Pandemic revives debate over nurse staffing ratios

Pat Kane, executive director of the New York State Nurses Association, has seen the pandemic intensify the decades-long fight over adequate nurse staffing.

Before COVID-19 struck, the Midtown South–based union of more than 42,000 frontline nurses made safe-staffing ratios a top priority for its members, who work in major hospitals and other health care settings across the state. The ratios regulate the number of patients that may be assigned to a single nurse.

Those efforts continued through the height of the crisis. Nurses felt their facilities were unprepared in terms of the size of their staff to take care of the vast number of critical care patients, said Kane, who is a registered nurse herself.

"Our feeling was that staffing was so tight, when this came to be, the system broke. It just broke," she said.

The most recent bill about the issue proposed in the state Legislature is the Safe Staffing for Quality Care Act of the 2019–20 legislative session. It's currently in committee. Some of the proposed ratios include one nurse to two patients in critical care and intensive care units, one nurse to four patients in medical-surgical units, and one nurse to six patients in well-baby nursery units. The union's position is that mandatory nurse-to-patient staffing ratios would improve safety, quality of care and staff retention at a time when nurses are more essential than ever.

Hospitals, however, are steadfast in their belief in flexible staffing, which they say enabled them to handle the COVID-19 surge and save patients. Flexible staffing operates without mandated nurse-to-patient ratios and allows providers to adjust their number of nurses in real time based on how they view the needs of patients.

The hospitals also say meeting set staffing ratios is unachievable thanks to fiscal constraints arising from the current crisis, which resulted in a loss of revenue as most nonmandatory procedures were postponed or canceled.

Sean Clarke, a registered nurse and executive vice dean and professor at New York University's Meyers College of Nursing, said he believes the pandemic could fan the flames of the staffing battle.

"We may see that debate continue," Clarke said.

Tanisha Thompson, a registered nurse at Wyckoff Heights Medical Center and a member of the New York State Nurses Association, said the volume of COVID-19 patients that local nurses took on during the pandemic was incredibly difficult.

Thompson, a 20-year veteran, is trained in critical care and was redeployed from other work to that high-need area during the peak of the crisis in New York.

"Staffing is a huge issue," she said. "The patients are getting sicker and sicker and sicker. They require more and more care, and you really need to have a manageable patient load."

Thompson said she believes setting nurse-to-patient staffing ratios would aid facilities in retaining experienced nurses.

Last month the state Department of Health released a highly anticipated report that considered the logistics of implementing set staffing ratios. Researchers found that if the proposed legislation to do so were passed, hospitals would need to hire nearly 25,000 more nurses—at an annual cost of between $1.8 billion and $2.4 billion. And nursing homes would incur between $1.9 billion and $2.3 billion in annual costs.

The estimates reflect an increase in wage costs of between 40% and 53% for hospitals, and between 79% and 96% for nursing homes, at a time when local providers have been financially strained by COVID-19.

Aside from recruitment and costs, the department noted in its report that some stakeholders have voiced concerns that mandated nurse-to-patient ratios don't take into consideration the differences in types of hospitals, patient populations and care practices.

It added that the evolution of clinical care and types of patients suggest providers need flexibility to implement staffing plans that best meet all needs.

A spokeswoman for the state Department of Health reiterated the need for adaptability in staffing, especially as a result of the current crisis.

"The staffing study concluded that maintaining a health care workforce that effectively meets the needs of patients requires a flexible and comprehensive approach to address today's multifaceted and complex health care delivery challenges," the spokeswoman said in a statement. "The department continues to support measures to improve quality of care and patient outcomes, and the pandemic has only underscored the need to maintain workforce flexibility."

The Greater New York Hospital Association concurred.

"Nurses are indispensable professionals without whom there would be no patient care," the association said in a statement. "Our hospitals are always looking for ways to better support them and the critical work they do." However, it said, mandated nurse-to-patient ratios would have been "unworkable and unaffordable" even before the pandemic, and now such a requirement is unthinkable for hospitals.

"Every hospital in New York state will lose money this year," the association said. "Some of our hospitals are contemplating layoffs—a terrible conundrum at a time when we are continuing to ask for heroism during the ongoing pandemic. And we fear, in a post-COVID era—if it ever comes—hospital revenues will not return to their pre-COVID levels due to consumer concerns about hospital care and out-migration of patients from New York City."

When Maureen White, a registered nurse and executive vice president and chief nurse executive at Northwell Health, first joined the health system in 1999, it employed 7,500 nurses. Two years ago Northwell had reached a workforce of about 17,000 nurses; now it employs 18,500.

The level of nurse staffing is a moving target for the health system, White said.

Patients face complex medical and socioeconomic issues, she said, and their status can change in the blink of an eye. Instituting inflexible staffing ratios is a stagnant approach to a dynamic care environment, she said, and taking the approach that one nurse is always equal to another nurse is a disservice to the field. The idea that "a nurse is a nurse" does not adequately address the needs of patients, she added.

At the height of the pandemic in New York, there were some Northwell hospitals in which staffing became stretched, White said. The health system had anticipated an uptick in patients, however, and it brought in outside agency nurses to fill gaps.

As operations return to normal, Northwell is prehiring for the last quarter of the year, during which nurses typically retire. And it's using predictive analytics to help determine areas of need should a resurgence of COVID-19 coincide with flu season.

Because many medical-surgical nurses have expressed interest in critical care as a result of the pandemic, the health system in July established new fellowship programs in that area.

"You're never at a loss if you have too many critical care–prepared nurses," White said.

At NYU Meyers, the first-year students who were accepted came despite the pandemic, Clarke said.

"There's been some wonderful positive attention on frontline nurses and physicians," he said.

Additionally, many individuals have been displaced from jobs in other industries, he said. Historically, health care has been a stable field. But that's not to say nursing hasn't been affected by current uncertainties.

"Whenever you see a decline in [patient] admission volumes and procedures, you're going to see a financial impact and perhaps an effort to rebalance things," Clarke said of hospitals and other providers. That includes laying off staff.

The demand for nurses remains, however, particularly in new areas such as telemedicine and at community-based health organizations.

Kane of the New York State Nurses Association said nursing remains an attractive career despite the pandemic. But that can't be taken for granted, she said. As tenured nurses age and retire, Kane questioned who will replace them.

"Safe staffing would really attract people to the profession," she said, "because it's something that people leave over."

There are nurses who go to school, love the profession and want to help, she said, but then enter the workforce and have eight or 12 patients at a time and realize they can't really help people in that situation.

She said she doesn't believe set staffing ratios are inflexible. Legislation to implement them could simply establish a floor, she said.

Although Kane does not agree with the recruitment and cost figures for mandatory nurse-to-patient staffing ratios included in the Health Department's report, she does agree with the state's assertion that more data is needed to better determine current workforce numbers and what the need is going forward.

The department wrote in its report that although more RN graduates are entering the workforce each year, hospitals that participated in a 2017 study reported difficulty recruiting and retaining nurses, both experienced and newly licensed. Research suggests that the state will continue to experience a nursing shortage during the next decade, which could make meeting mandated staffing levels unachievable for some providers.

The department noted that in 2016, the Center for Health Workforce Studies, an academic research center based at the School of Public Health at the University at Albany, projected that if RN graduation and retirement trends remain the same, the supply of nurses would grow by 5% to 9% between 2015 and 2025, largely keeping pace with demand.

However, the department also acknowledged that other projections, such as those published more recently in the American Journal of Medical Quality, indicated a shortage of more than 39,000 registered nurses in New York by 2030.

In anticipation of a second wave of COVID-19—or another public health crisis—Kane said hospitals and other health care providers can help bolster frontline staff by including nurses in planning conversations.

Maintaining the new mental health and wellness resources recently put in place at facilities is also important, she said. And it's essential that nurses feel their employers are protecting them by being transparent about preparation efforts and achieving adequate personal protective equipment and staffing levels.

"These people just want to do their jobs," Kane said. "They just want to save people."

This story first appeared in our sister publication, Crain's New York Business.