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Aug. 17—In the winding hallways and gleaming corridors of Christus St. Vincent Regional Medical Center, staff members have debated a question for years. Sometimes in whispers. Often in tense soliloquies. The question: How many nurses does it take to provide safe care for patients?
Now, that question is at the heart of stalled contract negotiations between the nurses union and hospital administrators. And as the nurses inch toward a possible strike, it remains maddeningly difficult to answer.
There are no federal standards, and only one state — California — has adopted a law instituting strict nurse-to-patient ratios.
The union says the hospital needs more than the 368 nurses it has now. The hospital disagrees.
While evidence of the precise ratio of nurses to patients necessary to assure patient safety remains elusive, one of the nation’s foremost researchers on the topic says the objective evidence is clear: Hospitals with better staffed nursing forces save lives and prevent complications for patients.
“There’s an overabundance of evidence that shows hospitals that have better staffing have better outcomes when we look at things like mortality,” said Matthew McHugh, an associate professor at the University of Pennsylvania School of Nursing whose research has been published in some of the nation’s most prestigious medical journals.
He said hospital readmissions, failure to rescue patients in distress and patient satisfaction also have a correlation to increased staffing.
“Hospitals are better able to respond when something happens when they’re better staffed,” McHugh said. “If you compare any two hospitals — one that’s good at staffing and one that has not as good staffing, but are similar in other factors — the hospital with better staffing is much less likely to be penalized” for bad patient outcomes by Medicare and Medicaid.
Administrators at St. Vincent say the hospital is succeeding at the quality measures cited by McHugh, so increased staffing isn’t needed.
“At this point, with the results that we’re driving, we’ve probably got pretty close to the mix of caregivers we need,” said Dr. Frantz Melio, president of Christus St. Vincent Medical Group. “It seems to be working.”
The nurses fighting for increased staffing don’t think so. They draw on their own personal experiences and say that they often can’t give patients the care they need.
“Two patients are off the scale on pain. The antibiotics are like three hours late, and the person’s really infected. This one’s trying to crawl out of bed and go to the bathroom. And you’ve got a phone call and a family member of a patient coming at you at the same time, and you just can’t deal with it all,” said registered nurse Sharon Argenbright. “Bridges have limits, trucks have limits and nurses have limits.”
Chad Leet, a nurse in the emergency department at St. Vincent, said he frequently is pushed to the limit of being able to care for all the patients on his watch.
“At a certain point, you cannot satisfy everybody’s needs,” he said. “You have to focus on the most acute patient needs. If something arises that threatens life or limb, that’s going to occupy all of my attention.”
The demands on nurses’ attention comes at the expense of patients’ comfort and well-being when their needs for the toilet or pain management must wait, a common problem, Leet said.
“We’re not complaining about running around all day,” he said. “I can run for 12 hours. I’ve done it. What I’m complaining about is the care I can’t give the patients. I’d love to clone myself.”
The nurses want a commitment from the hospital to staff nursing on a par with the 50th percentile of staffing levels at comparable hospitals.
Currently, the hospital strives to match the staffing level at the 40th percentile of the hospitals it compares itself to, but the union contends St. Vincent frequently falls short of that mark.
A snapshot of staffing at hospitals in the state conducted last month by the New Mexico Hospital Association found St. Vincent to be above average, based on a measure that gauges hours of nursing care per patient per day. Union representatives say the staffing level found at St. Vincent in the survey is not the norm, and they argue that the method that was used to measure staffing is flawed. Hospital leaders said the manner of measuring staffing in the survey is a nationally accepted industry standard.
The hospital’s administrators say that during a time of funding uncertainty, with reductions in government reimbursements for services, pledging a specific staffing level constitutes a financial gamble.
And administrators say the hospital has been miscast during the labor unrest as providing poor care.
“From my perspective, it’s somewhat frustrating to see the outcomes at this institution depicted as very negative,” Melio said. “That’s just not the reality of it.”
Administrators say they would take the nurses’ complaints more seriously if they also were hearing complaints from patients.
“I really don’t take into consideration third-party perspectives,” said Lillian Montoya, vice president of policy and stakeholder engagement at the hospital. “I want to hear it from the patients themselves.”
The hospital contracts with Premier Operations Advisor, a consulting firm used by hundreds of hospitals,to compare itself to other institutions throughout the United States using a number of metrics, including staffing. Administrators say patient outcomes are foremost among their concerns. In its proposal to the union, the hospital has offered incentive pay for meeting improvement goals in some of those measures.
Based on the data derived from the contractor, the hospital’s leaders say they get a holistic view of the care and business aspects of the operation, and that nurse staffing is merely one variable to consider.
“You think of a hospital, and you think of nurses and doctors,” said Christus St. Vincent’s Chief Medical Officer John Beeson. “But there’s radiology. There’s pathology. There’s all the therapies. There’s discharge planners. There’s social workers. There are literally hundreds of people in the facility, and it all has to be carefully balanced. You have to have the balance of people that give you the best outcomes. It’s why you can’t really isolate one piece.”
Melio said that’s why he isn’t moved to support increased nurse staffing despite research such as McHugh’s.
“I don’t see how it’s possible to say that this one issue has a direct correlation to this outcome without any other considerations,” Melio said. “I don’t see how you can do that. When you take care of a patient, so many team members touch that patient, so many people have an impact on that patient.”
Increasingly, McHugh said, increased staffing is proving to benefit hospitals from a business perspective.
“Nursing costs money, there’s no way around that,” he said. “It’s a labor cost, and the cost benefits may not be immediately clear, so it’s a risk and that makes sense. But there’s growing evidence for the business case of improved nurse staffing. There’s evidence that it’s a value investment.”
Improved patient outcomes through added staffing stand to save hospitals money by avoiding penalties from Medicare and Medicaid based on bad patient results, McHugh said.
“This is something that has real cost in both directions,” he said. “It is a little bit of an open question as to what the balance is, but I think most of the evidence points to nursing being a good investment in the trade-off. Ultimately looking at what is the best investment for patient outcomes, that’s really the business of hospitals, so that’s what we try to provide some evidence for.”
He pointed to California, where for a decade hospitals have had to abide by statutory minimum nurse-to-patient ratios as proof that outcomes are better when hospitals are adequately staffed. Compared to other states with lower nurse-to-patient ratios, mortality rates and other measurable patient problems are lower in California since the law was enacted, the Penn research showed.
The California law requires at least one nurse for every two patients in the intensive care, surgery recovery and labor and delivery departments; one nurse per patient in operating rooms; one nurse for every five patients in the medical/surgical unit; and one nurse for every four patients in the emergency room, for instance.
In a 2010 study comparing California to New Jersey and Pennsylvania, two states without nursing ratio laws, McHugh’s Penn colleague Linda Aiken found nurses in California had smaller patient loads than their counterparts in the other states. Taking all staff nurses into consideration, California nurses on average had 4.1 patients compared to 5.4 in both New Jersey and Pennsylvania. The odds of a hospitalized patient dying in California were 1 in 13 compared to 1 in 10 in New Jersey and 1 in 6 in Pennsylvania.
“That’s just one policy design,” McHugh said about the California law. “There are lots of ways hospitals and states can put regulations in place to encourage or require hospitals to improve staffing.”
Because the hospital’s comparison to others fluctuates, neither the union nor St. Vincent could readily provide a precise picture of staffing ratios.
In New Mexico, efforts supported by the local nurses’ union and others to require public reporting of nurse staffing levels have met resistance from the New Mexico Hospital Association and the hospitals it represents. Proposed legislation has consistently fallen short, most recently this year, when Gov. Susana Martinez vetoed budget provisions to support the project.
Jeff Dye, president and CEO of the New Mexico Hospital Association, which lobbies for hospitals’ interests, said hospitals don’t want their business and patient care decisions to be dictated by unions or the Legislature.
“If a hospital is bound by a firm [staffing] number, no matter what the imposing source is, it limits flexibility,” he said, calling staffing mandates “a limiting factor” when hospitals need to be able to adjust to a rapidly changing funding landscape.
Dye said a statewide solution isn’t in order because the fight over staffing has been concentrated in Santa Fe. He said it has not been an issue of any concern to other hospitals that belong to the association.
Ellen Interlandi, a nurse consultant for the hospital association and a former nursing administrator, said hospitals are not swayed by research touting the value of increased staffing. She pointed to a recent industry survey of available studies that found contradictory reports. She said the academic studies also have not identified reliable numbers that constitute a safe nurse-to-patient ratio.
“The sweet spot has not been defined by these studies,” Interlandi said. “I think everyone agrees that when you have the higher registered nurse staffing that you do have the lower mortality rates and the better patient outcomes. You measure your quality outcomes, and you make determination on whether your staffing needs to change based on that.”
McHugh conceded that no magic number for appropriate staffing exists.
“That’s the golden question,” he said. “I don’t think it’s clear that there’s a specific number. We’d love to be able to say, ‘This is the number.’ But unfortunately, we’re not able to do that, nor am I sure that we want to. But I think setting some limits is not an unreasonable policy. We have seat belts in cars as a safety precaution. I think having standards in hospitals where things can go really bad makes some sense.”
