FACULTY Q&A

The bipartisan Safe Patient Care Act, which limits forced overtime for registered nurses, sets minimum nurse-to-patient staffing ratios, makes staffing ratios public and provides whistleblower protections, was introduced in the Michigan legislature in March.

Christopher Friese

Similar measures to protect nurses have a long and controversial–and so far futile–history in Michigan politics. The Michigan Hospital Association opposes the legislation, the Michigan Nurses Association backs the measures. The Michigan Chamber of Commerce just switched its position from oppose, to neutral.

Christopher Friese, a professor at the University of Michigan School of Nursing and School of Public Health, discusses the bills.

Hospitals argue that this is a one-size-fits-all approach to staffing and it won’t fix nurse staffing and burnout. How do you feel about this argument? Are there pros and cons to this legislation?

As a researcher and a nurse, I am compelled by the consistent finding that patient and nurse outcomes are better when nurses care for a reasonable number of patients during their shift. Evidence-based, consistent staffing approaches help nurses anticipate their workload, plan their work and help managers and others identify potential staffing problems that need quick solutions. Personally, I am pleased that the Michigan legislation restricts the use of mandatory overtime.

There is clear and compelling evidence that nurses who work exceedingly long shifts are exhausted and more likely to commit errors. We don’t let pilots fly planes after a certain amount of hours. Do you want your nurse working 16-hour days? There is pretty clear evidence that when hospitals assign high numbers of patients to nurses, patient outcomes are worse. This has been demonstrated in dozens of studies in the United States and around the world. California enacted minimum nurse staffing ratios in 2004. While the evidence has been mixed, a comprehensive evaluation has found that after implementation, patient outcomes were better and nurses were more satisfied with their jobs.

Most recently, Queensland, Australia, enacted a more flexible nurse staffing ratio policy, and a study identified similar improvements in patient outcomes, length of stay and potentially lower costs. It’s important to note that nearly all of the research in this area is observational, as it would not be ethical to conduct a trial that randomized patients to receive care in hospitals or units with different nurse staffing levels.

The arguments against the legislation, largely raised by hospitals, health systems and their respective professional organizations, usually center on unintended consequences, such as how rigid ratios tie the hands of administrators, make it hard to manage patients for nurses on breaks, can lead to backlogs in emergency departments and slow down hospital admissions. Most of these concerns are anecdotal reports, but they are important to recognize. I agree that flexibility is an important tool for hospital leaders to have. That’s why laws similar to the approach in Queensland—where local units have some flexibility to meet the overall staffing objective—may be a nice compromise.

How do hospitals set staffing ratios now?

In hospitals where the nurses are unionized, there are often components in their contract that specify how hospitals approach nurse staffing. In hospitals without nurse unions or state legislation, the process can be murky. In many cases, ratios aren’t set, but there are targets as to how many hours of nursing care are expected given the number of patients on a unit. It’s up to the units to determine how best to hit that number.

Regarding the staffing ratios set in the bill, do hospitals routinely exceed these ratios? Is this a huge departure from current standards?

At a quick glance, the ratios included in the bill are similar to those proposed in other states. Most patients in a hospital are cared for on medical/surgical units. The ratio of four patients per registered nurse is often cited as a good target, given multiple studies that find death rates are higher in hospitals that exceed that ratio. I was somewhat surprised to see a one patient to one nurse ratio in intensive care units, as often ICU nurses can care for two relatively stable patients at the same time.

Our own work has shown that other factors associated with nurses can improve patient outcomes, things like the nurses’ working environments and their educational preparation. But the strong and consistent association between nurse staffing and patient outcomes cannot be ignored.

Why can hospitals mandate overtime for nurses? Is this common? What might this mandatory overtime look like for nurses?

Mandatory overtime occurs often when, for some reason, the oncoming shift does not have enough nurses to reasonably care for the patients on a unit. There are often rules as to how this occurs—unit leaders call off-duty nurses and ask them to come in, hospitals sometimes have float pools of nurses to cover such contingencies, nurses on the current shift are asked if they wish to volunteer to stay and make overtime pay.

When that fails, hospitals will mandate that a nurse stays, and it is often determined by seniority (the nurse with the lowest seniority is mandated first) or by turn. It’s hard to know how often this occurs because it is rarely reported publicly. I think it happens more than we think, particularly during COVID and in hospitals with pervasive shortages. The result can be very long shifts (an eight-hour shift becomes a 12- or 16-hour shift). Nurses can be exhausted and as cited above, are more prone to errors. From a safety perspective, I would be in favor of limiting mandatory overtime.

Does this bill make patients and nurses safer?

Much in this bill aligns with the legislation in California, which in general has found similar or better patient outcomes and generally better nurse outcomes. I think having some guardrails in place whereby hospitals cannot place nurses in unsafe patient assignments is a good thing. I am increasingly worried about large patient assignments and the impact on nurses’ well-being. We will never have randomized trial data on this question. I think nurse staffing ratio policies in acute care hospitals are an evidence-based solution to improve safety and, importantly, keep nurses healthy and safe.

Across the state, nurses are hurting. And despite a lot of rhetoric (T-shirts, signs and pizza parties), some hospitals have not put the health and safety of their nurses first. I worry that if common-sense staffing policies are not enacted, we will face a tidal wave of retirements and resignations, putting patients at risk.

Can the legislation be retooled to appease the Michigan Hospital Association?

The MHA is in a tough position. Many hospital executives oppose this type of legislation because it ties the hands of local administrators. The MHA’s statement also cites concerns for a one-size-fits-all approach. I think there are strategies that could provide flexibility for local situations and differences across hospitals. The Queensland, Australia policy is one such approach.

Forms of these bills have a long history in Michigan politics, and so far, a futile one. Do you think that in light of COVID, the stories of overworked nurses, burnout and exhaustion, this bill has a better chance of passing now?

I was fascinated to see that this bill has bipartisan, bicameral support. In a contentious year for Michigan’s state legislature, it’s heartening to see state house members and senators recognize the enormous strains that nurses face, and propose legislation to provide them with predictable, manageable workloads.

It remains to be seen if this proposal can make it across the finish line. But hopefully this proposal increases recognition of the problem and can lead to a solution that satisfies nurses, patients and hospitals.