1. Mason, Diana J. PhD, RN, FAAN, AJN Editor-in-Chief

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The nurse's voice broke as she told of her first night shift on a busy medical-surgical unit. "My very first night off of orientation-by myself, without a preceptor-they gave me 12 patients, and I was in tears before I was out of report because I knew I couldn't do that."


This nurse and others related harrowing accounts of unsafe staffing at a town hall meeting sponsored by the Service Employees International Union.


The United American Nurses (UAN), the labor arm of the ANA, and other unions representing nurses under the AFL-CIO umbrella are making their top priority legislating minimum nurse staffing ratios, as are some state nurses associations. "More of our members consistently face caring for eight to 12 patients," said UAN president Cheryl Johnson. She told me that the union felt it had to support set ratios. But not all nurses are happy about this prospect.


In 1999 California became the first state to pass legislation that will set licensed nurse- patient ratios; the legislation will go into effect in January. They are expected to require the state's hospitals to have, for example, a minimum of one nurse for every six patients on medical-surgical units (one nurse per five patients in 2005), and one nurse for every two patients on critical care units.


As one nurse colleague who is an expert in public policy said to me, "If hospitals could be trusted to staff properly, they would have done so." While the best hospitals do staff properly, too many don't-and it's exhausting nurses and killing patients.


There are three major arguments against legislating staffing ratios, but they're not sufficiently compelling.


1. Staffing should be based upon principles that take into account the needs of patients and units, not a mandated ratio. The proposed legislation would set minimum ratios. While some fear that the minimum will become the maximum, the best hospitals will exceed these standards, and the worst will be forced to quit assigning eight or more patients to a medical-surgical nurse.


These minimum ratios don't preclude a hospital's use of the ANA's Principles of Nurse Staffing, incorporated into proposed federal legislation, the Registered Nurse Safe Staffing Act of 2003 (S. 991), and the best state or federal bills will incorporate both. But the staffing principles alone are insufficient; they're dependent on proper use of reliable and valid tools for assessing patients. Any bedside nurse at any understaffed hospital will tell you that no matter the acuity level on a unit, it seldom gets more nurses.


2. Because of the nursing shortage, there are not enough nurses to meet mandated ratios. But poor staffing is a cause of the nursing shortage; hospitals will hemorrhage good nurses until they fix the staffing problem. According to a nationwide survey in November 2002 commissioned by the UAN, 85% of nurses ranked reduced nurse-patient ratios as the most effective solution to the nursing shortage.


In 2001 Kaiser Permanente, the largest health care system in California, with 6.1 million members, committed to minimum staffing ratios that exceeded the state mandates as part of an initiative toward excellence in nursing care. According to Marilyn Chow, DNSc, RN, FAAN, vice president for patient care services at Kaiser, the target ratio for medical-surgical units is one licensed nurse (RN or LPN) to four patients. "In 2002 we hired 3,000 RNs and LPNs part time or full time," she said. While most of these nurses are new graduates or recruits from other hospitals, the Northern California branch of Kaiser reported that the number of nurses quitting declined by 47% in 2002.


3. Staffing at the levels set in California will cost too much. The 2002 publication Magnet Hospitals Revisited notes that, while a focused cost-benefit analysis of Magnet hospitals has not yet been conducted, the better staffing at these institutions doesn't cost more, because they have shorter lengths of stay, reduced nurse turnover, and fewer needlestick injuries. Of course, the most important question is, What should a hospital's spending priorities be?


So how long should nurses and patients wait for hospitals to do the right thing?