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Battle lines drawn in debate over nurse-to-patient ratios

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Neil Eicher, vice president of government relations and policy, New Jersey Hospital Association.
Neil Eicher, vice president of government relations and policy, New Jersey Hospital Association. - ()

Even as the New Jersey Legislature waits to consider bills setting minimum nurse-to-patient ratios at hospitals and nursing homes, the battle rages on.

Trade groups such as the New Jersey State Nurses Association and New Jersey Hospital Association are dead set against Senate bills 989 and 1612, which seek to implement ratios. They say a nursing shortage in the state, as well as the prohibitive cost of hiring additional nurses, make meeting the bills’ requirements unfeasible.

But groups such as 1199 SEIU United Health Care Workers East, the union that represents nurses in the state, and NJ Safe Ratios, a grassroots coalition of roughly 3,500 New Jersey nurses, are pressing for passage of the legislation. They contend inadequate nursing staffs are leading to poor outcomes and dangerous conditions for patients.

S989, sponsored by state Sen. Joseph Vitale, D-19th District, would require among other things hospitals and ambulatory surgery centers to have one nurse for every five patients at a medical/surgical unit; one nurse for every two patients in a critical care unit; and one nurse for every four patients in both an emergency department and intermediate care unit.

According to the legislation, there now is an average of one nurse to every 10 patients in hospitals, which it says is inadequate and “can result in dangerous medical errors, patient infections, and increased injuries to patients and caregivers.”


S1612, sponsored by state Sen. Brian Stack, D-33rd District, was passed by the Senate in a 21-15 vote, but a vote in the Assembly has been put on ice until the fall session. If passed, the bill would require the state’s 826 nursing home facilities to have one certified nursing assistant for every eight residents during daytime hours and another for every 16 patients during nighttime hours, among other requirements.

Both advocates and opponents of the bills point to California, which in 2004 became the first state to enact nurse-to-patient ratio requirements. Studies of how hospitals there fared after the passage of the bill offer mixed results.

A 2011 study by Health Services Research, for example, showed that increased staffing of nurses put substantial financial pressure on California hospitals in the year after legislation was enacted. But a 2010 study using cross-sectional data from hospitals in California, New Jersey and Pennsylvania concluded hospitals with staffing levels consistent with those mandated in California had significantly better nurse-reported quality and lower levels of mortality and failure-to-rescue incidents.

Benjamin Evans, a registered nurse and head of the NJSNA, said alternative approaches are available to hospitals that would not be able to afford hiring more nurses.

“There are two schools of thought about this,” Evans said. “There’s the ‘throw bodies at them’ model, which is to hire more nurses, and then there’s the model in which you match the acuity of the patient with experience level of the nurse, which we’re advocating. California has adopted the ‘throw more bodies at them’ model, but studies have shown that it’s not effective.”

Evans said his group estimates meeting the staffing requirements of S989 will collectively cost hospitals in the state an additional $65 million.

“Hospitals are financially tight to begin with, so that calls into question the feasibility of this bill,” he said. “The other issue that is not considered is that when you do set a ratio, the nurse cannot function at the highest level because ancillary staff, such as food transporters and patient transporters, would have to be reduced. Nurses would have to pick up those functions.”

In testimony before the state Senate in May, Theresa Edelstein, vice president of post-acute care policy at the NJHA, said that if S1612 were to be passed, it could force many nursing homes out of business.

NJHA estimates nursing homes in the state would have to hire roughly 3,000 additional certified nursing assistants at an annual cost of approximately $95 million to comply with the bill.

“Finding the CNAs to meet the ratio prescribed in the legislation is simply not feasible at this time with the direct-care staffing shortage that the nation is facing. There’s a national shortage of CNAs – that’s been well documented,” Edelstein said.

Neil Eicher, NJHA’s vice president of government relations policy, said adding additional nurses will not increase quality of care at hospitals but will put undue financial strain on hospitals.

“We fight back rather strongly against the argument that just throwing a nurse onto a floor as a statistic will improve quality of care,” Eicher said. “Our research shows that when you employ a team-based and evidence-based approach to care, you do a better job at producing the outcomes that you want. We need to figure out how to build a team of personnel that ensures the highest quality of care before discharge. That’s our main argument. We don’t think a state-mandated ratio of nurses-to-patients is the way to get to better care.”

He added: “This bill, if enacted, would be financially detrimental to hospitals. I do worry about the amount of nurses in the pipeline, because this ratio would also apply when nurses are on vacations and on breaks – you always have to make sure that the ratio is covered. Also, some nurses need specialized training for certain areas in the hospital. You might have a nurse that is right out of school, but she may not be the best nurse for the emergency room. Hospitals would rather have a nurse take a few years of training to get specialized in that type of care, rather than just throwing a nurse on to the floor because of a mandated ratio.”

Kate McLaughlin, one of the leaders of NJ Safe Ratios and herself a registered nurse, contend the legislation’s critics are aligned with hospital executives even though better staffing ratios could lead to safer conditions.

“Members of the NJHA are former board members at hospitals and don’t speak for bedside nurses in the state,” McLaughlin said. “When I speak with all of our nurses, we all say that there are not enough nurses to take care of the patients in this state. Our No. 1 goal is to take care of the patients and care to improve their outcomes. What’s happened in New Jersey hospitals is that care is not being administrated sufficiently.”

Hospitals would benefit financially in the long run because a higher ratio would lead to more nurses keeping their jobs, and would cut down on incidents of preventable harm being done to patients, she said.

“There are nurses in this state that see the unsafe staffing conditions,” McLaughlin said. “Many of them are working 12- to 13-hour shifts without break and are finding that they want to go back to school to get an advanced nursing degree in order to not be in that environment. California had implemented a safe ratios law in 2004, and in 2005, hospitals were able to recover more of their health care dollars due to length-of-stay issues.

“The costs of lawsuits due to falls in hospitals because when you have more nurses who aren’t exhausted, you can avoid preventable harm and falls. The nurse vacancy rate dropped to less than 5 percent in California hospitals since the safe ratios law was passed because the law helped hospitals in the state retain more of their nurses. When nurses leave, it costs a hospital, on average, $85,000 to train a new nurse, and that’s outside of student debt.”

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Vince Calio

Vince Calio

Vince Calio covers health care and manufacturing for NJBIZ. You can contact him at vcalio@njbiz.com.

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