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Join the “Crucial Conversations.

Lend your voice to the issue of Manadatory Hospital Nurse Staffing Regulations

Peter I. Buerhaus

What Is the Harm in Imposing

Mandatory Hospital Nurse Staffing
INSTITUTE OF MEDICINE’S care in terms of patient outcomes

EXECUTIVE SUMMARY Committee on the Ade- when controlling for all other like-
quacy of Nurse Staffing ly explanatory or confounding
Efforts to establish mandated
staffing ratios are shortsighted, (IOM, 1996) wisely rejected variables” (p. 121). Thus, it was
and, though proponents may the idea of mandatory minimum recommended that more rigorous
have the best intentions, many nurse staffing levels in hospitals. research be undertaken as this
negative outcomes would flow Such provisions would require would have “significant payoffs
from the public airing of this hospitals to employ a prescribed for policymakers, nursing educa-
issue. number of nurses (or full-time tors, and hospital administrators”
The Institute of Medicine con-
cluded in 1996 that there was positions) per diagnosis, disease- (p. 122). However, some nurses
insufficient quality outcome specific condition, number of have understood the committee’s
evidence to support the impo- patients, or other indicator linked position as implying that once
sition of mandated nurse to the provision of nursing servic- research studies provide answers
staffing ratios. es. Neither did the committee concerning the relationship be-
The Massachusetts Nursing endorse mandatory nurse staffing tween the quality of care and min-
Association got legislation intro-
duced in early 1996 which, if
ratios which would require hospi- imum nurse staff levels and/or
passed, would turn over to tals to employ a certain percentage staff ratios, then nurse staffing reg-
state lawmakers decisions gov- of registered nurses relative to ulations should be implemented
erning nurse staffing in hospi- licensed practical nurses or nurse based on these research findings.
tals and other employment set- aides. The committee, instead, Despite the IOM Committee’s
tings. concluded that “there is a serious rejection of policies that would
There are high opportunity paucity of recent research on the mandate minimum nurse staffing
costs. Staffing regulations (if
imposed) would force employ- definitive effects of structural levels or ratios in hospitals, certain
ers to ignore the dynamic inter- measures, such as specific staffing groups in nursing advocate legisla-
actions of economic, technolo- ratios, on the quality of patient tion that would impose these regu-
gy, capital, and labor supply
variables, and thus needlessly
impose the effect of increased PETER I. BUERHAUS, PhD, RN, FAAN, is NOTE: This article was originally pub-
labor costs on hospitals, tax- Valere Potter Distinguished Professor of lished in the March-April 1997 issue of
payers, and nurses themselves. Nursing; Director, Center for Inter- Nursing Economic$ (Vol. 15, No. 2, pp. 66-
Chance for passage of this disciplinary Health Workforce Studies, 72) and is reprinted here as a part of
highly controversial legislation is Institute for Medicine and Public Health, Nursing Economic$’ “Crucial Conver-
unlikely, but the expenditure of Vanderbilt University Medical Center, sations” initiative. See pages 73, 110, and
political chips (and the loss of Nashville, TN; and a Nursing Economic$ 119 in this issue for other articles related to
credibility) will increase the dif- Editorial Board Member. the conversation on Manadatory Hospital
ficulty of obtaining a hearing Nurse Staffing Regulations.
from legislators the next time a
nursing issue comes up.

NURSING ECONOMIC$/March-April 2010/Vol. 28/No. 2 87

lations. For example, in the Spring of the population with insurance 5. The employer’s objective
of 1996, the Massachusetts Nursing coverage, prevalence of diseases function, which refers to the
Association succeeded in getting such as the spread of HIV/AIDS or specific behaviors and goals
legislation introduced in the drug resistant infections, etc.). the organization’s decision
Massachusetts state legislature. If However, it is important to bear in makers are trying to accom-
voted into law, this legislation mind that the number of nurses plish.
could end up effectively turning actually employed at any given time 6. The type, availability, and
over to state lawmakers decisions is determined by health care organi- price of technology and capi-
governing nurse staffing in hospi- zations’ demand for nursing servic- tal which can be productively
tals and other employment set- es. Whether acute care, ambulatory, used to produce treatments
tings. The position of nurses in home care, or community based, and services at any given peri-
favor of regulatory intervention of these organizations are in the busi- od of time.
this kind is built around the recog- ness of producing mostly medical 7. The size of the budget avail-
nition that the health care system treatments and a variety of personal able for employing nursing
is changing rapidly and dramati- health care services to satisfy soci- and other health care person-
cally. Proponents believe that to ety’s demand for health care. Thus, nel.
ensure patient safety and protect they must decide how much and 8. External pressures to produce
the quality of patient care, hospi- how best to use nursing services services more efficiently (for ex-
tals must be required by law to supplied by different types of nurs- ample, the presence of HMOs in
configure their nursing staff ing personnel, and how to combine the market) (Buerhaus, 1995).
according to minimum numbers them with other human and nonhu- Conceptually, these economic
and/or ratios. man resources to produce the type criteria may seem straightforward;
The purpose of this article is to and quantity of treatments and serv- in reality, each is driven by com-
present a number of economic and ices desired by society. Each organi- plicated and constantly changing
political issues that nurses and zation takes into account certain events. In a never-ending process,
policymakers should consider as economic criteria when deciding employers use the best available
they contemplate the costs and the number and mix of nurses it information to weigh these criteria
benefits of seeking legislation that should employ. Briefly, these crite- when making decisions on the
would impose mandatory nurse ria include: amount and composition of their
staffing regulations. Even if results 1. The total compensation (going nursing staff. It is beyond the pur-
from rigorous research were avail- market wage plus fringe bene- pose of this article, however, to
able and could be used to deter- fits — health insurance, vaca- delve into the intricacies of these
mine the “correct” number and/or tion, child care, etc.) that must criteria. Instead, it will be more
ratio of nurses that would result in be paid to each type of nursing useful to focus on a few overriding
obtaining an objectively measured personnel (RNs, LPNs, and considerations and note the prob-
standard of quality, the position aides) relative to the compen- able impact of mandatory nurse
argued here is that nurse staffing sation paid to other health staffing regulations.
regulations would still be inappro- personnel. FIRST, holding the effects of
priate. Such regulations would 2. The additional output (num- other forces constant, as total com-
force employers to ignore the eco- ber of patients cared for, num- pensation rises (falls), employers
nomic criteria they would other- ber of treatments given, num- will have an economic incentive
wise consider when making nurse ber of patient/family visits, to employ fewer (more) nurses
staffing decisions, impose signifi- etc.) that can be obtained by and/or total number of hours of
cant costs on hospitals, taxpayers, employing a particular type of nurse labor or FTE positions.
and, perhaps most damaging of nurse compared to the output Thus, in the event that mandatory
all, would needlessly inflict sub- produced by others (for exam- nurse staffing regulations result in
stantial opportunity costs on the ple, the output produced by increasing an organization’s total
nursing profession. employing an additional RN compensation costs, then a strong
versus an additional LPN). economic incentive will be creat-
Economic Determinants and 3. The perceived or empirically ed for employing fewer nurses.
Nurse Staffing Regulations measured contribution to the Although the regulations may
The overall demand for nurses quality and clinical outcomes block the organization from reduc-
is derived from the forces that deter- of treatments and services that ing the size of its nursing staff in
mine society’s total demand for can be obtained by using each the near term, at least while they
health care (for example, changes in type of nurse. are in effect, over time it can be
the size and composition of the pop- 4. The available supply of each anticipated that employers will be
ulation, increases/ decreases in per type of nurse at any given motivated economically to find
capita personal income, proportion period of time. ways to subvert the regulations.

88 NURSING ECONOMIC$/March-April 2010/Vol. 28/No. 2

SECOND, the forces driving the forces that act on each of these Similarly, technology has
each of the mentioned employ- criteria and which employers been rapidly introduced in health
ment criteria arise from both must anticipate and carefully con- care and there are numerous
inside and outside the health care sider when making decisions on examples of how it has affected
industry. In many cases, these nurse employment levels and the demand for nurses. In some
forces can not be controlled or staffing composition. cases, technology has required
influenced by an employer (or a THIRD, beyond human re- more nurses’ time and thus creat-
regulatory agency). Rather, it is up sources, organizations also use ed a positive affect on demand; in
to employers to understand the capital to produce health care other cases, it has reduced the
forces and take into account their services. Capital refers to equip- number and/or type of nurses
impact on local market conditions ment, buildings, inventories, and required. And, not to be over-
when making nurse employment other nonhuman resources that looked, technology has substan-
and staffing decisions. To illus- contribute to the production, mar- tially affected the practice of
trate, consider the forces that keting, and distribution of person- physicians, pharmacists, respira-
determine the long-run supply of al health care services. However, tory therapists, and others in ways
nurses (number 4), which refers to the type, amount, and price of that have significantly affected the
the total number of nurses who will capital change over time, just as provision of nursing services (and
be available to offer their services in the type of labor and how it can be will continue to do so). Thus, the
the nurse labor market. The number productively combined or substi- development of technology in
is determined in part by changing tuted for each other and for capi- nursing and technology in com-
social preferences for nursing as a tal. This means that the relation- plementary health professions
career, the size of age cohorts from ship between capital and labor is influences the quantity and mix of
which prospective nursing students dynamic, not static. Consequently, nurse staffing, not to mention the
are drawn, the capacity and types of over time one would expect to kind of patient care that is provid-
nursing education programs, the observe different amounts and ed.
supply of faculty, the sensitivity of combinations of capital and labor FOURTH, an employer’s
prospective nursing students to being used by employers to pro- objective function influences its
changes in tuition rates, and duce patient care. decision regarding the number
increases/decreases in nurse wages In nursing this is illustrated by and combination of nurses to
in the labor market. However, the thinking about how the roles and employ. Some employers are cost
short-run supply (the probability productivity of one type of nurse minimizers, others emphasize
that existing nurses are willing to relative to another (an LPN versus quality and highly satisfied
work and the number of hours an RN versus a nurse practitioner, patients over anything else, some
actually worked) is determined by etc.) have changed markedly over direct resources toward services
different factors, such as the time. In part, these changes have and facilities that primarily bene-
nurse’s age, presence of young resulted from hospitals’ acquisi- fit physicians, and still other
children, marital status, enroll- tion of physical resources such as employers seek to build a reputa-
ment in an education program, the intensive care, special care, suba- tion as innovators, perhaps by
wage rate, and amount of non- cute, home health care units, etc. developing programs that better
nursing and other household Equally important, just as the serve the health needs of the com-
income. The point is that a broad amount and use of capital has munity. However, most employ-
array of forces are constantly and changed over time, so has the pro- ers’ objective function changes
simultaneously affecting the sup- ductive capabilities of nurses as a over time: this year’s cost mini-
ply of nurses as well as each of the result of modification in state mizer might emphasize quality
previously mentioned criteria that practice acts, changes in institu- improvement next year; or, this
employers must consider, but can- tional policies, and collective bar- year’s all-service hospital may
not completely control, when gaining agreements that have decide to confine itself to provid-
making decisions on nurse affected nurses’ relative prices ing only the services that it is best
employment and staff configura- (wages) and enabled the perform- at producing or has a comparative
tions. Furthermore, changes in ance of more/fewer tasks by differ- advantage in its local market.
any one of these criteria will exert ent types of nurses. Once again, Whatever the objective, it will
an effect on the employer’s imposing mandatory nurse staf- play an important role in deter-
demand for labor, and at different fing regulations would disregard mining the type of nursing servic-
points in time, some criteria will these kinds of changes and nega- es the organization provides and
exert a more important effect than tively affect opportunities for hence the quantity and type of
others. Mandating minimum employers to find new ways to nurses required to produce those
nurse staffing levels or specific combine capital and labor to services.
ratios would render impervious improve health care delivery. FIFTH, even though employ-

NURSING ECONOMIC$/March-April 2010/Vol. 28/No. 2 89

ers rarely have complete or neces- which employers would other- nurse staffing levels or ratios?
sarily accurate information on how wise use to produce nursing care. Should it be an existing state
each of the determinants of nurse More important, the standard health care agency, a local govern-
employment is changing, they are would be frozen for an indefinite ment agency, a quasi public/pri-
motivated to have an adequate sup- time during which the organiza- vate agency, or should a new
ply of nurses to produce the tion is prevented from responding agency or special committee be
amount and kind of patient care to changes in any of the economic developed? Each option carries
demanded. Assuming that enough determinants of nurse employ- different economic costs: Which
nurses are willing to work at the ment. one would be least costly from the
wages and working conditions Even worse, if enacted, these perspective of taxpayers who are
offered by employers, and taking regulations would be introduced paying for this undertaking?
into account the previously men- at a time when the health care Would members of the public,
tioned economic criteria, most industry is changing rapidly and as well as representatives of pro-
health care organizations seek to dramatically. Today employers fessional and provider organiza-
employ the number of each type of must respond ever more quickly tions, serve on the agency or group
nurse up until the point that the and effectively to new economic which is charged with implement-
marginal product (the extra demands or risk going out of busi- ing the regulatory process? Would
amount of output — however ness. For the nursing profession, there be an opportunity for public
defined — gained from hiring the this means that nurses must pay hearings or a comment period for
last nurse) is just equal to the mar- much greater attention to the eco- public response to proposed rules
ginal cost of employing that nurse. nomic determinants of nurse and regulations? Would the regu-
The goal is to employ the number employment. Nurses can not latory agency be required to
and mix of nurses that can most afford to ignore these determi- respond to the comments? Would
efficiently produce the required nants and the forces affecting a cost benefit analysis be required
treatments and services consistent them by seeking regulations that of the proposed regulations?
with the organization’s objectives, would erect a barrier between What would the budget of
budget, and quality standards; and themselves and employers’ deci- such a regulatory undertaking
to find ways that other health care sion with respect to employment involve? Would new staff be hired
personnel, capital, and technology and staffing. Rather, nurses should to develop the regulations, or
can be most productively com- focus on working closer with would existing personnel from
bined. employers to find new ways to other agencies be deployed? Who
These criteria, together with enhance nursing’s value in pro- will make these decisions, and
societal forces that influence the ducing hospital-based health care what is their self-interests in this
overall demand for health care, services. The more nurses raise matter? What should the qualifica-
determine the total employment their value to an organization, the tions be for those who would
of nurses by hospitals and other more positive the impact will be write and monitor the regulations?
health care organizations at any on their own employment and Are enough people with these
given point in time. But if state earnings, not to mention patient qualifications available?
lawmakers pass legislation man- welfare (for a further discussion How would proposed and final
dating minimum nurse staffing on this imperative, see Buerhaus, regulations be communicated to
levels and ratios, then essentially 1996). providers? Exactly how would the
all of these economic criteria regulations be implemented: phas-
would become irrelevant. In their Regulatory Costs ed in over a given period of time, or
place would be arbitrary and sub- Even if proponents of manda- made fully effective all at once?
jectively determined regulations tory nurse staffing regulations in How frequently should providers
that are virtually unrelated to hospitals believe that the econom- be monitored: once a week, once a
these criteria. In light of the ic criteria briefly reviewed here month, once a quarter, twice a year,
important considerations raised can somehow be ignored, such once per year? How will providers
by this albeit limited overview, regulations raise other questions be monitored? Would the public be
one must seriously question how that can not be so easily glossed notified of the effects (both intend-
an externally imposed regulatory over. Following are some exam- ed and unintended) of the regula-
process that ignores these employ- ples of the questions and issues tions? How long would the regula-
ment criteria could possibly pro- that proponents of nurse staffing tions remain in effect; temporarily,
duce the outcomes desired by pro- regulations should be prepared to or do proponents envision them as
ponents. The obvious result of answer. permanent controls?
such regulations is the creation of Who should develop the regu- How would nurse staffing reg-
a nurse staffing standard that lations needed to implement the ulations be enforced? Would
either exceeds or falls below that legislation mandating minimum penalties be levied against non-

90 NURSING ECONOMIC$/March-April 2010/Vol. 28/No. 2

compliant providers? If the penal- siderable amount of time, proba- incurred by nurses, both support-
ties are financial, what should be bly no less than 18 months. ers and opponents, means that
the dollar amount for each viola- Moreover, even if regulations are other issues important to the pro-
tion? Who would collect the fine put into effect, it is highly likely fession are not being addressed as
and what would be done with the that they will fail to achieve their fully as they might. These lost
collection? Would these dollars be intended outcomes. And when opportunities have value and
used to offset the costs of the regu- this occurs some will view the hence there is a cost to nurses
latory agency, or returned to the failure as evidence that new and when they are not achieved.
provider once compliance is stronger regulations are needed. In Therefore, proponents of regulato-
established? How would multiple turn, this could lead to the entire ry intervention confront two
violators be punished? What process being repeated, which important questions: What other
processes would need to be in would only increase the costs of objectives are being given up or
place to grant providers excep- nurse staffing regulations even are not being effectively attended
tions or waivers from the regula- further. to as a result of pursuing the goal
tions, assuming they are permitted Finally, assume for a moment of mandated nurse staffing legisla-
under the law? What would quali- that all of these issues were easily tion; and, what is the value of
fy as an exception and how would resolved and that the entire leg- these lost opportunities to nurses
providers who receive them be islative and regulatory processes and the public?
monitored? What due process pro- went smoothly and rapidly. What Given the provocative nature
cedures would be available to would happen if it turns out that of the issues surrounding nurse
providers who believe they are the regulated nursing staff level or staffing regulations, and given the
being harmed or unfairly affected? ratio (or both) was set either below depth of feeling held by interested
How would quality be meas- or above the staffing level that is parties, these are important ques-
ured? Would/should the regula- actually required to produce some tions that leaders of professional
tions distinguish nurses based on specified level of quality? This is a nursing associations, unions, poli-
educational credentials, years of problem because both the mean- cymakers, and other concerned
experience, or some other criteria? ing of quality and how it is meas- parties must address when formu-
Or would all RNs (as well as LPNs, ured are expected to change and lating political agendas. Nursing
aides) be considered as identical evolve rapidly in the years ahead. leaders should also ask if the
inputs and, therefore, counted How then can advocates of nurse anticipated benefits of the nurse
equally? staffing regulations be confident staffing regulations are likely to
Answers to every one of these that the staffing requirements they exceed the expected costs, espe-
questions (and many others) carry would impose on others will be cially the costs associated with the
certain economic costs. They also unaffected by changing defini- damage to relationships between
raise issues that are likely to tions of quality? Moreover, how nursing organizations holding
become the focus of intense can advocates ensure that the reg- opposing views. Even more funda-
debate, endless revision, special ulations can and would be applied mentally, leaders should assess
deals, and contentious private and equitably across different types of the chances that the regulations, if
public bickering at each stage of hospitals and would be relevant implemented, could realistically
the legislative process — introduc- and workable across different geo- achieve their intended outcome.
tion of the bill, public hearings, graphic regions? And what assur- In asking these questions, leaders
subcommittee and full committee ances can proponents offer that should consider other actions that
votes, floor debates and votes, the regulations would be adjusted could be taken that have a better
meetings of joint conference com- appropriately with the passage of chance of achieving the goal of
mittee to iron out differences, etc. time, development of technology, improving the quality of patient
And then, the squabbling is likely changes in nursing education, care (not merely protecting quali-
to resume once the regulatory changes in nurse wages, and other ty), which are less costly, can be
agency assigned to develop and changes in the hospital industry accomplished more rapidly, and
implement the law begins its that none of us can foresee? have less chance of fracturing rela-
work. tionships within the nursing com-
The struggle to obtain and Opportunity Costs to Nursing munity.
implement nurse staffing regula- Another important drawback
tions will not come cheaply or of nurse staffing regulations Expected Costs to Hospitals and
quickly. Tremendous investments would be the needless, self-inflict- Nurse Employment
of energy and resources will be ed, and potentially high opportu- Hospitals also should be con-
expended by both proponents and nity costs that nurses would sidered as they will bear a consid-
opponents, and the legislative and impose on themselves. All the erable portion of the direct costs of
regulatory process will take a con- time, energy, and expense nurse staffing regulations. If they

NURSING ECONOMIC$/March-April 2010/Vol. 28/No. 2 91

are required to staff according to where the costs of nurse staffing more, what will the public think
mandated minimum nurse staf- regulations are high and employ- of the nursing profession — one of
fing levels or ratios, then, in effect, er’s financial condition is weak, the few health professions that is
they will be forced to produce nursing units could be closed or still viewed favorably by the
patient care services inefficiently. reduced in size. These are not pos- majority of Americans — should
By constraining hospitals’ ability itive outcomes for nurses, and one the media exploit the bitterness
to select and experiment with dif- wonders how nurses would and strife that will be unleashed
ferent numbers and skill mixes of respond. Demand more regula- within the nursing community
nurses, they would be significant- tions? over this issue?
ly hampered in exploring ways to While nurse educators, re-
maximally combine nursing care Political Considerations searchers, and policymakers can
with the services of other The current mood of be proud of their accomplish-
providers or technologic innova- Americans is one of considerable ments in elevating the presence
tions. Hospitals, like any other mistrust and cynicism toward and effectiveness of nurses in the
employer of nurses, need the free- government. The public is very political and public policymaking
dom to take full advantage of the concerned about government arena over the past 2 decades, this
resources they are paying for to spending and reducing the federal is a good time to pause and con-
produce patient care using the budget deficit, resistant to tax sider some of the frank realities of
least amount of resources needed increases, and desires only a mod- the political and regulatory
to satisfy the demands of patients est level of government involve- processes. More often than not,
and also meet its objectives. ment in resolving national and the vast majority of bills that are
Moreover, think about situations state problems such as health care introduced never become law.
in which health care is being (Blendon, Hyams, & Benson, 1996; Usually, the more contentious the
delivered in ways that satisfy McDonough, 1997; Morin & Balz, issue, the more political groups
patients, purchasers, and nurses 1996). Indeed, these attitudes are involved, which in most cases
themselves. Nurse staffing regula- played a significant role in the extends the length of time needed
tions would cause hospitals to public’s rejection of the Clinton to reach a political outcome, if one
change the number of nurses and health plan (Blendon, Brodie, & is obtained at all. When they do,
staff ratios to comply with the Benson, 1995) and the over- most bills end up with language
“legal” requirement. Consequently, whelming defeat of the single that reflects compromise deci-
either patients, payers, or nurses payer proposal in California sions, take a considerable time to
would be made worse off. No mat- (Brodie & Blendon, 1996). Both be implemented by a regulatory
ter how hard regulators try, political parties are positioning agency, and are very costly for
mandatory staffing regulations themselves to shrink the size of what is materially accomplished.
will inevitably end up disadvan- government and reduce its inter- Nothing about the politics of
taging some hospitals and creating vention in the lives of Americans. enacting nurse staffing legislation
distorted and unintended incen- The current political environ- suggests that nurses would be
tives. To be sure, hospitals will ment and the mood of the spared from any of these consider-
respond by investing substantial American public with respect to ations. Rather, the outcome seems
resources to obtain political reme- government involvement in health fairly predictable: Nursing groups
dies to counter the harmful effects care, suggests that actions to will have aired their differences
of nurse staffing regulations. obtain nurse staffing regulations and not their unity in public and
Proponents of staffing regula- could adversely affect the public’s in the political marketplace; dam-
tions in hospitals should also real- trust and support of the nursing aged their reputations; spent valu-
ize that because the regulations profession. It is not difficult to able political chips; ended up
would contribute to the inefficient imagine that a considerable por- with no legislation enacted; and,
production of patient care, the tion of the public would view will have raised the costs of
economic effect on hospitals such legislation as another exam- obtaining future legislation as leg-
would be an increase in its labor- ple of unnecessary government islators are likely to be more cir-
related costs. Such an effect is not involvement and added bureau- cumspect about getting involved
unlike imposing an increase in the cracy serving special interests. with nurses. Although it is con-
minimum wage and its well- Some might even perceive this ceivable that mandatory nurse
known affect on employment. intervention as “make work” regu- staffing legislation could be enact-
Employers will have an economic lations designed to protect nurses’ ed, it would probably take several
incentive to reduce nurse employ- jobs, cynically cloaked in lan- sessions of the state legislature.
ment; substitute technology and guage proclaiming that the regula- However, by this time, the issue is
non-nursing personnel for nurses tions are necessary to protect the likely to have lost any of the polit-
whenever possible; and, in cases quality of health care. Further- ical salience it may have had, and

92 NURSING ECONOMIC$/March-April 2010/Vol. 28/No. 2

its relevance to the nursing profes- ty, as opposed to taking decisive REFERENCES
sion will have diminished. steps to find ways to work much Blendon, R.J., Brodie, M, & Benson, J.
(1995). What happened to Ameri-
closer with employers to discover can’s support for the Clinton health
Concluding Comments new ways to keep lowering the plan? Health Affairs, 14(2), 7-23.
No one should question the costs of health care while improv- Blendon, R.J., Hyams, T.S., & Benson, J.
well meaning intentions of those ing the quality of services. Finally, (1996). Health care and the 1996
election. Inquiry, 33(1), 10-13.
who believe in legislation to man- efforts to achieve these regulations Brodie, M., & Blendon, R.J. (1996). Public
date minimum nurse staffing lev- raise the specter of a public per- opinion and health policy. In T.
els or skill mix ratios in hospitals. ception that nurses are really Litman & L.S. Robins (Eds.), Health
To be sure, proponents care interested in protecting their jobs. politics and policy (3rd ed.). Albany,
deeply about the well-being of Given all of the issues raised NY: Delmar.
Buerhaus, P. (1995). Economics and
patients and the nursing profes- herein, nurse staffing regulations reform: Forces affecting nurse
sion. However, for all of the rea- would appear to impose far more staffing. Nursing Policy Forum, 1(2),
sons discussed in this article, costs than benefits and, therefore, 8-14.
mandatory nurse staffing regula- would be a step backward for Buerhaus, P.I. (1996). Creating a new
place in a competitive market: The
tions carry a high potential for everyone concerned. In contrast, value of nursing care. Nursing Policy
unwittingly leading to the eco- changing the incentives that pur- Forum, 2(2), 13-20.
nomic and political devaluation of chasers offer hospitals so that they Institute of Medicine. (1996). Nursing
the nursing profession. Pursuing are positively rewarded for staff in hospitals and nursing homes.
this regulatory strategy is short improving quality and producing Is it adequate? Washington, DC:
National Academy Press.
sighted, wasteful of nurses’ valu- well-defined and desired clinical McDonough, J.E. (1997). Tracking the
able time and energy, will almost outcomes, is a potentially more demise of state hospital rate setting.
certainly fail to achieve intended effective way to constructively Health Affairs, 16(1), 142-149.
effects or deal effectively with the address the many issues sur- Morin, R., & Balz, D. (1996, January 28). In
America, loss of confidence seeps
issues surrounding nurse staffing, rounding nurse staffing that can into all institutions. The Washington
and would exact high opportunity not be solved by a regulatory Post, pp. A1, A6.
costs on the nursing profession. agency.$
The regulations would force
employers to ignore the economic
criteria they would otherwise con-
sider when making nurse employ-
ment and staffing composition
decisions, which would result in
increasing the costs associated
with employing nurses and sour-
ing the relationship between nurs-
es and employers. Seeking govern-
ment intrusion into the nurse-
employer-patient relationship also
exposes nurses to all the costs and
setbacks that are part of the reality
of relying on political and regula-
tory intervention. Not only is the
public’s mood toward government
a reason for caution, but efforts to
obtain nurse staffing regulations
appear to carry especially high
political costs to nurses and a high
probability of defeat and disap-
Unfortunately, pursuing nurse
staffing regulations would divert
nurses’ and employers’ attention
to the political marketplace and
away from where real solutions
must be found — in the work-
place. They also risk focusing on
the wrong issue, protecting quali-

NURSING ECONOMIC$/March-April 2010/Vol. 28/No. 2 93

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