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Op-Ed: Staffing Ratios — The Wrong Formula for Patients and Nurses

Treating nurses as numbers rather than as the trained professionals they are, devalues them

aline holmes
Aline Holmes, senior vice president of clinical affairs for the New Jersey Hospital Association

My nursing career has spanned many decades. I’ve served in the Navy on a hospital ship, cared for patients in hospital ICUs and emergency departments, led healthcare quality and patient-safety programs, and earned my doctorate degree in nursing practice from Rutgers University. Patients have always been my No. 1 priority — followed by my fellow nurses in a very close second.

So it was eye-opening to hear from fellow nurse Peter Buerhaus, who spoke recently at a conference at the New Jersey Hospital Association on the nursing workforce of the future. Buerhaus is a professor of nursing and also leads the Center for Interdisciplinary Health Workforce Studies at Montana State University. With legislation pending in Trenton that would mandate rigid nurse ratios in hospitals, Buerhaus says such mandates have no proven connection to improved patient care. Not only that: They devalue nurses.

Buerhaus says the deterioration of nurses’ standing under ratios happens in numerous ways:

  • Professionally, nurses become a number in a ratio, rather than respected clinicians who should be allowed to practice using their professional expertise instead of constrained under a hard-and-fast formula determined by legislators.

  • Nurses’ contributions lose value under a simple formula of productivity. Ratios freeze the quantity of nurses and decrease the flexibility to allow the unit’s high performers to work to the full potential of their skills. There is no conclusive evidence that ratios improve patient outcomes, but there is plenty of documentation that ratios increase healthcare costs. If a nursing unit achieves the same results at greater costs, that’s less value at a time when patients expect quality care that is affordable. In other words, “patients would bear increased costs, yet receive no benefits,” said Buerhaus. The inevitable decline in healthcare value and efficiency isn’t the fault of the nurses; it’s the result of the ratio formula they work under.

  • And perception-wise, ratios send a message that nurses are one-size-fits-all. For a profession that ranks consistently as the most trusted and admired in the public eye, that’s demoralizing.

Faith in nurses

I have faith because nurses are problem solvers, and this recent conference also featured several New Jersey nurses who had proactive, constructive ideas for improving the workplace to promote the very best in patient care. Many of them are working under a pilot project of the Organization of Nurse Leaders - New Jersey, which is developing a model of nurse empowerment giving staff nurses a greater voice and decision making roles in their workplaces.

The initiative includes staffing committees to help determine the right level of staffing and nurses’ input into how the budget is allocated in their unit. I’ve heard examples in which the nurses decided collectively that they didn’t need another nurse on staff; they wanted a couple more aides to fill more routine roles or added security to ensure employee and patient safety. I can’t see that happening under a ratio format.

These young staff nurses sharing their insights said it better than this long-timer ever could:

“We’re all looking for a healthy environment for staffing, and this has brought that to us,” said an operating room nurse from Jefferson Stratford Hospital. “If we’re not healthy and happy, our patients won’t be healthy and happy.”

“This is a great opportunity to think outside the box,” added an emergency department nurse from Capital Health Medical Center in Hopewell.

Learning from the Left Coast

New Jersey should learn from the experience in California, the first state to enact a ratio law in 2004. In the ensuing 14 years, there has been no evidence of a significant increase in healthcare quality in the state, nor any study that identifies the “right” ratio, said Buerhaus. Initially, nurse satisfaction scores increased — and that’s important — but Dr. Buerhaus said further study showed that satisfaction scores increased at the same time nationwide, so it’s impossible to say whether California’s increase was truly the result of its ratio law.

A larger problem of the ratio debate, according to Buerhaus, is that it diverts the attention of nurses, healthcare executives, policymakers, and other leaders from much more pressing concerns in healthcare. They should be focused on the future, he said, rather than debating an outdated mode of staffing. More critical issues that demand attention include the uneven growth in the supply of RNs (with each coast, including New Jersey, especially vulnerable to a future shortage) and the healthcare needs of an aging population.

That focus — looking forward, not backward — is the right one for both New Jersey nurses and the people they care for. Here’s one more insight that defines the essential value of nurses as professionals, not numbers. This, from a critical-care nurse at Lourdes Health System: “Every nurse is a leader, and we all must work together on one goal — patient and staff satisfaction.”

Aline Holmes, DNP, RN, is the senior vice president of clinical affairs for the New Jersey Hospital Association and program coleader of the New Jersey Nursing Initiative, a Robert Wood Johnson Foundation program.

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