on the nursing staff at any given hospital.
Nurses who are exposed to staffing levels that they see as inadequate are more likely to leave
their current employer (Hairr et al., 2014). All information pertaining to skill mix, patient acuity,
and current staffing levels must be considered prior to mandating staffing ratios. When looking at
this legislation in California, the obvious finding is that reduction in number of patients assigned

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per licensed nurse occurred, the number of nursing hours per patient day increased, and
percentage of care provided by non-nurses decreased (Donaldson, Shapiro, 2010).
Having decreased patient-per-nurse ratios comes at a cost. The reduction in nursing aides
and assistants was necessary to make room for more nurses. Opportunities for RNs to delegate
tasks that are deemed appropriate for ancillary staff are reduced. This takes the nurse away from
higher level work such as following up with providers... responding to questions and concerns
of patients, families, and health care team members and completing discharge teaching and
counseling (Donaldson, Shapiro, 2010).
Implications for the Public
Mandatory nurse staffing ratios generally are introduced under the premise of improving
patient care and outcomes. There is comprehensive research which is broad in nature that finds
correlation between nurse staffing and patient outcomes. In one study, each additional patient per
nurse was associated with a 5% decrease in odds of surviving discharge after an in-hospital
cardiac arrest. In addition, a 16% decrease was seen in hospitals with poor nurse work
environments (Wallis, 2016). This data supports the need to address inadequate staffing, but does
not address or support mandates.
The case for mandated nurse staffing ratios suffers from the fact that research in this area
is not conclusive that this form of staffing is effective in meeting its stated goals. Sochalski,
Konetzka, Zhu, and Volpp (2008) found that there was a lack of evidence that mandated nurse
staffing improved outcomes for patients. They further concluded that questions should be raised
about the cost effectiveness of implementing state-wide mandatory ratios for nursing.
Instead, the necessary nurse staffing changes and ratios should be left up to those
institutions employing them. Through critical thinking and data analysis, Bronson Hospital was
able to track adverse patient events such as catheter associated urinary tract infections (CAUTI),
falls, medications errors, and others, against nursing full time equivalents (FTEs). They found
that when staffing is too low, there was an increase in adverse events from increased workload.

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Interestingly, however, there was also a rise in adverse events when staffing was too high,
perhaps attributable to complacency. The best outcomes for patients was somewhere between the
two extremes (D. Neely, personal communication, March 03, 2016).
Key stakeholders
When nurse staffing ratios are on the table, there are many key stakeholders that must be
considered. In the political environment, there are many players that must be considered when
looking to move an agenda forward, or stop it in legislation. The American Hospital Association
(AHA), the American Nurses Association (ANA), and the Michigan Hospital Association
(MHA) could play a key role in the passage or rejection of this bill.
The American Hospital Association and State Hospital Associations
The American Hospital Association as well as state hospital associations have universally
opposed laws that would mandate nurse staffing ratios. They argue that nurse-to-patient staffing
ratios would have a negative impact on the scheduling and staffing flexibility of hospitals as well
as individual nurses (Welton, 2007). The Michigan Hospital Association (MHA) concludes that
mandated staffing ratios would have a negative impact on patient access to quality care as well as
financial viability of hospitals (Michigan Health & Hospital Association, 2003). In addition, the
MHA goes on to criticize mandated staffing ratios in California as they were unable to
successfully remedy issues such as length of stay and adverse events through the mandated
staffing models. They conclude that studies show that nurse training is the most important factor
in assuring quality of care and encourages policy makers to make changes within our nursing
education programs (J. Falahee, personal communication, March 04, 2016).
The American Organization of Nurse Executives
The American Organization of Nurse Executives (AONE) acknowledges that adequate
nurse staffing levels ensure quality of care delivered in United States Hospitals as well as patient
and nurse satisfaction. However, researchers also concluded that results do not directly indicate
how many nurses are needed to care for patients or whether there is a minimum or maximum

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ratio (American Organization of Nurse Executives, 2003). The AONE is against mandated nurse
staffing ratios and further states that fixed ratios carry a high potential to economically as well as
politically devaluate the nursing profession, as nurses will be treated as numbers, and fails to
address the real issues surrounding safe staffing (American Organization of Nurse Executives,
2003).
The American Nurses Association
The American Nurses Association is very clear on their position on mandatory nurse
staffing. Although they agree that there is a need to address unsafe staffing practices, they do not
support mandated ratios. The ANA states they have real concerns about the establishment of
fixed nurse-to-patient ratio numbers in federal and state legislation (American Nurses
Association, n.d.). These concerns include lack of flexibility to revise legislated ratios to ensure
staffing needs and concerns are met for years to come and not just at one point in time, reduction
of ancillary staff, and the possibility of the minimum ratio translating into a maximum level of
care. They go on to further state that nurses should not be treated as numbers, and should be
recognized for their ability as professionals to have a say in the care that they provide (American
Nurses Association, n.d.).
Political Strategies
In order to prevent legislation on mandated nurse staffing from being passed, political
strategies must be employed in order to sway the vote to opposition. Through gathering data,
communication, and demonstrating a united front, legislations such as this can be shut down.
However, the same strategies can be employed, with the right voice, to push this through and
create problems for healthcare systems across states and across the country.
Many political tactics have been employed in attempts to gain support or provide
opposition for passage of these mandates. Of interest, it has proven difficult to find outright
support for passage of legislation such as this from major stake holders. National Nurses United

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is one of the largest unions and professional associations of registered nurses. They are in
support of mandated nurse staffing ratios. They applaud California for implementing minimum
staffing ratios. One tactic they are currently employing is creation of a coalition which can be
joined on their website. They encourage calls to legislators, offering the option to sign an online
petition, and even joining public protests for safe staffing levels (National Nurses United, n.d.).
Data from those in opposition to the bill directly relating to mandated staffing can be
much more convincing in the political arena. By drawing from the growing body of evidence that
mandated staffing may not translate into better outcomes, one can make a strong argument
against this form of staffing. Also, hospitals and nurses can speak out against the harsh penalties
that are incurred for non-compliance, the repercussions of stated mandates, and the issues with
mandating staffing levels without hard evidence to support their effectiveness.
Conclusion
While mandated nurse staffing issues are one way to address concerns over unsafe
staffing practices, the economic consequences, lack of data supporting it, and its devaluation of
the nursing profession in their ability to have a say in staffing at the hospital and unit level
should be cause for rejection of such legislation. California has become of the first and only state
to implement this mandate, and thus far, the improvements that this change hoped to realize have
not been documented. Current data does show that nurse staffing does play a role in patient
outcomes and nurse satisfaction, but is yet to show at what staffing level improvements can
universally be made across the nations healthcare systems. With this being said, legislation
advocating for mandated nurse staffing levels should be stopped, and other solutions to the
problem, supported by evidence, should be investigated.

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References
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