A Resident's View: Low Nurse Staffing Ratios Lead to Unsafe Outcomes

Osato Ukponmwan, MD, JD


September 02, 2022

Nursing staff ratios are an integral part of patient care, and numerous studies have shown that better hospital nurse staffing correlates with better patient outcomes, such as fewer complications and deaths, decreased stays in the hospital, and improved patient satisfaction. And yet, nurses are being forced to care for an unsafe number of patients.

Osato Ukponmwan, MD, JD

I am in my third year as an internal medicine physician working at three hospitals. During medical school, I worked in several hospitals in New York and New Jersey and I have seen nurses asked to take care of too many patients, limiting their ability to effectively do their job and leading to medical residents assisting in nursing duties.

Even before the COVID pandemic, hospitals in New York were dealing with high patient workloads. It has only gotten worse. In a recent survey of New York and Illinois nurses, 70% of nurses would not recommend their hospitals to someone in need of care. Half of the nurses gave their hospitals unfavorable grades on patient safety, and one third gave poor grades on infection prevention. Half of the nurses experienced high burnout, and one quarter plan on leaving their jobs within 1 year.

In other states, California implemented the first comprehensive state legislation in 2004 limiting the number of patients that hospital nurses can care for simultaneously. It took 14 years for a similar ballot issue to legislate nurse staffing in Massachusetts, but it failed to pass, partly because of a lack of awareness of nurse staffing ratios.

Hospital issues have never been more at the forefront globally than during the COVID pandemic. Conditions primarily confined to people working in hospitals and patients receiving care became common public knowledge, along with discussion about overworked staff and burnout, as New Yorkers banged on their pots and pans to salute "healthcare heroes."

A 2020 report by the New York Comptroller found that Governor Andrew Cuomo undercounted the number of pandemic-related deaths in nursing homes by over 4000. Nursing homes were incentivized to transfer funds from the facility to investors and owners instead of investing in additional staff.

Last year, the New York State legislature passed a bill touted as a win for labor unions. The New York Safe Staffing for Quality Care Act establishes minimum RN, LPN, and aide staffing hours for nursing home residents and safe staffing standards for hospitals. The act requires that nursing homes spend at least 70% of their revenue on direct patient care, with at least 40% dedicated to staffing that works with nursing home residents.

Opponents to nurse staffing legislation will suggest that there is not a ready supply of nurses to fulfill the legislation, but they would be incorrect. California currently has fewer nurses per capita than New York and has had nursing staffing laws in place for two decades. Currently, the state licensure mandate increases the burden on nurses to work in multiple states and supplement their income.

The Nurse Licensure Compact, which has passed in many, but not all, states allows for a nurse to practice in any other state via a multistate nurse license. New York recently introduced a bill to adopt the Nurse Licensure Compact, which will increase the supply of nurses able to work in New York.

Although legislation addresses this problem, its implementation is lagging. Continued discourse and laws need to be passed to ensure that low nursing ratios are the norm across New York. Ensuring that nursing ratios are kept low will give nurses more time to interact with patients and efficiently conduct their duties. Nurses may also feel less stressed. Medical residents will be able to focus on their duties, instead of assisting nursing staff with theirs. Lastly, and most importantly, patient safety will improve.

 Osato Ukponmwan, MD, JD, is a third-year internal medicine resident at SUNY Downstate Health Sciences University in Brooklyn, New York. Prior to medicine, he worked as an attorney and is currently a member of the New York State Bar Association.

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