Battle Continues Over Nurse-to-Patients Ratio as Measure Advances

Andrew Kitchenman | December 11, 2015 | Health Care
Nurses cite patient safety while hospitals say they need staffing flexibility

New Jersey Hospital Association President and CEO Betsy Ryan (left) testifies about proposed bill addressing nurse-patient ratios.
Labor unions representing the state’s nurses have won a key legislative skirmish over reducing the registered nurses-to-patients ratio allowed in hospitals and ambulatory surgery centers.

But it remains very uncertain whether the unions will win the long-running battle over a bill the measure, which they say would improve patient safety but which hospital executives contend would make it harder for them to determine how many nurses and other health workers are needed to meet patients’ needs.

The bill, A-647/S-1183, advanced further than it ever has before when the Assembly Health and Senior Services Committee voted to release it in a party-line 8-4 vote yesterday.

But even if the entire Legislature passes it during the closing weeks of the session, it’s doubtful that that Gov. Chris Christie would sign it.

And it remains controversial even among nurses, with opposition from a group representing nurse managers.

In any event, the bill has gained key legislative allies who could one day make New Jersey the second state in the country – after California — to enact stricter nurse-to-patient staffing ratios, even though it may have to wait for a future governor.

Hospital executives and those responsible for assigning nurses are vehemently opposed to the bill, which they say would lead directly to hospitals eliminating the jobs of nurses whose positions require less training than registered nurses, as well as other non-nursing positions, in order to hire more RNs.

The bill would overhaul regulations last revised in 1987. Mandates in the bill range from one patient per nurse in surgery to six patients per nurse in a nursery with healthy babies.

Health Professionals and Allied Employees President Ann Twomey tied the bill to research indicating a link between having fewer patients per RN and improved outcomes for patients.

“This is an issue that is No. 1 for every nurse in the state of New Jersey who works in a hospital,” said Twomey, who leads the largest nurses union in the state.

A New England Journal of Medicine paper cited by the unions found that staffing ratios below certain targets for each unit of the hospital was associated with death rates for patients rising between 2 and 7 percent.

The HPAE has also claimed broad public support for lower nurse-patients ratios, citing a HPAE-commissioned poll.

Avery Johnson, who as a “charge” nurse gives nurses their assignments at Monmouth Medical Center, said that it’s a complex task, drawing on the experience of each nurse, the needs of each patient, and other factors. Boiling it down to state-mandated maximum number of patients per nurse would leave hospitals without the ability to adjust for patient needs.

It was a point that New Jersey Hospital Association President and CEO Betsy Ryan emphasized. She said it would cost the state’s hospitals $159 million to hire enough nurses to meet the bill’s mandates.

“We need the flexibility to look at the patient, the ebb and the flow, the experience of the patient, the acuity of the patient … to determine the best staffing ratio,” Ryan said.

In an attempt to allay some of these concerns – and to head off the possibility that the measure might be blamed for any hospital closings — the bill’s sponsors amended it to allow for waivers of the rules. One change would allow the state Department of Health commissioner to waive the mandate for hospitals that are re financially distressed, while another would waive the mandate in the event of unforeseen emergencies.

Eileen Horton, representing the Organization of Nurse Executives, added said the mandates would hinder hospitals’ ability to adjust to broader changes in healthcare.

“We don’t know what it’s going to look like in five or 10 years, but we do know that flexibility is going to be the key,” said Horton, senior vice president of hospital administration for Capital Health System in Hopewell.

Elfrieda Johnson, board president of JNESO (the second-largest New Jersey nurses’ union), countered the argument that mandating stricter staffing levels would ignore patients’ individual conditions.

“As any nurse will tell you, patient acuity plays an important role when allocating our time throughout the workday,” with all nurses giving more time to sicker patients, said Johnson, a nurse at Saint Michael’s Medical Center in Newark.

Perhaps the most adamant bill opponent was Assemblywoman Nancy F. Munoz (R-Morris, Somerset, and Union), who has worked as a registered nurse.

Munoz argued that the bill would force RNs to do work that has long been performed by other workers, as they are laid off to make room for more RNs.

“This bill will set nursing back 40 years,” she said.

Assemblywoman Nancy J. Pinkin (D-Middlesex), who has also worked as a nurse, andAssemblywoman Shavonda E. Sumter, an administrator at HackensackUMC Mountainside hospital, supported releasing the bill.

However, Sumter added that she wants to make sure that it won’t too difficult for hospitals to declare the unforeseen emergency that would give them flexibility in assigning nurses. Sumter also said she was concerned that the declaration of financial distress needed to receive a waiver might send a message that would concern consumers.

But bill supporter Assemblyman Daniel R. Benson (D-Mercer and Middlesex) said safe staffing levels and quality health outcomes are “not a zero-sum game.” He noted that some hospitals have had good outcomes after negotiating with their unions and enacting maximum patients-per-nurse ratios similar to those called for in the bill.

Assemblyman Herb Conaway Jr. (D-Burlington), a doctor and the committee’s chairman, said legislators must balance the “health of the hospital system,” with the “health of the nurses.”