[ The case for strict staffing ratios in American hospitals and
skilled nursing facilities is remarkably straightforward: They save
lives and reduce nurse turnover.]
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WHEN CALIFORNIA SET MINIMUM STAFFING LEVELS FOR OVERWORKED NURSES,
BETTER PATIENT OUTCOMES FOLLOWED  
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Mark Kreidler
May 12, 2023
Capital & Main
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_ The case for strict staffing ratios in American hospitals and
skilled nursing facilities is remarkably straightforward: They save
lives and reduce nurse turnover. _

, Photo: SDI Productions/Getty Images

 

WHEN CATHERINE KENNEDY BEGAN her career as a registered nurse in
California in 1980, staffing situations often resembled the Wild West.
On some overnight shifts in San Francisco, Kennedy said, she and one
other RN shared responsibility for a 48-bed facility. Their only help
was four aides.

“It was unmanageable,” Kennedy remembered. “You would work as a
team, get through the night, and pray nobody would code [i.e. suffer a
cardiac or respiratory arrest].”

It took years of prodding, much of it coming from union-organized RNs,
to get state legislation passed that mandated far stricter
nurse-to-patient ratios than those Kennedy and her colleagues faced
back then. The result has been profoundly positive. California’s
safe-staffing laws, in practice since 2005, have led to fewer patient
deaths [[link removed]], less burnout and
higher retention rates among nurses than under policies in other
states.

They’re also a complete outlier. Despite abundant evidence that
increasing nurse staffing saves lives and leads to better patient
outcomes (and potentially saves money), no other state has enacted
specific ratios that cover all hospital and skilled nursing settings.
Few have even come close.

Why?

“Pretty simple: The hospital industry has a lot of money,” said
Nerissa Black, an RN at Henry Mayo Newhall Hospital in Valencia. “We
advocate for our patients. The industry advocates for its profits.
That’s the problem.”

THE FORCES ALIGNED AGAINST EACH OTHER meet again on a national scale
this year. In both the U.S. Senate and the House of Representatives,
the Nurse Staffing Standards for Hospital Patient Safety and Quality
Care Act of 2023 has been introduced — the fourth go-round for the
legislation, which stalled in committee in 2017, 2019 and 2021.

The proposal
[[link removed]] mirrors
California’s current staffing laws, mandating that RNs be assigned a
limited number of patients: one in trauma and operating rooms, two in
intensive care units, three in emergency rooms and no more than five
in rehabilitation and skilled nursing settings. The bill is a loud
endorsement of the only such staffing requirement in the country.

“We know that safe staffing levels mean better outcomes for
patients,” Sen. Sherrod Brown (D-Ohio) said in introducing
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bill in March. “But too often, nurses are stretched too thin, caring
for too many patients with not enough support.”
 

Researchers at the University of Pennsylvania found that each surgical
patient added to a nurse’s workload results in a 7% increase in
mortality.

 
That’s true across the country, as staffing ratios vary wildly
[[link removed]] from
state to state — including Brown’s home of Ohio, which for years
was the only state that did not license its hospitals before a new
law
[[link removed]] took
effect in 2022. But all of them are consistently higher overall than
California’s ratios, which have gone almost unchanged since they
were implemented.

It wasn’t without a struggle. Lobbyists for the health industry in
California fought furiously against any set ratios, said Kennedy, a
pediatric ICU nurse who eventually rose to become co-president of the
powerful California Nurses Association, part of National Nurses
United. It was the CNA/NNU that sponsored the legislation signed into
law by then-Gov. Gray Davis in 1999, taking effect six years later.
(Disclosure: CNA is a financial supporter of Capital & Main.)

“And even then, we had to fight to keep it, because Gov. [Arnold]
Schwarzenegger came in and wanted to roll the ratios back
[[link removed]],
if not get rid of them,” Kennedy said. “So it was constant
enforcement — we never gave up. And we’re not going to stop until
we get this done on a federal level, too.”

THE CASE FOR STRICT STAFFING RATIOS in American hospitals and skilled
nursing facilities is remarkably straightforward: They save lives and
reduce nurse turnover.

According to research
[[link removed]] by Linda
Aiken and others at the University of Pennsylvania, each surgical
patient added to a nurse’s workload results in a 7% increase in
mortality and a 7% increase in failure to rescue, “which is just
what it sounds like: patients experiencing an adverse outcome with
nobody there to witness, monitor it and intercede,” said CNA board
member Michelle Moran.

In another study, published in 2020, Aiken and researchers at the
Center for Health Outcomes and Policy Research at Penn’s School of
Nursing concluded that New Jersey hospitals would have 14% fewer
deaths [[link removed]] and
Pennsylvania’s 11% fewer deaths if they adopted California’s 1:5
ratios in surgical units. The study also found less burnout and lower
job dissatisfaction among nurses in all three states whose employers
applied California’s ratios.

That is a significant note. While hospital administrators, even
pre-pandemic, spoke of an ongoing nursing shortage, those in the
business say it’s not the case. What is happening, they say, is that
nurses are being driven out of the workforce by burnout and stress
over hospital conditions that the nurses feel lead to inferior care of
their patients.
 

“It’s a real sense of moral distress when I cannot do what I know
needs to be done for each of my patients.”

~ Nerissa Black, registered nurse

 
Black was working in the telemetry unit at Henry Mayo when COVID
arrived in 2020. Within a couple of months, the hospital closed an
entire wing that had previously handled elective procedures, she said,
and laid off the RNs and staff in the unit. But when the COVID surge
hit that winter, the hospital received a waiver from the state to
relax its nurse to patient ratios, arguing that it didn’t have
enough nurses.

RNs in the telemetry unit, who are charged with constantly monitoring
the cardiac conditions of each patient, suddenly found themselves with
50% more people to care for — six, rather than the usual four.
“That may not seem like much, but it meant that we had only 10
minutes out of each hour for each patient,” Black said. Her duties
included cardiac monitoring, making patients’ beds, helping them
eat, taking them to the bathroom and speaking with family members, all
while taking extreme COVID precautions.

“That went on for three straight months, and it was heartbreaking.
It’s a real sense of moral distress when I cannot do what I know
needs to be done for each of my patients,” Black said. By the fall
of 2021, she left the telemetry unit, moving to a less stressful
nursing job after pondering leaving the profession altogether.

AN ANALYSIS OF 2021 Bureau of Labor Statistics data by NNU determined
that there are roughly 1 million licensed nurses in the U.S. who are
not working — generally, the union contends, because hospital
conditions and staffing levels are so dire that the available jobs are
unappealing. Earlier this year, the National Council of State Boards
of Nursing projected that another 900,000
[[link removed]] —
about a fifth of all RNs in the nation — plan to exit the field
within five years.

California survived the nursing crunch of the pandemic in part because
it was able to hire travelers, nurses who go from one assignment to
the next, often far from their home states. “We needed travelers
because our nurses were getting sick in record numbers, because the
hospitals weren’t giving them the protective equipment they
needed,” Moran said. “And we seemed to have no problem hiring
them. When I spoke to some of the travelers about why they’d come
all the way to California, they said, ‘Well, you guys have
ratios.’”

But RNs cost money. In California, for example, the average RN wage is
$60 an hour, or about $125,000 a year for a full-time nurse working 40
hours a week. And the latest push for federal staffing guidelines is
set against a backdrop that isn’t new: the decade-long infusion
of private equity investment
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the health care sector, a place investors see as ripe for massive
profits.

How to maximize those profits? Slice nursing staff levels to the bone,
thus eliminating a significant percentage of operating costs,
and push digital health
[[link removed]] practices as
an alternative.
 

When nurses in Massachusetts qualified a ballot initiative in 2018 to
establish safe staffing ratios, they were outspent more than 2 to 1.

 
“What we have seen is that corporations and people who want to make
money have gotten more into health care in general,” Rep Jan
Schakowsky (D-Ill.), who introduced the safe staffing bill alongside
Brown, told Modern Healthcare
[[link removed]] in
a recent interview. “We need to make sure … more money is going to
go into nursing itself.”

The hospital industry has consistently and effectively pushed back
against any such legislation, either at the state or federal level.
When nurses in Massachusetts qualified a ballot initiative in 2018 to
establish safe staffing ratios, they were outspent more than 2 to 1,
and voters ultimately rejected the measure
[[link removed]].
Opponents, including the powerful American Hospital Association
[[link removed]],
marshaled more than $25 million
[[link removed]] to ensure the
proposal’s defeat.

The AHA is gearing up to fight the latest federal legislation as well.
“Mandated nurse staffing ratios are a static and ineffective tool
that does not guarantee a safe health care environment or quality
level to achieve optimum patient outcomes,” said Robyn Begley, the
association’s senior vice president of workforce. “Staffing ratios
are usually informed by older care models and do not consider advanced
capabilities in technology or interprofessional team-care models.”

Begley, whose association spent $27 million on lobbying
[[link removed]] last
year, was referring not only to the rise of telehealth during the
pandemic, but also to farther-flung models, such as fewer RNs
operating out of central command centers while lesser-paid,
lesser-trained nursing assistants and other staffers carry out
directives at the actual hospitals or care centers — a “generic
workforce,” as some nurses put it.

“We are seeing an absolute explosion of untested and unproven
technologies in our facilities,” Moran said. “What we’ve been
watching, through the pandemic and now beyond, is disaster capitalism
in action in the health care industry.”

THE IRONY IS THAT HAVING an adequate number of nurses on staff can
save money. In a 2021 study, Aiken and a group of researchers found
that, if New York had applied a proposed 1:4 nurse to patient ratio in
medical-surgical units over a recent two-year period, hospitals would
have saved $658 million each year
[[link removed]] because
of shortened hospital stays due to improved care.

Those estimates included only about 25% of Medicare hospitalizations;
the actual cost savings when taking into account all patients,
Medicare and non-Medicare, would “likely be many-fold higher,” the
researchers wrote. They also projected that there would have been
nearly 4,400 fewer in-hospital deaths.

New York eventually enacted a law that mandates safe staffing
committees
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each hospital, although the precise nurse-to-patient ratios are up to
those committees to determine. A recently passed
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in Washington state would essentially do the same thing after a
stronger measure, which set specific staffing ratios, faced lobbying
pushback from the hospital industry. A bill in Oregon
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establish staffing levels with local control to amend them, and
Massachusetts has a statewide law
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ICU ratios.

How the federal legislation will fare is unclear, but history is not
kind. Brown’s Senate proposed bill has been referred to the
Committee on Health, Education, Labor and Pensions, the same place
where it stalled two years ago.

Nurses say they are undeterred. Their organized numbers have grown
tremendously in recent years; NNU’s membership is up to 225,000
nationally, and the Service Employees International Union, which
represents perhaps 80,000 nurses, has endorsed the federal legislation
as well.

During National Nurses Week, which ends Friday, union members are
lobbying members of Congress for support of a number of measures
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including the bill introduced by Sen. Brown and Rep. Schakowsky.
California, they say, continues to be the model of success.

“Nurses around the country see what’s happening in California,”
said Sandy Reding, an operating room nurse who began working in 1983
and routinely handled 12 to 15 patients per shift before joining the
fight for safe staffing ratios.

“We got it done all those years ago because we were organized, and
we’ve seen the good results of that bill — and that’s what every
patient deserves, that level of care. That’s why we want a federal
bill.”

_Mark Kreidler is a California-based writer and broadcaster, and the
author of three books, including Four Days to Glory._

_Capital & Main is an award-winning nonprofit publication that reports
from California on the most pressing economic, environmental and
social issues of our time.  Winner of the 2016 Online Journalist of
the Year prize from the Southern California Journalism Awards and a
2017 Best in the West award, Capital & Main has had
stories co-published in more than 30 media outlets, from The
Atlantic, Time, Reuters, The Guardian and Fast Company to The
American Prospect, Grist, Slate and the Daily Beast. Working with
top writers, editors and visual artists, we cover income inequality,
climate change, the green economy, housing, health care, public
education, immigration, race, and criminal justice. Capital & Main is
a 501(c)3 tax exempt organization._

* Nurses
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* Staffing Ratios
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* nNational Nurses United
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* SEIU
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* hospital industry
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* California
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