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What Is the Harm in Imposing
Mandatory Hospital Nurse Staffing
Regulations?
EXECUTIVE SUMMARY
Efforts to establish mandated
staffing ratios are shortsighted,
and, though proponents may
have the best intentions, many
negative outcomes would flow
from the public airing of this
issue.
The Institute of Medicine con-
cluded in 1996 that there was
insufficient quality outcome
evidence to support the impo-
sition of mandated nurse
staffing ratios.
The Massachusetts Nursing
Association got legislation intro-
duced in early 1996 which, if
passed, would turn over to
state lawmakers decisions gov-
erning nurse staffing in hospi-
tals and other employment set-
tings.
There are high opportunity
costs. Staffing regulations (if
imposed) would force employ-
ers to ignore the dynamic inter-
actions of economic, technolo-
gy, capital, and labor supply
variables, and thus needlessly
impose the effect of increased
labor costs on hospitals, tax-
payers, and nurses themselves.
Chance for passage of this
highly controversial legislation is
unlikely, but the expenditure of
political chips (and the loss of
credibility) will increase the dif-
ficulty of obtaining a hearing
from legislators the next time a
nursing issue comes up.
NURSING ECONOMIC$/March-April 2010/Vol. 28/No. 2
Peter I. Buerhaus
INSTITUTE OF MEDICINE’S
T
HE
Committee on the Ade-
quacy of Nurse Staffing
(IOM, 1996) wisely rejected
the idea of mandatory minimum
nurse staffing levels in hospitals.
Such provisions would require
hospitals to employ a prescribed
number of nurses (or full-time
positions) per diagnosis, disease-
specific condition, number of
patients, or other indicator linked
to the provision of nursing servic-
es. Neither did the committee
endorse mandatory nurse staffing
ratios which would require hospi-
tals to employ a certain percentage
of registered nurses relative to
licensed practical nurses or nurse
aides. The committee, instead,
concluded that “there is a serious
paucity of recent research on the
definitive effects of structural
measures, such as specific staffing
ratios, on the quality of patient
PETER I. BUERHAUS, PhD, RN, FAAN, is
Valere Potter Distinguished Professor of
Nursing; Director, Center for Inter-
disciplinary Health Workforce Studies,
Institute for Medicine and Public Health,
Vanderbilt University Medical Center,
Nashville, TN; and a Nursing Economic$
Editorial Board Member.
care in terms of patient outcomes
when controlling for all other like-
ly explanatory or confounding
variables” (p. 121). Thus, it was
recommended that more rigorous
research be undertaken as this
would have “significant payoffs
for policymakers, nursing educa-
tors, and hospital administrators”
(p. 122). However, some nurses
have understood the committee’s
position as implying that once
research studies provide answers
concerning the relationship be-
tween the quality of care and min-
imum nurse staff levels and/or
staff ratios, then nurse staffing reg-
ulations should be implemented
based on these research findings.
Despite the IOM Committee’s
rejection of policies that would
mandate minimum nurse staffing
levels or ratios in hospitals, certain
groups in nursing advocate legisla-
tion that would impose these regu-
NOTE: This article was originally pub-
lished in the March-April 1997 issue of
Nursing Economic$ (Vol. 15, No. 2, pp. 66-
72) and is reprinted here as a part of
Nursing Economic$’ “Crucial Conver-
sations” initiative. See pages 73, 110, and
119 in this issue for other articles related to
the conversation on Manadatory Hospital
Nurse Staffing Regulations.
87
 lations. For example, in the Spring
of 1996, the Massachusetts Nursing
Association succeeded in getting
legislation introduced in the
Massachusetts state legislature. If
voted into law, this legislation
could end up effectively turning
over to state lawmakers decisions
governing nurse staffing in hospi-
tals and other employment set-
tings. The position of nurses in
favor of regulatory intervention of
this kind is built around the recog-
nition that the health care system
is changing rapidly and dramati-
cally. Proponents believe that to
ensure patient safety and protect
the quality of patient care, hospi-
tals must be required by law to
configure their nursing staff
according to minimum numbers
and/or ratios.
The purpose of this article is to
present a number of economic and
political issues that nurses and
policymakers should consider as
they contemplate the costs and
benefits of seeking legislation that
would impose mandatory nurse
staffing regulations. Even if results
from rigorous research were avail-
able and could be used to deter-
mine the “correct” number and/or
ratio of nurses that would result in
obtaining an objectively measured
standard of quality, the position
argued here is that nurse staffing
regulations would still be inappro-
priate. Such regulations would
force employers to ignore the eco-
nomic criteria they would other-
wise consider when making nurse
staffing decisions, impose signifi-
cant costs on hospitals, taxpayers,
and, perhaps most damaging of
all, would needlessly inflict sub-
stantial opportunity costs on the
nursing profession.
Economic Determinants and
Nurse Staffing Regulations
The overall demand for nurses
is derived from the forces that deter-
mine society’s total demand for
health care (for example, changes in
the size and composition of the pop-
ulation, increases/ decreases in per
capita personal income, proportion
88
of the population with insurance
coverage, prevalence of diseases
such as the spread of HIV/AIDS or
drug resistant infections, etc.).
However, it is important to bear in
mind that the number of nurses
actually employed at any given time
is determined by health care organi-
zations’ demand for nursing servic-
es. Whether acute care, ambulatory,
home care, or community based,
these organizations are in the busi-
ness of producing mostly medical
treatments and a variety of personal
health care services to satisfy soci-
ety’s demand for health care. Thus,
they must decide how much and
how best to use nursing services
supplied by different types of nurs-
ing personnel, and how to combine
them with other human and nonhu-
man resources to produce the type
and quantity of treatments and serv-
ices desired by society. Each organi-
zation takes into account certain
economic criteria when deciding
the number and mix of nurses it
should employ. Briefly, these crite-
ria include:
1. The total compensation (going
market wage plus fringe bene-
fits — health insurance, vaca-
tion, child care, etc.) that must
be paid to each type of nursing
personnel (RNs, LPNs, and
aides) relative to the compen-
sation paid to other health
personnel.
2. The additional output (num-
ber of patients cared for, num-
ber of treatments given, num-
ber of patient/family visits,
etc.) that can be obtained by
employing a particular type of
nurse compared to the output
produced by others (for exam-
ple, the output produced by
employing an additional RN
versus an additional LPN).
3. The perceived or empirically
measured contribution to the
quality and clinical outcomes
of treatments and services that
can be obtained by using each
type of nurse.
4. The available supply of each
type of nurse at any given
period of time.
NURSING ECONOMIC$/March-April 2010/Vol. 28/No. 2
5. The employer’s objective
function, which refers to the
specific behaviors and goals
the organization’s decision
makers are trying to accom-
plish.
6. The type, availability, and
price of technology and capi-
tal which can be productively
used to produce treatments
and services at any given peri-
od of time.
7. The size of the budget avail-
able for employing nursing
and other health care person-
nel.
8. External pressures to produce
services more efficiently (for ex-
ample, the presence of HMOs in
the market) (Buerhaus, 1995).
Conceptually, these economic
criteria may seem straightforward;
in reality, each is driven by com-
plicated and constantly changing
events. In a never-ending process,
employers use the best available
information to weigh these criteria
when making decisions on the
amount and composition of their
nursing staff. It is beyond the pur-
pose of this article, however, to
delve into the intricacies of these
criteria. Instead, it will be more
useful to focus on a few overriding
considerations and note the prob-
able impact of mandatory nurse
staffing regulations.
FIRST, holding the effects of
other forces constant, as total com-
pensation rises (falls), employers
will have an economic incentive
to employ fewer (more) nurses
and/or total number of hours of
nurse labor or FTE positions.
Thus, in the event that mandatory
nurse staffing regulations result in
increasing an organization’s total
compensation costs, then a strong
economic incentive will be creat-
ed for employing fewer nurses.
Although the regulations may
block the organization from reduc-
ing the size of its nursing staff in
the near term, at least while they
are in effect, over time it can be
anticipated that employers will be
motivated economically to find
ways to subvert the regulations.
 SECOND, the forces driving
each of the mentioned employ-
ment criteria arise from both
inside and outside the health care
industry. In many cases, these
forces can not be controlled or
influenced by an employer (or a
regulatory agency). Rather, it is up
to employers to understand the
forces and take into account their
impact on local market conditions
when making nurse employment
and staffing decisions. To illus-
trate, consider the forces that
determine the long-run supply of
nurses (number 4), which refers to
the total number of nurses who will
be available to offer their services in
the nurse labor market. The number
is determined in part by changing
social preferences for nursing as a
career, the size of age cohorts from
which prospective nursing students
are drawn, the capacity and types of
nursing education programs, the
supply of faculty, the sensitivity of
prospective nursing students to
changes in tuition rates, and
increases/decreases in nurse wages
in the labor market. However, the
short-run supply (the probability
that existing nurses are willing to
work and the number of hours
actually worked) is determined by
different factors, such as the
nurse’s age, presence of young
children, marital status, enroll-
ment in an education program, the
wage rate, and amount of non-
nursing and other household
income. The point is that a broad
array of forces are constantly and
simultaneously affecting the sup-
ply of nurses as well as each of the
previously mentioned criteria that
employers must consider, but can-
not completely control, when
making decisions on nurse
employment and staff configura-
tions. Furthermore, changes in
any one of these criteria will exert
an effect on the employer’s
demand for labor, and at different
points in time, some criteria will
exert a more important effect than
others. Mandating minimum
nurse staffing levels or specific
ratios would render impervious
NURSING ECONOMIC$/March-April 2010/Vol. 28/No. 2
the forces that act on each of these
criteria and which employers
must anticipate and carefully con-
sider when making decisions on
nurse employment levels and
staffing composition.
THIRD, beyond human re-
sources, organizations also use
capital to produce health care
services. Capital refers to equip-
ment, buildings, inventories, and
other nonhuman resources that
contribute to the production, mar-
keting, and distribution of person-
al health care services. However,
the type, amount, and price of
capital change over time, just as
the type of labor and how it can be
productively combined or substi-
tuted for each other and for capi-
tal. This means that the relation-
ship between capital and labor is
dynamic, not static. Consequently,
over time one would expect to
observe different amounts and
combinations of capital and labor
being used by employers to pro-
duce patient care.
In nursing this is illustrated by
thinking about how the roles and
productivity of one type of nurse
relative to another (an LPN versus
an RN versus a nurse practitioner,
etc.) have changed markedly over
time. In part, these changes have
resulted from hospitals’ acquisi-
tion of physical resources such as
intensive care, special care, suba-
cute, home health care units, etc.
Equally important, just as the
amount and use of capital has
changed over time, so has the pro-
ductive capabilities of nurses as a
result of modification in state
practice acts, changes in institu-
tional policies, and collective bar-
gaining agreements that have
affected nurses’ relative prices
(wages) and enabled the perform-
ance of more/fewer tasks by differ-
ent types of nurses. Once again,
imposing mandatory nurse staf-
fing regulations would disregard
these kinds of changes and nega-
tively affect opportunities for
employers to find new ways to
combine capital and labor to
improve health care delivery.
Similarly, technology has
been rapidly introduced in health
care and there are numerous
examples of how it has affected
the demand for nurses. In some
cases, technology has required
more nurses’ time and thus creat-
ed a positive affect on demand; in
other cases, it has reduced the
number and/or type of nurses
required. And, not to be over-
looked, technology has substan-
tially affected the practice of
physicians, pharmacists, respira-
tory therapists, and others in ways
that have significantly affected the
provision of nursing services (and
will continue to do so). Thus, the
development of technology in
nursing and technology in com-
plementary health professions
influences the quantity and mix of
nurse staffing, not to mention the
kind of patient care that is provid-
ed.
FOURTH, an employer’s
objective function influences its
decision regarding the number
and combination of nurses to
employ. Some employers are cost
minimizers, others emphasize
quality and highly satisfied
patients over anything else, some
direct resources toward services
and facilities that primarily bene-
fit physicians, and still other
employers seek to build a reputa-
tion as innovators, perhaps by
developing programs that better
serve the health needs of the com-
munity. However, most employ-
ers’ objective function changes
over time: this year’s cost mini-
mizer might emphasize quality
improvement next year; or, this
year’s all-service hospital may
decide to confine itself to provid-
ing only the services that it is best
at producing or has a comparative
advantage in its local market.
Whatever the objective, it will
play an important role in deter-
mining the type of nursing servic-
es the organization provides and
hence the quantity and type of
nurses required to produce those
services.
FIFTH, even though employ-
89
 ers rarely have complete or neces-
sarily accurate information on how
each of the determinants of nurse
employment is changing, they are
motivated to have an adequate sup-
ply of nurses to produce the
amount and kind of patient care
demanded. Assuming that enough
nurses are willing to work at the
wages and working conditions
offered by employers, and taking
into account the previously men-
tioned economic criteria, most
health care organizations seek to
employ the number of each type of
nurse up until the point that the
marginal product (the extra
amount of output — however
defined — gained from hiring the
last nurse) is just equal to the mar-
ginal cost of employing that nurse.
The goal is to employ the number
and mix of nurses that can most
efficiently produce the required
treatments and services consistent
with the organization’s objectives,
budget, and quality standards; and
to find ways that other health care
personnel, capital, and technology
can be most productively com-
bined.
These criteria, together with
societal forces that influence the
overall demand for health care,
determine the total employment
of nurses by hospitals and other
health care organizations at any
given point in time. But if state
lawmakers pass legislation man-
dating minimum nurse staffing
levels and ratios, then essentially
all of these economic criteria
would become irrelevant. In their
place would be arbitrary and sub-
jectively determined regulations
that are virtually unrelated to
these criteria. In light of the
important considerations raised
by this albeit limited overview,
one must seriously question how
an externally imposed regulatory
process that ignores these employ-
ment criteria could possibly pro-
duce the outcomes desired by pro-
ponents. The obvious result of
such regulations is the creation of
a nurse staffing standard that
either exceeds or falls below that
90
which employers would other-
wise use to produce nursing care.
More important, the standard
would be frozen for an indefinite
time during which the organiza-
tion is prevented from responding
to changes in any of the economic
determinants of nurse employ-
ment.
Even worse, if enacted, these
regulations would be introduced
at a time when the health care
industry is changing rapidly and
dramatically. Today employers
must respond ever more quickly
and effectively to new economic
demands or risk going out of busi-
ness. For the nursing profession,
this means that nurses must pay
much greater attention to the eco-
nomic determinants of nurse
employment. Nurses can not
afford to ignore these determi-
nants and the forces affecting
them by seeking regulations that
would erect a barrier between
themselves and employers’ deci-
sion with respect to employment
and staffing. Rather, nurses should
focus on working closer with
employers to find new ways to
enhance nursing’s value in pro-
ducing hospital-based health care
services. The more nurses raise
their value to an organization, the
more positive the impact will be
on their own employment and
earnings, not to mention patient
welfare (for a further discussion
on this imperative, see Buerhaus,
1996).
Regulatory Costs
Even if proponents of manda-
tory nurse staffing regulations in
hospitals believe that the econom-
ic criteria briefly reviewed here
can somehow be ignored, such
regulations raise other questions
that can not be so easily glossed
over. Following are some exam-
ples of the questions and issues
that proponents of nurse staffing
regulations should be prepared to
answer.
Who should develop the regu-
lations needed to implement the
legislation mandating minimum
NURSING ECONOMIC$/March-April 2010/Vol. 28/No. 2
nurse staffing levels or ratios?
Should it be an existing state
health care agency, a local govern-
ment agency, a quasi public/pri-
vate agency, or should a new
agency or special committee be
developed? Each option carries
different economic costs: Which
one would be least costly from the
perspective of taxpayers who are
paying for this undertaking?
Would members of the public,
as well as representatives of pro-
fessional and provider organiza-
tions, serve on the agency or group
which is charged with implement-
ing the regulatory process? Would
there be an opportunity for public
hearings or a comment period for
public response to proposed rules
and regulations? Would the regu-
latory agency be required to
respond to the comments? Would
a cost benefit analysis be required
of the proposed regulations?
What would the budget of
such a regulatory undertaking
involve? Would new staff be hired
to develop the regulations, or
would existing personnel from
other agencies be deployed? Who
will make these decisions, and
what is their self-interests in this
matter? What should the qualifica-
tions be for those who would
write and monitor the regulations?
Are enough people with these
qualifications available?
How would proposed and final
regulations be communicated to
providers? Exactly how would the
regulations be implemented: phas-
ed in over a given period of time, or
made fully effective all at once?
How frequently should providers
be monitored: once a week, once a
month, once a quarter, twice a year,
once per year? How will providers
be monitored? Would the public be
notified of the effects (both intend-
ed and unintended) of the regula-
tions? How long would the regula-
tions remain in effect; temporarily,
or do proponents envision them as
permanent controls?
How would nurse staffing reg-
ulations be enforced? Would
penalties be levied against non-
compliant providers? If the penal-
ties are financial, what should be
the dollar amount for each viola-
tion? Who would collect the fine
and what would be done with the
collection? Would these dollars be
used to offset the costs of the regu-
latory agency, or returned to the
provider once compliance is
established? How would multiple
violators be punished? What
processes would need to be in
place to grant providers excep-
tions or waivers from the regula-
tions, assuming they are permitted
under the law? What would quali-
fy as an exception and how would
providers who receive them be
monitored? What due process pro-
cedures would be available to
providers who believe they are
being harmed or unfairly affected?
How would quality be meas-
ured? Would/should the regula-
tions distinguish nurses based on
educational credentials, years of
experience, or some other criteria?
Or would all RNs (as well as LPNs,
aides) be considered as identical
inputs and, therefore, counted
equally?
Answers to every one of these
questions (and many others) carry
certain economic costs. They also
raise issues that are likely to
become the focus of intense
debate, endless revision, special
deals, and contentious private and
public bickering at each stage of
the legislative process — introduc-
tion of the bill, public hearings,
subcommittee and full committee
votes, floor debates and votes,
meetings of joint conference com-
mittee to iron out differences, etc.
And then, the squabbling is likely
to resume once the regulatory
agency assigned to develop and
implement the law begins its
work.
The struggle to obtain and
implement nurse staffing regula-
tions will not come cheaply or
quickly. Tremendous investments
of energy and resources will be
expended by both proponents and
opponents, and the legislative and
regulatory process will take a con-
NURSING ECONOMIC$/March-April 2010/Vol. 28/No. 2
siderable amount of time, proba-
bly no less than 18 months.
Moreover, even if regulations are
put into effect, it is highly likely
that they will fail to achieve their
intended outcomes. And when
this occurs some will view the
failure as evidence that new and
stronger regulations are needed. In
turn, this could lead to the entire
process being repeated, which
would only increase the costs of
nurse staffing regulations even
further.
Finally, assume for a moment
that all of these issues were easily
resolved and that the entire leg-
islative and regulatory processes
went smoothly and rapidly. What
would happen if it turns out that
the regulated nursing staff level or
ratio (or both) was set either below
or above the staffing level that is
actually required to produce some
specified level of quality? This is a
problem because both the mean-
ing of quality and how it is meas-
ured are expected to change and
evolve rapidly in the years ahead.
How then can advocates of nurse
staffing regulations be confident
that the staffing requirements they
would impose on others will be
unaffected by changing defini-
tions of quality? Moreover, how
can advocates ensure that the reg-
ulations can and would be applied
equitably across different types of
hospitals and would be relevant
and workable across different geo-
graphic regions? And what assur-
ances can proponents offer that
the regulations would be adjusted
appropriately with the passage of
time, development of technology,
changes in nursing education,
changes in nurse wages, and other
changes in the hospital industry
that none of us can foresee?
Opportunity Costs to Nursing
Another important drawback
of nurse staffing regulations
would be the needless, self-inflict-
ed, and potentially high opportu-
nity costs that nurses would
impose on themselves. All the
time, energy, and expense
incurred by nurses, both support-
ers and opponents, means that
other issues important to the pro-
fession are not being addressed as
fully as they might. These lost
opportunities have value and
hence there is a cost to nurses
when they are not achieved.
Therefore, proponents of regulato-
ry intervention confront two
important questions: What other
objectives are being given up or
are not being effectively attended
to as a result of pursuing the goal
of mandated nurse staffing legisla-
tion; and, what is the value of
these lost opportunities to nurses
and the public?
Given the provocative nature
of the issues surrounding nurse
staffing regulations, and given the
depth of feeling held by interested
parties, these are important ques-
tions that leaders of professional
nursing associations, unions, poli-
cymakers, and other concerned
parties must address when formu-
lating political agendas. Nursing
leaders should also ask if the
anticipated benefits of the nurse
staffing regulations are likely to
exceed the expected costs, espe-
cially the costs associated with the
damage to relationships between
nursing organizations holding
opposing views. Even more funda-
mentally, leaders should assess
the chances that the regulations, if
implemented, could realistically
achieve their intended outcome.
In asking these questions, leaders
should consider other actions that
could be taken that have a better
chance of achieving the goal of
improving the quality of patient
care (not merely protecting quali-
ty), which are less costly, can be
accomplished more rapidly, and
have less chance of fracturing rela-
tionships within the nursing com-
munity.
Expected Costs to Hospitals and
Nurse Employment
Hospitals also should be con-
sidered as they will bear a consid-
erable portion of the direct costs of
nurse staffing regulations. If they
91
 are required to staff according to
mandated minimum nurse staf-
fing levels or ratios, then, in effect,
they will be forced to produce
patient care services inefficiently.
By constraining hospitals’ ability
to select and experiment with dif-
ferent numbers and skill mixes of
nurses, they would be significant-
ly hampered in exploring ways to
maximally combine nursing care
with the services of other
providers or technologic innova-
tions. Hospitals, like any other
employer of nurses, need the free-
dom to take full advantage of the
resources they are paying for to
produce patient care using the
least amount of resources needed
to satisfy the demands of patients
and also meet its objectives.
Moreover, think about situations
in which health care is being
delivered in ways that satisfy
patients, purchasers, and nurses
themselves. Nurse staffing regula-
tions would cause hospitals to
change the number of nurses and
staff ratios to comply with the
“legal” requirement. Consequently,
either patients, payers, or nurses
would be made worse off. No mat-
ter how hard regulators try,
mandatory staffing regulations
will inevitably end up disadvan-
taging some hospitals and creating
distorted and unintended incen-
tives. To be sure, hospitals will
respond by investing substantial
resources to obtain political reme-
dies to counter the harmful effects
of nurse staffing regulations.
Proponents of staffing regula-
tions in hospitals should also real-
ize that because the regulations
would contribute to the inefficient
production of patient care, the
economic effect on hospitals
would be an increase in its labor-
related costs. Such an effect is not
unlike imposing an increase in the
minimum wage and its well-
known affect on employment.
Employers will have an economic
incentive to reduce nurse employ-
ment; substitute technology and
non-nursing personnel for nurses
whenever possible; and, in cases
92
where the costs of nurse staffing
regulations are high and employ-
er’s financial condition is weak,
nursing units could be closed or
reduced in size. These are not pos-
itive outcomes for nurses, and one
wonders how nurses would
respond. Demand more regula-
tions?
Political Considerations
The current mood of
Americans is one of considerable
mistrust and cynicism toward
government. The public is very
concerned about government
spending and reducing the federal
budget deficit, resistant to tax
increases, and desires only a mod-
est level of government involve-
ment in resolving national and
state problems such as health care
(Blendon, Hyams, & Benson, 1996;
McDonough, 1997; Morin & Balz,
1996). Indeed, these attitudes
played a significant role in the
public’s rejection of the Clinton
health plan (Blendon, Brodie, &
Benson, 1995) and the over-
whelming defeat of the single
payer proposal in California
(Brodie & Blendon, 1996). Both
political parties are positioning
themselves to shrink the size of
government and reduce its inter-
vention in the lives of Americans.
The current political environ-
ment and the mood of the
American public with respect to
government involvement in health
care, suggests that actions to
obtain nurse staffing regulations
could adversely affect the public’s
trust and support of the nursing
profession. It is not difficult to
imagine that a considerable por-
tion of the public would view
such legislation as another exam-
ple of unnecessary government
involvement and added bureau-
cracy serving special interests.
Some might even perceive this
intervention as “make work” regu-
lations designed to protect nurses’
jobs, cynically cloaked in lan-
guage proclaiming that the regula-
tions are necessary to protect the
quality of health care. Further-
NURSING ECONOMIC$/March-April 2010/Vol. 28/No. 2
more, what will the public think
of the nursing profession — one of
the few health professions that is
still viewed favorably by the
majority of Americans — should
the media exploit the bitterness
and strife that will be unleashed
within the nursing community
over this issue?
While nurse educators, re-
searchers, and policymakers can
be proud of their accomplish-
ments in elevating the presence
and effectiveness of nurses in the
political and public policymaking
arena over the past 2 decades, this
is a good time to pause and con-
sider some of the frank realities of
the political and regulatory
processes. More often than not,
the vast majority of bills that are
introduced never become law.
Usually, the more contentious the
issue, the more political groups
are involved, which in most cases
extends the length of time needed
to reach a political outcome, if one
is obtained at all. When they do,
most bills end up with language
that reflects compromise deci-
sions, take a considerable time to
be implemented by a regulatory
agency, and are very costly for
what is materially accomplished.
Nothing about the politics of
enacting nurse staffing legislation
suggests that nurses would be
spared from any of these consider-
ations. Rather, the outcome seems
fairly predictable: Nursing groups
will have aired their differences
and not their unity in public and
in the political marketplace; dam-
aged their reputations; spent valu-
able political chips; ended up
with no legislation enacted; and,
will have raised the costs of
obtaining future legislation as leg-
islators are likely to be more cir-
cumspect about getting involved
with nurses. Although it is con-
ceivable that mandatory nurse
staffing legislation could be enact-
ed, it would probably take several
sessions of the state legislature.
However, by this time, the issue is
likely to have lost any of the polit-
ical salience it may have had, and
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-
pointment.
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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