Nurses Rally Renews Debate Over Mandatory Staffing Ratios

May 12, 2010

May 12, 2010 — Nearly 1000 registered nurses rallied today outside the US Capitol in support of legislation that would set adequate ratios of nurse-to-patient staffing in the nation's hospitals to ensure good care and prevent nurse burnout.

Virtually everyone agrees that hospitals need more nurses on duty, but when it comes to a solution, the 1000 voices in Washington, DC, during National Nurses Week were not speaking for their entire profession.

These nurses were members of the 150,000-strong National Nurses United (NNU), a union formed from the recent merger of the California Nurses Association/National Nurses Organizing Committee, the Massachusetts Nurses Association, and United American Nurses. Ambitious, aggressive, and ready to take up bullhorns and protest signs, the NNU aims to unionize every nurse in the country.

"We should all be under the same roof," NNU copresident Karen Higgins told Medscape Medical News.

In contrast, another powerful force in the profession, the American Nurses Association (ANA), stands opposed to lawmakers regulating how many nurses work a given shift, which has already happened in California. The ANA would rather see Congress follow in the footsteps of other state legislatures and pass a law requiring hospitals to develop customized staffing plans with strong input from nurses.

In a way, the disagreement between the NNU and ANA should come as no surprise. The California Nurses Association and the Massachusetts Nurses Association are former ANA affiliates who left the fold, and the United American Nurses used to be the ANA's official labor arm. So the clash over staffing regulations reflects a battle for the loyalty of individual nurses.

"The Study Shows We Were Right All Along"

The nurses that gathered in Washington, DC, today had several messages to deliver to lawmakers. One was a sense of frustration about the new healthcare reform law, which fell short of the NNU's vision of a single-payer system. In a recent article in the Huffington Post, NNU executive director Rose Ann DeMoro characterized the law as "wimpy" and geared to the needs of health insurers rather than patients. For example, the law will allow insurers to sell their products across state lines, motivating them to "set up in the least-regulated states in a race to the bottom, threatening public protections won by consumers in various states," according to DeMoro. In addition the law lacks a competing government-sponsored health plan — the public option — that would keep private plan premiums under control.

Worse yet, lawmakers who drafted reform legislation did not seek the input of frontline nurses on how to improve the quality of patient care, said NNU copresident Higgins. "We were not involved in this discussion. We were pretty much left out."

Other items on the NNU agenda were a bill that would restore the collective bargaining rights of nurses in the Department of Veterans Affairs and another that would eliminate manual lifting of patients by nurses in most circumstances and require hospitals to do the job with mechanical devices.

Arguably the most controversial agenda item was a bill on staffing levels titled the National Nursing Shortage Reform and Patient Advocacy Act. The bill is modeled after a landmark California law passed in 1999 and implemented in 2004 that sets nurse–patient ratios for various hospital settings. A nurse may not care for more than 5 patients on a medical-surgical unit, 2 patients in an intensive care unit, or 3 patients in a labor and delivery unit, for example.

The American Hospital Association is on record as opposing any law that would limit a hospital's flexibility to determine the appropriate staffing levels for its employees. Left unsaid is the additional expense such laws would impose. However, hospitals can afford to hire extra nurses because improved patient outcomes will lower their overall costs, according to Higgins. "You cut down on infections and injuries. Patients come home earlier."

The NNU is touting a study published last month in Health Services Research reporting that mandatory staffing levels in California have helped reduce mortality rates among general surgery patients while improving nurse job satisfaction. The study, which came out of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing, Philadelphia, stated that if hospitals in Pennsylvania and New Jersey were to institute California-style staffing levels, deaths among surgery patients would decrease by 10.6% and 13.9%, respectively.

"The study shows we were right all along," said Higgins. "The more nurses you have, the better off patients are."

Mandatory Ratios Have Their Critics

Although the NNU points to the study in Health Services Research, not everyone agrees that nurse staffing ratios in California have lived up to expectations. In February 2009, the philanthropic California HealthCare Foundation published a study finding that although the California law put more nurses to work, it had "at most a marginal impact" on hospital financial stability, and "there was no evident change in patient length of stay or adverse patient safety events."

One critic of taking the California law national is Peter Buerhaus, PhD, RN, a professor of nursing at Vanderbilt University, Washington DC. Mandatory staffing arrangements, Dr. Buerhaus told Medscape Medical News, will lead inevitably to greater inefficiency and higher costs without the likelihood of improved care. His solution for undernursed hospitals smacks more of a free-market philosophy: Give these institutions a sufficient financial incentive to improve patient safety, and they will figure out a way to do. Some hospitals would be forced to address nurse–patient ratios, some would not.

"Not all patient safety problems have to do with staffing," Dr. Buerhaus said.

He worries that by failing to deliver what it promises in terms of patient care and lower costs, mandatory staffing ratios could hurt the reputation of his profession. The public, he said, might suspect such regulations were designed only to keep nurses off the unemployment line.

He also warns that the push for mandatory ratios could divide the profession. In an article in the March-April issue of Nursing Economic$, Dr. Buerhaus writes that nursing leaders should consider other solutions that "have less chance of fracturing relationships within the nursing community."

"Our Approach Doesn't Treat Nurses Like Numbers"

The ANA solution to a shortage of bedside nurses is a compromise between imposing across-the-board standards on hospitals and dangling incentives in front of their noses. The bill it supports, titled the Registered Nurse Safe Staffing Act, would require hospitals to work with direct-care RNs to determine the number of RNs needed on each shift and in each unit. Staffing systems must reflect, among other things, recommendations from specialty nursing organizations, as well as the skill sets of individual RNs. Hospitals that ignore the law are subject to fines.

The ANA stresses that its plan puts a premium on flexibility and a nurse's good judgment.

"We believe in having nurses who are the frontline workers — who know their patients best and who know their units best — develop the best staffing ratios," said Rose Gonzalez, RN, ANA director of government affairs. "Our approach doesn't treat nurses like numbers (in a ratio), but as an individual responsible for care."

For its part, the NNU views the ANA plan as an open door for widely varying and potentially harmful staffing levels among hospitals. "Why shouldn't you get the same level of care at one hospital vs another?" asked Karen Higgins. She also distrusts the source of the plan.

"The ANA is now mostly hospital administrators," she said. "It's basically an organization that works for the hospitals."

Rose Gonzalez counters that the ANA is very "staff-nurse driven," with many of its members belonging to nurses unions. Higgins' characterization of the ANA, said Gonzalez, is merely "a way to create a difference between us and them."

Gonzalez, however, draws some differences between the 2 groups as well. "We're a professional organization," she said. "We're not just about rallies. We're about advancing issues."

The participation of the 2 groups in the healthcare reform debate highlighted these differences, according to Gonzalez.

"The NNU was looking for a single-payer system, and once they didn't get it, they were very frustrated and they stepped away from the table," said Gonzalez.

"We have a position that supports single-payer, but we're also pragmatists. We know at times you have to move toward incremental reform. So we stayed at the table. We didn't say it was single-payer or nothing. We worked to get a compromise."

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