Got enough nurses? Nurse groups cite Kentucky case to support push for staffing ratio laws
Skip to main content
MDHC_Logotype_white
Subscribe
  • My Account
  • Login
  • Subscribe
  • News
    • This Week's News
    • COVID-19
    • Providers
    • Insurance
    • Government
    • Finance
    • Technology
    • Safety & Quality
    • People
    • Regional News
    • Digital Edition
    • Joe Biden
      Revamp of the nation's vaccination effort may not be enough
      A man in a room with servers.
      Momentum grows to outsource hospital tech functions in 2021
      Firefighter walking towards forest fire.
      Wildfires producing more harmful pollution
      Dr. Bruce Siegel
      By protecting the healthcare safety net, Biden can put us on the path to a stronger country
    • Dr. Bruce Siegel
      By protecting the healthcare safety net, Biden can put us on the path to a stronger country
      Joe Biden
      Revamp of the nation's vaccination effort may not be enough
      COVID-19 hastens hospitals' revenue cycle outsourcing moves
      Operation Warp Speed Dr. Moncef Slaoui, Pfizer Group President Angela Hwang, Moderna CEO Stephane Bancel, CVS Health Executive Vice President Karen Lynch and McKesson CEO Brian Tyler participate in a panel discussion on the COVID-19 vaccine.
      Hospitals, drug companies strive to stand out virtually at JPM
    • The Check Up: Trenda Ray
      The Check Up: Trenda Ray of the University of Arkansas for Medical Sciences
      Trenda Ray
      Q&A: Arkansas nursing leader looking for creative staffing solutions as COVID cases surge
      Cook Lydia 4x6_i.jpg
      Northeast Ohio health systems increase community benefit values in 2019
      Vaccine rollout hits snag as health workers balk at shots
    • CMS approves rule forcing insurers to ease prior authorization
      COVID-19 still a big uncertainty for insurers in 2021
      Health insurers' outlook boosted after Dems' Georgia win
      humana_i.jpg
      Humana supports Ohio not-for-profits with $500,000
    • Joe Biden
      Revamp of the nation's vaccination effort may not be enough
      CMS will raise Medicare Advantage plan payments by 4.08% in 2022
      CMS approves rule forcing insurers to ease prior authorization
    • Operation Warp Speed Dr. Moncef Slaoui, Pfizer Group President Angela Hwang, Moderna CEO Stephane Bancel, CVS Health Executive Vice President Karen Lynch and McKesson CEO Brian Tyler participate in a panel discussion on the COVID-19 vaccine.
      Hospitals, drug companies strive to stand out virtually at JPM
      Intermountain, Trinity, Memorial Hermann behind $300M private equity fund
      Operation Warp Speed to bump up McKesson's stock price
      Reporter's notebook: J.P. Morgan's 2021 health conference
    • A man in a room with servers.
      Momentum grows to outsource hospital tech functions in 2021
      5 things to know about Google's $2.1B Fitbit acquisition
      Providence bets on machine-learning, consolidating data centers
      Mental health treatment was most common telehealth service during COVID
    • Sticking to Mediterranean diet is good for the brain
      Chance of COVID-19 triage care looms over Arizona hospitals
      U.S. ramps up vaccinations to get doses to more Americans
      367146427.jpg
      Should businesses mandate that staff get the COVID vaccine?
    • Cone Health CEO, CFO to depart amid pending Sentara merger
      Tower Health's finance chief resigning after years of steep losses
      AHRQ director Gopal Khanna resigns in response to Capitol riot
      Brigham president stepping down after Moderna controversy
    • Midwest
    • Northeast
    • South
    • West
  • Insights
    • ACA 10 Years After
    • Best Practices
    • InDepth Special Reports
    • Innovations
    • The Affordable Care Act after 10 years
    • New care model helps primary-care practices treat obesity
      doctor with patient
      COVID-19 treatment protocol developed in the field helps patients recover
      Rachel Wyatt
      Project to curb pressure injuries in hospitals shows promise
      Yale New Haven's COVID-19 nurse-staffing model has long-term benefits
    • Michellene Davis
      Healthcare leadership lacks the racial diversity needed to reduce health disparities
      Dr. James Hildreth
      How medical education can help fight racism
      Modern Healthcare InDepth: Breaking the bias that impedes better healthcare
      Videos: Healthcare industry executives describe their encounters with racism
      Quotes from rebadged employees
      Outsourcing IT, revenue cycle takes toll on internal culture
    • A woman with a wearable sensor talking to her provider.
      Wearable sensors help diagnose heart rhythm problems in West Virginia
      self service station
      COVID-19 pushes patient expectations toward self-service
      Targeting high-risk cancer patients with genetics
      A nurse holds up a phone with a message to a family member saying surgery has started.
      Texting, tablets help hospitals keep family updated on patient care
  • Transformation
    • Patients
    • Operations
    • Care Delivery
    • Payment
    • Highmark Health inks six-year cloud, tech deal with Google
      Study: 1 in 5 patients report discrimination when getting healthcare
      HHS proposes changing HIPAA privacy rules
      Android health records app launches at 230 health systems
    • California hospitals prepare ethical protocol to prioritize lifesaving care
      Amazon, JPMorgan Chase, Berkshire Hathaway disband Haven
      Digital pathways poised to reshape healthcare continuum in 2021
      Healthcare was the hardest hit by supply shortages across all U.S. industries
    • A woman with a wearable sensor talking to her provider.
      Wearable sensors help diagnose heart rhythm problems in West Virginia
      New care model helps primary-care practices treat obesity
      How hospitals are building on COVID-19 telehealth momentum
      Researchers: Hospital price variation exacerbates health inequities
    • MedPAC votes to boost hospital payments, freeze or cut other providers
      Most Next Gen ACOs achieved bonuses in 2019
      Congress recalibrates Medicare Physician Fee Schedule after lobbying
      CMS approves rule to encourage value-based drug pricing
  • Data/Lists
    • Rankings/Lists
    • Interactive Databases
    • Data Points
    • Health Systems Financials
      Executive Compensation
      Physician Compensation
  • Op-Ed
    • Bold Moves
    • Breaking Bias
    • Commentaries
    • Letters
    • Vital Signs Blog
    • From the Editor
    • Wellstar CEO calls adapting for the pandemic her bold move
      Howard P. Kern
      Recognizing the value of telehealth in its infancy
      Dr. Stephen Markovich
      A bold move helped take him from family doctor to OhioHealth CEO
      Dr. Bruce Siegel
      Why taking a hospital not-for-profit was Dr. Bruce Siegel’s boldest move
    • Barry Ostrowsky
      Ending racism is a journey taken together; the starting point must be now
      Laura Lee Hall and Gary Puckrein
      Increased flu vaccination has never been more important for communities of color
      John Daniels Jr.
      Health equity: Making the journey from buzzword to reality
      Mark C. Clement and David Cook
      We all need to 'do something' to fight inequities and get healthcare right, for every patient, every time
    • Dr. Bruce Siegel
      By protecting the healthcare safety net, Biden can put us on the path to a stronger country
      Healing healthcare: some ideas for triage by the new Congress, administration
      Dr. Sachin H. Jain
      Medicare for All? The better route to universal coverage would be Medicare Advantage for All
      Connectivity: a social determinant of health that can exacerbate all the others
    • Letters: Eliminating bias in healthcare needs to be ‘deliberate and organic’
      Letters: Maybe dropping out of ACOs is a good thing for patients
      Letters: White House and Congress share blame for lack of national COVID strategy
      Letters: VA making strides to improve state veterans home inspections
    • Sponsored Content Provided By Optum
      How blockchain could ease frustration with the payment process
      Sponsored Content Provided By Optum
      Three steps to better data-sharing for payer and provider CIOs
      Sponsored Content Provided By Optum
      Reduce total cost of care: 6 reasons why providers and payers should tackle the challenge together
      Sponsored Content Provided By Optum
      Why CIOs went from back-office operators to mission-critical innovators
  • Awards
    • Award Programs
    • Nominate
    • Previous Award Programs
    • Other Award Programs
    • Best Places to Work in Healthcare Logo for Navigation
      Nominations Open - Best Places to Work in Healthcare
      Nominations Open - Health Care Hall of Fame
      Nominations Open - 50 Most Influential Clinical Executives
    • 100 Most Influential People
    • 50 Most Influential Clinical Executives
    • Best Places to Work in Healthcare
    • Health Care Hall of Fame
    • Healthcare Marketing Impact Awards
    • Top 25 Emerging Leaders
    • Top 25 Innovators
    • Top 25 Minority Leaders
    • Top 25 Women Leaders
    • Excellence in Nursing Awards
    • Design Awards
    • Top 25 COOs in Healthcare
    • 100 Top Hospitals
    • ACHE Awards
  • Events
    • Conferences
    • Galas
    • Webinars
    • COVID-19 Event Tracker
    • Leadership Symposium
    • Healthcare Transformation Summit
    • Women Leaders in Healthcare Conference
    • Workplace of the Future Conference
    • Strategic Marketing Conference
    • Social Determinants of Health Symposium
    • Best Places to Work Awards Gala
    • Health Care Hall of Fame Gala
    • Top 25 Minority Leaders Gala (2022)
    • Top 25 Women Leaders Gala
  • Listen
    • Podcast - Next Up
    • Podcast - Beyond the Byline
    • Sponsored Podcast - Healthcare Insider
    • Video Series - The Check Up
    • Sponsored Video Series - One on One
    • Carter Dredge
      Next Up Podcast: Ready, set, innovate! Innovation and disruption in healthcare
      Next Up Podcast: COVID-19, social determinants highlight health inequities — what next?
      Next Up Podcast: Saving Rural Health
      Ceci Connolly
      Next Up Podcast: How to navigate the murky post-election waters
    • An older man wearing a mask receiving a vaccine.
      Beyond the Byline: Verifying information on the chaotic COVID-19 vaccine rollout
      doctor burnout
      Beyond the Byline: How healthcare supply chain struggles contribute to employee burnout
      Beyond the Byline: Covering race and diversity in the healthcare industry
      Beyond the Byline: How telehealth utilization has impacted investor-owned company earnings
    • Leading intention promote diversity and inclusion
      Introducing Healthcare Insider Podcast
    • The Check Up: Trenda Ray
      The Check Up: Trenda Ray of the University of Arkansas for Medical Sciences
      The Check Up: Dr. Kenneth Davis
      The Check Up: Dr. Kenneth Davis of Mount Sinai Health System
      The Check Up: Dr. Thomas McGinn
      The Check Up: Dr. Thomas McGinn of CommonSpirit Health
      The Check Up: Mark Ganz
      The Check Up: Mark Ganz of Cambia Health Solutions
    • Video: Ivana Naeymi Rad of Intelligent Medical Objects
  • MORE +
    • Advertise
    • Media Kit
    • Newsletters
    • Jobs
    • People on the Move
    • Reprints & Licensing
MENU
Breadcrumb
  1. Home
  2. Providers
October 24, 2015 01:00 AM

Got enough nurses? Nurse groups cite Kentucky case to support push for staffing ratio laws

Sabriya Rice
  • Tweet
  • Share
  • Share
  • Email
  • More
    Print
    Getty Images

    Last March, a nursing assistant noticed a large pressure ulcer on the backside of a patient needing intensive care at the Hazard (Ky.) ARH Regional Medical Center. It was about 10 days after the patient had been admitted for leg ulcers and complications related to diabetes and renal disease.

    Those conditions are known to increase the risk of pressure sores, which develop quickly. So the patient should have been repositioned at least once every hour.

    But on the day the sore was reported, the patient had been lying in one position on top of a bedpan for more than a day. The pressure from sitting too long in one position with limited blood flow had caused a large blister that covered the patient's entire buttocks.

    A federal investigation found the patient may not have been moved for “an extended period of time” because the hospital, part of the not-for-profit 10-hospital Appalachian Regional Healthcare system, was understaffed. Its policy required one RN for every six patients in this unit where most patients required intensive care. But that day, one registered nurse was caring for about a dozen patients, while the certified nursing assistant on duty had 14. Experts say it's physically impossible for one nurse to attend to that many very sick patients.

    In April, the CMS placed Hazard ARH in “immediate jeopardy” of losing Medicare funding due to failure to provide adequate staffing. That status was lifted in May. The hospital did not respond to requests for comment for this article.

    Nursing groups and some safety experts say inadequate nurse staffing is a widespread problem in U.S. hospitals. They argue that it's a key factor in poor quality of care, higher rates of readmission, infection and mortality, lower patient satisfaction and staff burnout. They blame the problem on blunt cost-cutting by hospital executives, and say state and federal legislation is needed to address the issue.

    “It is a systemic problem we see constantly,” said Gerard Brogan, lead nursing practice representative for the California Nurses Association. “Nurses complain all the time, but nothing ever happens.”

    “You're talking about risking patients' lives,” said Pamela Cipriano, president of the American Nurses Association. “That's what this comes down to.”

    MH Takeaways

    Massachusetts in June passed a mandatory ICU nurse staffing law. Similar bills are pending in other states, and there's a bill in Congress to require hospitals to closely track staffing levels.

    But there is sharp disagreement about how to address inadequate nurse staffing and protect patients from similar harms. The American Organization of Nurse Executives, a subsidiary of the American Hospital Association, says that it doesn't support mandated nurse staffing ratios because staffing is a complex issue composed of multiple variables, and ratios cannot guarantee that the healthcare environment is safe.

    AONE adds that mandatory nurse-staffing ratios “will only serve to increase stress on a healthcare system that is overburdened by an escalating … shortage of registered professional nurses and has the potential to create a greater risk to public safety.”

    In June, Massachusetts passed a law to mandate that ICU nurses be assigned no more than two patients. Similar bills are pending in Michigan and the District of Columbia. At least five states require public reporting of staffing ratios.

    The ANA supports the Registered Nurse Safe Staffing Act, a Democratic-sponsored bill in the U.S. House that would require hospitals to track nurse-patient ratios more carefully and create staffing action plans, but does not mandate certain staff ratios. There has been little action on the bill since it was first introduced in 2013.

    But hospital groups warn that such requirements raise costs without necessarily improving quality of care. “A rigid numeric ratio that is etched into law and that must be adhered to at all times does not account for the dynamic nature of the hospital environment,” said Jan Emerson-Shea, vice president of external affairs for the California Hospital Association. “At best, the jury is mixed.”

    Prior to the Massachusetts law, California was the only state to require healthcare facilities to have a set ratio of nurses per patient. The state's law took effect in 2004.

    California remains the only state to have ratios for most types of hospital units. Its law requires that hospitals have one registered nurse for every two intensive- or critical-care patients; one RN for every four mother-baby sets in the post-partum unit; one RN for every five patients on continuous cardiac-care monitoring; and one RN for every six psychiatric unit patients.

    Nursing groups recommend that hospitals across the country use the California ratios as a benchmark for establishing staffing policies. They also encourage facilities to track adherence to the ratios and regularly survey nursing staff about whether they are feeling burned out.

    But some experts say fixed staffing-ratio laws do not take into account the demands of unique patient populations that differ from facility to facility. “The obvious result of such regulations is the creation of a nurse-staffing standard that either exceeds or falls below that which employers would otherwise use to produce nursing care,” Peter Buerhaus, director of the Center for Interdisciplinary Health Workforce Studies at Vanderbilt University Medical Center, Nashville, wrote in the journal Nursing Economics in 2010.

    Dr. Christine Cassel, CEO of the National Quality Forum, also criticized the staffing-ratio approach, arguing there is not enough research evidence to indicate how effective fixed staffing ratios are at improving patient outcomes. “This is an area that is very much in flux right now and where I think measurement science actually could add a lot,” she said.

    Advocates for required staffing ratios say, however, that evidence exists that adequate ratios make a significant difference in patient outcomes. For example, investigators in a 2002 JAMA study estimated that nurses caring for eight patients had 2.6 additional deaths per 1,000 patients compared with nurses caring for four patients.

    A study in January in the journal Medical Care looked at more than 220,000 patients from California, Florida, New Jersey and Pennsylvania. California, where nurse-staffing ratios are mandated, had a lower percentage of readmissions from seven days to 90 days after discharge compared with the other states, where nurse-staffing ratios are not mandated.

    But a study commissioned by the California HealthCare Foundation and written by University of California at San Francisco researchers in 2009 found that while California's rules increased the hiring of RNs, the ratios had no clear impact on quality measures associated with nursing care. The study found that hospital administrators reported difficulty absorbing the cost of the ratios, and that many reported having to reduce budgets or services in other areas.

    Both the Joint Commission and the CMS in their guidelines require healthcare facilities to have “adequate numbers” of nurses. But neither agency specifies what “adequate” means.

    Such guidelines are too vague, said Bonnie Castillo, director of the Registered Nurse Response Network for the National Nurses United union. “It's difficult to enforce without a law,” she said.

    The Joint Commission said that while it does not specify hospital staffing ratios, for healthcare organizations to receive accreditation they must establish structures and processes that focus on safety and quality throughout the hospital.

    Linda Aiken, director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania and author of several studies on staffing ratios, said even in the absence of mandates, public reporting is needed to help patients and families. They currently have no way to know what a hospital's staffing ratio is or if a hospital is meeting recommendations. “It's like a tightly held secret,” she said. “There's no transparency, and data is routinely not available.”

    Kentucky, where Hazard ARH Regional Medical Center is located, has no nurse-staffing ratio requirements. The American Nurses Association says the bedsore case at that hospital demonstrates the need for mandated ratios.

    Following the CMS' decision to place the hospital on “immediate jeopardy” status, Hazard ARH complied with the agency's recommendations to conduct staff education on wound care, update policies for tracking patient-care issues, and improve education and communication during shift changes. Its immediate jeopardy status was lifted in May.

    But the CMS did not recommend facilitywide improvements in nurse-staffing ratios—even though there were at least 15 internal staff complaints about staffing levels filed between January 2015 and April 2015. One nursing assistant said at one point he worked a shift when he had more than 30 patients. Many of the patients required “total care,” meaning they depended on nurses for eating, toileting and bathing, which could require several hours of individualized attention.

    Nurses at the hospital had even threatened a walkout last year, calling staffing shortages a chronic problem that put patients at risk. The facility received the maximum 3% CMS penalty on the readmission reduction program in both 2015 and 2016, according to Modern Healthcare's Quality & Safety Database.

    Officials at Hazard ARH acknowledged to federal investigators that they had a nursing shortage due to difficulty in recruiting registered nurses and certified nursing assistants. They said they hosted a job fair. “It was not successful, as anticipated,” the hospital risk manager, who is not named in the report, told surveyors. In the meantime, the hospital had to “work with what we had,” facility CEO Dan Stone says in the report.

    The medical center formed an on-call pool for nurses and said it would reassign staff from areas with less demand, while it continued efforts to recruit more RNs and aides.

    While recruiting and retaining nurses can be a challenge in rural areas like Hazard, Ky., experts say that's not a good reason for lacking an adequate number of nurses. Facilities that offer competitive salaries and safe work environments will draw applicants, given the growth in the number of registered nurses and licensed practical nurses being trained, they say. Between 2012 and 2025, the rate of new RNs and LPNs entering the field is expected to surpass demand, increasing 21% and 28% respectively, according to estimates from the federal Health Resources and Services Administration.

    “People want jobs,” Castillo said. “When you go to nursing school and have the opportunity for gainful employment, people take those opportunities.”

    Having adequate nurse-patient staffing ratios makes it easier to recruit and retain nurses, Aiken said. “We need to address the fundamental issues, like workloads that are too great and chaotic environments,” she said. “It's not to say that nothing else matters in patient safety. But it does say nurse staffing matters a lot.”

    Letter
    to the
    Editor

    Send us a letter

    Have an opinion about this story? Click here to submit a Letter to the Editor, and we may publish it in print.

    Recommended for You
    Q&A: Arkansas nursing leader looking for creative staffing solutions as COVID cases surge
    Q&A: Arkansas nursing leader looking for creative staffing solutions as COVID cases surge
    The Check Up: Trenda Ray of the University of Arkansas for Medical Sciences
    The Check Up: Trenda Ray of the University of Arkansas for Medical Sciences
    Sponsored Content
    Get Free Newsletters

    Sign up for free enewsletters and alerts to receive breaking news and in-depth coverage of healthcare events and trends, as they happen, right to your inbox.

    Subscribe Today

    The weekly magazine, websites, research and databases provide a powerful and all-encompassing industry presence. We help you make informed business decisions and lead your organizations to success.

    Subscribe
    Connect with Us
    • LinkedIn
    • Twitter
    • Facebook
    • RSS
    • Instagram

    Stay Connected

    Join the conversation with Modern Healthcare through our social media pages

    MDHC_Logotype_white
    Contact Us

    (877) 812-1581

    Email us

     

    Resources
    • Contact Us
    • Advertise with Us
    • Ad Choices Ad Choices
    • Sitemap
    Editorial Dept
    • Submission Guidelines
    • Code of Ethics
    • Awards
    • About Us
    Legal
    • Terms and Conditions
    • Privacy Policy
    • Privacy Request
    Modern Healthcare
    Copyright © 1996-2021. Crain Communications, Inc. All Rights Reserved.
    • News
      • This Week's News
      • COVID-19
      • Providers
      • Insurance
      • Government
      • Finance
      • Technology
      • Safety & Quality
      • People
      • Regional News
        • Midwest
        • Northeast
        • South
        • West
      • Digital Edition
    • Insights
      • ACA 10 Years After
      • Best Practices
      • InDepth Special Reports
      • Innovations
    • Transformation
      • Patients
      • Operations
      • Care Delivery
      • Payment
    • Data/Lists
      • Rankings/Lists
      • Interactive Databases
      • Data Points
    • Op-Ed
      • Bold Moves
      • Breaking Bias
      • Commentaries
      • Letters
      • Vital Signs Blog
      • From the Editor
    • Awards
      • Award Programs
        • 100 Most Influential People
        • 50 Most Influential Clinical Executives
        • Best Places to Work in Healthcare
        • Health Care Hall of Fame
        • Healthcare Marketing Impact Awards
        • Top 25 Emerging Leaders
        • Top 25 Innovators
        • Top 25 Minority Leaders
        • Top 25 Women Leaders
      • Nominate
      • Previous Award Programs
        • Excellence in Nursing Awards
        • Design Awards
        • Top 25 COOs in Healthcare
      • Other Award Programs
        • 100 Top Hospitals
        • ACHE Awards
    • Events
      • Conferences
        • Leadership Symposium
        • Healthcare Transformation Summit
        • Women Leaders in Healthcare Conference
        • Workplace of the Future Conference
        • Strategic Marketing Conference
        • Social Determinants of Health Symposium
      • Galas
        • Best Places to Work Awards Gala
        • Health Care Hall of Fame Gala
        • Top 25 Minority Leaders Gala (2022)
        • Top 25 Women Leaders Gala
      • Webinars
      • COVID-19 Event Tracker
    • Listen
      • Podcast - Next Up
      • Podcast - Beyond the Byline
      • Sponsored Podcast - Healthcare Insider
      • Video Series - The Check Up
      • Sponsored Video Series - One on One
    • MORE +
      • Advertise
      • Media Kit
      • Newsletters
      • Jobs
      • People on the Move
      • Reprints & Licensing