Mandating Nurse-to-Patient Ratios Is Not Enough

Added on Jul 9, 2018

By Andrea Fitzgerald, Staff Writer

nurse executivesIn May, Pennsylvania Governor Tom Wolf voiced support for mandated nurse-to-patient staffing rules, making state history. In mid-June, the Massachusetts Supreme Judicial Court ruled that a proposed ballot initiative to mandate nurse staffing ratios met constitutional requirements and could go before voters on the November 2018 ballot. These recent developments have reignited the countrywide debate over staffing-ratio legislation that has largely divided the health care industry.

While supporters believe the proposal would improve the safety and quality of care by limiting the number of patients assigned to nurses, opponents worry that the costs could outweigh the potential benefits.

In Massachusetts, for example, critics want to keep the proposal off the ballot, citing not just a lack of evidence linking mandated staffing ratios to higher quality of care, but also its exorbitant price tag—according to a study commissioned by the Massachusetts Health and Hospital Association, mandated nurse staffing ratios would cost the state’s health care system $1.3 billion in the first year and $900 million each subsequent year. Meanwhile, advocates focus on the safety benefits. Kate Norton, a spokesperson for the Committee to Ensure Safe Patient Care, which supports the ballot question, stressed that “more nurses will never equal poorer quality of care.”

But more nurses won’t necessarily equal higher quality of care either. “Mandated staffing ​may appear to be ‘a quick fix’ for low safety, patient experience or engagement outcomes,” said Christy Dempsey, chief nursing officer and president of Clinical Excellence Solutions at Press Ganey. “However, to truly drive performance improvement across domains, health care leaders must invest in cultivating key elements of the overall environment, which include availability of nursing resources, education and certification of the workforce, engagement, team culture and skill mix in addition to patient volume and acuity, to ensure that nurses and other members of the care team feel safe, supported and mission-driven.”

Press Ganey research cited in a recent nursing special report that examines the relationship between the nurse work environment and key performance measures found a complex interdependency that often gets boiled down to one item: nurse staffing. Although nurse staffing aspects such as hours of care and skill mix were proven to influence outcomes, integrated analyses of data from multiple performance domains indicate that nurses’ overall work environment has a much larger influence across most measures than nurse staffing specifically, according to the report.

What does this mean for the current legislation battle? Simply that supporters cannot expect nurse-to-patient ratios to be the magic bullet that will improve patient safety, clinical quality, nurse engagement and other important domains. A win for mandated nursing ratios would only be a steppingstone on the journey to advancing the delivery of safe, high-quality, patient-centered care and improving caregiver and patient engagement.

“Rather than looking for a magic bullet—legislative or otherwise—organizations should focus on activities that are proven to make a difference in performance across care domains,” said Joseph Cabral, chief human resources officer and president of Workforce Solutions at Press Ganey. “This includes leveraging the expertise of nurses and others, especially those at the bedside, to determine what the right resources are at the right time, and using integrated, cross-domain analytics to understand and act upon the strong, positive relationships across safety, quality, patient experience and workforce engagement to drive and sustain improvement for patients and nurses.”