COMMUNITY VIEW

View: Mandate safer patient-to-nurse ratios

Dr. Fred Hyde
Nurse-to-patient ratios need to be appropriate, for patient safety and quality care.

Legislative proposals calling for "safe staffing" patient-to-nurse ratios in hospitals seem to be "controversial." Why is that?

Every parent knows that a high ratio of students to teachers leads to poor results for the students. The same is true in hospitals, where the consequences of inadequate staffing involve life and death. Why don't we have the same level of concern for the ratio of patients to nurses in hospitals?

The answer is simple. Most of the time we are not sick, much less in hospitals. But most parents of school age children, most of the time, have constant information about school. "How was school today?" "What homework do you have?" "Was the teacher interested in your report?"

We have only scattered bits of information about nurse staffing in hospitals. A minority of the population are patients in hospitals in a given year, and even then mostly only for a few days.

But the people who do know about the problem of low staffing, and who can do something about it, are the executives in our hospitals, many of them millionaires in tax-exempt institutions.

Wrong incentives

Unfortunately, these executives have no incentive to support increases in nurse staffing. Rather, most of them are on the hot seat when expenses exceed revenues. Cutting down on nursing (and other care) hours is the quick way (and sometimes the only way) to make short-range hospital profit goals. And the boards who hire these executives do not insist on incentive plans that reward safer hospitals, or higher quality hospitals. Rather, most of the incentive plans for executives only reward the profitable performance of hospitals.

The practice of hospital nursing is hard, difficult and valuable. It is hard because the work has physical demands. It is difficult because, on top of the physical demands, hospital nursing is sophisticated, complex and mentally challenging. And it is important because, without the hospital nurse, we have no advocate in the hospital, our immediate care suffers, and the effectiveness of what doctors might do for us is compromised.

In fact there are a large number of studies on hospital nursing staff ratios and hours. Here is one theme from these studies: adding staff improves patient outcomes, especially by reducing mistakes. Here is another theme: reducing staff increases morbidity and mortality. Here is a third: adding staff reduces injuries to nurses – back injuries, needle sticks, falls and the like.

Still, we leave decisions about the workload of those doing hard, difficult and important work almost entirely to those whose financial incentives focus on short term hospital profitability.

Without state legislation, it is difficult for an individual hospital executive to take the initiative to improve his or her own hospital's staffing ratios. That executive will increase his or her hospital expenses over the short run, while competing hospitals do not. We know that enriching hospital nursing hours saves money over the long run—in reducing mistakes, injuries, reducing unnecessary readmissions and the like. But the hospital executive has to "take a chance" in the short run, betting that an investment in richer nurse staffing will pay off.

Legislation needed

That is, the executive is "taking a chance" unless all of his or her competitors are compelled to achieve the same nurse ratios. How would that happen? Only through state legislation mandating nurse staffing ratios. These proposals are fought tooth and nail by health care executives whose compensation, in some cases, is actually linked to the profitability of their tax-exempt hospitals, not to the safety of patients or the quality of care in those hospitals.

This proposed legislation is also fought by "trade associations" fronting for hospital executives who do not want to be seen as working in opposition to their own nurses. The executives of these trade groups are also among the higher paid in health care.

And, unfortunately, "safe staffing" legislation is a matter of indifference to some unions which do not represent many or any nurses.

If you don't do something to support safe staffing ratios for nurses in hospitals, nobody will do it for you.

What does your legislator think about this? Ask him or her. Find out why your legislator allows hospitals to get away with understaffing where it counts—in patient care.

And by all means ask nurses you may know what they think. I predict you will get an ear-full.

The writer is an independent consultant who teaches hospital management and hospital finance as a clinical professor in the Mailman School of Public Health at Columbia University.