2001 FNHP Professional Issues Conference

The dream of the AFT’s health care division is that nurses and health care workers have the power to create and maintain an environment where they can deliver quality care. "That dream is the vision of our union," said Federation of Nurses and Health Professionals program and policy chair Candice Owley, speaking to the annual FNHP professional issues conference on April 20. "It is what we all yearn for and fight for every day, against all odds, against an industry determined to keep us weak so it can stay strong."

In the battle to strengthen health care workers so they can realize high-quality care for their patients, all health care unions are allies, said Owley. All must work together to continue building the unions that make us strong. "We have to remember who the enemy is--it’s corporate greed and those who put cost before patient care."

Sharing that dream, said Owley, is the health care division’s national and international leader, Sandra Feldman, who "shares our passion for quality and for a better health care system and a better life."

AFT president Feldman addressed the opening session of the annual conference in Washington, D.C., telling the nearly 250 health care members gathered, "We believe in an America where the priority for health care systems will be the quality of service for all, not the size of profits for a few."

In her speech, Feldman highlighted the startling results of a Peter Hart Associates poll of nurses conducted for the AFT health care division. The national poll of 700 current nurses and 207 former nurses revealed that one in five current nurses age 18 to 59 expects to leave nursing in the next five years "because they’re fed up," said Feldman. Sixty-eight percent of all current nurses say morale where they work is poor, and from 49 percent to 75 percent said they would pursue a different career if they were just starting out.

"The good news," said Feldman, "is that three-quarters said they’d stay if improvements were made.

"We learned even more about the problems of health professionals through a Healthwire survey [conducted in the March/April 2001 issue]. More than two-thirds said overtime had increased, more than three-quarters said they’re suffering health problems because of overtime.

"We have a problem and it’s getting worse so long as jobs are increasingly unattractive and leave health professionals feeling used up, worn down and burned out."

Feldman added, "one way to break this cycle is to ban mandatory overtime--once and for all and not just for the professionals, but for the patients who suffer from it."

The union president then read just a few of the written comments from Healthwire readers. Scores of responses indicated exhaustion, an increase in errors, depression, negative effects on home life (including disrupted family life, fights and divorce) and personal health problems--all because of overwork and understaffing.

"Just as airline passengers put their lives in the hands of pilots, the patients in hospitals put their lives in the hands of nurses at the bedside. We’re going to be fighting mandatory overtime in every way we can."

Workshops

Safe needles; staffing lawsuit

This year’s professional issues conference was preceded by a day of training on safe needle use, led by AFT health and safety specialist Darryl Alexander, American Nurses Association occupational safety and health specialist Susan Wilburn and Dr. June Fisher, director of TDICT Foundation, University of California at San Francisco.

The participants in the training workshop practiced injections on oranges, which simulated human injection sites, and role-played a variety of situations in which safe-needle devices would be used.

The conference also featured an array of speakers and panelists, including Kansas attorney Brad Prochaska, who successfully sued a Wichita hospital for understaffing that resulted in permanent injury to a patient in 1998.

Prochaska’s case involved 61-year-old Shirley Keck, who sought medical attention at Wesley Medical Center in Wichita, Kan., for shortness of breath. Within three hours of being admitted to the hospital, Keck went into respiratory arrest and then into a coma, suffering irreversible brain damage. All the while, Keck’s daughter was "complaining and screaming and asking for help and going to the nurses’ station," said Prochaska. She found no help until it was too late.

Prochaska uncovered evidence and testimony indicating that the Columbia/HCA-owned hospital was severely understaffed. A nurse who was deposed during the legal proceedings said she had complained of understaffing to the boss five times, and "it was like beating her head against the wall," said the Kansas lawyer. In fact, the hospital’s own records showed that around the time Keck was hospitalized, the hospital was understaffed 51 out of 59 days, according to its own guidelines.

"The year before this lady was injured [the hospital] had an annual gross income of almost a half-billion dollars," Prochaska revealed. "Maybe through lawsuits we can help to get hospitals to staff better."
 

Legal issues

"Unlicensed personnel are getting used more frequently than ever before," says Janine Fiesta, vice president of legal services for Lehigh Valley Hospital in Allentown, Pa. Fiesta gave an update on what’s going on regarding legal accountability in the nursing world at the 2001 FNHP professional issues conference.

With more and more hands-on care being performed by unlicensed staff, it’s no longer a new idea that such workers as orderlies, home health aides and other unlicensed workers are being held directly accountable for their actions.

"We are responsible for our own actions not for anyone else’s," said Fiesta. "Whether it’s a support person, nursing assistant, technician, student nurse, they’re held responsible for their own actions."

If you supervise or "manage" or if you’ve been a charge nurse and have others working under you, you might wonder about your legal accountability for their actions. "The courts have said consistently that [you] should not be held accountable for the actions of a second person who has a job description and duties to follow," said Fiesta. The one exception to that rule is if you’re a supervisor and the staff person you’re supervising is incompetent or has an impairment--usually, a chemical impairment. While the intoxicated nurse is not excused from an act of incompetence, said Fiesta, there is "secondary liability" on the part of the supervisor who may be aware of the nurse’s impairment.

"The manager is also held legally accountable for [his or her] own actions," she noted. "If you staff the unit and do not make use of available resources, you will be held liable for what goes wrong."

While employers have always had vicarious liability when it comes to staff making mistakes, what’s new and different is corporate liability. "In addition to being responsible for employees, [the corporation] has its own set of duties and responsibilities," said Fiesta. "They’re liable for short staffing, inadequately trained staff, not having adequate policies, not making sure they’re followed, environmental safety issues, lack of security, no appropriately trained security"--all problems in today’s environment.

One trend this year has been the number of cases involving RNs committing medication errors. Short staffing can be a successful defense but not for medication errors, said Fiesta. "Courts believe that the single most important activity in the workplace is safe administration of medications," she noted. "No matter how bad things are, how disruptive, etc., the courts believe that the professional nurse must be able to focus on safe administration of medication. Be particularly careful with medications."

Unsafe staffing forms are "very good protections" in a legal setting, said Fiesta. "They are documented ways to show to your lawyer what the situation was. But if you didn’t do them, it’s harder to prove."

You have a responsibility to fill out an unsafe staffing form every time you feel you’re in an unsafe situation, said Fiesta. "It is your duty to communicate those situations that are not in your control even though they occur again and again." Why bother calling or filling out the form? "To get resolution and to discharge your individual legal responsibility," answers Fiesta. "You’ve passed it up the chain of command. You’re not responsible for hiring or training more staff. The challenge is to get the information repeatedly in the chain of command."

The same holds true for inappropriate floating. You have a responsibility to express your concern over floating that’s inappropriate or unsafe but don’t refuse the assignment, said Fiesta, who also recommended that health professionals "chart factually" and include such things as "monitor not available" or "doctor notified" and how many times the doctor was notified.
 

Chained to your job?

Are you working overtime voluntarily or is it being mandated? Sometimes it’s hard to tell the difference, said FNHP senior associate Joni Ketter in her workshop on mandatory overtime.

Mandatory overtime is "any work you’re doing in excess of your predetermined schedule that you’re not doing voluntarily," said Ketter. "Is it really voluntary if you feel you have to stay because the person for the next shift didn’t show up? If you’re doing it because you wonder who will do it if you don’t?" Because we are the caregivers, "we’re loath to leave people in need," said Ketter. "[But] if you’re actually mandated, you should get a bonus or more money. Stop volunteering. Schedules that come out with holes in them make mandatory overtime a fait accompli."

While we really don’t know how bad mandatory overtime is because of a lack of scientific data, the survey on mandatory overtime in the March/April 2001 issue of Healthwire revealed that 66 percent of those responding said there had been an increase in overtime in the past two years, and 80 percent said their facilities were understaffed. In the Hart survey, 64 percent said they had worked more hours in the past month than originally scheduled.

One workshop participant said that she knew a nurse who was told to go home and get her children in order to work overtime and another who had to put a mattress on the floor for her kids to sleep on while she worked.

The Healthwire survey also showed that almost 64 percent of those responding believe that mandatory overtime has had a negative impact on patient care, said Ketter. "We’re not giving quality care, we’re just pushing pills and moving on. We know that mandatory overtime is harmful to patients."

Research shows, says Ketter, that certain amounts of sleep deprivation result in performance that’s equal to or worse than that of people who’ve been drinking; sleep-deprived subjects make more mistakes; loss of sleep may contribute to heart disease; and nurses who work rotating shifts have twice the odds of nodding off while driving to or from work and twice the odds of an accident or error related to sleepiness.

Research also reveals that other industries in which performance is affected by the number of hours worked and hours of sleep are regulating both. Airline pilots, flight attendants, truck drivers, rail workers all have limits on the number of hours they can work consecutively.

So, what are health care workers doing? They’re organizing more than ever before, said Ketter. Two percent more nurses are in unions today than 10 years ago. They’re also bargaining overtime limitations into their contracts and creating and lobbying for legislation to curb its abuse. In fact, 12 states have introduced legislation so far, said Ketter.

In a separate workshop on pensions, AFT research department associate director John Abraham recommended that health care professionals make some pension plan changes that would help compensate for the overtime they’re forced to work. Both changes would improve vesting and benefits for our members, says Abraham.

• Count overtime as credited service for pension vesting and benefits (i.e., if you work one month of overtime in a calendar year, you earn 13-1/2 months of vesting service).
   
• Count overtime as wages for the determination of the average wage rate used in your pension benefit formula (i.e., if your annual wage is $30,000 and you earn $3,000 in overtime, your average wage for pension purposes is $33,000).

Additionally, said Abraham, overtime could be used to determine the value of all wage-related fringe benefits, from life insurance to vacations.

A new FNHP publication, Stopping the Clock--Controlling the Use of Mandatory Overtime in the Health Care Industry more fully describes the problem and what members can do and are doing about it. (Contact the FNHP for a copy of the booklet.)
 

Workplace violence

It’s a myth that most workplace violence is caused by workers seeking retribution against supervisors or co-workers, said Jonathan Rosen, director of the New York State Public Employees Federation (PEF) occupational safety and health department. What is true, however, is that health care providers are at greater risk of violence than many other workers, since the likelihood of violence increases for employees who work alone, at night or with the public. Robberies and assaults account for most workplace violence.

At the FNHP workshop on violence, PEF member and co-presenter Jill Dangler, RN, spoke about the workplace assault she suffered and the toll it takes not only on the victims but also on their families and co-workers. After recovering from her physical injuries, Dangler was asked by management to return to duty at the facility where her attacker was still a psychiatric patient. Through the intervention of her union and a member of Congress, the patient eventually was transferred to another facility.

Workplace violence was looked at primarily as a police issue just a decade ago, Rosen noted, but now violence is seen as a workplace safety issue and emphasis is being placed on preventing, not just managing, crises. Unions are playing an increasingly important role in efforts to prevent and respond to incidents of violence. Getting management on board is an important part of the process.

"We need to demand to be treated as equals [with management] in this process," Rosen said. If management "won’t play, there are things we can do." These include: mobilizing members; filing grievances; going to the police, elected officials, district attorneys; educating workers and the community; holding public hearings and press conferences with victims and their families; conducting petition drives; and having union "safety specialists" go to facilities to perform safety checks. "Workers’ and patients’ safety are tightly connected," Rosen said.

Union contracts provide another avenue for action. One United Federation of Teachers contract in New York City has an expedited security clause, which mandates that management meet with the union within a specified number of hours after an incident of violence. Conditions-of-employment clauses might include beefed-up security requirements or provisions for escorts or mandatory beepers.

For more information and links to other health and safety Web sites and recent OSHA guidelines, visit www.aft.org/fnhp/safety/index.html.
 

Teaching hospitals at risk

Academic health centers (AHCs), once financially viable and academically rich institutions, are facing unprecedented challenges as health care has taken a dramatic turn toward corporatization, where cost considerations outweigh the provision of quality patient care.

The problems, said Michael Silverberg, vice president (academics) of the United University Professions local at Stony Brook Health Science Center, presenter of the workshop "Teaching Hospitals: Survival of the Fittest," stem from managed care’s emergence in the 1980s and have been compounded by public policy in the 1990s. Specifically, cutbacks in reimbursement rates, combined with changes in Medicare and Medicaid payments, have been met by legislatures that are unwilling to fund the difference, despite the fact that AHCs now provide more than 40 percent of the indigent care in the country.

Meanwhile, because it costs about 30 percent more to treat a patient at an AHC, academic health center administrators are responding to the financial shortfalls by privatizing services, and in some cases, eliminating functions altogether.

As a result, Silverberg said the traditional mission of AHCs--education, research and patient care, including indigent care--are compromised. Yet all are vitally important to society.

"It is inappropriate to view AHCs as revenue generating," said Silverberg. "We need, as a nation, to develop a rational way to provide health care and train the people who deliver it. That means, in the end, a political process."

Silverberg urged workshop attendees to lobby lawmakers for sound public health policy--a policy that embraces patient care as well as innovation and research.

For more information about the issues affecting AHCs, visit the Web sites of the American Association of Medical Colleges (http://www.aamc.org/) and The Commonwealth Fund (http://www.cmwf.org/).