Clinical Leaders, Not State Legislators, Should Determine Nurse Staff Levels

By Kevin Dahill

Multiple times every day, nursing leaders make decisions on the number of nurses per patient needed to staff each unit in their hospitals, based on factors such as the severity of their patients’ illnesses, the skill set of their workforce, clinical research and professional guidelines.  It is both a legal and an ethical obligation to do so – but it’s also a very practical obligation.  Illness and injury do not manifest themselves the same way in every patient, because every patient, every case, and every hospital is uniquely different.  Flexibility in nurse staff planning is, in reality, a requirement for quality patient care.

Instead of affording these highly-trained clinical professionals the flexibility to make decisions about the best way to care for their patients, there is an effort in Albany to instead put nursing staffing decisions into the hands of the state legislature.  A bill called the Safe Staffing for Quality Care Act would write into law explicit nurse-to-patient ratios that would apply to every unit of every hospital in the state, every hour of the day and every day of the year, regardless of those critical factors that go into the staffing decision-process now.  For some years, advocates of nurse staffing ratio laws have been pressing their case before the state legislature but the effort has gained particular momentum this year.  The Assembly has passed the bill in the past and is on the verge of doing so again, while the Senate has generally taken a more cautious approach.  However, the Safe Staffing for Quality Act has bipartisan support in the Assembly and Senate and the vigorous backing of the New York State Nurses Association.

Research shows that nurse staffing ratio mandates do not improve patient care and, in some cases, impede effective care.  California is the only other state in the nation to have a mandated nurse staffing ratio law on the books, and the results have not been what advocates expected.  California’s law became effective January 1, 2004 and several studies to prove its effectiveness followed.  One study found no significant change in falls, pressure ulcers, or use of restraints occurred after the mandated ratios were in place.  Another found that most quality measures analyzed after the implementation of the staffing law were not affected by the mandate.  In other words, there was no empirical evidence that linked the law to improved quality care.

What researchers have found, however, is that team-based care, which includes a mix of other direct care professionals, leads to improved patient outcomes.  Ironically, mandating nurse staffing ratios may cause the elimination of these important support positions such as nursing aides and therapy technicians because the labor cost to implement mandated ratios is exorbitant – in the area of about $3 billion annually to New York’s hospitals and nursing homes.  Such an expense would be justified, if the research backed up proponents’ claims of improved quality care.

Nurse staffing ratios would render individual hospitals helpless to adjust nurse staffing needs based on patient complexity, volume surge, and workflow fluctuations.  Hospitals need the flexibility to respond to patient complexities that constantly change, almost minute by minute depending upon the unit, as well as the ability to respond to surge capacity needs.  The flu is a good example.  In these cases, mandated staffing ratios actually hinder quality care.

So what’s the solution?  Staffing is a local issue and a one-size fits all approach will do more harm than good.  Research has shown that the combination of higher levels of nurse education, the use of evidence-based treatments, and an appropriate mix of staff levels are all critical to quality care.  The New York State legislature took a step in the right direction when it passed the BSN in 10 law last year. This law requires new nurses to earn a bachelor’s degree within 10 years of initial licensure.  Academic and leading governmental research bodies have looked at the issue of bachelor degree training and beyond for the nation’s nurses.  There is widespread agreement that as hospital patients present with more complex and multiple chronic conditions, higher-educated nurses are needed because they bring with them a more extensive skill set and enhanced decision-making ability.

Workforce complexity, staffing flexibility, local control, and evidence-based treatment lead to quality care and improved patient outcomes – not arbitrarily assigned nurse staffing ratios.

Kevin Dahill is president/CEO of the Suburban Hospital Alliance of New York State

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