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Would mandating nurse-to-patient ratios make Michigan hospitals safer?

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Michigan hospitals need another 8,500 nurses right now, according to the state's hospital association. The shortages are leading to long waits for beds, with some patients spending hours or even days in the ER.

There’s one thing everyone in Michigan’s health care system agrees on: the nursing shortage has reached desperate levels.

Hospitals are understaffed across the board, with a shortage of about 27,000 positions overall, said Laura Appel, a VP with the Michigan Health and Hospital Association. That’s about 10% of statewide hospital staffing, and 8,500 of those unfilled jobs are nurses.

“If 8,500 nurses suddenly moved to Michigan, we would hire all of them,” she said. “[Hospitals] are trying to do everything they know how to, to take care of the patients the way they need to be taken care of, and yet deal with these shortages.”

But the impact of those shortages falls mainly on nurses and their patients, said Jamie Brown, the president of the Michigan Nurses Association and a registered nurse for nearly 20 years.

“Nurses are taking care of more patients than they have been in recent years: on a med-surg [general inpatient] unit, they are taking care of up to eight patients, when it should be no more than four. And 42% of nurses have said that they know of a patient death due to understaffing in the last year,” she said, citing a recent MNA poll of some 400 nurses around the state.

How mandatory ratios would work 

But the industry and the unions are split over legislation in Lansing that would mandate nurse-to-patient ratios. Called the Safe Patient Care Act, it would require 1-to-1 ratios in the ICU, and as many as six patients per nurse in stabler departments like maternity wards.

It would fine hospitals up to $25,000 for each violation.

“It's a matter of life and death,” said Brown. “Every person is going to be in a hospital at some point in their life. And they need to know that they are going to survive that hospital stay, because there is enough nurses at the bedside to take care of them…So this is really to protect the public, and it's a public health crisis right now.”

But the hospital industry has lobbied against similar proposals for years, arguing they make it impossible for hospitals to be flexible and respond to needs in real time. The results could be dangerous, Appel argued.

“Let's say that right now, you have a hospital with 75 beds,” she said. “Under the ratios, you only have enough to staff 60 beds. Then you're going to wait longer [in the emergency department] to get a bed. And delivering inpatient services in the ED is less positive for patients.”

Some nurses in administrative positions also worry the ratios “will not be without consequence” for the quality of patient care.

Douglas Dascenzo is the regional chief nursing officer at Trinity Health Michigan, which operates several hospitals in southeast Michigan. He’s also a board member of the Michigan Organization for Nursing Leadership (MONL) which collaborates with the state hospital association.

Mandatory ratios would require short staffed hospitals to make tough decisions, he said.

“It’s difficult to, for instance, pull a nurse from labor and delivery, and have them work in the emergency department,” Dascenzo said. “That would not be wise. It would not be safe. And so it puts the nurse in a position that makes them feel vulnerable. And that potentially places a patient in a very vulnerable situation.”

Hospitals argue the needed nurses “simply don’t exist”

The debate also centers around a fundamental question: is this a nursing shortage, or are nurses simply unwilling to work in the current conditions? The union argues as many as a third of Michigan registered nurses with active licenses aren’t working in the state, citing the Michigan Department of Licensing and Regulatory Affairs and the U.S. Bureau of Labor Statistics.

“We have more than 50,000 licensed Michigan licensed nurses that are currently not working in the profession, because of the conditions the hospitals are putting us under,” Brown said. “We are not able to take care of our patients safely…It’s driving nurses away.”

A recent University of Michigan poll of more than 9,000 nurses across the state found nearly 40% plan to quit within a year, with a majority citing inadequate staffing as their chief complaint. The youngest nurses were the most likely to say they plan to leave, raising concerns that even if the “pipeline” to train new nurses improves, it could just lead to a revolving door situation.

But industry leaders say that doesn’t account for how many of those with active licenses may have already retired or are about to retire. A survey from the Michigan Public Health Institute last year suggests more than a third of Michigan nurses are over the age of 55, while another 10% of RNs are part time and may not want to move to full-time work.

“I can't make people out of nothing,” Appel said. “We do want to have more nurses on our staff. Everybody wants that. But I can't simply say we’re just going to just conjure people up. And I don't think staffing ratios will make that happen.”

Yet the Nurses Association believes mandatory staffing legislation will fare better in the state Legislature than it has in the past. Already, more Democrats (who have control of the state House, Senate and governor’s office for the first time in decades) have signed on as co-sponsors, Brown said.

“Post pandemic, the public has seen the amount of trauma we've gone through… We have days where we send nurses in to talk to their lawmakers, and tell them what it's really like in the hospitals. Because we're the experts at the bedside there, we're the ones taking care of the patients. And when the hospital association sends people, they are sending in executives that are out of touch, and haven’t been at the bedside to know what it's like taking care of the patients.”

Lessons from California’s mandatory staff ratios 

Both proponents and opponents of mandatory nurse ratios point to California, where similar legislation went into effect in 2004.

“California has had staffing ratios for almost 20 years, and [has] the same sort of type of [nurse] shortage that we do,” Appel said. “It hasn't been the thing that saved them from having the same type of nursing shortage that places like Michigan and other states have.”

But it’s not quite that simple, said professor Joanne Spetz, the director of the Institute for Health Policy Studies at the University of California, San Francisco. Spetz has spent years researching the impact of the state’s mandatory staffing law. Yes, California has a nursing shortage, Spetz said: the state is projected to be about 40,000 nurses short, according to a study she co-authored.

“Forty thousand nurses sounds like a lot, [but] California has approximately 400,000 [licensed] nurses. So in terms of percentages, it's actually not a crazy difference,” Spetz said.

What researchers have also found, Spetz said, is nurses in California are happier, better paid, and have lower burnout rates after the mandatory staffing ratios went into effect. Nurses also “reported consistently better quality of care,” according to a 2010 study.

But did patient outcomes improve as a result of the mandated ratios? “It was really a wash,” Spetz said. “There was no systematic improvement in patient outcomes. There also wasn't any systematic worsening, but there was no systematic evidence of things getting better.”

That could be for several reasons, Spetz said. Measuring patient outcomes is tricky: do you do it based on the number of medication errors before the mandatory ratios vs. after? What if nurses in the pre-mandated ratio era were so understaffed, they didn’t have time to report all the medication errors?

It’s also possible that hospitals cut staffing in other areas, in order to be able to hire more nurses to meet the required ratios, Spetz said. “It could be that if you lay off a bunch of your aides in order to have more money to hire [nurses], you are now missing things that were really important that the aides were doing…So you may have had some diminishing benefits because of that.”

The increase in staffing levels also varied widely, Spetz said.

“The data suggests that the hospitals that were really badly staffed were forced to come up to a better level of staffing. And the ones that were doing really well [even before the mandated ratios] didn't really change very much at all. They kind of stay pretty stable. So you know that there may have been more of an equalization of outcomes…There might have been really poorly performing hospitals that did better.”

While the proposed legislation in Michigan would only allow hospitals one-two years to prepare before the ratios take effect, California had a four-five year “ramp up” process, Spetz said. The state simultaneously poured millions into statewide education and training initiatives.

“It took a year or two for some of the nursing schools to really do all the planning they needed to grow their enrollment,” she said. “And then it takes another two to four years for those nurses to hit the street.”

If Michigan does mandate nurse-to-patient ratios, then lawmakers also have to invest more in improving the supply of new nurses, Spetz said. “We know that it can be beneficial to establish those kind of requirements, but you can't do it as a single silver bullet. There are multiple things that need to happen in order for it to be successful.”

Kate Wells is a Peabody Award-winning journalist currently covering public health. She was a 2023 Pulitzer Prize finalist for her abortion coverage.
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