A bill currently in front of the Pennsylvania House of Representatives would mandate specific registered nurse-to-patient ratios within hospitals, in an attempt to improve patient care and retain nurses. For example, the Patient Safety Act requires intensive care units to staff a minimum of one nurse per two patients; psychiatric units would require a nurse for every four patients.
The proposed law has proved contentious, dividing nurses who say they’re overworked and hospital administrators who say there simply aren’t enough RNs to go around.
Hospitals have struggled to hire enough registered nurses to care for patients for years. According to a survey from the Hospital and Healthsystem Association of Pennsylvania that was published last fall, more than one in four RN positions are vacant.
The shortage has been blamed on a variety of factors, including challenging working conditions, a lack of young people entering the profession and ongoing struggles to retain experienced workers.
A McKinsey report from last year found that in order to meet the growing need for nurses, “The United States would need to more than double the number of new graduates entering and staying in the nursing workforce every year for the next three years straight.” Some of this demand is fueled by older nurses retiring, though the report also finds that 29% of RNs surveyed want to leave direct patient care.
Tammy May, a critical care nurse at Butler Memorial Hospital and an executive board member of the Pennsylvania Association of Staff Nurses and Allied Professionals, blames the understaffing on a self-perpetuating cycle: The lack of nurses engenders stressful, unsafe working conditions that drive qualified nurses from the bedside to seek other professional opportunities, thus exacerbating the issue.
"Those days when you're extra stretched because you feel like you didn't have adequate staffing, you're constantly replaying your shift in your head even after you get home. 'What did I miss? What could I have done better?'" said May.
Research shows that higher patient-to-nurse ratios do increase mortality. May, who supports the passage of the Patient Safety Act, says that many hospitals cut corners by loading up nurses with too many patients instead of finding ways to make the work more attractive or sustainable. By capping the number of patients a nurse can legally care for, the law would set a floor and force hospitals to make the systemic changes needed to retain staff: better pay, more flexible scheduling, and meaningful improvements on workplace violence and safety concerns.
Hospital administrators are not fans of the proposed law
The Patient Safety Act has been introduced during the previous legislative sessions, but the former chair of the House's Health Committee, Rep. Kathy Rapp, a Republican from Warren County, never allowed it to move out of committee. Now that Democrats control the Pennsylvania Legislature's lower chamber, the legislation might have some legs.
That concerns hospital administrators.
"I have literally spent the last couple weeks on the phone talking to nurse leaders about this," said Robert Shipp, vice president of population health and clinical affairs for the Hospital and Healthsystem Association of Pennsylvania. "Every one of them is generally concerned [about] the negative impact they feel it will have on their hospitals."
Chief nursing officers and other hospital administrators want to be flexible with scheduling and to pay nurses higher salaries, said Shipp. He's adamant this is an education-pipeline issue: Colleges and universities should start or expand nursing programs, and this expensive education can become more affordable through loan forgiveness and scholarships.
If mandatory ratios are implemented, Shipp warns hospitals will face two bad options: Either turn away people who need medical care or break the law and deliver health care when the number of patients exceeds the legally set maximum.
"When the government is involved, it becomes more complicated and more complex when they're not in this environment," said Carol Ann Gioia, president of the Organization of Nurse Leaders.
Gioia believes that imposing new restrictions during a workforce crisis will hamper innovation and potential solutions. For example, many facilities now have licensed practical nurses and other health care staff take on duties that RNs have historically performed. In addition, different patients within a given unit will have varying degrees of need, so the rigid guidelines will shut down holistic approaches and force health systems to waste precious resources.
Following in California's footsteps?
The only state to have mandated staffing ratios for RNs is California, which it created in 1999 and then implemented in 2004.
Now two decades later, in the wake of the COVID-19 pandemic, the idea is again picking steam across a handful of states — Becker's Hospital Review reports that bills have been introduced in the statehouses of Connecticut, Massachusetts, Minnesota, Oregon and Washington.
"In California, the nurses came back to work in hospitals, and they came to work in the state from other states," said Linda Aiken, the funding director of the University of Pennsylvania's Center Health Outcomes and Policy Research, who notes that Pennsylvania has more RNs per capita than California.
More recently, however, nurses in California have complained their hospitals are "out of ratio," meaning they're getting assigned patient loads that exceed the state's limits. It was commonplace early in the COVID-19 pandemic when Gov. Gavin Newsom granted an emergency waiver to allow facilities to exceed the state's legal limits to care for the waves of COVID-19 patients requiring critical care. As a result of challenges that have been exacerbated by the pandemic, some California nurses are calling for investments into nursing education to strengthen the pipeline.
While California's ratios have not been a perfect solution, many nurses who work at the bedside believe it's a start to creating a safer health care environment.
"This is about the safety of a patient, which any of us, or our loved ones, could be at any given point in time," said Tammy May at Butler Memorial. "We do standards for many different things. Why we don't do it for health care, I have no idea."
