Twin Cities talks: How many patients per nurse?

  • Article by: MAURA LERNER
  • Star Tribune
  • May 30, 2010 - 10:48 PM

If the Minnesota Nurses Association has its way, emergency-room nurses wouldn't have to care for more than three patients at a time.

In Labor and Delivery, no nurse would have more than two patients.

And in some intensive care settings, every nurse would be assigned just one patient.

That ideal -- setting permanent staffing ratios -- is at the heart of the contract dispute that has brought 12,000 union nurses to the brink of a walkout at 14 Twin Cities hospitals.

The Minnesota nurses union has proposed some of the strictest staffing rules in the country, saying they're the only way to ensure that patients get safe care. "These numbers improve patient outcomes," said Susan Mason, the lead union negotiator. "These are not made just for the sake of decreasing the workload of nurses."

But the hospitals call the plan a nonstarter, saying it would add hundreds of millions of dollars in unnecessary costs. "We're not going to look at these rigid rules," said Maureen Schriner, spokeswoman for the hospitals. "The community right now is asking us to have better quality of care and keep it at a reasonable cost, and this doesn't do either."

So far, only one state -- California -- has imposed fixed nurse-to-patient ratios in its hospitals, and experts disagree on whether it really helps patients. But nurses' unions are trying to spread the idea across the country through changes in the law and collective bargaining.

With their contract expiring Monday, the nurses have scheduled a one-day strike on June 10 if the two sides don't reach agreement. While wages and benefits are at stake, nurses say the real battle is over who gets to decide how many nurses are enough.

The Minnesota nurses acknowledge their proposal would go even further than California's staffing law, imposing the tightest nurse-to-patient ratios in the country. "That's what we're asking for," said Mason. "In the process of bargaining, [we] are more than willing to address the numbers."

The nurses point to studies showing that understaffing leads to more falls, infections and other serious complications.

Benefit or costly mistake?

In April, researchers at the University of Pennsylvania found that California's staffing ratios were associated with better patient outcomes and fewer deaths. The study found that California nurses cared for one less patient, on average, than their counterparts in New Jersey and Pennsylvania, and that "lower ratios are associated with significantly lower mortality." Another benefit: Nurse satisfaction was higher and turnover lower.

Other researchers, though, say mandating ratios would be a costly mistake.

"I want quality and safety to be as good as it possibly can," said Peter Buerhaus, a professor of nursing at Vanderbilt University. "But to wave this idea of regulating staffing as the solution is completely false, and it's disingenuous."

In a recent essay, Buerhaus wrote that it's time to stop mandatory staffing "dead in its tracks." He argued that nurses and hospitals need to be more "nimble and flexible" to control costs and cope with health reform. "It is difficult to imagine how nurses can possibly meet these challenges when employers are locked into inflexible staffing arrangements," he wrote in the journal Nursing Economics.

Even in California, critics say the staffing ratios had no scientific basis. "[They] were the result of political compromise," said Jan Emerson, spokeswoman for the California Hospital Association. "This honestly had absolutely nothing to do with any science that showed ratios were the right direction for health care."

Emerson said California hospitals have adapted to the staffing rules "because it's the law."

But she disputes the claims that the staffing ratios, introduced in 2004, deserve credit for improving patient outcomes. During the same period, she said, the hospitals were engaged in major patient-safety campaigns, so it's hard to know what role the ratios played.

What the new rules have done, Emerson said, is add to waiting times in emergency rooms. A nurse with four patients can't take any more, she said, even if three are waiting to be discharged and need no attention.

Nor can the rules be bent, say, if there's a multiple car crash, she said. In some cases, she said, hospitals have to send ambulances elsewhere to stay in compliance with the ratios.

The desired ratios

The staffing ratios, as proposed in Minnesota, call for one nurse for every four to six patients in the least critical situations; and in the most extreme cases, two nurses for every patient. Those ratios would stay the same day or night, Mason said, even though most hospitals staff lighter on evenings, nights and weekends.

In some cases, the ratios wouldn't make a dramatic difference, Mason said, because hospitals use similar guidelines to make staffing decisions now. They basically assign nurses according to a grid or matrix, which takes into account how sick the patient is, and how experienced the nurse.

The only difference, Mason said, is that "they're not always enforced." If someone calls in sick, she said, other nurses simply pick up more patients, and sometimes they're stretched so thin that they can't get a bathroom break.

In the Twin Cities it would cost about $250 million to hire enough nurses to meet the union's demands, said Schriner, the hospital spokeswoman.

The nurses argue that they'll save money by improving care, but Schriner said that's wishful thinking. "The implication from the union is that the hospitals could just pass these costs along to our payers," she said. "That's from a bygone era." The hospitals are under pressure to cut costs, she noted, and Medicare "hardly covers our costs right now."

At the same time, she said, "we have among the best quality of care in the country in how our staffing works right now." The hospitals have proposed their own staffing solution, giving managers the right to transfer or "float" nurses where they're most needed. But the union has balked at that.

Working together

The problem is that both sides should be working together to find a solution, said Alice Swan, associate dean of nursing at St. Catherine University in St. Paul. It's important, she said, "any time when you're feeling overworked and under-appreciated, if you have someone that really listens and acknowledges that."

But she said there may be other ways to ease the workflow, short of hiring more nurses. That might mean asking how they can reorganize the work so they're not perpetually overwhelmed.

"The key thing is, in a time of change you've got to have a lot of dialogue," she said. "Everybody wants a good outcome. They want satisfied patients. They want safe patients. They want patients that get better and go home."

And, she said, "They want satisfied nurses."

Maura Lerner • 612-673-7384

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