Calls for staffing ratios pit nurses, hospitals on opposite ends of debate

HARRISBURG — Pennsylvania lawmakers on Tuesday considered opposing opinions concerning minimum staffing ratios for hospital nurses, with advocates saying the legislative change could stabilize nursing turnover and ensure patient safety while opponents warned the measure would jeopardize the availability of medical services and potentially force hospital closures.

The merits of House Bill 106, titled the “Patient Safety Act,” positions nursing staff and hospital administrators, including nurses, on either side of the issue. While there’s plenty of disagreement on the bill’s potential impact, no one disputes that a lack of nursing hires is taxing the collective capability of Pennsylvania hospitals.

The Hospital and Healthsystem Association of Pennsylvania, with 235 member facilities, found that nursing vacancy rates remain above 30%. It opposes the measure on the grounds that hospitals should retain local control of staffing and that a one-size-fits-all mandate could cause hospitals to reduce patient capacity and discontinue certain services.

“The staffing challenges we face today are reflective of a supply issue and not the absence of mandated staffing ratios. In the past 15 months, St. Luke’s has hired more than 1,000 nurses and would gladly hire more if they are available,” said registered nurse Stephanie Pollock, patient care manager with St. Luke’s University Hospital in Bethlehem.

The National Council of State Boards of Nursing estimated 81,000 licensed registered nurses, or 36% of all RNs in Pennsylvania, aren’t currently working in health care. Nursing associations like Nurses of Pennsylvania and the Pennsylvania Association of Staff Nurses and Allied Professionals (PASNAP) support the proposal in order to combat burnout in nursing and recruit new nurses and licensed professionals who left their careers to return to the industry.

Linda Aiken researches nursing issues including staffing as the founding director of Penn Nursing’s Center for Health Outcomes and Policy Research. She estimates that patient-nurse ratios vary across Pennsylvania hospitals from 3:1 to 11:1. The average, she said, is 5.6:1.

“The single biggest reason why nurses leave hospitals is their workloads are way too high to sustain over time,” Aiken said.

The bill is getting a look in the Health Committee under the Democratic majority. A prior version wasn’t broached under the Republican majority and its former majority committee chair, Rep. Kathy Rapp, R-Warren/Crawford/Forest, who reiterated on Tuesday her concerns that it could undercut rural hospitals already working on shaky financial footing.

Rep. Thomas Mehaffie III, R-Dauphin, reintroduced the bill. It’s modeled after legislation enacted in California nearly 20 years ago, which remains the only state law like it, advocates say. Mehaffie’s version proposes a new chapter on patient safety to the commonwealth’s Health Care Facilities Act. Among its provisions are mandates for staffing ratios for registered nurses engaged in direct care.

The ratios differ across 18 different hospital areas specified in the bill. For example, the measure would require nurses care for no more than four patients in emergency departments or up to one trauma patient. The ratio dips to two patients in intensive care, one patient in operating rooms, and two patients in labor and delivery but only one patient in active labor or suffering complications.

An initial violation of the ratios and other proposed requirements like establishing a nurse staffing committee and implementing a staffing plan would bring a warning; second violation, $7,500 fine; third and subsequent violations, $15,000 fine. Facilities risk $1,500 fines for instances when a direct care nurse fails to attend a mandated staffing committee meeting.

Michele Szkolnicki, registered nurse and chief nursing officer at Penn State Health Milton S. Hershey Medical Center, said staffing ratios don’t impact patient acuity, co-morbidities and the high-risk nature of nursing including physical assaults by patients. She suggested lawmakers address immigration issues that prevented an estimated 200 international nurses from relocating to Pennsylvania, a lack of nurse educators, and “price gouging” by agencies employing travel nurses. She noted that Pennsylvania’s interstate nursing compact isn’t yet active.

“How do you handle a sudden rush of patients and care needed because of a mass casualty incident?” Szkolnicki asked with respect to the prospect of staffing ratios. “How do you account for when several nurses call in sick on the same day?”

Shannan Giambrone, registered nurse with Suburban Community Hospital in Norristown and an executive board member with PASNAP, said minimum staffing ratios are basic policy. She said a new state law mandating staffing levels is necessary because hospitals refuse to change otherwise.

“We have tried to solve this problem with the hospitals,” Giambrone said. “It never comes to fruition, not without some sort of legislation that will hold them accountable to the ratios we all know we need to take care of patients.”