The following article was originally published in the Ohio Capital Journal and published on News5Cleveland.com under a content-sharing agreement.
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Last week was National Nurses week, and in Ohio, lawmakers held the first hearing for a measure codifying nurse-to-patient ratios. To nurses, it’s a critical protection for workers stretched too thin, but to hospitals it’s a potentially devastating obstacle to delivering care.
Nurses have been pushing for some kind of legally mandated staffing ratio for at least a decade, but hospitals have so far been able to nip those efforts in the bud.
First hearing
About forty nurses wearing matching shirts emblazoned with “code red” filled the basement hearing room last Tuesday. The show of force was notable given they’ll have to wait for a future hearing to speak.
The measure’s sponsors, state Reps. Elgin Rogers, D-Toledo, and Haraz Ghanbari, R-Perrysburg, described how higher workloads for nurses lead to mistakes or oversights.
“That’s why House Bill 285 would also create minimum staffing standards between one-to-one and one-to-six for all hospitals here in Ohio,” Ghanbari explained. “These ratios are based on best practices, that take into account how many patients are safe for nurses to handle at any given time.”
At the most critical level of care, including operating rooms and trauma emergency units, the bill requires at least one nurse per patient. Intensive care units and maternity wards focused on labor and delivery would allow a nurse to care for two patients. From there, the requirements continue to relax — emergency room nurses can cover three patients, acute psych nurses can cover four. In a rehab setting, nurses can treat five patients and nurses can handle six babies at a time in a well-baby nursery. The bill further directs the state health director to set ratios for any unit not explicitly defined in statute.
Ghanbari stressed that while the staffing guidelines are needed, it will take time for providers to implement them.
“Hospitals have two years to implement these ratios,” he explained, “except for those hospitals in rural areas, which have a longer on-ramp of four years.”
He added the bill also carries numerous exceptions to ensure hospitals operating in good faith aren’t penalized. States of emergency, patient diversion or transfer and even the inability to hire staff “after reasonable efforts” are included among those exceptions.
So long as a hospital doesn’t deny workers their meal breaks, Ghanbari added, they won’t be punished for minor deviations from staffing requirements.
Rogers stressed the exceptions are meant to “ensure flexibility for hospitals that make efforts to meet the ratio but are unable to due to circumstances out of their control.”
“This legislation was created with the mindset that this is not just for the nurses and the patient but is also for the industry and the hospital,” he added. “I want you to understand that we took great care to think about all the parties involved.”
Staffing research
Perhaps the most eye-popping statistic Rogers and Ghanbari cited had to do with increases in patient mortality as a nurse’s workload increases. With each additional patient, they explained, the mortality rate increases by 7%.
That comes from a 2002 study conducted by Linda Aiken, a professor of nursing and sociology at the University of Pennsylvania. She explained that, despite stemming from a 20 year old study, those findings have proven durable — and not just in the U.S.
“We’ve been studying this particular relationship between nurse staffing and patient outcomes for over 30 years,” she explained. “Very large studies in the U.S. and 30 other countries. And we find this is a generic finding, in every large study we’ve ever done about the variation in hospital outcomes.”
That 2002 study looked at California, the first state in the country to impose nurse-to-patient staffing ratios, on the eve of those ratios taking effect. Since those staffing requirements took effect, Aiken said, patient mortality has declined, but she acknowledged the exact causes remain a point of contention.
“There wasn’t really a proper scientific evaluation of California. There was no baseline, there was no prospective evaluation,” she explained. “And so, there’s a lot of arguments about, how much of the improved and lower mortality of California could be attributed to this particular policy.”
On the other hand, she’s quick to note California’s legislation didn’t undermine the hospital system. No hospitals closed because of nurse staffing despite massive economic challenges like the Great Recession and COVID-19. The requirements have been particularly important for safety-net hospitals which traditionally treat the most vulnerable patients.
What’s more, Aiken argued, she and researchers on her team have repeatedly shown the link between staffing and mortality since that 2002 study. In 2014, for instance, Aiken found the same 7% increase in patient mortality with each patient added to a nurses workload across in nine EU countries.
Even more striking, in 2021 her team published a study of 55 hospitals in Queensland, Australia. Half of them imposed minimum staffing ratios and half didn’t. The study compared both groups before, and two years after, the policy took effect. For hospitals with no staffing minimums, mortality rates rose slightly, but the for the group with a ratio in place, they dropped substantially.
The hospitals with minimum staffing out-performed the control group on readmissions and length of stay as well. Based on the study’s estimates, the hospitals would’ve seen “145 more deaths, 255 more readmissions, and 29,222 additional hospital days,” without the policy in place.
Those reductions in length of stay translate to millions in savings, according to Aiken.
“We estimated that in Australia, for example, the offset on the shorter lengths of stay they were getting by having better staffing was saving them the equivalent of $20 million a year,” she said.
That was more than double the labor costs from hiring additional nurses to meet the minimum staffing guidelines.
Friday rally
The same day Reps. Rogers and Ghanbari introduced their bill, the Ohio Hospital Association wrote a letter to House Speaker Jason Stephens attempting to torpedo the measure. The Ohio Children’s Hospital Association, Ohio Chamber of Commerce and Ohio Business Roundtable signed on to the letter as well.
“A one-size-fits all approach to staffing simply does not consider the many complexities and nuances of running a business and a hospital is no exception,” the letter insisted.
The letter treated the Golden State as a kind of boogeyman, warning HB 285 “is a giant step toward the Californication of Ohio.” The OHA complained staffing requirements will make the difficult job of hiring nurses even harder and argued California mandates have led to some hospitals reducing services. They argued the bill could lead to greater reliance on travel or temp nurses, and criticized the measure for treating a nurses with a few months or a few decades of experience as interchangeable.
A statistic Rogers and Ghanbari brought up might undermine those concerns about staffing shortages.
“42% of nurses,” Ghanbari told the committee. “42% who have left the bedside would consider returning to the bedside if Ohio had legally enforceable minimum staffing standards.”
Aiken echoed the argument, stating California “solved their nursing shortage in two years” by requiring minimum staffing. A separate study from the California Healthcare Foundation found that staffing changes had no discernible effect on hospital finances. Instead the authors pointed to changes in Medicare reimbursement and seismic retrofitting as far more substantial hits to the balance sheet.
At a rally on the statehouse steps last Friday, Ohio Nurses Association President Rick Lucas derided the letter.
“They’re afraid of the truth,” he said, “They’re afraid that we’ll show the community who they are.”
“They use their deep pockets and dark money political groups not to serve patient care or worker safety, but to maintain their stranglehold on our healthcare system,” he went on, “prioritizing profits over the well-being of patients and those who care for them.”
The rally was organized by the Smith family, whose daughter Tristin was a Dayton nurse who died by suicide. Her sister Sarah Smith criticized the OHA’s suggestion that staffing mandates would place too great a burden on the industry.
She asked the nurses present to raise their hands if they were stressed, and a couple dozen hands shot up. Then she told them to keep their hand up if they would be more stressed with ratios in place. Every hand went down.
“If there’s a representative from the Ohio Hospital Association here, I want them to look at that,” she said, “because they said that it would cause more stress on a system already struggling. You know who it would cause stress on? Them to do their jobs — not the people doing the work.”
“It would force their hand to actually do something for the good of people,” she added, “instead of saying you know what? I want to make that extra money right there.”
After Sarah spoke, her dad Ron Smith passed out posters, and the group marched around the building. They chanted slogans like, “Do your part, staff smart.”
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