States' Nurse Staffing Bills Differ in Approach

By Debra Wood, RN, contributor

 Updated March 5, 2013 - Legislators in Minnesota, Michigan and the District of Columbia are considering nurse staffing bills, with a goal of improved patient safety and better outcomes. Two focus on nurse-to-patient ratios, while the other considers RN staffing according to “national standards.”

But all pieces of legislation are based on research studies that have shown how many patients a nurse cares for at one time has a direct bearing on adverse events, patient satisfaction and other quality indicators.

The DC Patient Protection Act is a mandatory minimum nurse-to-patient ratio bill similar to the one currently in place in California, except it would set the medical–surgical unit ratio at four patients to one nurse instead of five to one. In addition, charge nurses would serve as a resource nurse, not carrying a patient load, who could also teach patients preparing for discharge.

Minnesota and DC Nurse Staffing Bills Differ in Approach
Washington Hospital Center RN Rajini Raj explained the DC staffing bill would establish minimum nurse-to-patient ratios by hospital unit, augmented by additional staffing based on individual patient needs.

“We hope the ratios will give patients better care,” said cardiac nurse Rajini Raj, RN, a shop steward for National Nurses United (NNU) at Medstar Washington Hospital Center in DC. “Safety is our biggest concern as nurses, and we are taught in school to advocate for our patients. But when we try to do that with five or six patients, it’s hard to do.”

More education about diet and medications provided by the additional nurses could, ultimately, save the hospital money, by reducing preventable hospital readmissions and decreasing nurse turnover, Raj said. She reported nurses are leaving the bedside and many new graduates quit soon after starting their hospital careers to pursue other, less frustrating opportunities.

A 2012 survey by NNU found 57 percent of DC nurses reported inadequate nurse staffing always or almost always, and 60 percent said changes in a nurse’s workload have led to worse outcomes for patients. Eighty-seven percent said that mandatory nurse-to-patient ratios, such as those in California, are needed in DC.

The District of Columbia Hospital Association did not respond to requests for information about its position. However, the association’s website said the act “would significantly impair nurses’ and hospitals’ ability to make individualized patient care decisions” and have “negative consequences.” That’s not how Raj views it.

“We see it as a win–win for the patients, the nurses and the hospital,” Raj said. “We want to raise the bar for our patients, and this is the best way to do it.”

Council Chairman Phil Mendelson introduced the bill on February 4, 2013 and a public hearing will be scheduled. Then the council will consider the bill as is or with “mark ups,” or changes. 

Meanwhile in Michigan, State Rep. Jon Switalski (D-Warren) and State Sen. Rebekah Warren (D-Ann Arbor) have introduced the Safe Patient Care Act (HB 4311) that would require hospitals to have a comprehensive nurse staffing plan, including minimum nurse–patient ratios.

“Safe nurse staffing can be a matter of life or death,” said Jeff Breslin, RN, Michigan Nurses Association president. “Nurse-to-patient ratios have been a success story for patients in California and they can make a life-saving difference here in Michigan.”

Another nurse staffing bill in Minnesota is working its way through the legislative committee process. The Standards of Care Act (H 588) aims to ensure hospitals are adequately staffed, but it does not include specific ratios, instead referring to “national standards.”

Sen. Jeff Hayden, (DFL-Minneapolis), the bill’s co-sponsor, cited in a written release that more than 60 research studies show that safe nurse staffing levels eliminate unnecessary complications, reduce preventable medical errors and curb extended hospital stays, thereby reducing risks to patients and saving precious health care dollars. The bill had its first of several committee hearings in February.

The Minnesota Nurses Association declined to comment or provide any information about the bill. However, a press release at its website includes a quote from Linda Hamilton, president of the Minnesota Nurses Association, saying, “We need a standard to hold these hospitals accountable so patients and their loves ones can count on adequate RN staffing.”

In that release, the Minnesota Nurses Association reported that a survey of 800 Minnesotans, including 400 nurses, revealed that nearly a third of respondents reported situations where they have witnessed too few nurses on duty, which affected the quality of care patients received.

The Minnesota Hospital Association, on the other hand, reports that the state has achieved from the Agency for Healthcare Research & Quality (AHRQ) the best overall health care quality in the nation, with hospitals contributing to that No. 1 ranking. The National Healthcare Quality Report for Minnesota indicates the state is strong on overall health care quality.

“Being already ranked at the top in quality, we think this is a solution in search of a problem,” said Wendy Burt, spokesperson for the Minnesota Hospital Association.

The hospital association has also raised concerns about unintended consequences, such as nurses leaving nursing home positions for hospital jobs which will pay more, and layoffs of non-nursing hospital employees to compensate for the additional nursing salaries. Additionally, members have raised concerns about meeting the safe staffing rules during emergency situations.

“The bill will drive up cost across the continuum,” Burt said. “There are lots of questions about how it would be implemented.”

More insights on the nursing workforce:
Supply of Nurses in the Workforce Expected to Vary by Region
2012 Survey of Registered Nurses: Job Satisfaction, Career Patterns and Trajectories
2012 Healthcare Workforce Summit


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