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.”