Healthcare facilities in California have been required to adhere to mandatory nurse-to-patient ratios since 2004. These ratios vary depending upon the degree of patient care involved. More recently, Massachusetts passed a law requiring mandatory staffing minimums in the state’s ICU’s. Other states are considering jumping on the bandwagon. A California-like bill is currently pending in the Illinois General Assembly. Additionally, groups in Florida, Iowa, Minnesota, New Jersey, New York, Texas, and the District of Columbia are asking state lawmakers to consider similar measures.

At first blush, such legislation might not seem controversial, however, it is a topic of fierce debate among healthcare policy experts. Proponents, such as patient advocacy groups and nurses’ unions, tout that mandatory ratios will result in improved patient outcomes and reduced nurse stress and exhaustion levels.

Opponents, such as healthcare executives and administrators, express skepticism for some of the reasons summarized below.

1. Increased Costs.  Most healthcare facilities will be required to hire more nurses in order to ensure ratio compliance. Additionally, as has occurred in California, healthcare facilities may feel compelled to increase nurses’ salaries and benefits in order to retain them. Already budget-strapped healthcare facilities will have to divert resources from other priority areas. In addition, some question whether there are enough nurses available in the labor market to satisfy these patient ratios in all facilities.
2. Longer Patient Wait Times.  Consider this scenario: A nurse has four patients on her floor. This is the maximum number of patients she is allowed to treat. Two of her patients are not currently on the floor because they are at physical therapy. The other two are stable in their beds. There is a new patient waiting in the ER to be admitted to the floor. Under a ratio law, the nurse cannot go down to the ER to bring the patient up to the floor for admission even though she has no current patient care needs to address. The patient will have to wait in the ER until coverage is available.
3. Lack of Flexibility And Potential Poor Patient Outcomes. Another example: There is a nearby industrial chemical spill or a catastrophic fire. Scores of patients are pouring into the ER requiring immediate care. Under a ratio law, nurses cannot be diverted from one floor. The healthcare facility must wait for other nurses to report to work. This could have a negative impact on the prognosis of patients who need urgent treatment.

Is there a compromise that will make both sides happy? Possibly.

At least 21 states have varying regulations that require healthcare institutions to develop their own staffing policies and plans. Many healthcare facilities in these jurisdictions have found success managing the competing tensions surrounding staffing issues by collaborating with stakeholders on both sides to develop staffing plans that meet the specific needs of their community demographics.

While it remains to be seen what additional action will be taken by states considering mandatory ratios, now is an opportune time for healthcare institutions to review their nurse staffing plans, and consider what changes may be appropriate. Changes to those staffing plans may require bargaining with nursing unions.