Health care professionals see the benefits and pitfalls

by Christina Bartolomeo

"Our hospital tells nurses, don't talk about staffing. Don't talk about it in the elevator where people can hear you. Don't talk about it in front of patients' families. So we go home and talk. At home we're mothers and aunts and sisters and friends, and we're talking about how bad it is. And the thing is, everyone knows a nurse. People are beginning to realize just how awful things in our health care facilities are becoming."

Those are the words of a Connecticut nurse, but they could just as easily be from a nurse in Florida, Missouri or Nevada. Her sentiments express a new wave of activism on the staffing issue: nurses and health professionals just won't "keep quiet" anymore about overwhelming caseloads and the catastrophes such caseloads can and do cause.

In the past few years, nurses have been turning to the media, to their communities, and to their contract negotiators to find ways to bring a halt to short staffing. Now they're calling on their state legislatures to take decisive steps. It's a trend that's being manifested across the country, and it's opening up the issue of short staffing to public debate as never before. A striking case in point: California's Assembly Bill 394.

Championed by nurses' unions and fiercely opposed by the hospital lobby, AB 394 mandates nurse-patient ratios in every unit in every hospital in the state. It's the first law of its kind in the nation, a response to increasingly dangerous staffing patterns in a state suffering a nursing shortage; last year, California had a 20 percent RN vacancy rate, according to the Hospital and Healthcare Compensation Survey.
 

Kaiser supports ratios proposed by nurses

Passage of the California staffing law was a hard-won victory. For the past 10 years, hospital lobbyists have foiled attempts to regulate staffing levels. Now the battle enters phase two, with nurses demanding that the state set medically realistic ratios and the hospital lobby decrying "cookbook ratios" while pressuring state officials to set staffing standards that allow hospitals as much leeway as possible.

The issue of specific staffing ratios, which AB 394's language says must go into effect in January 2002, is clearly engendering as much controversy as the bill's passage did. California has long had a law on the books mandating a nurse-patient ratio of 1:2 in intensive care units--but when it comes to other hospital units, disagreement is fierce. Nurses' organizations in the state have called for medical-surgical unit ratios of either 1:3 or 1:4. Meanwhile, the hospital lobby--led by the California Healthcare Association (CHA), a 500-hospital consortium--is asking for a med-surg ratio of 1:10. The hospitals' proposed ratio of 1:6 in pediatric units is double the 1:3 for pediatrics that unions are supporting.

Recently, nurse leaders and patient safety advocates were joined by a surprise ally: Kaiser Permanente, one of the nation's largest HMOs. Kaiser broke with the rest of the California hospital industry to endorse a staffing ratio of 1:4 on medical-surgical units. The health care giant is also endorsing ratios for other units in accordance with staffing standards proposed by unions representing California nurses. The union-backed ratios include a 1:2 nurse-patient ratio in labor units, and a 1:3 nurse-patient ratio in pediatrics. Kaiser announced that it would work toward the recommended ratios in all Kaiser-owned hospitals in California.

The California hospital lobby's recommended ratios demonstrate the historic resistance American hospitals display when pushed to account for how they staff. As Chicago Tribune writer Michael Berens wrote in a December 2000 article about overworked nurses, "Staffing ratios are the equivalent of trade secrets at many hospitals. Even the American Hospital Association doesn't ask its members to disclose specific ratios."
 

Nurses vary in opinions about mandated staffing

Given this management climate, some nurses and health care professionals are skeptical about legislatively mandated staffing ratios. They fear that what hospitals accept as "minimum standards" today could become the norm tomorrow.

Says Leslie Remington, a PRN at Health Midwest Research Hospital in Kansas City, Mo. "I'm not sure about state-mandated ratios. They sound good but they don't always account for differences in patient acuity. I work on a med-surg floor where sometimes one or two patients will take up all my time. At other times, I can take care of five or six patients who aren't very sick. So I'm a little wary about the California law, waiting to see how it works out."

Tammy Krokstrom, a cardiac care unit RN at another Health Midwest facility, Lee's Summit Hospital, just outside Kansas City, says: "Right now, our hospital has a straight numerical ratio. Our union is in contract negotiations, and we're proposing a staffing formula that takes acuity into account rather than just numbers per nurse."

But other FNHP members and leaders strongly support mandated ratios as the only choice in a system where hospitals currently hold nearly autocratic power in staffing decisions. Says Ann Twomey, president of the Health Professionals and Allied Employees of New Jersey/AFT Healthcare, "I'm in favor of nurse-to-patient ratios, as well as caregiver-patient ratios. Staffing on the basis of patient acuity is the so-called system that has been used by hospitals and health care facilities. In practical terms, it has given license to managers to favor costs over care."

Twomey is aware that some nurses have misgivings that mandated staffing ratios could be used as an excuse for hospitals to use the lowest staffing numbers possible. But she feels that has already happened. "Employers establish their own staffing numbers on a given unit or floor and seldom, except on very rare occasions, do they ever surpass those numbers. And the numbers are based on their budget, not patient needs.

Those who oppose establishing ratios say it's because the [mandated] number will become the ceiling, the maximum staffing level that will be used. Yet, that's the case now, with the current numbers used by hospitals. The difference is that staffing often falls short of the current [hospital-controlled] numbers because there is no minimum staffing level required."

Candice Owley, chair of the FNHP program and policy council and an AFT vice president, also feels that mandating ratios is an idea whose time has come. "Without the force of law we would have no minimum wage, no overtime pay, and children in the workforce," she says. "The time has come to force employers to provide safe staffing standards. We know what a system without legally mandated ratios looks like--a disaster. Mandated ratios developed by frontline nurses will go a long way to restoring quality of care to the system and reversing the nursing shortage."

As mentioned earlier, Connecticut, Massachusetts and New Jersey are considering legislation similar to the California law. Although not as tough as California's legislation, a bill was recently passed in Oregon that will require hospitals to set minimum staffing levels.

Some states are considering approaches that would increase public scrutiny of hospital staffing practices. In Rhode Island, proposed legislation would create a Hospital Staffing Standards Commission that would develop staffing standards and report to the public on hospitals' compliance with staffing standards. In New York, the Nursing Quality Act would require health care facilities to make public the nurse-to-patient ratios in each unit.

Walter O'Connor, president of the New Milford (Connecticut) Federation of Registered Nurses, loves the concept of giving the patient the data to compare hospitals. He says, "Why not have hospitals' staffing ratios be part of the public records? HMOs and hospital management are always talking about market forces rather than patient care. If that's their game, let's use market forces to beat them at it. We'll publish staffing data and let patients choose."

Leslie Remington takes the same view. "I totally believe in a bill that would require hospitals to post ratios. That way, patients can shop around. It also would give nurses a little protection from managers who lean on them not to discuss ratios with patients."
 

Where nurse organizations stand

As state legislatures begin to evaluate the pros and cons of legally mandated staffing minimums, nurse organizations are weighing in on the issue. What may be confusing to the public is the fact that these organizations vary in their views on mandatory staffing.

The American Nurses Association, for example, does not promote specified numerical staffing ratios, citing the complexity of the staffing issue and the need for more empirical data on staffing variables and their effect on patient outcomes. Instead, the ANA calls for "appropriate staffing levels ... that reflect analysis of individual and aggregate patient needs," including patient age and functional ability, the severity and urgency of the patient's admitting condition, and the procedure scheduled.

The American Association of Critical Care Nurses and the Emergency Nurses Association have taken stances similar to the ANA's.

By contrast, the National Association of Neonatal Nurses (NANN) and the Association of Perioperative Registered Nurses (AORN) do endorse specific ratios. The AORN declared, in an October 2000 statement, that "whenever invasive procedures are performed, the minimum nurse-to-patient ratio [should be] one professional perioperative registered nurse [for] each patient." In April 1999, the National Association of Neonatal Nurses called for a staffing ratio of not less than two registered nurses with neonatal expertise when fewer than six intermediate patients or four intensive care neonatal patients are in the unit.

Nurses' groups are unanimous in demanding further study of staffing variables and their relationship to a spectrum of patient care outcomes. But concrete evidence already exists to demonstrate that the presence of sufficient RNs in a unit is a crucial beneficial factor in patient care. AFT Healthcare has issued a summary of recent research, "Safe Staffing = Quality Health Care" showing that higher numbers of RNs have been associated with decreased mortality; fewer medical errors; shorter patient stays; and lower rates of pneumonia, thrombosis, urinary tract infections, gastrointestinal bleeding, shock, and pressure ulcers.
 

In Australia, a real-world experiment in progress

Although studies clearly demonstrate that more nurses mean healthier patients, what hasn't been documented in this country yet--because California is the first state to make the experiment--is the potential positive effect of state-mandated staffing ratios on nurse recruitment and retention. But encouraging data on the subject has come out of the Australian state of Victoria, where unionized nurses in the Australian Nursing Federation (ANF)'s Victoria Branch last year won a landmark agreement with the state government mandating specific nurse-patient ratios, including a ratio of one nurse to four patients on medical surgical units and one nurse to seven patients in nursing homes.

Since the agreement's implementation, an estimated 2,300 Victoria nurses have returned to the profession. According to the ANF, the majority of hospital wards and units in Victoria have already reached the mandated ratios. Turnover is down and morale is up, the union reports.

In an interview with Healthwire, Belinda Morieson, RN and secretary of the ANF's Victoria Branch, discussed why she felt mandated ratios were necessary. "In the past, nurses in Victoria had control of workloads through using 'professional judgment.' At times of budget cuts and nurse shortages, [that's] of little value if you require an additional nurse on the shift but there is no nurse available."

Morieson sees a night-and-day improvement since the ratios law came into effect. "Since the introduction of nurse-to-patient ratios, for many Victorian nurses it has been the first time they have experienced an ability to have a workload such that they're able to fully care for each and every patient."

"Nowadays, when patients and nurses say 'there ought to be a law' about staffing, it's actually possible, and we want to consider the implications of that possibility," says Owley, noting that AFT Healthcare will continue to closely monitor developments in California.

No matter how the war over staffing ratios there is resolved, one thing is certain: California hospitals have been put on notice that short staffing won't be permitted to be a "trade secret" anymore. Because nurses spoke out and legislators listened, the whole state--make that the whole country--is watching now.