Will hospital staffing legislation solve Minnesota's nursing shortage, or make it worse?

Depending on whom you ask, hospital staffing legislation is either going to solve Minnesota's shortage of bedside nurses, or force hospitals to close entire floors and deny patients care.

Reality probably lies between the extremes, but Minnesota is getting closer to finding out. Sweeping staffing reforms are advancing through the state House and Senate.

Proponents say the need is urgent. An exodus of nurses from hospitals is contributing to longer ER wait times and less patient care, sometimes leading to verbal or physical abuse from patients and families — which in turn drives more nurses away. A record 5,625 nursing positions were vacant in Minnesota at the end of 2022, according to preliminary state survey data.

"We don't want to ruin some small rural hospital. We don't want to make it more difficult for the big hospitals in the metro to serve the people that need them. But it has to work," said Sen. Jim Abeler, R-Anoka, about the staffing bill he coauthored. "I do believe that many nurses are leaving because of this."

The Republican joined with DFL supporters because the proposal requires hospital administrators and nurses to work together on staffing solutions, rather than government-mandated nurse-to-patient ratios. While ratios have boosted nurse staffing in California, they have been a poison pill to prior legislation backed year after year by the Minnesota Nurses Association.

This year's union-backed legislation is only the second in two decades to drop staffing ratios. The bill instead proposes committees of administrators, nurses and other caregivers to set their own staffing levels for every inpatient unit in their hospitals. Advocates believe this teamwork would result in manageable workloads, drawing nurses back to hospitals or to increase part-time hours.

Rachel Hanneman works three 12-hour shifts per week at M Health Fairview Southdale Hospital in Edina, and sometimes stretches them to 16 hours. But she said she gets exhausted if shifts are overloaded with six or seven patients, instead of four or five.

"That's not safe," she said. "That's why you're not going to see me coming back into work tomorrow" for an extra shift.

Hospital leaders said they already use workforce committees or nurses' real-time feedback in electronic records to adjust staffing, but are facing demographic challenges that won't improve with legislation.

Veteran nurses are retiring and younger replacements prefer the work-life balance of part-time hours. The share of hospital nurses who work full-time declined from 52% in 2016 to 43% in 2022, according to the Minnesota Hospital Association's workforce report.

Hospital leaders fear the state-mandated committees would set inflexible nurse staffing ratios, forcing the closure of units that can't meet those ratios and the denial of inpatient care when staffing is short. They estimated a 15% reduction in hospital capacity that would disrupt access to care for 70,000 Minnesotans.

"That's the problem with this legislation," said Dr. Rahul Koranne, the association's chief executive. "The patient is coming second."

Lessons from other states

The proposal is gaining serious consideration, being added to the billion-dollar House and Senate budget bills that set Minnesota's public health care priorities for the next two years.

Minnesota isn't alone in seeking legislative remedies to nursing shortages. Colorado and New York recently added staffing committee laws and Oregon is considering one this year.

A recent study offers pessimism. Researchers at George Washington University found that California's mandated staffing ratios increased the number of hours worked by nurses in hospitals per day, which other studies equate with better patient care. However, nursing hours did not increase in eight states with staffing committee laws, nor in five states that sought to motivate improvements by publicizing hospitals' staffing levels.

"Especially when committees are mandated by law, it seems like it's pretty easy to basically eviscerate their power and just have people meet for the sake of meeting," said Patricia Pittman, director of the university's Fitzhugh Mullan Institute for Health Workforce Equity.

Union leaders said ratios weren't going to gain political support in Minnesota, but that staffing committees could work if given authority.

New York gives hospital chief executives final say over nurse staffing if committees reach an impasse. Colorado requires that nurses make up 60% of committees, but allows hospital leaders to rewrite their staffing plans.

Minnesota's legislation would only allow hospital leaders to request arbitration if they disagreed with their committees' staffing plans. And hospitals would only be exempt from the staffing plans in emergencies, such as blizzards or pandemics.

Minnesota's health commissioner also would publicly grade hospitals on their compliance with staffing levels and on problems such as falls and bed sores that can increase when patients lack nursing care. Minnesota already publicly reports whether hospitals fall short of staffing plans created by their chief nursing officers, but the data is difficult to compare.

Hospitals suggest that rigid staffing levels will limit care for patients, but their care is already limited, said Carrie Mortrud, a staffing specialist for the nursing union.

"Nobody is going to get turned away — any more than they are right now," she said. "They're coming in and just sitting in the hallways, which isn't bedside care, either."

Other proposals in the bill to boost nurse staffing include increasing nurse loan forgiveness and improving workplace safety. The bill also calls for a wait-time meter in emergency departments to reduce stressful interactions between waiting patients and nurses. Many hospitals already post ER wait times online.

'Window dressing' or solution?

Solutions are needed, said Linda Aiken, founding director of Penn Nursing's Center for Health Outcomes and Policy Research. Her research in Queensland, Australia, found an association between higher patient loads for nurses on medical-surgical units and worse rates of patient mortality and nurse exhaustion.

Aiken said she is worried states are opting for the "window dressing" of politically palatable staffing committees over California-style ratios that have measurably increased nurse staffing. Increased staffing costs can be offset if more nurses prevent complications in patients, she argued.

"Infections, even if they don't kill patients, they're very expensive," she said.

Nurse John Welsh is hopeful. The number and severity of patients have been increasing, and the stress prompted him to cut hours at Mercy Hospital's Fridley campus. Welsh replaced some lost income by adjunct teaching at colleges, but he said he would increase his nursing work under favorable conditions.

"Wages are one thing," he said, "but just getting beat up day to day on a shift and not being able to provide the care that you want? It wears you down."