Expand Nurse Staffing Ratio Laws, Union Leaders Tell Senator

Laws mandating nurse-to-patient ratios would help remedy unsafe staffing levels at hospitals, nursing union leaders testified during a field hearing of the Senate Health, Education, Labor, and Pensions (HELP) Committee on Friday.

Despite criticism from his ranking member, committee chair Bernie Sanders (I-Vt.) hosted the hearing solo near the Robert Wood Johnson University Hospital (RWJUH) in New Brunswick, New Jersey, where 1,700 nurses have been on strike since August.

Nancy Hagans, RN, president of National Nurses United and of the New York State Nurses Association (NYSNA), said understaffing can lead to preventable medical errors, avoidable complications, and even patient death, and said a growing number of nurses refuse to work in hospitals because the level of understaffing makes them feel unsafe. She recalled working on a surgical unit where the staffing ratio was one nurse for 18 patients.

“I’ve been in situations where I know if I had fewer patients, I might have been able to save a patient’s life. It is the worst feeling you can imagine,” said Hagans.

Generally, one nurse for every four patients is the recommended ratio. Hospitals with a 1:8 ratio experience five additional deaths per 1,000 patients than those with a 1:4 ratio, according to the NYSNA website. Ratio laws in the only two states that have enacted them — California and Oregon — include requirements that differ by unit or patient acuity.

Hospitals often argue that an overall shortage of nurses makes it difficult to meet safe staffing requirements, but Hagans flatly disagreed: “That’s a lie.” She pointed out that nationally, 1.2 million active licensed nurses were not employed in 2022, while in New Jersey alone, there are 56,000.

“There is no nursing shortage. There is a staffing crisis,” Hagans argued, emphasizing that the solution is safe staffing ratios.

‘Now New Jersey’

Sanders voiced support for the striking New Jersey nurses: “All they are asking for is for this very large, nonprofit hospital chain to mandate the same nurse-patient ratios that the state of California mandated some 20 years ago.”

In a statement, he said that Robert Wood Johnson hospital management has spent “some $90 million on traveling nurses, but somehow could not afford to sign a fair contract with their own nurses to increase patient safety.”

No federal mandates regulate the number of patients that registered nurses can care for simultaneously, according to a National Nurses United report. In March, Sen. Sherrod Brown (D-Ohio) and Rep. Jan Schakowsky (D-Ill.) reintroduced the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act, federal legislation modeled after California’s law, which went into effect in 2004.

In August, Oregon became the second state to mandate nurse-to-patient ratios, and the New Jersey legislature introduced a safe staffing ratio bill last year.

“Chairman [Sanders], with your help we’ll be able to say, ‘First California, then Oregon, now New Jersey,'” said Debbie White, RN, president of the Health Professionals and Allied Employees (HPAE), a labor union in New Jersey and Pennsylvania.

White argued that safe staffing ratios could improve retention and the overall working environment. In a 2022 HPAE survey of 512 New Jersey-based nurses, 95% of those with 0-5 years of experience responded that they’re likely to leave soon, with “poor staffing” and “burnout” cited as the top two reasons, she said.

Hospitals will “never agree to safe staffing on their own,” she said. “We need laws to force hospitals to staff safely.”

Sanders noted that Mark Manigan, president and CEO of RWJ Barnabas Health, and Alan Lee, president of RWJUH, were invited to the hearing but declined to attend. In a written testimony for the hearing, Manigan said: “I am troubled by the inaccurate and misleading assertions put forth by the Chairman in recent public comments. Unlike a significant number of healthcare organizations in the Northeast and around the country, RWJUH has safe staffing guidelines in place that are derived from national, evidence-based practice by peer academic medical centers,” he said.

Moving Forward

Patricia “Polly” Pittman, PhD, of the Milken Institute School of Public Health at George Washington University in Washington, D.C., explained that the three general strategies commonly enacted to improve working environments are:

• Mandating nurse-to-patient ratios
• Requiring staffing committees to include bedside nurses
• Public reporting of staffing levels

However, research has indicated that only ratios actually boosted staffing, she said, stating that “fixing unsafe staffing in U.S. hospitals is an essential first step — one that would not only improve patient outcomes, but will contribute to the health and the retention of hundreds of thousands of nurses.”

Pittman also called for other reforms, such as the inclusion of both nursing staffing-hours per patient-day and nurse turnover rates on the CMS Hospital Care Compare website. She said including these measures may eventually lead to their inclusion in certain agency hospital rewards programs.

She also argued that hospitals need to rethink how nurses are paid. Currently, nurse services are wrapped into room and board charges, under labor, but some experts have floated the idea of nurse-hours per patient-day being explicitly listed as a component of diagnosis-related-group payments.