The Washington PostDemocracy Dies in Darkness

More nurses are better for patients. Why is it so hard to get hospitals to hire them?

It's not clear that mandating higher staffing ratios works -- but it's not clear that anything else will, either.

A scene from a Washington Hospital Center’s nurses’ strike in 2010. (Juana Arias for the Washington Post)
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On a freezing night in late December, Ann Mead shivered outside the gates of Medstar’s Washington Hospital Center, drawing only emotional warmth from the cluster of fellow nurses singing protest songs and receiving updates on contract negotiations that had stalled the previous month. They were nearing the end of a grueling strike: A one-day action had lengthened to 10 days when the hospital said it couldn’t find replacement nurses for a shorter period. Ambulances and fire trucks honked in solidarity as they drove by.

Mead, 32, left her career in international relations to become a nurse only a year ago — but she’s already starting to feel burned out. That’s why she decided to take the financial hit of an extended unpaid vacation rather than break the strike: One of National Nurses United’s key bargaining objectives is to increase the number of nurses at the hospital, which would give her fewer patients at a time to deal with in the cardiac surgery unit where she works.

“I am incredibly exhausted after every shift that I work, so mentally and physically exhausted,” said Mead, a slim blonde, hunching into her parka. “I feel like some days I think of everything I did that day, and I think, ‘I could’ve done this for this person, if I’d just had the time to get to it.’ And I have to convince myself that I did my best to prioritize what the most important things are for each person, because I couldn’t get to everybody.”

Why won’t the hospital hire more people? It’s not because there aren’t enough nurses around — the much-talked-about “nursing shortage” has dissipated. RNs have put off retirement through the bad economy, and nursing schools have doubled their output of new graduates. Washington Hospital Center received 6,316 applications last year, and hired 7.5 percent of them.

“There’s plenty of evidence that there’s a shortage of nursing care, and it’s not solved by anything to do with the hospital supply,” said Linda Aiken, director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania’s nursing school. “All the shortage of care at the bedside has to do with how much hospitals want to pay nurses, and whether they want to use their resources on something else.”

“There’s plenty of evidence that there’s a shortage of nursing care, and it’s not solved by anything to do with the hospital supply,”

That shortage of care at the bedside tends to be the worst in nursing homes, as well as in under-resourced rural facilities where it’s hard to attract anyone to work. But if Mead’s experience is any indication, staffing levels could be better at large urban institutions like Washington Hospital Center, too. And a growing body of research has tied more nurse attention to better patient outcomes, from lower rates of infection to shorter hospital stays — which ultimately save money and can help hospitals avoid costly lawsuits.

So, what’s the best way to get more nurses on duty? The debate has been simmering for decades and is likely to only get more intense as health-care reform extends coverage to more people, and creates new standards that hospitals have to meet.

National Nurses United, a powerful and combative union that has grown quickly through mergers and organizing new hospitals over the last decade, has a preferred solution: mandatory minimum nurse staffing ratios. In 2002, it pushed through a law that imposed ratios in California, NNU’s power base.

It’s hard to tell how much the law helped patients. There’s pretty solid evidence linking understaffing to bad results, like hospital-acquired infections and increased mortality rates. The evidence on the benefits of mandated nurse ratios is more mixed, with several reporting no significant changes to patient outcomes — although since the severity of illnesses and injuries in the California system increased at the same time, stasis may actually indicate that increased staffing helped prevent a corresponding increase in bad outcomes.

That’s why even experts who’ve spent years building the case that nurses are crucial to health outcomes — such as Lori Melichar, a labor economist at the Robert Wood Johnson Foundation —  aren’t willing to say that legislated minimums are the way to go. “It’s a complicated question already,” Melichar said. “And when you layer on ‘Is this policy going to be effective,’ as a researcher and an economist, I can’t make that determination.”

It seems clearer,  however, that the California law is good for nurses. Over the first few years of implementation, patient loads decreased by an average of one whole person per nurse, which boosted nurse job satisfaction and lowered their rates of occupational injury.

That’s why NNU has pressed on, proposing mandatory nurse staffing ratios nationally through Congress and in more than a dozen states and the District of Columbia. Faced with intense resistance from the hospital industry, none of the measures have passed. A few states have required hospitals to set up labor-management committees to negotiate over staffing levels, but NNU dismisses that as a fake solution. And at Washington Hospital Center, the idea that NNU will be able to get any language on staffing levels through contract negotiations seems more remote by the day.

“They want no conversation with the union or anybody about the way staffing goes,” said Stephen Frum, the union’s shop steward at Washington Hospital Center. “They want complete control.”

“They want no conversation with the union or anybody about the way staffing goes,” said Stephen Frum, the union’s shop steward at Washington Hospital Center. “They want complete control.”


To understand why hospital executives hate the mandatory minimums idea, listen to Washington Hospital Center’s nursing director, Sue Eckert, talk about running the facility on a snow day. On Jan. 6, for example, Eckert got to work at 6:30 a.m. to deal with the chaos she knew she’d find when she arrived.

“Influenza is hitting beyond belief; our emergency room is packed,” she said on an afternoon break in the hospital’s administration suite. “The patients who are ready to leave aren’t leaving, because nobody can come pick them up. But everybody who had a surgical procedure got here on time.” Meanwhile, nurses are late, snarled in traffic, or calling in sick themselves.

Every four hours, Eckert got an e-mail with a little box that described the census of nurses, doctors and technicians in each unit. To keep staffing levels adequate across the building, Eckert shifted people around to the areas of greatest need — leaving some temporarily with a less-than-ideal ratio. If the District had a law like California’s, Eckert said, that would’ve been illegal. “And I felt very comfortable that everything was safe,” Eckert said. “I would probably do it no matter what, but would possibly be exposed to a violation.”

Eckert said she thinks that most of the time the hospital would meet California’s requirements — but she doesn’t want to have to make sure that the numbers don’t ever sink below its stipulated ratios. “I have such concern that people think a number is magic, and that number’s is going to fix the problem,” she said.

So, again, if nurses are available, and more nurses improve patient outcomes, why not just hire more nurses to avoid situations where you might have fewer people than you need?

“You could do that,” Eckert said. “And then the reality is, you have the cost.” The cost, of course, is increasingly relevant as the Affordable Care Act is requiring hospitals to be more efficient with their dollars — which they have historically done by cutting staff, not adding them.

As for Ann Mead’s distress: Eckert chalked that up to the fact that it’s her first year on the job, and first-years are always stressed out until they gain more experience. To try to mitigate that feeling, Washington Hospital Center has a nursing residence program, which is supposed to help newbies through the hardest stage. Over the past few years, the hospital has actually improved staffing, hiring more nurses and reducing the number of temporary nurses it used to hire from staffing agencies to fill gaps. Turnover rates have declined, from a high of 20 percent three years ago to an industry-average 12.8 percent in 2014.

But Mead isn’t the only one feeling overburdened. A survey of nurses from last spring revealed that nurses were more concerned about staffing levels than almost any other aspect of their working conditions — especially on the general inpatient floors, where higher nurse staffing levels have more subtle benefits than in the intensive care units. And in the anonymous comments section, more than gripes about managers, the issue of staffing came up again and again.

“Employees frequently verbalize frustration and without much hope of change,” wrote one nurse, in a unit where 66 percent of respondents felt staffing levels were inadequate. “All clinical staff are stretched too thin.”

Another offered the kind of scenario that results from having not enough hands on deck: A nurse is in the middle of passing medications, when a patient at risk of falling calls to go to the bathroom. Since there aren’t enough nurses or technicians around to help, the unstable patient gets up to go by himself, exactly the kind of precarious situation that everyone is trying to avoid.


So, if mandatory minimums aren’t going any further, what’s the way forward? The American Nursing Association supports flexible approaches, such as requiring hospitals to come up with adequate staffing plans for each unit, which allows them more freedom to adjust to sicker patients. Another partial remedy is transparency: Currently, hospitals aren’t required to disclose staffing ratios at all, which makes it difficult to track whether they’re improving or to compare one hospital with another. If nurse-to-patient ratios became one of the public metrics that go into rankings and evaluations, perhaps hospitals would staff up to compete for patients.

NNU thinks that’s a fake solution, too. “The problem is that it assumes that the way people decide what hospital people will seek care in is based on some consumerist model, like buying a car,” said Ken Zinn, NNU’s national political director. “Sure, for some elective surgeries that’s the case. But mostly, it’s where does your doctor have privileges, or where does the ambulance take me.”

“I can do it for a while longer,” Mead finishes, as the crowd starts to disperse. “But it’s one of the main reasons I don’t think I can do it for that long.”

That may be true. But at the moment, NNU doesn’t appear to have a better option. And until things get better, Ann Mead isn’t sure how long she can stick around.

“I expected to be on my feet on my time; I expected it to be stressful because you’re caring for lives — obviously that’s a stressful thing in itself,” she said. “I did not expect it to be this intense, so often. What I did not expect was to not be listened to by my own hospital management, who are nurses themselves, to not regard what we’re saying we need.”

“I can do it for a while longer,” Mead finishes, as the crowd starts to disperse. “But it’s one of the main reasons I don’t think I can do it for that long.”