The battle over nurse staffing has heated up in several states in the last year. In Toledo, Ohio, nurses fed up with short staffing at their hospital are on strike. In New York, more than 10,000 nurses threatened to strike over staffing at three of the state’s biggest hospital systems. Earlier this month, those nurses won a groundbreaking contract that includes the initial hiring of 1,500 new nurses to fill current vacancies and an additional $100 million to hire nurses for newly added full-time positions.
Nurses are organizing and taking a stand to demand safe staffing because they know that limiting the number of patients they care for at one time makes a difference in their ability to do their jobs effectively.
Attempts have been made to pass legislation on the federal level to ensure safe staffing levels in hospitals. In May, Sen. Sherrod Brown (D-Ohio) and Rep. Jan Schakowsky (D-Ill.) again introduced the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act in Congress.
Rick Lucas, a critical care nurse and member of the Ohio Nurses Association, supports the federal legislation. “As a bedside nurse, I see the impact of unsafe staffing levels every day,” he says. “I’ve watched too many colleagues stressed, depressed, injured and eventually forced to leave a job they love because they aren't given the needed support to do their jobs well.”
Last fall, Massachusetts voters rejected the proposed nurse-to-patient ratios in a statewide ballot initiative, in spite of overwhelming support and activism by members of the Massachusetts Nurses Association and other unions, including the AFT. Although there are 14 states that have laws or regulations that address nurse staffing in hospitals, California is the only state with a law to mandate nurse-to-patient ratios.
“It’s been nearly 15 years since the law was enacted, and California still has better nurse staffing and better patient outcomes than any other state in the country,” says Linda Aiken, a well-known nurse researcher and director of the University of Pennsylvania’s Center for Health Outcomes and Policy Research.
Aiken published a landmark study in 2010 that compared patient-to-nurse ratios in California hospitals with similar ratios in New Jersey and Pennsylvania hospitals. The study found New Jersey hospitals would have nearly 14 percent fewer patient deaths and Pennsylvania would have nearly 11 percent fewer deaths if they matched California’s ratios in medical-surgical units. In the study, nurses and nurse managers both agreed that the ratio legislation achieved its goals of improving recruitment and retention of nurses, reducing nurse workloads and improving the quality of care.
“There has never been one shred of evidence to show more nurse staffing made things worse, but there have been a lot of studies to show they made things better,” says Aiken. She also notes that all of the fears the hospital industry in California expressed were unfounded. “No hospitals closed, and the public didn’t pay more even though it was an unfunded mandate. The hospitals just shifted their resources.”
How California got ratios
During the AFT Nurses and Health Professionals conference in April, the AFT assembled a panel of experts to discuss how nurses can solve the staffing crisis. Denise Duncan, president of the United Nurses Associations of California/Union of Health Care Professionals, spoke about how unions in California were able to turn safe staffing ratios into law. “Getting staffing ratios was hard work, but they were able to do it with a grass-roots campaign run by three nurses unions that worked together before the age of social media,” said Duncan.
The unions were organized and faced fierce opposition from hospital management who stoked fears that hospitals would close if ratios were enacted, said Duncan. But nurses shared their stories, which resonated with the community. “Every nurse has a story,” she added. “The most powerful stories were the ones about ‘near misses,’ that were caught before something happened.” said Duncan.
Even though there have been ratios in California for more than a decade, the challenges are still there, Duncan said. Employers are constantly trying to beat back the ratios, she said, with frequent violations and failure to budget for the ratios.
“There was no data to support our work at that time, so we were thrilled with Linda Aiken’s study in 2010. We still have to bargain ratios to prevent delay; but it is getting harder for employers to deny that ratios work,” said Duncan. Achieving safe staffing ratios is possible with organizing, she added. “Nurses must share their stories, especially on social media. Telling your story is the most powerful way to make positive change.”
Realities of short staffing
“Hospitals have to be forced to reckon with the realities of understaffing, from increased turnover as a result of job dissatisfaction to higher hiring costs and a lower quality of care, to increased secondary care costs. The staffing crisis hurts us all,” said Ethan Miller, research and outreach manager at the AFL-CIO’s Department of Professional Employees.
Short staffing leads to emotional exhaustion, job dissatisfaction and fatigue. Working long hours in facilities that are understaffed also increases nurses’ risk of developing conditions such as musculoskeletal disorders, hypertension and depression. In 2017, registered nurses had 24,540 reported incidents of illness or injury resulting in one or more days away from work.
“Nurses need to be a part of the conversation—unionized nurses do have a seat at the table—using your power at the bargaining table to push for improved staffing standards even in states where the legislative solutions are years away,” said Miller.
And many of the AFT’s healthcare affiliates are negotiating staffing solutions into their contracts. For example, at Englewood Hospital and Medical Center in New Jersey, nurses who are members of Health Professionals and Allied Employees have preserved staffing ratios based upon unit and shift into their contract.
“Critics of nurse-to-patient ratios say they take away from nurses’ discretion, but I don’t buy it,” says nurse researcher Aiken. “We can show people are dying unnecessarily. I’ve been doing research for over 40 years, and there has been no other example that improves patient outcomes more than staffing.”