by Lori King, DNP, RN, APRN-BC

The threat of labor strikes in health care surged in 2019. National Nurses United (NNU) is calling unit after unit of nurses out on the picket line, chanting for mandated nurse-to-patient ratios in contracts. A New York Times press release on the most recent strikes in Chicago parrots the typical NNU rhetoric on ratios. Hospitals are doing all they can to counter this aggression, but their carefully crafted public responses often fail to persuade their nurses or the public.

How can you counter NNU’s aggressive tactics in your facility? What are the facts about mandated ratios? Why do so many well-informed nurses conclude they are bad for patients, nurses, and employers? This article answers these questions and many more.

Calling for nurse-to-patient ratios at the state and national level has been yelled through NNU’s organizing megaphone for years. Why can they leverage this message? It’s a simple message for a complex issue and one of significant concern to nurses. That said, it is not the Right answer.

Yes, research shows that the workload of nurses has direct impact on patients. But mandated ratios in state or federal legislation or forced into union contracts does not effectively address the issues of staffing. Instead, this “one-size fits none” approach creates massive issues for the system.

Staffing is a big deal

Hospitals already know staffing is a big deal- inadequate staffing practice is not good for them either. CNA and NNU use mandated nurse-to-patient ratios as an organizing campaign because it is easy to get nurse and community attention on the issue. Staffing is a hot issue in healthcare with the nurse shortage and let’s face it, there are a few “bad actor” employers that simply do not staff appropriately as a mechanism to save dollars and improve their bottom line. This commands that employers ensure they can counter the unions message by substantiating their staffing methods and challenges.

Staffing impacts all things related to the bottom-line and, contrary to NNU’s chants, hospitals are not in the business of imposing patient harm. Let’s review the research.

There are a lot of issues in healthcare and staffing is one of the biggest- for many reasons. Likely the most significant is the research that substantiates the link between nurse staffing and patient outcomes. This commands that hospitals achieve an ethical imperative of balancing smart business and the care of human beings. This is a big deal.

Another well-known fact is errors in healthcare are occurring at an alarmingly high rate- also tied to staffing through research. Preventable medical errors are currently debated as the third leading cause of death in our nation- ask researchers at John’s Hopkins University. This is a big deal too.

Yes, numbers matter

Research shows the number of nurses on the care team measured with hours per patient day (HPPD) and full-time equivalents (FTEs) correlates with patient mortality, failure to rescue rates, and length of hospital stay. Additionally, the total number of RNs in the staffing mix is associated with decreased pneumonia and decreased mortality.

Another number that matters is that of baccalaureate prepared nurses providing care. We know that higher levels of education for nurses- specifically nurses with BSN preparation- is associated with decreased patient mortality and failure to rescue.

Evidence like this is used to support mandated ratios. If nurses make such an important impact on patient care then mandating more of them is a simple solution, right? If only it were that simple.

Numbers are not all that matters

Mandated numbers of patients per nurse fail to account for numerous key contributors to staffing problems. In fact, mandating ratios can worsen many of these contributors. For instance, experience of individual nurses varies greatly as does the intensity, complexity and stability of patients. All are critical to consider in staffing decisions.

Then there are the unpredictable occurrences in a shift that dramatically impact staffing needs. These include factors like changes in patient condition and care needs. There are times that 3:1 means three nurses to one patient–just ask a behavioral health nurse or a nurse in any area of where critical care is provided. Actually, this can happen to any nurse on any unit caring for patients.

Also unpredictable are shifts in workflow which further impacts workload. Turnover isn’t always about nurse staff retention and recruitment. Admissions and discharges increase workload, and high patient turnover correlates with increased risk of patient mortality.  Click here for a study which links staffing levels and workload to clinical outcomes. Mandated ratios don’t provide the flexibility for these unpredictable changes in workload demands.

Anything else?

Each healthcare environment and individual patient care units also have unique needs. Not all healthcare environments are created equal- they have unique needs that require careful consideration and specially trained nurses. Just ask NNU. They will say a “a nurse is not a nurse.” That is one point I think we can all agree on.

Specialties exist and employers can be forced (just ask employers in California) to move nurses to units where they are not qualified to work in order to meet state law or be compliant with a contract. If I am the patient? No thanks. NNU’s “one size fits all” nurse-to-patient ratios do not consider these unique circumstances.

What do leading nurse organizations have to say about mandated ratios?

The American Nurses Association (ANA) opposes fixed ratios. They state, “Optimal staffing is complex. While ANA respects all attempts to address nurse staffing and believes any attention to improving staffing levels can have a positive impact, we have real concerns about the establishment of fixed nurse-to-patient ratios in state law or regulations.”

ANA just released their updated staffing principals this past month. The announcement stated, “ANA believes that providing appropriate nursing resources must account for human factors including a nurse’s years of experience, knowledge, education, skill set and patient mix, acuity, and intensity. This flexible approach to nurse staffing is associated with improved patient outcomes, including reduced mortality rates, shorter stays, lower readmission rates, and reduced incidents of hospital-acquired conditions.”

The American Organization of Nurse Leadership (AONL) also opposes mandated ratios. They state, “Because staffing is a complex issue composed of multiple variables, mandated staffing ratios, which imply a ‘one size fits all’ approach, cannot guarantee that the healthcare environment is safe or that the quality level will be sufficient to prevent adverse patient outcomes.”

Let’s review the economics of mandated ratios

Access and affordability must also be considered. Community hospitals and small rural hospitals (44% of which lost money last year) will struggle with mandated ratio staffing requirements due to the shortage of nurses. Also, they rely on Medicare and Medicaid payments which will not automatically increase with mandating hospitals to hire more nurses, putting them under further financial strain.

This unnecessary “perfect storm” situation will cause community hospitals (particularly small rural strugglers) to shut down units that cannot staff to meet the mandates or close their doors altogether. Even if small community hospitals in rural areas can find the nurses to hire, they will most likely be pulling them from clinics and post-acute health centers in the same community who are also struggling for enough nurses.  How does this help anyone?

Are these concerns justified? California, which has had legislated mandated nurse to patient ratios since January 2004 (the only state that does), is a great place to look. A recent study published in the National Bureau of Economic Research focused specifically on rural hospital closures in California. It demonstrated an increase in mortality rates with closure of rural hospitals and longer distances for patients to travel for care.

Another report substantiates that closing rural hospitals leads to decreased access to care. Reducing access to care and employment opportunities for nurses in these rural communities is terrible for both patients and the nurses who lose their jobs in communities they love.

What’s not working in California?

Just ask nurses in California. Marketa Houskova, Executive Director of ANA-California in Sacramento states, “we have had legislated nurse-to-patient ratios for years and yet staffing remains the top issue among nurses in the state.” The law has not fixed complex staffing issues in healthcare for California. There are still concerns with staffing, quality of care, and safety of patients.

Then ask hospitals in California. The state just passed law- signed by the Governor on October 12- that now imposes monetary penalties if hospitals don’t meet nurse to patient ratios “at all times.” The organization says the law will lead to hospitals “making staffing decisions to meet the law rather than putting the needs of the patient first.”

Other concerns outlined by the hospital association include the $2.9 billion that mandated nurse to patient ratios has added annually to the cost of care in California “without any linked evidence of improved quality of care provided.” The organization heavily questions Dr. Linda Aiken- nurse researcher on healthcare staffing, who says her research findings show California’s mandated ratios law has improved both staffing and patient outcomes in the state.

A report by the District of Columbia Hospital Association gives a concise outline of the following issues experienced after the passage of mandatory ratios in California:

  • reduction of non-nursing personnel in order to address budget constraints;
  • reduction or elimination of services due to inability to meet the legislated ratios;
  • patients facing longer waits in the emergency room if nurse to patient ratio on units was maxed;
  • diversions of patients to other facilities when nurse ratios could not be met; and
  • reduced access to care including hospital closures.

Further, here are just some of the realities of nurse-to-patient ratios in contracts or in state legislation:

  • Staffing language in contracts is not a given and is rare. Most employers maintain the right to staff under a management rights clause. As with any bargaining agreement or legislative effort, there is no assurance that any language will be included or that employers will even discuss. This is not a mandatory subject of bargaining under the National Labor Relations Act.
  • Diminished flexibility. If language is legislated (CA is only state) or agreed to in a contract (there are very few), there is no guarantee that the minimum ratio does not become an average, or a maximum level. And, there is risk of no flexibility for reality.
  • The process to revise legislated or contracted ratios can take years. Healthcare delivery is constantly innovating and changing at a rapid pace. Legislation is slow–and depending on the political situation sometimes impossible–to change. Legislating mandates is an unreasonable approach to meet staffing needs and concerns that happen in the moment in a rapidly evolving healthcare environment.
  • Job reduction. Employers may need or decide to reduce the numbers of ancillary staff to finance increased RN staff if mandated ratios are in place. This simultaneously increases stress on nursing staff (who often have to pick up these additional tasks) while reducing the overall time they have to provide quality of care for patients. It’s a lose-lose situation for health system employees and patients.

If not mandatory ratios, then what is the answer to staffing concerns?

Research shows that ratios do make a difference, but only as one component of a comprehensive approach to staffing. All factors must be considered together and one alone is not the answer. Additionally, staffing decisions must account for the unique healthcare settings including all appropriate team members. Staffing issues cannot be corrected by one size fits all approach dictated in state and federal laws.

The healthcare team, including management, staff, and anyone involved in patient care, must work together in their own unique setting to devise the best plan. There are great examples of what works. Check out Sharp Memorial Hospital’s creative approach and Ohio-based West Chester Hospital’s (WCH) model which goes beyond strict ratios- considering patient acuity and volume surges. Systems like Sharp and WCH are developing creative and innovative approaches needed during these tough times when there are not enough healthcare professionals to fill the gaps, belts are tightening on reimbursement, and laws and regulation further increase pressure on healthcare systems.

Rational thinkers in healthcare who understand the complexity of staffing also understand there is more than one pathway to reasonable solutions. A great deal of research proves many things benefit patients in staffing decisions, including but not limited to numbers of patients to nurses, numbers of hours nurses work, and experience and education of the nurse. There are many stakeholders who have a vested interest is solving these issues.

While over two decades of research tells us that staffing is complex and multi-faceted, NNU pushes to take staffing decision out of the hands of the healthcare team (including nurses) and give it to the government or forcing it into contract language through massive strikes. This helps no one. Not the nurse, not the employer, and especially not the patient. Just ask those patients who rushed to the University of Chicago hospital during the September strike, only to be diverted to other facilities because the hospital was forced to shut down units because of an NNU strike.

Anyone in the healthcare system who has anything to do with patient care has an obligation and responsibility to contribute to ensuring safe patient staffing in their environment. There is an ethical obligation to prioritize care that is safe and of high quality. There is also a moral obligation to carry out what we know is right and just. There is no need to create legal obligations where these ethical and moral obligations drive everything we do. Legislated “solutions” result in costly impacts to everyone.

What can you do to counter mandated ratio rhetoric?

Given all this information it is natural to ask, “why would nurses support mandated ratios?” This is a great question to consider and important to fully understand. It’s especially important if you are being bombarded by aggressive nurse unions like CNA and NNU, who organize almost exclusively on the patient-to-nurse ratios platform. Most nurses say ratios are not perfect but they are a “start.” But once again, staffing is complex and there is no one magic answer. Here are some things to consider.

The number one thing employers can do is ensure your nurses are involved in overall staffing plans and daily staffing decisions. It’s imperative. This gives nurses a deeper understanding of the global staffing challenges across the organization and gives employers a front-line view of issues the nurses and the healthcare teams are facing. This positions you perfectly to achieve creative solutions to your unique needs.

Involving front-line staff nurses in the global staffing plan and decisions also allows them to take ownership in the issues and solutions along with organization leadership. This approach counters the NNU chant favoring mandates- given your nurses are involved as a valued part of the decision-making team. This also undermines NNU’s ability to encourage a strike over mandates as your nurses are more connected and contributing actively to the staffing challenges the hospital faces.

And here is a little magic. Check out the American Association of Critical Care Nurses (AACN) where more than 80 percent of 400 attendees answered a post event survey that they were confident or very confident that they had at least one potential staffing strategy to share with their institution. Further, these nurses felt very or extremely comfortable having a meaningful discussion with their leadership team about staffing issues. Here is the info. This is your gold standard. Encourage your team to bring their ideas, and then listen to them.

Lori King, DNP, RN, APRN-BC, is LRI’s healthcare practice leader. She is an executive leader, educator, and nurse practitioner. She has held the position of CEO in two statewide nurse associations and serves in state and national elected and appointed positions. Lori is dedicated to the “health of healthcare.” Her professional focus is partnering with healthcare clients. She works in healthcare settings from front-line staff to executive leadership levels to navigate cultural issues, create positive environments, and strengthen relationships across systems.