Michigan lawmakers are considering legislation that could fundamentally change how hospitals and healthcare facilities provide patient care. HB 4550 and 4552, along with SB 0334 and 0336, set nurse-to-patient ratios for units in direct care settings and restrict employers’ ability to assign mandatory overtime to meet ratio requirements.
Three Republicans have signed on to the introduction of the Democratically-supported bills. Two of the three, Representatives Jamie Thompson (R-Brownstown) and David Prestin (R-Cedar River) have a background in providing patient care before joining the legislature. While many of the Democratic Party’s first cycle of bills have passed on a party line vote, there is a bipartisan path for passing nurse-patient ratios. The potential for a bipartisan path can be seen in Rep. Thompson’s questions during the May 5th Health Policy Committee testimony of Richie Farran, EVP of Government Services for the Health Care Association of Michigan (HCAM). EVP Farran’s testimony concerning the state of the nursing workforce prompted Rep. Thompson to ask about his views on the scope of practice for nurses, which vary widely between acute care and residential nursing facilities. Rep. Thompson finished by saying that she “understands that no one wants a mandate of nurse-patient ratios,” but her questions may indicate that ratios are an option to make patient care safer for patients and nurses. With a bipartisan path forming in the State Capitol, where do organizations lobbying Lansing stand?
Support for this bill package comes from the collective bargaining unit for Michigan nurses, the Michigan Nurses Association (MNA), with additional support from the national nurses’ bargaining unit, the American Nurses Association (ANA). The push for nurse-patient ratios is not new. The pre-pandemic HB 4279 from 2019 aimed to establish work plan committees at the hospital level to meet unit-specific nurse-patient ratios, which failed to pass out of the Health Policy Committee. However, with a Democratic majority, the 2023 iteration of this bill has an improved chance of making it to the House floor. MNA recently commissioned a survey and the University of Michigan conducted its own research presenting serious issues impacting Michigan nurses. The polls find that nurses feel the prevalence of safe patient workloads has decreased since 2016, and a majority of nurses feel that patient care has been negatively impacted by the assignment of too many patients. MNA’s commissioned research reports that 24% of nurses plan to leave direct patient care entirely (White and Johnson, 2023). The University of Michigan survey finds that nearly 40% of surveyed nurses plan to leave in the next year. This number inflates to 59% for nurses under the age of 25 (Bailey, 2023). MHC Insight, our research and data center, is currently conducting surveys to further understand the views of nurses in Michigan.
The Michigan Health & Hospital Association (MHA) and its member health systems and community hospitals oppose this bill package. The main argument MHA advances against nurse-patient ratios is that ratios would exacerbate the current nurse shortage, negatively impacting patient care in Michigan. Opposition groups attribute nurse shortages to educational pipelines not meeting the demand of state hospitals. This is confirmed to be a nationwide issue, exemplified by the testimony of Dr. James Herbert of the University of New England, during a U.S. Senate Health, Education, Labor, and Pension (HELP) Committee meeting. Dr. Herbert describes the state of the nursing pipeline, in response to Senator Susan Collins (R-ME) pointing out that the University of Maine had over 1,000 applications submitted for 80 nursing program openings. The testimonies of the other witnesses at the HELP Committee meeting indicated similar situations in other states as well. With this in mind, MHA makes policy suggestions that focus on increasing the supply of the nursing workforce and reducing the barriers for nurses from other states to quickly become licensed in Michigan.
The messaging from hospital associations across the country is that hospitals cannot hire more nurses if the supply of nurses is insufficient and there simply are not nurses to recruit. The counterargument made by MNA is there are existing nurses to recruit since Michigan has approximately 150,000 registered nurses but only 100,000 that are currently practicing, according to a Fox 2 News interview with James Walker, a member of MNA’s Board of Directors. Understanding the status of these potentially 50,000 nurses that may be willing to work if working conditions change requires more investigation. The likelihood that all 50,000 nurses would rejoin the nursing workforce in response to this legislation is unknown, but they remain a population that could be targeted in addition to bolstering the nursing education pipeline.
California’s experience with nurse-patient legislation provides some insight into the impact of ratios. In 1999, when the state enacted its nurse-to-patient ratio legislation, many of the same arguments in support of and against ratios were advanced by California labor and hospital group equivalents. In a systematic review of the academic literature centered on the California legislation, Teresa Serratt finds positive impacts for nurses in terms of perceptions of daily workloads and organizational support. The evidence for ratios reducing nurse burnout and turnover is mixed. In considering the institutional impact, Serratt finds that while some hospitals needed to employ traveling or contract nurses to comply with the newly-set ratios, overall nursing staff levels increased after the ratios went into effect (Serratt, 2013).
A study from 2022 examines the effects of ratios on healthcare employers. In observing the effects of the 2008 recession on nurse staffing, Andrew Dierkes et al. acknowledge that the average cost of implementing nurse-patient ratios in California hospitals was nearly $800,000 per institution. However, the authors claim that previous literature makes the case that implementation costs are offset by avoiding near-miss incidents and overall improved patient outcomes. The authors subsequently find that while other states saw decreases in nurse staffing during the 2008 recession, followed by an eight-year-long recovery period with nearly zero nurse staffing growth, California hospitals maintained their nurse staffing levels during the recession and experienced sustained growth in nurse staffing levels starting in 2009. The authors conclude that staffing ratios in California may act as a safeguard to protect nurse staffing during economic recessions (Dierkes et al., 2022).
Despite these findings, MHA and groups representing nurse management hold the position that ratio legislation may restrict patient access to care when, for instance, a 75-bed facility only has the nursing staff to maintain a 60-bed capacity. They assert that ratio legislation creates an inflexible framework that restricts hospitals’ and health care facilities’ ability to adapt to economic and labor supply changes. These opposition groups continue to stress the importance of investing in the educational pipeline and reducing barriers to licensure and immigration that would entice nurses from other states and countries to come to Michigan. MHA emphasizes that the nurse supply is strained, highlighted in a comment by MHA Vice President Laura Appel in a recent Michigan Radio interview that “if 8,500 nurses suddenly moved to Michigan, we would hire all of them (Wells, 2023).”
MHC Insight’s Take
Michigan stakeholders need to focus on recruiting licensed nurses back to the bedside while also training more nurses. The bills in the Michigan legislature will likely be reworked, but the chance that nurse-patient ratios become law is a real possibility. In predicting what nurse-patient ratios may look like, or how the MNA and MHA arguments could be reconciled, there are a couple of legislative developments that provide insight.
In a similarly Democratically-empowered legislature, the Democratic, Farmer, Laborer Party (DFL) of Minnesota submitted to pressure from the Mayo Clinic, who threatened to pull funding should nurse-patient ratios pass. In response, the DFL reworked the bill to eliminate ratio mandates, instead focusing on hospital safety, nurse burnout, and loan forgiveness. This may be an option for health systems not geographically tied to Michigan. Another potential path forward for Michigan is unfolding in Oregon. The Oregon bill sets up hospital committees that establish ratios, stipulating that representatives of hospital associations and nurse associations must be present to provide input. The Oregon approach focuses on shared influence for each side and addresses the supply side of training health professionals. A bill similar to the one in Oregon remains an interesting prospect, providing a potential framework to find compromise if Michigan legislators decide to take action.
White, Emma, and Griffin Johnson. 2023. Survey of Registered Nurses Living or Working in Michigan. Ann Arbor, Michigan: Emma White Research LLC. https://www.misaferhospitals.org/poll.html.
Bailey, Laura. 2023. “Nearly 4 in 10 nurses in Michigan plan to quit soon.” Michigan News University of Michigan (Ann Arbor), April 6, 2023.
Serratt, Teresa. 2013. “California's Nurse-to-Patient Ratios, Part 1.” The Journal of Nursing Administration 43, no. 9 (September): 475-480.
Dierkes, Andrew, Duy Do, Haley Morin, Monica Rochman, Douglas Sloane, and Matthew McHugh. 2022. “The Impact of California's Staffing Mandate and the Economic Recession on Registered Nurse Staffing Levels: a Longitudinal Analysis.” Nursing Outlook 70, no. 2 (March): 219-227.
Wells, Kate. 2023. “Would mandating nurse-to-patient ratios make Michigan hospitals safer?” Michigan Radio, June 22, 2023. https://www.michiganradio.org/health/2023-06-22/would-mandating-nurse-to-patient-ratios-make-michigan-hospitals-safer.