News & Events

New York Times Op Ed Trumpets Need for Safe Patient Limits for Nurses


June 18, 2010

Is There a Nurse in the House?



PICK any of the hospital dramas that have run for decades on American TV, and chances are the heroes are the doctors, running to a patient’s bedside to save a life whenever an alarm goes off.

Doctors can indeed be heroes. But when a patient takes a sudden turn for the worse, it’s the nurses who are usually the first to respond. Each patient has a specific nurse assigned to watch over him, and it is that nurse’s responsibility to react immediately in the event of an emergency.

That’s getting harder to do, though. Cost-cutting at hospitals often means fewer nurses, so the number of patients each nurse must care for increases, leading to countless unnecessary deaths. Unless Congress mandates a federal standard for nurse-patient ratios, those deaths will continue.

A few states already have minimum ratio requirements, most notably California, which in 2004 instituted a one-to-five ratio for surgery patients — as well as a one-to-four ratio in pediatrics and a one-to-two ratio in intensive care — after a decade-long fight led by the California Nurses Association.

Laws like these could make a huge difference nationally. A recent study led by Linda Aiken, a professor at the University of Pennsylvania School of Nursing, found that New Jersey hospitals would have 14 percent fewer surgical deaths if they matched California’s ratio, while Pennsylvania would have 11 percent fewer. Professor Aiken looked at surgical units only, but it’s reasonable to assume that the percentages would apply on any hospital floor.

The reason is simple. The fewer patients each nurse oversees, the easier it is to respond when a patient has an emergency, like a sudden, severe decline in oxygen saturation, a precipitous drop or rise in blood pressure or a heart rate that suddenly skyrockets. A nurse juggling the needs of too many patients might not have the time to notice, let alone respond.

Nevertheless, hospitals have resisted mandated ratios. While higher personnel costs are most likely at the core of their opposition, they also argue that hospitals that already have good ratios will use the standards to justify cutting the number of nurses on each floor.

This is a reasonable concern, but one that rarely if ever proves true. In more than a decade of research, Professor Aiken reports never seeing such reductions in the wake of mandated ratios. Moreover, if hospitals were so callous, why do many — including my own — often meet or exceed California’s standards?

Moreover, it’s not as if such low ratios are a luxury; there’s a reason why minimum ratios are also called “safe staffing levels.” Say a nurse can’t come in because of a family emergency. Then another nurse becomes ill and has to go home. The charge nurse will call around to other staff members, trying to find last-minute replacements. But sometimes there’s no one to come in and no nurses available at the last minute to “float” to the understaffed unit. The lower the ratio, the more likely the nursing staff will be able to cover if and when personnel suddenly become unavailable.

The real issue, of course, is cost. There’s no denying that hiring more nurses is more expensive in the short term. But having too few nurses leads to burnout, not only because it’s too much work, but because good nurses quit from the stress of knowing they can’t keep their patients safe. Mandated ratios could ultimately save money, because they would reduce both staff turnover and the number of patients who become critically ill due to insufficient care.

And it’s true that, as some argue, the nurse-patient ratio is not the only factor in improving the quality of care. But the data provided by Professor Aiken and others clearly shows that hospitals with the best staffing ratios have the best outcomes overall.

The benefits of mandating nurse-to-patient ratios are so compelling that last year Senator Barbara Boxer, Democrat of California, introduced a bill to set national standards, while Representative Jan Schakowsky, Democrat of Illinois, offered similar legislation in the House. Yet both bills have languished in committee.

On television the doctors and nurses always arrive in time to help a struggling patient. In real life, when nurses are overworked, a patient in distress may be overlooked.

To be the nurse in such situations feels horrible. But for the patient it can be far worse.

Theresa Brown, an oncology nurse, is a contributor to The Times’s “Well” blog and the author of “Critical Care: A New Nurse Faces Death, Life and Everything In Between.”