No other state has passed rigid nurse-to-patient staffing ratios since California became the first to do so 14 years ago. But when the Minnesota Legislature convened this year, it appeared poised to dictate to hospitals costly, controversial and unproven limits on how many patients a bedside nurse can care for.
The same unusual political constellation that favored California’s staffing legislation had come together over Minnesota. Like California in 1999, Minnesota has a Democratic governor, Democratic majorities in both legislative chambers and a politically active nurses union intensely pushing staffing mandates, which would boost nurse hiring, as a panacea for patient-safety concerns.
Sure enough, nurse staffing legislation was introduced early in the session by some DFL lawmakers. While not specifically calling for California-style ratios, the plan as introduced would have mandated that hospitals meet staffing quotas developed by outside professional groups rather than allow health care facilities to more efficiently set their own nursing staff levels according to patient needs and on-duty nurses’ experience and skills.
But Minnesota is not California. Our lawmakers’ sensible handling of the “Standards of Care Act” is yet another reason to celebrate the difference.
Over the course of the session, the nurse staffing legislation has morphed into something far more cautious and pragmatic that strikes a calm balance between nurses’ concerns about understaffing and state hospitals’ objections to a mandate’s cost and inflexibility.
The legislation is still a work in progress, but it now calls for compiling hospital staffing information on a public website, and having the respected Minnesota Department of Health (MDH) study staffing levels and patient outcomes.
These two steps, if executed with care, could yield Minnesota-specific information to help move the long-simmering debate beyond the talking points of both the nurses union and the hospitals.
The Minnesota Nurses Association, which made nursing ratios a signature issue during its tense 2010 contract negotiations with Twin Cities hospitals, has contended since that nurse understaffing puts patient safety at risk. It conceded on this issue in the settlement but has continued to publicize unverifiable anecdotal incidents reported to it by union members about situations in which patients may have been put at risk.
More context and analysis is needed to make such information meaningful. Were these rare incidents at the hospitals where they occurred or signs of chronic understaffing? Are these incidents more common at certain facilities?
At the same time, the Minnesota Hospital Association’s continued citing of the state’s top national health care quality rankings as evidence of staffing adequacy here is reassuring. But is there variation between facilities’ staffing, and are some chronically shorthanded? It’s unlikely that dictating costly ratios would be the answer if that’s the case, but improvement may be needed.
The incremental approach in the Minnesota legislation is reasonable given the potential cost of staffing mandates. Studies of the effectiveness of California’s ratios on patient safety have also delivered mixed results.
“Whether the strict regulatory strategy that California chose to use produced better outcomes, I don’t think there’s strong evidence to support that at this point,’’ said Joanne Spetz, a well-known economics researcher at the University of California, San Francisco.
Legislators still have work to do on the bill, which needs to do more than generically order up a staffing study. Lawmakers must ensure that hospital data is provided. More detail is also needed about the questions the study should address.
Minnesota is a national health care leader. Its study of this important issue should reflect that and aim to move the debate on staffing forward — here and nationally.