Meg Sinclair, an emergency department nurse at Maine Medical Center, says she can’t imagine going back to work full time under current working conditions. She is hoping the Legislature adopts mandatory nurse staffing levels for the state’s hospitals. Shawn Patrick Oullette/Staff Photographer

For Meg Sinclair, getting more nurses on staff could improve working conditions enough to help lure her back to work full time as an emergency department nurse at Maine Medical Center in Portland.

“You walk out of the hospital and you feel like you provided horrible care,” said Sinclair, who now works part time. “The working conditions definitely affected my mental health.”

Sinclair is hoping the Legislature passes mandatory minimum staffing levels for the state’s hospitals.

But Megan Flynn, a nurse in the neonatal intensive care unit at Maine Med, worries that inflexible state-mandated nurse-to-patient ratios could cause a host of operational problems, including less capacity for prematurely born infants who benefit from Maine Med’s specialized care.

The diverging views by two nurses who work at the same hospital reflect the complex battle over how to solve a shortage of nurses caring for patients in Maine hospitals. A bill pending in the Legislature would take a particularly controversial approach – requiring hospitals to employ a minimum number of nurses per patient, with ratios that vary by department.

How such a bill would affect working conditions, patient care and the capacity of the state’s health care system is far from certain.

The Legislature’s Labor and Housing Committee voted 8-3 in favor of the bill, despite opposition from the top health official in the Mills administration. Votes on the House and Senate floor are expected in the coming days.

Lobbying for and against the bill has been intense. Hospital officials say it could cost hospitals hundreds of millions of dollars to comply and result in reduced services because there are simply not enough nurses to hire. Nurses say the mandate would improve working conditions and patient care because many exhausted nurses would go back to work if adequate staffing levels were assured. It’s an idea that has been debated in Maine and other states for years, but has so far only been adopted in California.

There are national guidelines for safe nursing staff levels, although there is no standard nurse-to-patient ratio. The American Nurses Association does not recommend specific ratios, but advises that each hospital develop safe staffing plans with input from nurses. Meanwhile, mirroring the debate in Maine, national nurses’ unions are in favor of ratios, while the American Hospital Association is against.

The Maine bill includes a range of minimum staffing ratios depending on the types of patients and the severity of a patient’s condition. Averaged out, the minimum ratio would be roughly one nurse for every two patients. It is not known what the average ratio is now at hospitals statewide, but hospital representatives and nurses agree that there are significant staffing shortages and ratios in some cases fall below those required in the bill.

Nursing shortages are a problem for hospitals across the country. The shortfall is caused by many factors, including the pandemic pushing some nurses to leave the workforce, an aging population needing more care, and older nurses retiring at a faster rate than they can be replaced.

“Part of that is that health care jobs were extremely stressful – and dangerous – over the past two years, which probably led people to find other jobs or to retire early,” said James Myall, economic policy analyst for the Maine Center for Economic Policy, a progressive think tank.

But in Maine, the number of nurses graduating into the workforce is now on the rise and hospitals are offering higher pay, trends that are expected to stabilize the workforce and gradually ease the shortage in the coming years.

A 2022 analysis prepared for the hospital association and the Maine Nursing Action Coalition says there was a shortage 2,250 registered nurses in 2021. It projects the shortage will remain at that level or fall to 1,450 registered nurses by 2025. An earlier analysis had projected the shortfall would grow to 3,200 by 2025, but the estimate was reduced based on the increasing number of nursing graduates.

Even as Maine’s colleges and universities are graduating more nursing students than in past years, the overall labor market remains extremely tight in Maine and in neighboring states. And that means hospitals and the health care system are fighting over a limited pool of workers with all the other industries in Maine that have similar labor shortages.

Unable to fill all of their vacant jobs, hospitals have had to rely on expensive traveling nurses – who get paid three times as much or more as staff nurses – a trend that has strained budgets and added to concerns about mandatory ratios.

‘NOT PROVIDING THE CARE’

Sinclair scaled back her nursing hours from full time to part time this year, in part because she had a baby but also because of the working conditions. Working a 12-hour shift in a short-staffed emergency department is extremely stressful, she said. The 31-year-old used to take anxiety medication when she worked full time because of the stress of staff shortages, she said.

“Sometimes you’re not providing care that makes you feel good about being a nurse,” said Sinclair, who is a union steward for Maine Med’s nurses union. “I don’t have time to say to patients, ‘I’m giving this medicine for this reason.’ Instead, I’m just pushing the medicine and running out of the room to put out the next fire.”

She recalled when a psychiatric patient in the ED needed something simple – she doesn’t remember exactly what it was – and she was so busy she couldn’t get to it immediately. The patient hit her. “We both experienced trauma from it, and it was preventable,” Sinclair said.

Depending on staffing levels on a given day and the condition of each patient, Sinclair said patient-to-nurse ratios in the ED can vary from 1-1 up to 4-1. Mandatory ratios would vary under the bill, but for the most severe patients in the ED, the legislation would require a 1-1 ratio.

Sinclair is now working 24 hours a week and she couldn’t imagine going back to 36 hours under current working conditions. She knows many other nurses who have switched to other health care jobs, such as in outpatient settings. She’s reluctant to leave bedside nursing for another job, but says money is tight as a part-time nurse and she may have to.

“I really do love ER nursing, and I know I’m good at it,” Sinclair said. “All I know is, I’ve been a nurse now for nearly a decade and the job has gotten way harder.”

UNINTENDED CONSEQUENCES

Unlike Sinclair, Flynn opposes mandatory ratios because of the potential for unintended consequences.

Megan Flynn, a clinical nurse leader in the neonatal intensive care unit at Maine Medical Center, is opposed to a proposed bill that would mandate nurse-to-patient ratios because it could limit the department’s ability to care for sick children. Gregory Rec/Staff Photographer

Nurses need maximum flexibility in the NICU to provide the best care, she said. The babies in intensive care have a wide range of needs, and strict ratios would not account for all the nuances of caring for the youngest and most vulnerable patients.

“Some of our babies are close to going home, while other babies are really, really sick,” Flynn said. The NICU and the continuing care nursery – which is for the healthiest infants who still need hospital care – largely share a staff of about 130 nurses. Being able to go where care is needed without following mandated ratios is one of the keys to the success of the two units, she said.

Some babies need 1-1 nurse-to-patient care while other babies can do well with 3-1 care, she said. Mandatory ratios in the proposed bill vary for NICU patients, but the sickest patients would require 1-1 care.

Flynn said strict ratios might result in babies who would now go to Maine Med for specialized care having to be redirected to hospitals with nurses who are less familiar with the needs of premature infants. She said the training to care for those children is so specialized that it takes six months to onboard a new nurse.

“Some babies are still learning how to suck, swallow and breathe on their own,” Flynn said.

The Maine Department of Health and Human Services lodged its opposition to the mandatory ratios in part because of the potential for unintended consequences, including limited access for patients.

“While the goal of this bill is to improve patient care, the current health care workforce challenges may result in difficulty in compliance at best and a reduction in access at worst,” said Jeanne Lambrew, Maine’s health and human services commissioner, in testimony before the Labor and Housing Committee in May. “Some facilities under these requirements could cut back or discontinue services due to the inability of securing the proposed minimum staffing resources. In a rural state like Maine, the unintended negative impact of service or facility closures due to an inability to meet these new proposed requirements cannot be understated.”

The agency’s opposition indicates that Gov. Janet Mills could veto the bill if it passes. Spokespeople for the governor did not respond to questions about her position or the potential for a veto.

ATTRACTING NURSES

As the debate continues about the wisdom of mandatory ratios, nursing schools and hospitals in Maine and other states are working to build up the labor supply. Recent graduates of nursing schools are getting their pick of jobs, along with previously unheard-of signing bonuses.

Kaitlynn Hutchins graduated from the University of Southern Maine nursing school in May and will start a job in the Emergency Department at Maine Med in July. She said she was told that, in the past, new graduates would not be able to land a job in an emergency department and would typically have to start in other parts of the hospital and work up to the ED.

“The opportunities are kind of endless right now,” Hutchins said. “People are able to score their ideal position right out of school.”

Hutchins, 26, said the pay was secondary to her when she decided to become a nurse, but she was surprised at how well the job pays. She said she will be earning $34 per hour to start, and will get a $10,000 signing bonus. Hutchins said she has heard that nurses with experience are getting $20,000 signing bonuses. Hutchins will be one of a dozen recent graduates working in the ED who will receive six months of training starting in July.

Signing bonuses, increased pay and improved benefits over the past few years have helped increase MaineHealth’s efforts to hire and retain nurses, said Sharon Baughman, director of nursing for MaineHealth, the parent of Maine Med and seven other hospitals in the state. MaineHealth nurses have received – at a minimum – 15% pay increases since January 2021, according to spokeswoman Caroline Cornish.

MaineHealth has hired 340 newly graduated nurses since October, compared with 246 during the same time period the previous year. But Baughman said MaineHealth is still too reliant on traveling nurses, with more than 800 traveling nurses on staff in its hospital network at a cost of $180 million per year. A ratio mandate would require the system to hire even more traveling nurses, about 50% more, and would be unsustainable for hospital budgets, she said.

“The solution to our staffing problems is not a mandated staffing ratio,” Baughman said.

But Cokie Giles, president of the Maine State Nurses Association and a nurse at Northern Light Eastern Maine Medical Center, said ratios would improve working conditions at hospitals to the point where more nurses would choose to work in hospitals, rather than seek positions in outpatient settings.

“The amount of nurses choosing to work in an acute care hospital continues to decline,” Giles said. “There is no shortage of nurses. There is a shortage of nurses willing to work in hospitals under the current working conditions.”

Whether there is enough available nursing labor to achieve the mandated ratios is a matter of much debate among those for and against the bill.

According to a June letter from the Maine Board of Nursing addressed to lawmakers, the state’s RN workforce increased from 27,767 in 2021 to 28,798 in 2022. But the percentage of nurses who are unemployed remained steady at 3%, according to the board.

The number of nursing graduates in Maine is expected to increase by about 25% from 2016 to 2025, with about 875 graduates expected statewide in 2025, according to the Cypress Research Group, which conducted an analysis.

That increase in nurses entering the field is expected to reduce earlier projections of a 20% gap between vacancies and workforce to between 9% and 14% by 2025, according to the research. The difference between a 9% shortage and 14% depends on how many nurses return to the workforce full time after leaving during the pandemic.

“This effort to increase the number of RNs educated in Maine will pay off for years, as most of the new RNs are young and can be expected to be a part of the workforce for decades to come,” according to the analysis.

CALIFORNIA MODEL

Both sides in the Maine debate point to different aspects of California’s experience as a reason to support or oppose the bill.

But research on California’s ratio law – in effect since 2004 – has not produced clear conclusions about impacts of the law on the health care workforce or the patient experience.

Nicole Rapfogel, health policy analyst for the Washington-based think tank Center for American Progress, said that while the California experience is complex, on balance it has helped with worker retention.

“California’s model has been successful in improving job quality for nurses, including allowing nurses to deliver care they feel good about,” Rapfogel said.

The nursing shortage, Rapfogel said, is “multi-factorial” and includes nurses leaving the workforce during the pandemic, many nurses being close to retirement age and not enough newly graduating nurses entering the field. Incentives to get more nurses into the workforce, including loan forgiveness programs and focusing on increasing educational opportunities, like what Maine is doing, are part of the solution, she said. But once in the workforce, job happiness is key to retention, and Rapfogel said having a ratio mandate in place helps ensure there’s enough staff to do the job.

But Jeff Austin, vice president of government affairs for the Maine Hospital Association, said when California passed its law more than 20 years ago, nursing shortages were far worse at many California hospitals than those that currently exist in Maine.

And Austin pointed to a 2018 analysis conducted for the Massachusetts Health Care Commission when lawmakers there were considering a ratio law. “Taken together, the literature indicates that California’s regulations did not systematically improve the quality of patient care,” the analysis concludes.

Advocates for the ratios point to studies that have linked the quality of patient care to nurse staffing levels.

A 2011 study published in the New England Journal of Medicine that assessed nearly 200,000 patients at an undisclosed hospital did not explicitly study ratios, but found “that the risk of death increased with increasing exposure to shifts in which RN hours were 8 hours or more below target staffing levels or there was high turnover. We estimate that the risk of death increased by 2% for each below-target shift and 4% for each high-turnover shift to which a patient was exposed.”

However, the study also found that flexibility for staffing is crucial. “This study underscores the importance of flexible staffing practices that consistently match staffing to need throughout each patient’s stay,” the study said.

Giles said nurses are lobbying for the bill on behalf of their patients as much as themselves.

“Patients in these beds need to have nurses available to them when they need it,” Giles said. “We would not be fighting this hard if it weren’t for the concern for the patients.”