The effects of the COVID-19 pandemic, the largest public health crisis of our lifetimes, continue to be felt nationwide. Workforce shortages are impacting every industry. There has also been an increased need for health care following the pandemic. In Hawaii, the average hospital census has increased by more than 400 patients a day.
Nationally and locally, health care organizations are taking extraordinary measures to solve the complexities of these challenges, including nurse staffing. One of the proposed solutions to nurse staffing being introduced by nursing unions across the nation is mandating patient staffing ratios for nurses.
Evidence from California, which is the only state nationwide to have comprehensive staffing ratios in place for decades, shows that it has not helped to ease workforce shortages. This is because mandated staffing ratios don’t address the underlying issues causing staffing shortages. They don’t produce more nurses and, if implemented, would further strain the overburdened health care infrastructure across our state.
Staffing ratios use a one-size-fits-all approach. They are about static numbers and patients are not numbers. Inflexible ratios assume that all patients are the same and take the clinical judgment of the nurse out of the picture. Nursing clinical judgment is essential to solving the day-to-day changes in patient acuity, or the severity of a patient’s illness, and flexibility is needed. During emergencies or surges in patient numbers, hospitals need the freedom to allocate staff according to immediate demands. Patient care takes a team and mandated ratios inhibit the ability of the health care system to have flexibility in leveraging other health care team roles.
Studies from California have shown there are several unintended consequences that accompany staffing ratio mandates, including reduced access to care and added costs passed on to patients.
Currently, health care in Hawaii ranks among the best for patient care and efficiency in the nation at the most affordable cost. Hawaii ranks higher than almost every other state in overall health care quality, including California.
In Hawaii, the impact of forcing fixed staffing numbers will likely result in irreparable consequences to those most at risk in our community. Mandated ratios affect access to care and health care organizations’ abilities to provide services. Delays in care and longer wait times for patients occur when an organization can’t meet the staffing ratios, and the cost penalties associated with fixed staffing ratios get passed along to patients. The impact of ratios in Hawaii would be exponentially greater on smaller hospitals, long-term care facilities and rural hospitals, where staffing and financial challenges are most prominent.
Fixed staffing ratios remove hospitals’ ability to remain agile and are an oversimplified answer to a highly complex issue. They are an out-of-date solution that fails to consider advanced capabilities in technology that can help to reduce the burden on our nurses and innovative care delivery models that can repurpose non-nursing related tasks to the appropriate health care team members.
During negotiations with the Hawaii Nurses’ Association (HNA) for a new contract for nurses at Kapiolani Medical Center for Women & Children, we have bargained in good faith by offering an innovative approach to staffing that gives nurses a voice in the process and other proposals to focus on keeping nurses. HNA has done little to bring us closer to a contract resolution, including refusing multiple times to use a federal mediator to help us reach agreement on the many outstanding issues that remain.
We live in a different world after COVID. The speed and pace of changes in patient care are unparalleled. The time we are in calls for partnerships, innovation and creative solutions to address these issues. By doing so, our clinicians will have more time for what they value most, which is caring for their patients.
Amy Thomas, MSN, APRN, FNP, is the system chief nurse executive for the Hawaii Pacific Health System.
This column originally ran in the Honolulu Star-Advertiser on Jan. 17, 2024.