Nurse-Staffing Ratio: Hospital’s Perspective

Nurses are expensive! Nurses comprise the largest labor force in an acute care facility. By the nature of their professional status and licensure and their direct legal responsibilities to the patients they serve, nurses do not trade their professional skills and knowledge for cheap. When their nursing experience at the bedside is calculated in years, their income per nurse can be almost double that of a new graduate nurse. Add a nurse’s certifications, specialty training and graduate degrees to that bottom-line and a single clinically-functioning nurse can cost a hospital almost the same as an exempt nurse manager – sometimes more.

Business 101 explains that labor is the highest expense of most any company. Control labor costs and a business can move along toward solvency. Control labor costs and other expenses hard enough and a business should be profitable. Accordingly, whenever expenses need to be controlled due to decreasing and/or slow payments and/or poor strategic business decisions, labor is the first reviewed for immediate cost savings. Since the Nursing Department comprises the largest number of employees, a single slash to pay raises for clinical nurses accomplishes a lot, but not everything.

Throughout the entire hospital, inventories are reduced, positions are held un-filled, ‘what constitutes hazardous waste’ (paid by the pound for removal) is re-taught, new positions are denied, overtime is deeply restricted and incremental overtime is punished, traveling nurses and agency nurses (used to fill gaps) are eliminated, employee goodies (Holiday parties, appreciation gifts, etc…) are wiped-out, nurse-extenders (nursing assistants and technicians) are pared to almost nothing, and still…it is not enough to effectively produce the cost-savings needed. The most effective cost reduction is always a reduction or re-purposing of the number of nurses themselves.

To the best mindset of traditional manufacturing management, if each nurse would just care for 1 or 2 more patients in the medical-surgical environments, the business could maintain their profit margins. (The ICU’s, needing their strict nurse-staffing ratio’s to protect the patient and the hospital, are not considered for this cost-saving measure.) The most experienced nurses, ‘if they are good’ as the thinking goes, should be able to care for more than just 6 or 7 recovering (read: no real work at all) medical-surgical patients and the hospital executive team expects them to do so. It is an expansion of the nurse’s skills and the hospital leaders consider it a mission to support the growth of their employees.

Since there are few stringent nurse-staffing guidelines for the medical-surgical units of a hospital – maternal-child areas excluded – and since the patients admitted to those areas are recovering and not in need of frequent, direct nursing care and since the risk for sudden death or debilitating injury is extremely low and thereby not putting the hospital is increased legal risk, these are the units most available to the hospital to cut labor costs in terms of nurse staffing. One experienced nurse to 6-8 patients during the day and upwards of 7 – 10 at night should be completely within the abilities of a good nurse.

A government mandated hospital-wide nurse-staffing ratio without a commiserate increase in direct or third-party payments to cover the costs of hiring the extra nurses is an unfunded mandate that hospitals insist they cannot accomplish. Yes, they are building. Yes, they are hiring physicians as employees. Yes, they are paying four-, five- and six-digit cash bonuses and providing other non-monetary incentives to their senior leadership and physicians. Yes, they are investing millions in electronic and surgical and diagnostic technology. Yes, they pay a six-digit fee to be members of their state’s hospital political lobbying group. Yes, they pay a six-digit fee to be and keep their Magnet recognition status. Why, yes, they did pay millions to a business-consulting firm to assist them with identifying cost-savings. And, in order to continue on those extremely important paths of growth and profitability, expending anything whatsoever for more nurses (read: general house labor) would be counter-productive and injurious to their financial health.

Besides, there is a nursing shortage. Hospitals contend they can barely hang on to the nurses they already have. The median age for a nurse at this time is 46 years old. The back-fill is not there and until the nursing schools start producing more nurses, there are pitifully few extra to meet a government mandate.

Mandating nurse-staffing ratios at this time in the U.S. economy would put a large percentage of hospitals completely out of business, they say. Hospitals across the country would have to shutdown and leave entire communities without access to healthcare. Advocates for the hospital perspective frequently include a personal rejoinder along the lines of, “If mandated staff-nursing ratios were implemented today, whole intensive care units would have to be staffed with newly graduated nurses just to meet the legal requirements. …I would not want that for my family-member or myself and I do not think you would either.”