WA legislators weigh mandating nurse-to-patient ratios in hospitals

Nurses across Washington state, and the country, are experiencing the stress of short staffing in hospitals.

It’s a problem that workers say pre-dates the pandemic. But when Covid-19 hit, pre-existing issues only got worse.

One solution currently being proposed in the Washington State Legislature is the creation of nurse-to-patient ratios, requiring a cap on the number of patients a hospital nurse can care for at any given time.

A similar bill failed in the legislature last year.

The most recent bill, scheduled for a hearing in the Senate Ways and Means committee this week, differs slightly.

Among other things, instead of mandating specific staffing levels, it calls for the state Department of Labor and Industries to develop and implement minimum staffing standards for registered nurses and nursing assistants in all units in a hospital, taking into account stakeholder input.

If passed, the bill would see ratios in place starting in mid-2027.

As they consider the measure, lawmakers are wading into a decades-old debate in the health care industry.

While all parties agree there’s a staffing crisis in the state’s health care system, nursing unions and hospital leaders are split on how best to address it.

Missed breaks, ethical dilemmas, and burnout

Getting a 15-minute break, or going to the bathroom, during a shift at work may not seem like a big deal. But for Jomay Ruiz, a labor and delivery nurse, it is.

Ruiz started her nursing career in Washington state nearly six years ago.

Over time, she said, understaffing became more common. Then the pandemic hit and things intensified.

"And we saw that in different ways," Ruiz said. "That means I would have to take care of more than two or three moms at a time. That means I wouldn't have breaks in like 12 and a half hours."

That meant running between patients in labor, worrying that something might be missed, and being relieved at the end of a shift when nothing bad had happened. But there's more to the stress than just extra work and missed breaks.

Ruiz said she and her colleagues also feel an ethical dilemma when they’re short-staffed.

“I can no longer give this patient ... beyond basic care,” Ruiz said. “The care that I'm giving is just not fair. I think they deserve more."

This is the kind of stress that contributes to burnout.

Eventually, Ruiz left her job in Washington to join the swelling ranks of travel nurses. She figured she’d make more money, even if working conditions didn’t improve.

But when Ruiz took a contract in California, she was pleasantly surprised. She was getting breaks again, she was looking after fewer patients, and she felt she could do her job adequately and started enjoying it again.

“I think that was all due to just having an adequate number of nurses on the floor," Ruiz said.

Ruiz credits that to a law implemented nearly 20 years ago in California establishing the kind of nurse-to-patient ratios being considered in Washington.

The ratios aren’t a silver bullet and things in California have been far from perfect during the pandemic. Nurses still dealt with staff shortages and hospitals broke the mandated ratios.

But Ruiz said her experience there was far better than the conditions she dealt with in Washington. So much so, that when she moves back to be closer to loved ones, Ruiz said she’ll leave her role in bedside nursing.

And she’s not alone.

A recent poll of 1,200 health care workers in Washington, done by health care unions, shows that nearly half say they’re likely to leave the profession in the next few years, with most citing short staffing as a primary reason.

Proponents of implementing staffing ratios in Washington say these measures could help decrease burnout, keep nurses like Ruiz at the bedside, and improve the quality of care.

They say health care workers have hit a breaking point, and ensuring that they don’t have unsafe patient loads is one way to help address the crisis.

Currently, hospitals in Washington are required to have staffing committees tasked with creating staffing plans. But workers say those plans aren’t always followed or adequate.

What does the research say about staffing ratios?

As Washington lawmakers wade into the debate over nurse-to-patient ratios, the test case they can look to is California.

While many states are currently discussing similar measures, California remains the only state in the country to have implemented staffing ratios for all units in a hospital.

Ratios have been in place there since 2004. Research shows the legislation resulted in increased nurse staffing in the state.

"Patients in California hospitals, compared to patients in hospitals in the rest of the country, on average, get two to three more hours of [registered nurse] care a day as a result of that legislation," said Linda Aiken, professor of nursing and founding director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania.

Consensus isn't universal on the impacts of California's ratios. But there’s ample evidence that shows having more nurses on staff is associated with positive patient outcomes, like lower mortality, better patient satisfaction, and better job satisfaction for nurses.

Aiken said ratio laws aren't meant to cap staffing or dictate the ideal nurse-to-patient mix, but to set a minimum. Roughly half the hospitals in California were already staffed above the required levels when the law went into place, she added.

It was the most poorly staffed hospitals that made the biggest improvements, including many that typically serve low-income and minority communities.

"The safety net hospitals in California, which were the worst staffed hospitals in the state, had to come up to the minimum standard. And they did. And that was just a huge improvement in hospitals for the poor," Aiken said.

Fears of limited access and rigid standards

While many nurses and health care unions support the idea of ratios in Washington, hospital leaders strongly oppose the approach, saying it’s not the way to address the current staffing challenges.

“What this boils down to is really a cap on the number of patients that can be served in a hospital at any given time, based on the number of nurses who are working that shift,” said Ashlen Strong, senior director for government affairs with the Washington State Hospital Association.

Strong and other opponents say imposed ratios could result in bed closures and would stifle flexibility and innovation in staffing models.

They say health care is dynamic and things like how sick patients are, how experienced a nurse is, and what’s happening in other units in the hospital at any one time should factor into the way staffing is arranged, instead of having prescribed ratios at all hours of the day.

The state’s hospital association recognizes that hospitals are a tough place to work currently, and leaders say they back other solutions to help address staffing challenges. Among other things, they’re asking the legislature to help address the number of patients who no longer need hospital care but continue to take up beds due to difficulties discharging them to other settings.

They’re also backing bills aimed at recruitment, retention, and development of the health care workforce, as well as looking at innovative staffing ideas outside the legislative environment.

But hospital leaders worry that nurse-to-patient ratios will only exacerbate issues at a time when hospitals are struggling to hire enough nurses.

“Creating a mandatory ratio for the number of nurses that need to be on staff at any given time does not, in itself, create more nurses. And we are living through a nursing workforce shortage,” Strong said.

Disagreement on what shortage the system is facing

Just as hospital leaders and health care unions are split on the solutions to the staffing crisis, they also disagree on what shortage is occurring.

Hospital leaders say there are simply not enough nurses to meet the growing demands for care as the population ages and pandemic-era deferred care results in sicker patients.

But unions and some experts say there are in fact enough trained nurses, the issue is recruiting and retaining them in environments that have been chronically understaffed and no longer feel safe.

The number of registered nurses who are licensed in Washington, and also reside here, has grown over the past decade.

Thousands of registered nurses are graduating in WA each year. However, retaining these graduates in the health care system is difficult. There’s high turnover, which contributes to the shortage of workers in hospitals.

At the same time, there’s also a need for more instructors and increased education opportunities to meet the growing demand.

As the workforce and population age, the Bureau of Labor Statistics projects that about 203,200 openings are expected nationally each year through 2031.

There are thousands of nurses licensed in Washington who are currently not practicing.

While unions point to this as an indication of the working environment issues in hospitals and say staffing ratios could provide one piece of the solution, hospital leaders say there’s more nuance involved, and many of these workers are not people who could be brought back to the bedside with something like minimum staffing standards.

Washington lawmakers will discuss the staffing ratio bill again on Thursday. The bill has to clear several more hurdles to be passed into law.