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How Will HB 4550 Mandatory Staffing Ratios Affect Michigan's Health Care System?

Prominent Member
Joined: 11 months ago
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Long form story in last night's Lansing State Journal on the possible effects of HB 4550, a bill which mandates maximum patient-to-nursing staff ratios for hospitals:

What could Michigan's proposed nurse staffing changes mean for you?
By Sheldon Krause - June 27, 2023

LANSING — Nurse Jeff Breslin was caring for eight patients at once during the height of the COVID-19 pandemic, an experience that left him worn out and providing less care than he thought was acceptable.

Breslin says he has seen patients suffer adverse health outcomes because they didn’t receive one-on-one care and, like 42% of nurses surveyed in the state, he attributes at least some patient deaths to staffing shortages among nurses.

“Try as I might, I'm not able to do everything that I see that the patient could use for quicker recovery, for a shorter hospital stay — I'm doing the necessities and that's about it,” he said.

The Democratic-controlled Michigan Legislature is considering legislation that would set specific maximums for the number of patients nurses could be assigned to care for at a time.

Hospital and health association officials say requiring nurse-to-patient ratios will increase costs, won't help solve current staffing shortages and could lead to some facilities shutting down departments or closing completely because they can't maintain required staffing. Proponents call those concerns overblown and say the law would reduce costs, improve worker mental health, lure nurses back into the field and, most importantly, better protect patients.

As the Legislature considers the requirements, here's how could they impact patients seeking care, and affect quality and cost of that care.

What would the legislation do?

The legislation — HB 4550 — would set mandatory staffing ratios, meaning only a certain number of patients could be assigned to a specific nurse’s care. The ratios differ, depending on the type of care, from 1-to-1 for an intensive care unit or birthing center, 1-to-4 for pediatrics and 1-to-6 for healthy postpartum mother and baby care.

Currently, there are no universal regulations in place for nurse staffing across hospitals or departments.

"I've heard of some nurses getting up to eight, nine or 10 patients apiece," Breslin said.

Amy Brown, chief nursing officer at Sparrow's Lansing hospital, said there are staff-to-patient ratios set in union contracts — but the ratios in the legislation would leave nurses caring for fewer patients in most settings.

Sparrow's contract with its professional employees union generally calls for staffing levels at or fewer than two patients per nurse in intensive care, five patients per nurse for surgical and oncological work, and eight patients per nurse for rehabilitative care.

Sunny Yohannes, a registered nurse at McLaren Hospital Lansing, said adequate staffing ratios are essential for patient safety.

“When nurses are assigned too many patients, they struggle to provide the timely and appropriate care for their patients, which increases risk of medical errors, adverse effects, complications,” she said.

'I think it'll be harmful to hospitals'

Brian Peters, CEO of the Michigan Health and Hospital Association, which represents and lobbies for Michigan community hospitals, has shared his group's opposition to the proposal.

Peters said the group has “always felt that this legislation may sound good on the surface, but when you really do the analysis would not be helpful at all.”

“This becomes an access-to-care issue in rapid fashion,” Peters said. “So, again, it's well-intended, perhaps, sounds good, but just a practical matter of this legislation would cause more problems than it would solve.”

Brown echoed those comments, saying that requiring nurses to see fewer patients could leave gaps in the level of care hospitals are able to legally provide. Already, Brown said, Sparrow has had to reduce its capacity by several dozen beds due to lack of nurse staffing.

"The thing that worries me the most is when we require hospitals to hire even more nurses when we don't have the supply right now," she said. "I think it'll be harmful to hospitals in their ability to offer health care services to their communities.

"We ended up closing two of our adult inpatient units because we just couldn't find enough staff," Brown said, referring to two 30-bed units in Sparrow's Lansing hospital that closed in mid-2022. The hospital also has had trouble in finding employees to work nights and weekends, she said.

Breslin called the comments “scare tactics” by the hospital industry, and said the biggest positive would be better patient care.

“Instead of having to cut corners, instead of having to rush through, we'll be able to actually give them good care or better care than we're able to with too many patients,” Breslin said.

Brown didn't have specifics on the possible impacts on patient costs, but said the hospital would continue to "always try to do the very best thing for our patients."

Breslin dismissed concerns about possible increased costs that may be passed on to the patients.

“Hospitals will actually save money. There will be less nurse turnover because there will be a higher job satisfaction, because we'll be able to take care of patients in a manner that we know they need to be taken care of,” he said. “They won't have to spend so much to train and onboard new nurses.”

Yohannes, a member of McLaren’s Local OPEIU 459, also believes costs will decrease because of improved patient outcomes.

“You're preventing your adverse events, your complications, your hospital acquired infections, which can be expensive to treat,” she said.

Wait times?

The Michigan Health and Hospital Association and the Michigan Organization for Nursing Leadership said in a joint statement that the legislation would “prolong the time it takes for a patient to receive care and hinder the ability of hospitals to respond to a crisis in fear of violating Michigan law.”

Breslin, however, claims wait times would improve through more effective care nurses would be able to provide, as well as nursing staff expanding over time.

“If we've got the proper staff on the floor, and we get the staff on the floor as outlined in the bills, then we'll be able to take the patients out of the emergency department, and they won't have the extended wait times that they're seeing right now,” he said.

Yohannes agreed more nurses could have a positive affect on wait times.

“When I have a manageable workload, I can devote time and attention to every single one of my patients and address their individual specific needs by providing more of a comprehensive care instead of feeling rushed,” Yohannes said. “It allows me to monitor my patients closely administer medications on time, do my assessments on time and provide timely interventions.”

Where would the nurses come from?

ICU nurses Mary-Jo Julin, left, and Lauren Brandon, middle, are briefed about patients Oct. 20, 2020, during shift change at Sparrow Hospital's medical intensive care unit in Lansing.
Critics of the legislation have asked where new nurses will come from to fill the positions required by the proposed law. There are about 8,000 open positions in Michigan hospitals, Peters said.

The MHA and MONL statement said claims that the legislation could address the nurse shortage “couldn’t be further from the truth.”

Tangible, proven steps are needed to attract more nurses to Michigan. Those include passing legislation that allows Michigan to join the Nurse Licensure Compact, expanding Michigan Reconnect eligibility and increasing penalties for those who commit acts of violence against healthcare workers.

But both nurses said the openings could easily be filled by an already existing group: registered nurses who have left the field.

“What we have is a shortage of nurses that are willing to work currently in the hospitals,” Breslin said, rather than an overall nurse shortage.

“By passing this legislation, we would end up retaining a lot of these new nurses into the profession that they have chosen to go into. And, in fact, the hospital would have a lot less turnover costs a lot less training costs, because people would stay,” he added.

The Bureau of Labor Statistics published data from May 2022 showing there were 101,470 registered nurse positions occupied in Michigan, at an average salary of $80,660.

Data from the Michigan Department of Licensing and Regulatory Affairs data shows more than 196,000 registered nurses, meaning more than 95,000 registered nurses are working in other fields, retired or unemployed. LARA did not have information on the employment status of the individuals.

A view of Sparrow Hospital and the downtown Lansing skyline, seen Sept. 9, 2021.
According to a University of Michigan study from this year, 39% of Michigan nurses plan to leave their position in the next year. Among currently practicing nurses, 83% indicated their greatest workplace concern was adequate staffing levels.

Brown said there are more than 100 registered nurse positions open at her hospital, but she doesn't believe the legislation would assist filling those slots.

"I think there's other things that we could do to attract them back to the industry," she said, highlighting protections against violence and harassment as possible draws back into the field. Brown said hospitals had to get creative in finding ways to attract nurses and bring workers into the industry, like teaching and training programs.

"We've really been focused on doing more things to help the workforce with regards to either staying in the profession, or even thinking about how do we get more to enter the profession," she said.

Brown highlighted the Earn While You Learn program, a joint venture between Sparrow and Lansing Community College that pays students double time to gain experience in the field while going through nursing school.

Impact on the nurses

In addition to improving patient care, Breslin and Yohannes said, the issues are a matter of mental health and career satisfaction for employees.

“We are also the ones that end up suffering the moral injury because we're not able to do what we know should be done because we got too many patients,” Breslin said. “And we got to live with that.”

“When you're overwhelmed with heavy patient assignments, you can feel that emotional and physical exhaustion which can reduce morale for you and your co-workers, your job satisfaction and ultimately it increases your turnover rates in each department,” Yohannes said. This legislation would promote overall wellbeing and help retain skilled professionals in the industry, she added.

Breslin said most nurses simply want to be able to work a fulfilling job without some of the stresses that currently come with the position.

“What we're trying to do with this legislation is to make safe, no matter what hospital any of your family or loved ones or friends. If they have to go to the hospital,” he said, “we want to make sure that they're safe.”

Brown said hospitals could better support nurses by working to fill additional positions, like those who support non-treatment parts of the environment.

"I think that all those roles are essential and really making a nurse feel like at the end of the day, they are able to provide good care to their patient," she said.

The Democrats seem to be retconning all their past rhetoric about getting government out of health care decisions which was featured during their abortion campaign.

Abigail Nobel
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Joined: 3 years ago
Posts: 484

Management tried this at one hospital where I worked. Guess who got to take 10 minutes every shift to calculate patient acuity and staffing ratios? It fell to the nurses. No one thought it added value to the shift experience. Eventually, it was dropped.

But Michigan doesn't have to speculate whether such a law would be effective. Look at California, which has a 20 year record.

Beckers' reported extensively on resullts of staffing ratios in February, 2023. They reveal the tug-of-war between unions, which advocate for staffing ratios, and hospitals, which oppose them.

Passing the CA law actually led to more strife: 


"California is currently short more than 40,000 RNs — despite having nurse staffing ratios in place for almost 20 years," Jan Emerson-Shea, vice president of external affairs for the California Hospital Association, told Becker's

Ms. Emerson-Shea pointed to a study, also led by Dr. Spetz, that highlights the shortage of nurses in California is estimated to take at least until 2026 before it evens out. 

Once enacted, the ratios became a lot to finance for some hospitals, Dr. Spetz said. In certain areas, they chose to finance some of the now additionally needed nurse positions by cutting from other areas like nurse aids. 

"That worried us, because for some patient outcomes, the presence of aids to help licensed nursing staff would be very important to affecting some patient outcomes," she said. 

Another area of contention between California's hospitals and nurses after the ratios went into effect, Dr. Spetz said, was "around whether the ratios truly applied at all times, including scheduled breaks."


It's important for nurses and legislators to consider the questions underlying staffing ratios.

In your experience, do unions make workplace relationships better or worse? What about patient care?

In my experience, relationships were stifled and care was sidelined by union drama and control tactics. It was always about the union image, interests, and control over staff.

Does more time calculating ratios translate to better care in some, all, or no cases?

Regardless of decades of union advocacy, no one can promise this law will help in all cases and harm in none. More law does however mean less freedom at the bedside, and another drain on staff time and hospital resources. 

In the end, it's simplistic to depend upon staffing laws to overcome nationwide shortages and troubled systems. Local healthcare problems are nothing if not complex. Local institutions should be directed to confront their own problems, and allowed more leeway, not less.

Abigail Nobel
Member Admin
Joined: 3 years ago
Posts: 484

American Nurses Association - Michigan has taken an interesting, nuanced position opposing this set of bills. 

On May 11, 2023, a legislative package was introduced on the topics of staffing ratios, mandatory overtime, and reporting transparency. Upon detailed review of the package, ANA-Michigan supports the mandatory overtime and reporting transparency pieces in concept, but directly opposes the staffing ratios language as written. It is the position of ANA-Michigan that the current legislation simplifies a complex issue, without taking into account numerous contributing factors. Simultaneously, the legislation would remove decision-making power from nurses statewide regarding safe staffing and addressing patient care needs at the local level.

More statements and press releases are available on the ANA-MI website.

Prominent Member
Joined: 11 months ago
Posts: 399
Topic starter  

James K. Haveman, Jr. was a director of the Michigan Department of Community Health, now the Michigan Department of Health and Human Services, during the Engler Administration and later during the Snyder Administration.  In between, he was the Coalition Provisional Authority Senior Advisor to the Iraqi Ministry of Health during the Bush (43) Administration.  His opposition to mandatory nurse staffing ratios recommends the national Nurse Licensure Compact as a better option:

Opinion | Revisiting failed policies isn't the answer to Michigan’s nursing shortage
By James K. Haveman, Jr. - March 29, 2024

Peter Allen’s song “Everything Old Is New Again” touches on the importance of reflecting on the past to guide how to navigate current challenges. It was a simple musical earworm at the time, but the idea that everything old becomes new again seems more prophetic the longer I’m around.

During my first term as the director of the Michigan Department of Community Health in the ‘90s (now the Michigan Department of Health and Human Services) our state, like many others, faced a shortage of skilled health-care workers. During conversations about what policies might help, the idea of a one-size-fits-all, government-mandated nurse staffing ratio was raised as a possible solution.

We find ourselves with a similar workforce shortage today — one we anticipated before the pandemic and was only exacerbated by it — in which this same discussion has come back around. As our policymakers explore the options before us today, I implore them to heed the advice from past leaders: The proposed government-mandated nurse-to-patient ratio solution in Michigan House bills 4550-4552 and Senate bills 334–336 will only set health care back and pose serious risks to patient care. We recognized it in the ‘90s, and it still rings true today.

Let me be clear: when implemented locally to address the unique patient care and resource needs of a community, nurse staffing ratios can work. They are not a bad one-off option in the toolbox of a health-care leader. The issue lies in the use of them as a one-size-fits-all government mandate that treats the needs of patients in densely populated southeast Michigan the same as those in rural northern Michigan.

States like California that implemented statewide nurse staffing ratios 25 years ago have experienced negative outcomes as a result. Despite having these ratios in place for decades, California still faces a shortage of 40,000 nurses and employs fewer nurses per capita than Michigan. Additionally, hospitals in California reported increased operating expenditures and decreased margins, leading to reduced services and even the closure of hospitals altogether. These consequences further restrict access to care and result in delays in treatment. When Massachusetts tried this mandate, there was no improvement on patient care outcomes.

If Michigan were to implement this flawed policy, it would have dire consequences for patients. Our state would stand to lose 5,100 hospital beds, which is the equivalent to losing our six largest hospitals, or all hospitals north of Grand Rapids and Flint. In short, the medical services Michiganders rely on every day would be jeopardized.

Mandating a statewide staffing ratio will not address the nursing shortage in Michigan. Instead, we must focus on solutions that support the expertise of local health-care experts and their efforts to recruit, retain and support nurses. The good news is that there are several actions policymakers can take to support the workforce and improve care. Michigan has already begun taking steps towards common-sense solutions, such as the signing of bipartisan legislation to increase penalties for those who commit violence against health-care workers. Solutions that support local experts while building the pipeline are key.

First, Michigan should pass legislation to join the national Nurse Licensure Compact, supported by 67% of Michigan voters according to an August 2023 poll. This compact would reduce barriers for out-of-state nurses to move to and practice in Michigan immediately, helping to alleviate staffing shortages.

Second, we must support the retention and recruitment of nursing professionals. Post-secondary education programs such as the Michigan Achievement Scholarship and Michigan Reconnect help individuals pursue careers in nursing by providing financial assistance and access to educational opportunities.

For current nurses, support is needed on efforts to make clinical opportunities more robust. For example, nurse preceptorships provide hands-on experience for students and help prepare them for the challenges of clinical practice. A new state tax credit could decrease the costs associated with career advancement. And most importantly, we must listen and react more quickly when healthcare workers, especially nurses, express concerns about workplace issues.

Policymakers must learn from the wisdom of leaders before them and refocus their efforts on implementing initiatives that will actually build a stronger workforce and ultimately, a healthier future for our state.

This post was modified 2 weeks ago by 10x25mm



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