Federal, state, and local governments regulate many aspects of health care. However, it is physicians, nurses, and other health professionals that provide care directly to patients. The ever growing demands of an aging population have led to overfilled hospitals, struggling to avoid turning away patients, with some nurses caring for five or more patients at any given time. As a result, there has been considerable debate over the past few years as to whether or not such a workload can be detrimental to patients.
This debate has recently been renewed by the Council of the District of Columbia. The “Patient Protection Act of 2013” (Leg. No. B20-0101), presented by Council Chairman Phil Mendelson and cosponsored by eight other Council Members,[i] sets strict nurse-to-patient limits depending on the type of hospital setting in which a patient is treated. For example, an operating nurse would only be permitted to care for one patient at any given time, while a non-trauma emergency department nurse or a medical/surgical nurse could only cover a maximum of four patients.
This proposed legislation is based on a similar framework created by the California state government in 1999 and put into force in 2005. That system has been touted as a “landmark” law by National Nurses United (NNU), a nursing union. While NNU points to California as glowing proof for the need for state-mandated limits on nurse staffing ratios, the evidence is not so clear.
A California HealthCare Federation study of various nurse-sensitive indicators in California hospitals suggests that despite significantly increased costs, there is little positive effect on patient care. The study found that between 1999 (when the legislation was passed) and 2006, the rates of pneumonia death and failure to rescue steadily declined, yet the rates of post operative sepsis, deep vein thrombosis, and pressure ulcers increased. The study concluded that most of the indicators they measured “do not appear to have been directly affected by the increase in RN staffing.”[ii] On the contrary, the authors found that some hospital staff members reported experiencing difficulties in meeting both staffing requirements and requirements that nurses take mandatory breaks during the day, that emergency department wait times had increased, and that in some rare cases ambulances were being diverted to other hospitals in an effort not to break the ratio requirements.
The American Nursing Association (ANA) lists California as the only state to require minimum nursing ratios for all nursing units at all times. Instead, most of the states listed have laws requiring individual hospitals to have committees, comprised of nurses and administrators, that set ratios based on the specific needs of the patients on that unit. These laws let the health care professionals decide what is appropriate for the patients under their care. Notably, the California law cited by the NNU only required that the California Department of Public Health establish and enforce ratios, but the law itself did not take on the task of mandating specific ratios, as the D.C. proposed legislation does.
The ANA supports a model where the nurses themselves are involved in creating unit-specific staffing plans. This model is similar to competing D.C. legislation put forth by Council Member Mary M. Cheh, representing D.C.’s Ward 3. The “Nurse Safe Staffing Act of 2013” (Leg. No. B20-011) calls for each hospital in Washington D.C. to create a committee comprised of at least 55% direct-care registered nurses, with at least one patient care nurse from each unit,[iii] which will be tasked with setting hospital-wide nurse-to-patient ratios. The ratios set by the committee must “[b]e based upon input from the registered nurse staff of the hospital who provide direct patient care or their exclusive representatives,”[iv] standing in stark contrast to the Mendelson bill, which puts the job of determining what is best for patients solely in the hands of politicians.[v]
Given that the ANA and the D.C. Hospitals Association reject such strong requirements, the loudest voice in support of the proposed legislation is the NNU nursing union. Their Uniform National Professional Standards largely match the proposed Mendelson bill. However, certain provisions buried in the legislation may point to an additional goal. Despite the stated goal of patient protection, section 6(h)(4) of the Mendelson bill states that a “hospital (or an individual representing [a hospital]) shall not in any way interfere with the rights of nurses to organize, bargain collectively, and engage in concerted activity under section 7 of the National Labor Relations Act.”[vi] (Emphasis added).
The D.C. Council should strongly consider the difference between the Mendelson and Cheh bills. The Mendelson bill calls for local politicians to determine how many patients a nurse can care for, based only on the general nature of a hospital unit. The Cheh bill puts that decision in the hands of the very healthcare professionals who provide direct hands-on patient care. The nurses working in a hospital unit, caring for patients 24 hours a day, 7 days a week, 365 days a year, are in a far better position to decide on staffing levels than politicians. In an era of personalized medicine, local politicians should not use the broad brush of legislation to make generalized decisions in place of nurses and healthcare administrators.
[i] This bill was introduced by Council Members Mendelson, Barry (Ward 8), Evans (Ward 2), Grosso (At-Large), Orange (At-Large), Alexander (Ward 7), Bonds (At-Large), Graham (Ward 1), and McDuffie (Ward 5), and it was co-sponsored by Council Member Wells (Ward 6).
[ii] Joanne Spetz, et al., Assessing the Impact of California’s Nurse Staffing Ratios on Hospitals and Patient Care, California HealthCare Foundation at *7 (Feb. 2009).
[iii] Nurse Safe Staffing Act of 2013 § 3(c)(1)(a-d).
[iv] Nurse Safe Staffing Act of 2013 § 3(d)(1).
[v] The Mendelson bill does require each hospital unit to create a committee to review staffing measures. However, the committee is only permitted to impose restrictions which are more stringent than those laid out by law. Patient Protection Act of 2013 § 4(b)(1). For example a medical/surgical unit committee could decide that the mandated 4 patients to 1 nurse is not sufficient, and the committee could then set the ratio to 3 patients to 1 nurse, but it could not change it to 5 patients to 1 nurse.
[vi] Patient Protection Act of 2013 § 6(h)(4).