Nurse Alliance Campaign for Safe Staffing
by Richard Bermack
If you've needed hospital care recently, one of the first things you probably noticed was the shortage of nurses. In the managed care environment, complaints of patients ringing call buttons and then waiting and waiting and waiting for a nurse to arrive are commonplace. Nurses complain of being turned into assembly line workers, rather than quality care givers. And like social workers who can't provide quality services to their clients because of overwhelming caseloads, nurses can't provide quality care if they have too many patients and not enough time. Many nurses and patient advocates believe the consequences are a national tragedy. For liability reasons, nurses are reluctant to talk on record. "If you asked me if we have had negative outcomes that could have been avoided, I would have to say yes. Have patients died? Yes," one nurse stated.
SEIU's Nurse Alliance has been fighting hard to force hospitals to lower the patient- to-nurse ratio. In January of 1997, the Department of Health Services set the first staffing standards for non-critical care hospital units. (Critical care units already had standards.) The changes were the result of a long campaign by SEIU nurses. The new regulations set patient-to-nurse staffing ratios based on acuity, the severity of a patient's condition. For example, a patient who just got out of heart surgery would have a high acuity level, of say level six, and require a one-to-one nurse-to-patient ratio. Two days after surgery, as that patient improved, the acuity level would be reduced to a lower level, say level four, and the patient would require only a one-to-two or one-to-three nurse-to-patient ratio.
Although this was a start, hospital management found ways to play with the numbers. The problem with this system, according to Kaiser Sunset Nurse Chapter president Rhonda Goode, one of the nurses who helped draft the regulations, is the way hospitals determine the acuity level. The hospitals use a software program that allows them to modify the ratios based on their budgets. The hospitals enter information about their total staff numbers, and the software program then sets acuity staffing ratios based on the budgeted numbers, rather than on patient needs. There is no standardization and each hospital sets its own acuity ratios.
"The hospital has a budget and they determine that each patient gets so many nursing hours," Tarzana-Encino Medical Center nurse Karen McDaniel explains. "They use a grid to spread nurses around, but the budget doesn't take into account categories, just the number of patients on a typical floor." Problems arise when one patient has a condition that needs a higher level of care than the other patients on the floor. McDaniel offers the following example. "You might get a patient on the med/surge floor with a Fentanyl-marcaine epidural drip, and those patients require a one-to-four ratio. But the budget for the floor will call for an eight-to-one ratio. So there might be 22 patients and three nurses, but with the Fentanyl drip it really requires four nurses. But they will just tell us we have to absorb the other patient." "They change the acuity to match the staffing," Los Robles Medical Center nurse Leslie Whitehouse states, backing up McDaniel. "They have a system, but they don't go by it."
Even if hospitals followed the system correctly there would be problems, according to Whitehouse, because the system is based on outmoded studies. Whitehouse has been a nurse for 18 years and has seen her workload vastly increase with managed care. "We're suggesting an acuity system based on real acuity, not one that is antiquated. Things are not the same as they were 10 years ago. Patients are much sicker. They only come in when they really need care. Instead of tonsillitis, they will have pneumonia." Under managed care and Medicare cutbacks, patients that would have been admitted are now sent home. But that is not the only difference. According to Whitehouse, the new technology that hospitals use requires much more attention. There are more monitors to check, and the intravenous medications are much stronger, requiring constant attention and adjustment by the nurse. And because the doctors spend less time with the patients, the nurses find themselves filling in for the doctors. "Before we might have just gotten the patient ready and comfortable for the doctor. The doctor would have time to see the patients and work them up. Now I have to be one jump ahead and get everything going before the doctor gets there, order the lab tests, the x-rays, and suggest the medication to the physician. I need to do it now, because once we're on to the next patient, there is no time to come back. I have no time to spare, or even to go to the bathroom. Sometimes you get to go once in a 12-hour shift."
Assembly Bill 395, authored by Los Angeles Assemblywoman Sheila Kuehl, would have amended the regulations to set minimum fixed patient-to-nurse staffing ratios for each department. However, as a result of pressure from the governor, the final bill did not attach actual numbers to the ratios, but deferred to the Department of Health Services to determine those numbers.
The SEIU Nurse Alliance immediately took the lead. Nurse Alliance coordinator Glenda Canfield brought together a group of 30 to 40 nurses from hospitals all over California, in both the public and the private sectors. They worked together to create a proposal for safe staffing ratios based on their experiences working with patients. "We divided up into committees for each unit, like med/surge, and then had conference calls, comparing our experiences. Then we looked at the literature from organizations like the American Academy of Pediatrics and other professional groups. Of course all the research showed that the more nurses on a unit, the better the care."
"I'll never forget all those conference calls," states McDaniel. "There would be 10 people on the line, and then you would go to the next Nurse Alliance meeting, and you would meet the people you had been talking to over the phone. It was a very condensed process, since we knew the bill would pass, and we wanted to have our proposal ready. It was gratifying to see so many nurses from different areas of SEIU working on a common goal, for the common good of nurses and patients."
The Nurse Alliance submitted a 50-page document to the DHS hearings, with recommendations not only for staffing levels, but also for changes in Title 22 language and patient classifications.
At this point the Nurse Alliance proposal is the only one that has been submitted to DHS, although the hospital industry is expected to submit its proposals. "We know hospital management will have a lot to say," states Goode. "But we want to make sure that hospital staffing is determined by patient need, not by the bottom line of a budget."