What is the harm in imposing mandatory hospital nurse staffing regulations?

Executive Summary

* Efforts to establish mandated staffing ratios are shortsighted, and, though proponents may have the best intentions, many negative outcomes would flow from the public airing of this Issue.

* The Institute of Medicine concluded in 1996 that there was insufficient quality outcome evidence to support the imposition of mandated nurse staffing ratios.

* The Massachusetts Nursing Association got legislation introduced in early 1996 which, if passed, would turn over to state lawmakers decisions governing nurse staffing in hospitals and other employment settings.

* There are high opportunity costs. Staffing regulations (if imposed) would force employers to ignore the dynamic interactions of economic, technology, capital, and labor supply variables, and thus needlessly impose the effect of increased labor costs on hospitals, taxpayers and nurses themselves.

* Chance for passage of this highly controversial legislation is unlikely, but the expenditure of political chips (and the loss of credibility) will increase the difficulty of obtaining a hearing from legislators the next time a nursing issue comes up.

The Institute of Medicine's Committee on the Adequacy of Nurse Staffing (IOM, 1996) wisely rejected the idea of mandatory minimum nurse staffing levels in hospitals. Such provisions would require hospitals to employ a prescribed number of nurses (or full-time positions) per diagnosis, disease-specific condition, number of patients, or other indicator linked to the provision of nursing services. Neither did the committee endorse mandatory nurse staffing ratios which would require hospitals to employ a certain percentage of registered nurses relative to licensed practical nurses or nurse aides. The committee, instead, concluded that "there is a serious paucity of recent research on the definitive effects of structural measures, such as specific staffing ratios, on the quality of patient care in terms of patient outcomes when controlling for all other likely explanatory or confounding variables" (p. 121). Thus, it was recommended that more rigorous research be undertaken as this would have "significant payoffs for policymakers, nursing educators, and hospital administrators" (p. 122). However, some nurses have understood the committee's position as implying that once research studies provide answers concerning the relationship between the quality of care and minimum nurse staff levels and/or staff ratios, then nurse staffing regulations should be implemented based on these research findings.

Despite the IOM Committee's rejection of policies that would mandate minimum nurse staffing levels or ratios in hospitals, certain groups in nursing advocate legislation that would impose these regulations. For example, in the Spring of 1996, the Massachusetts Nursing Association succeeded in getting legislation introduced in the Massachusetts state legislature. If voted into law, this legislation could end up effectively turning over to state lawmakers decisions governing nurse staffing in hospitals and other employment settings. The position of nurses in favor of regulatory intervention of this kind is built around the recognition that the health care system is changing rapidly and dramatically. Proponents believe that to ensure patient safety and protect the quality of patient care, hospitals must be required by law to configure their nursing staff according to minimum numbers and/or ratios.

The purpose of this article is to present a number of economic and political issues that nurses and policymakers should consider as they contemplate the costs and benefits of seeking legislation that would impose mandatory nurse staffing regulations. Even if results from rigorous research were available and could be used to determine the "correct" number and/or ratio of nurses that would result in obtaining an objectively measured standard of quality, the position argued here is that nurse staffing regulations would still be inappropriate. Such regulations would force employers to ignore the economic criteria they would otherwise consider when making nurse staffing decisions, impose significant costs on hospitals, taxpayers, and, perhaps most damaging of all, would needlessly inflict substantial opportunity costs on the nursing profession.

Economic Determinants and Nurse Staffing Regulations

The overall demand for nurses is derived from the forces that determine society's total demand for health care (for example, changes in the size and composition of the population, increases/decreases in per capita personal income, proportion of the population with insurance coverage, prevalence of diseases such as the spread of HIV/AIDS or drug resistant infections, etc.). However, it is important to bear in mind that the number of nurses actually employed at any given time is determined by health care organizations' demand for nursing services. Whether acute care, ambulatory, home care, or community based, these organizations are in the business of producing mostly medical treatments and a variety of personal health care services …