Legislation Mandating Nursing-Patient Ratios?

I asked Nurse Leaders. Here is what they had to say

Photo by Hush Naidoo on Unsplash

The Illinois Legislature is considering legislation mandating nurse-to-patient ratios. Initially advocated by the Illinois Nurses Association, the proposed legislation would mandate that no more than 4 patients be assigned to one nurse. In the ICU and other units, the ratio would be less.

The argument for having a lower nurse-to-patient ratio is patient safety:

Paul Pater, with the Illinois Nurses Association, said high patient-to-nurse ratios are dangerous for everyone.
“Hospitals and administrators take advantage of our empathy and sense of duty to our patients to force unsafe situations on the nurses of Illinois in a misguided attempt to save money,” Pater said.
According to the INA, lower ratios reduce the likelihood of death, injury and readmission among patients. They also decrease the likelihood of workplace violence, illness and injury for nurses.
As an ER nurse, Pater said he’s regularly handling up to eight patients at a time — and his experience is not unusual.

As a doctor working in the ICU, I am used to nurses having no more than 2 patients assigned to them (for the most part), and it is great for patients. So, it would make sense to mandate that lower nurse-to-patient ratios for all hospital units.

Not so fast, say Illinois Hospital executives:

“There is no conclusive evidence that these one size fit all nurse staffing ratios actually improve patient outcomes or the quality of care,” said A.J. Wilhelmi, with the Illinois Hospital Association.
He said not every hospital has the same resources, and the legislation does not include funding to hire more nurses.
“About 42 percent of our hospitals are currently operating at a negative or very thin margin of less than two percent,” he said.
Wilhelmi said the plan would drive up healthcare costs by more than $2 billion a year — which would be especially burdensome for safety-net and critical-access hospitals, like Touchette Regional Hospital in Centreville, where Sulbrena Day is the CEO.
“Touchette is highly dependent upon the Medicaid program, which has historically and currently been a low and slow payer,” she said. “Two-thirds of our patients are covered by Medicaid. With the expansion of Medicaid managed care, our financial challenges have only worsened.”

I thought this debate was interesting, and so I asked a number of current Illinois Hospital Nursing leaders to see what they thought. Their views were right on line with that of the Illinois Hospital Association.

“What if a nurse needs to go to the bathroom? Or on break for lunch,” asked a Nurse Manager. “What do we do then? We would be breaking the law by having another nurse look after them for even 5 minutes.” And under the proposed legislation, hospitals could be fined up to $25,000 for violations of the law.

I also asked Mary Shilkaitis, RN — Chief Nursing Officer for Rush Copley Medical Center in Aurora, IL — about her views of the proposed legislation. Here is what she wrote to me in an email:

I oppose mandated ratios for the following reasons:
“Hospitals and their nurses are most qualified to make staffing decisions, and it is imperative that we have the flexibility to make resource and staffing decisions based on the patient care needs. One size fits all mandated ratios do not improve quality of care outcomes.
No other state, except Calif., [has] mandated ratios. These are unfounded mandates and could threaten critical access and safety net hospitals. At Rush Copley, we have a Nurse staffing committee at which we discuss nurse staffing. Our team meets monthly and can document great outcomes.”

I agree with the Nurse Leaders with whom I spoke.

The idea is noble. In an ideal world, there should be one nurse for one patient. We don’t live in an ideal world.

We do not have an unlimited number of nurses (or doctors, either). As a result, I think it should be left to nurses on the ground — not lawmakers in Springfield — to determine the safe number of patients assigned to a nurse. Sometimes, no matter how good the idea, things mandated from on high end up doing more harm than good. The same may happen, I fear, with this proposed legislation.

The opinions expressed in this post are my own and do not reflect those of my employer or the organizations with which I am affiliated.