On February 15, 2018, the newest safe nurse staffing bill was introduced to the U.S. Congress. The bill (H.R.5052 and S.2446) has bipartisan support, and is championed by Reps. David Joyce (R-OH), Suzan DelBene (D-WA), Suzanne Bonamici (D-OR), and Tulsi Gabbard (D-HI), as well as Sen. Jeff Merkley (D-OR).
In the past, several safe staffing bills have been presented in previous Congresses but have failed to pass committee. This bill, the Safe Staffing for Nurse and Patient Safety Act of 2018, is slightly different than previous iterations. Under this staffing legislation, Medicare-participating hospitals would be required to form committees that would create and implement unit specific, nurse-to-patient ratio staffing plans. At least half of each committee must comprise direct care nurses.
“It is so important for nurses on the front lines to be able to have a say in what they believe is safe staffing,” says Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN, the president of the American Nurses Association (ANA). “This bill benefits bedside nurses by giving them decision-making power, control, and the ability to influence the delivery of safe care,” Cipriano continues.
A committee made of staff nurses—who would make staffing decisions that directly affect their own units—is so important because it is nurses who can best assess patient needs and the resources required to provide safe patient care. Staffing committees would be able to address the unique needs of specific units and patient populations by involving specialty nurses in the decisions, and would have the ability to modify the hospital safety plans as needed.
Overwhelmingly, research supports adequate nurse staffing. Over the last several decades, literature has demonstrated a decrease in patient morbidity and mortality and an increase in patient safety when units are well staffed. “With adequate amounts of staffing we see mortality go down and patient complications can be prevented or diminished,” Cipriano says. “It is important for nurses to have sufficient resources to care for patients, because nurses experience moral distress when they cannot provide the care they know a patient needs.”
Short-changing patients also contributes to nurse burnout, and low nursing retention is expensive. Additionally, adequate nurse staffing leads to reduced health care costs, as a result of fewer hospital readmissions, hospital-acquired infections, medical errors, and other significant measurable patient outcomes. “Patients deserve to have the right care,” Cipriano says. “They need to be kept safe, and the best way to prevent problems and complications is to have the right nurse staffing.”
Is there hope that this bill will pass, when so many previous iterations have not? “It may be difficult to pass the legislation, even this time around,” Cipriano admits. “But the most important impact is that every time we have an opportunity to have this legislation discussed, it’s another opportunity to educate another decision maker. Whether it is congresspeople, their staff, or other leaders in their communities, it gives us the opportunity to continue to reinforce why it is so important to have the right nursing care.”
It is ethically challenging when a nurse is asked to take staffing assignments that do not feel safe. On many units, nurses are expected to care for several acute and critically ill patients at a time, and are given patient loads that stretch them far beyond their reasonable care delivery capabilities. What should a nurse do when faced with an unsafe assignment? Nurses should raise immediate concerns by following the chain of command, and talking with immediate supervisors to express that they believe the situation is unsafe. “The first obligation is to make sure that no patient is left uncared for,” Cipriano says. “Short term, use the chain of command and do everything you can within in your power to make sure that you’re providing at least the minimum care the patient needs.” Longer-term, if nurses truly believe that their organization is not supporting the right staffing ratios, the ANA encourages an active dialogue with leadership, such as a conversation with responsible nursing leaders, quality directors, or patient care committees or councils to focus attention to the issue.
“Nursing care is like a medication,” Cipriano says. “You wouldn’t withhold a life-saving medication, so why would you withhold the right amount or right dose of nursing care?”
If you are passionate about safe staffing laws, consider calling or writing your congressperson and encourage them to support the Safe Staffing for Nurse and Patient Safety Act of 2018.
Stethoscopes dangled around the necks of nurses wearing navy NursesTakeDC t-shirts and big smiles. “Where are y’all from? We’re from Arizona!” More than 800 nurses from 40 U.S. states congregated at the NursesTakeDC Rally on May 5th in Washington, DC. The rally was to support legislation establishing federally mandated requirements for safe nurse-to-patient staffing ratios, while drawing public attention to the staffing crisis in many U.S. hospitals. This was the second such rally; last May, the inaugural event drew about 250 participants to the steps of the U.S. Capitol.
The rally was cosponsored by the grassroots nursing movement Show Me Your Stethoscope, a group that formed spontaneously on Facebook after nurse Janie Harvey Garner watched The View host Joy Behar ask why a nurse in the Miss America pageant was wearing “a doctor’s stethoscope” around her neck. That group now has more than 650,000 members. Other rally sponsors and supporters included the Illinois Nurses Association, Hirenurses.com, Nursebuzz, The Gypsy Nurse, Century Health Services, and UAW Local 2213 Professional Registered Nurses.
The NursesTakeDC rally was originally scheduled to take place on the steps of the Capitol, but thunderstorms and downpours forced the meeting indoors at a hotel in nearby Alexandria, Virginia. Although the setting lacked symbolism, participants still raised handmade posters and shouted rally cries. Rally organizers estimated the weather had an impact on overall attendance, but they were still encouraged by the turnout. After the speakers wrapped up, a group of about 150 nurses headed to the U.S. Capitol steps for photographs and final thoughts.
© 2017 David Miller, RN
Two, Four, Six, Eight, Patient Safety Isn’t Fake
“We aren’t laughing, we want staffing!” Cheers and whistles erupted out of the crowd. After 10 minutes of rally cheers and chants, the gathering turned its attention to the first of many speakers who would highlight issues faced by nurses in every specialty and across the profession. Actress Brooke Anne Smith began by reciting a moving poem about nurse warriors on the front lines.
Event organizer Jalil Johnson then took the stage, giving a keynote speech that addressed the challenges bedside nurses face every day. He spoke about nurses as the foundation of health care, and the unrelenting pressure to perform in deteriorating conditions. While discussing dire staffing situations, Johnson said that he fought every day, “making sure I didn’t give anyone a reason to come after the license I had worked so hard for.”
He discussed the paradox that year after year, nurses are rated the most trusted profession, yet no one trusts nurses when they say they are overworked, overburdened, and practicing in unsafe conditions. Nurses alone are not enough to fight this battle, he said. “To the public, we say: Trust us when we say the industry makes it nearly impossible to deliver the care you need. Trust us when we say we need your support.”
Other NursesTakeDC rally speakers included Katie Duke, Terry Foster, Deena McCollum, Linda Boly, Julie Murray, Catherine Costello, Kelsey Rowell, Leslie Silket, Dan Walter, Nicole Reina, Monique Doughty, Doris Carroll, Charlene Harrod-Owuamana, Debbie Hickman, and Janie Harvey Garner.
The Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act
On May 4th, the day before the rally, Representative Jan Schakowsky (D-IL) and Senator Sherrod Brown (D-OH) reintroduced the latest iterations of the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act (H.R. 2392 and S. 1063). The bills seek to amend the Public Health Service Act to establish registered nurse-to-patient staffing ratio requirements in hospitals.
In a press release, Rep. Schakowsky’s office writes: “This bill is about saving lives and improving the health of patients by improving nursing care—ensuring that there are adequate numbers of qualified nurses available to provide the highest possible care.” The press release acknowledges that study after study has shown that safe nurse-to-patient staffing ratios result in better care for patients. “It’s time we act on the evidence and the demands of nurses who have been fighting to end to dangerous staffing,” the release continues. “I’m proud to be a partner with nurses across the country in promoting this bill and working to ensure quality care and patient safety.”
Rep. Schakowksy attended last year’s event, but was unable to attend this year. The Nurse Staffing Standards Act is the latest in a string of bills that have been introduced to Congress every session. Previous bills S. 864 and H.R.1602 died in committee last session. S. 864 was first introduced in May of 2009; H.R. 1602 was first introduced in 2004 and has been sponsored seven times so far. Rally co-chair Doris Carroll explained why: “The legislation is reintroduced session after session, and it continues to die in committee because there is no bipartisan support.”
In today’s environment, politics can be touchy. The day before the rally, the House of Representatives passed the American Health Care Act of 2017. Among nurses there are very polarized viewpoints on health care, abortion, assisted suicide, and other controversial topics. In his speech, Johnson acknowledged that not all nurses think alike. “We are a profession divided,” he admitted. “But when it comes to safe staffing, we all agree. This is a movement devoid of partisanship. Staffing is not a partisan issue.”
The proposed text and ratios for the Nurse Staffing Standards Act are below:
A hospital would be required during each shift, except during a declared emergency, to assign a direct care registered nurse to no more than the following number of patients in designated units:
1 patient in an operating room and trauma emergency unit
2 patients in all critical care units, intensive care, labor and delivery, and post anesthesia units
3 patients in antepartum, emergency, pediatrics, step-down, and telemetry units
4 patients in intermediate care nursery, medical/surgical, and acute care psychiatric care units
5 patients in rehabilitation units
6 patients in postpartum (3 couplets) and well-baby nursery units
Rally speakers encouraged nurses to reach out to their representatives in Congress to show support for safe staffing legislation, and handouts for participants detailed how to find representative names and numbers for letter writing campaigns and phone calls.
Where Is Everybody?
When one of the speakers asked why there wasn’t more involvement in the grassroots movement, and why there weren’t more nurses present, several voices called back from the crowd. “Everyone’s working!” one shouted. Another called out, “They don’t have the money!”
“Really, where the heck is everybody else?” one rally participant said. She gestured to the conference room, which at the time held about 100 nurses. This nurse was part of a group attending from New Jersey, including Kate McLaughlin, a registered nurse and founder of NJ Safe Patient Ratios, a group dedicated to the support of safe staffing in New Jersey and promotion of ratio law S. 1280 in New Jersey’s Senate.
“In New Jersey, multiple bills have been introduced, every single session, and nothing ever passes,” McLaughlin said. “In California it was the same thing, and then the tenth year, they involved unions and patients and it finally worked.” She said she started to pay attention to safe staffing laws in her state, and launched a petition on change.org. “I stalked nurses on Facebook and found people that way,” she continued. “Each week, we organize and post the contact information for two state senators.” She is starting a movement in New Jersey, hoping to motivate others to show support for these bills. “It’s an election year,” she said. “Now is the time.”
McLaughlin said her state’s ratio law was first introduced in February 2016, but there has been no vote and no hearings, “which just feels disrespectful.” She was told the governor didn’t support the bill, and “that we might need to wait until there’s a new governor.”
The problem, according to several nurses at the rally, isn’t a lack of awareness. “I think it’s apathy,” McLaughlin said. “This is a profession of predominantly women, and we are taken advantage of. They know we don’t get breaks, but they’re okay with the labor law violations. We’ve somehow accepted that this is normal—this is not normal.”
Carroll also expressed discontent that no one seems to care about this issue. “Why has this taken so long? Why hasn’t California’s success spread like wildfire?” she asked. “Well, health care changed, and it became a multi-billion dollar business for hospitals and insurance companies.”
Dan Walter, another speaker, acknowledged that sometimes nurses do not report safety issues because they fear retribution. Walter is a former political consultant and publisher of HospitalSafetyReviews.com, a web site that he established for nurses to anonymously post about patient safety issues where they work. In his speech, he explained the inspiration for creating the site: “You are the activists and you know what needs to be done. I want people to be able to go there, post, and we will keep it as anonymous as possible so we can protect you.” He expressed hope that this web site will be a powerful platform to improve patient ratios.
How Bad Is Staffing?
Nurses from a hospital in downtown Washington, DC, expressed frustration with the lack of support and resources from hospital administrators. “The other day, we had so many critical patients in the department we ran out of monitors,” one said. Another said that 80% of the nurses who work in her hospital’s emergency department have less than two years’ experience. “The turnover is so high,” she said. “People get so burned out because of the short staffing.”
Just how short are units staffed? “In our ED [emergency department], someone the other night was taking care of seven patients,” one nurse from this group said. “And these were sick patients, people with LVADs [left ventricular assist devices], and ICU patients.” This is common all over the country. A medical-surgical nurse may be taking care of up to eight or more patients at a time.
Llubia Albrechtsen, a registered nurse and family nurse practitioner at the rally, said there have been times she has refused to take on additional patients in the emergency department where she works. “When I have five patients, I need to take a step back and pay more attention, because their conditions may worsen,” she said. “It’s hard, because we could be providing excellent care to many of our patients, but with limited resources we have to do the best we can and hope nothing bad happens.”
Albrechtsen said that although hospital administration makes an effort to listen to nurse concerns about staffing, through town halls or open meetings, not much has changed. “Many areas still work understaffed,” she said.
Why Does Staffing Matter?
A policy brief disseminated at the rally lists the effects of inadequate nurse staffing, including the overwhelming evidence that safe staffing saves lives. High patient-to-nurse ratios lead to poor outcomes and a demonstrated increase in patient morbidity and mortality. Inadequate staffing has been associated with an increase in hospital readmissions, falls, pressure ulcers, hospital-acquired infections, and medication errors.
Poor staffing is expensive. In addition to causing poor patient outcomes, nurse burnout causes injuries, illness, and contributes to the growing nursing shortage. Replacing nurses due to turnover takes between 28 to 110 days, and costs the average hospital $6.2 million per year.
“The health care industry generates $3 trillion annually,” Johnson said in his address. “We are living in an age of greed, where the health care industry measures patient satisfaction by a customer service model. This is prioritized over quality and safety. Reducing burnout, staff retention, and caring for your staff are at the bottom of the barrel of priorities.”
The grassroots movement behind safe staffing is fighting for environments that allow nurses to do their work in the way in which they were trained. “[A nurse’s] work has been diminished to defensive practices; it has been reduced to a list of tasks to complete,” Johnson said. “That is not nursing.”
In Johnson’s final remarks, he spoke to empower nurses to return to their states, hospitals, and colleagues with a message to inspire change. “We have to show up in person, put boots on the ground, and be ready to engage and pull more nurses into this movement,” Johnson said. “Most importantly, we have to believe that with over 3 million registered nurses and over 1 million licensed practical nurses, our profession can come together as one. We will take back our profession and regain control of our practice.”
Another rally is already in the works for next year. The organizers of NursesTakeDC will now direct their focus toward supporting any state that has pending policy and legislation aimed at improving nurse-to-patient ratios and safe staffing. Organizer Carroll said that this year is a learning curve for the organizers, and they hope that next year they will have something even better with an even bigger audience.
“We encourage all nurses, practicing at all levels and in all settings, to unify and support beside nurses in the fight for safe staffing,” said Johnson to a room full of applause and cheers. “We fight for recognition—we will not justify our existence! There is no health care industry without us, and we will determine what is best for our practice and for our patients.”
A recent proposal from the Obama administration seeks to lift a ban that prevents physician assistants (PAs) and nurse practitioners (NPs) from providing home care to Medicare patients. In an article from Forbes contributor Bruce Japsen, Japsen explains that the current ruling limits access to care provided by PAs and NPs, resulting in more expensive treatment in nursing facilities and other inpatient care centers. PAs and NPs are working hard to earn full practice authority within the scope of their education, including writing proposals that would allow them direct access to patients across all states and expanded roles within Veterans Affairs facilities. The Obama administration views PAs and NPs as a crucial part of expanding the number of primary care providers nationwide, especially in certain areas where primary care providers are in shorter supply.
Following the lead of the Obama administration, the Centers for Medicare & Medicaid Services (CMS) published a proposal to amend a rule from the Program of All Inclusive Care for the Elderly, a program called PACE, designed to help provide home care access to senior Medicare patients and poor Americans covered by Medicaid. If implemented, the proposal could allow Medicare reimbursement to primary care providers who treat Medicare/Medicaid patients within the year.
CMS wants to see the PACE program used to its full potential and suggests expanding reimbursement to NPs and PAs as a way to increase access and lower costs. According to the New York Times, only 40,000 seniors were enrolled in PACE as of January 2016 and CMS wants to grow that number and expand the PACE program.
Due to population growth, aging, and expanded health insurance, demand for primary care is expected to continue rising. The Health Resources and Services Administration (HRSA) predicts there will be a primary care physician shortage of 20,400 by 2020. However, the Institute of Medicine (IOM) notes that this projection does not consider the potential that PAs and NPs have on increasing access to primary care.
According to Andy Slavitt who runs a blog on the CMS website, team-based models like PACE which put the individual in the center are a vital part of the fabric of our healthcare system. Since the Affordable Care Act was passed six years ago, CMS has been taking significant steps to care for more people with better and more affordable health care. However, in order for these models to be successful, every member of the health care team will have to work together to find and implement new approaches to care.
PAs and NPs are petitioning to be a part of PACE, arguing that providing care in the home benefits PAs and the country’s aging population. President of the American Academy of Physician Assistants (AAPA), Josanne Pagel, believes in the ability of the PACE program to provide comfortable and convenient high-quality healthcare to elderly patients in their homes at a lower cost than hospital stays and nursing homes.
The proposed rule from the Obama administration redefines the meaning of a primary care provider. Adding PAs and NPs under the blanket of primary care provider could allow for more cost-effective care, especially in rural zones and areas with high labor costs.
Below, I interview Lt. Meg Whelpley, a nurse practitioner (NP) with the National Heart, Lung, and Blood Institute (NHLBI) on the Cardiology Consult Service at the National Institutes of Health (NIH). She tells us about her career as a bedside nurse, a travel nurse, an NP, and now as an officer in the Commissioned Corps of the US Public Health Service.
Tell me about your background.
I got my bachelor of science in nursing in 2005 from Johns Hopkins University. My first degree, however, was in information technology, and I worked for the federal government before deciding that I needed to go into nursing. I have worked in both adult and pediatric emergency departments (ED), the intensive care unit (ICU), and I now work in cardiology.
What was your first nursing job?
My first job as a nurse was in the ED at Inova Fairfax Hospital, a level-one trauma center in Fairfax, Virginia. It was wild and fun, and the teamwork was outstanding. It was an amazing introduction to nursing and medicine, and I am grateful each day that I started my career there. The challenges of that environment were innumerable, and the lessons I learned continue to impact my daily life, both personally and professionally.
What did you do next?
As can frequently happen in an ED, there was a mass staff exodus when I had been at Inova Fairfax for almost two years. Travel nurses were hired to fill open nursing positions. The new travelers told me about the glory of the travel nurse life, and I was single and ready for a change.
Where was your first travel assignment?
My first stop was a tiny rural hospital on the Eastern Shore of Maryland. They had fewer beds in their entire hospital than we had in the ED at Fairfax! It was a huge eye opener. In only my second week there, I was made charge nurse of the ED four nights a week. The manager told me I had more experience than any of her night nurses despite having less time actually at the bedside.
Being a charge nurse must have been a great leadership experience for you. Where did you go for your next assignments?
My next adventure was to was Denver, in a pediatric ED. I was nervous about taking care of kids, but I had a great time and loved the work. I was there for nine months before heading to Chicago. There, I was in the ED of a level-one trauma center, and again was part of a great team, but the work was tough. Inner city Chicago was very different from suburban northern Virginia. I was there for the last six months of 2008 when the financial markets crashed. The effect was definitely felt in travel nursing. I was thrilled to be asked to come back to Denver and returned there for a three-month contract in January of 2009. I was then offered a position there as a staff nurse, and I took it while I worked on taking the next steps to pursue my master’s degree.
What led you back to school for your advanced practice degree?
I really liked the idea of participating in patient care at a higher level. As a bedside nurse in the ED, most of the physicians I worked with appreciated my assessments, and they challenged me to think further about possible differential diagnoses. They were wonderful teachers. I wanted to focus more on diagnosing and treating patients, and I really believe in both the art and science of nursing, so becoming an NP was the clear choice for me.
Where did you start working after you were a CRNP (certified registered nurse practitioner)?
My first job was in the ICU at Inova Fairfax. I loved the work, but the schedule was really challenging. We rotated days and nights, and I even worked a few 24-hour shifts as needed. It was harder than any schedule I had as a nurse in the previous seven years! I quickly found a new position with the cardiology service at MedStar Washington Hospital Center in the District of Columbia, and I stayed there for two years. It was a great place to learn, and we had a great team of NPs. It was a very autonomous NP service, which was professionally satisfying. I had the opportunity to return to federal service with a position at NIH in 2013, and I jumped at the chance!
Do you remember when you first heard about the United States Public Health Service (PHS)? What drew you to this organization?
My first encounter with the PHS Commissioned Corps was at a job fair at Hopkins during my nursing undergrad. I was reintroduced to the service when I took my position at NIH—many of the people that work here are Commissioned Corps officers. I had always been interested in serving. You could say it’s in my blood: My brother was in the Marine Corps, my father spent his entire career as a civil servant, and my mother worked as a priest and social worker. Of course, my husband’s service in the fire department was also a big influence on my decision to serve. We hope to instill the value of service in our son, as well.
The idea of being a part of a group dedicated to “protecting, promoting and advancing the health and safety of the nation” was very appealing to me. I had looked at other branches of service a few times through my years of education, but the fit with the PHS was definitely right for me.
What did it take for you to become a lieutenant in the PHS?
There is a multi-step application process (detailed at www.usphs.gov) that requires that you obtain employment in a federally qualified position prior to commissioning. My position with the NIH qualified, but many other positions are available throughout the federal government, and you can begin the PHS application process before securing a qualified position. We work in the Bureau of Prisons, the Indian Health Service, the Centers for Disease Control, and the Federal Drug Administration, to name a few agencies. Once you receive your call to active duty, there is a required two-week Officer Basic Course as a part of the commissioning process, and then it’s time to get to work.
Where do you work? What is your role? What is a “day in the life” like for you in your current position?
I am currently an NP with the National Heart, Lung, and Blood Institute on the Cardiology Consult Service at NIH. I work with a team to evaluate patients enrolled in any number of research protocols there. We see patients before, during, and after their participation in research, depending on their cardiac history and needs. I get to spend a lot of time educating and learning, with both my patients and the students that round with us. It is a very rewarding job. I wear my uniform every day with pride.
What responsibilities do you have with the PHS?
As an officer in the Commissioned Corps, I have added responsibilities with the PHS, which include working with the Capital Area Provider (CAP) team in support of the Office of the Attending. My CAP team duties also include local deployments to act as medical support for mass gatherings throughout the District of Columbia. Additionally, I volunteer with the MobileMed-NIH Heart Clinic, which is an organization that provides cardiac evaluations for underserved citizens of Montgomery County, Maryland.
What is most challenging about your job?
Understanding the complex diagnoses of my patients in addition to the proposed treatments and their cardiac implications is a challenge every day! We see some amazing things at NIH, and almost none of it is straightforward. I have been here three years and not a day has gone by that I haven’t learned something new.
What type of person would be good in this role?
I think that my success in this job has come from my strong foundation and training in the art and science of nursing. Caring is an art form, and it is essential in developing relationships with patients and the teams with which we consult. Science requires focusing on details and critical thinking about patients to ensure the best outcomes possible. The type of nurse that would be good in this role needs to be a caring, detail-oriented, critical thinker—oh, and I write patient reports constantly, so good written communication is a must!
What is most rewarding about your work?
Patients here are very appreciative of their care. Because they are participating in research, there is no charge for the care they receive, which makes people really grateful. Grateful patients are refreshing for me, as that was not always the case in the other places I have worked. I also get to take my time with patients. I can really help them better understand their own hearts and how to best care for themselves. Education is an amazing gift to give to patients, and empowering them in their own care is very rewarding.
“You are so overburdened. The situation has made it impossible to give the care you need to. We need more of you. We need much better staffing ratios. It’s really that simple.” –Congresswoman Jan Schakowsky (D-Illinois), author of Nursing Staffing Standards for Patient Safety and Quality Care Act (HR 1602), in a speech on Capitol Hill at the Nurses Take DC Rally
It had rained in Washington, D.C., for 15 straight days, but on May 12, 2016, the weather held off. Nurses from all over the country gathered under cloudy skies and congregated around a simple speaker stand with flags to either side stating, “Safe Nursing Ratios Save Lives.”
The ground was boggy, causing many nurses to sink into the mud, but none could turn their eyes away from the Capitol building that hung over the scene, a reminder of the power of the people. On this misty, humid, and rain-free day, nurses made their demands for safer staffing ratios known with the smell of wet grass in their noses and a cheer in their throats for the thoughts so passionately and aptly expressed by the many speakers.
The speakers roused the crowd with inspired words, and nurses held up signs in support of the legislation. They shared heartfelt stories of nurses and patients who have suffered poor ratios on the front lines. What happened on this slate gray day in front of the great building of government? Promises of safe ratios, belief in the power of legislation, and a comradery that transcended specialty, geography, and years of service rang out from Congresswomen and nurses alike.
Of all of the problems nursing has—bullying, burnout, and nurses leaving the profession—why are all of these people focusing on ratios? It is because ratios affect patient safety the most, and nurses are always focused on patient safety first.
Janie Harvey Garner, RN, founder and executive director of Show Me Your Stethoscope, was asked why she chose this issue for her group. “Because I have been that nurse with the third patient in the ICU,” she says. “I’ve been the nurse with the nine patients on med/surg. It’s not safe for anybody, and quite honestly, though I am extremely concerned about hurting a patient, I’m also very concerned about hurting a nurse because second victim syndrome is a super health issue, for me anyway. I don’t think it is with hospital organizations, but it sure is with me. Kim Hyatt died. Let’s not make it in vain.” (Hyatt committed suicide after making a medication error, which may or may not have been related to staffing issues.)
Rebecca Love, BA, MSN, RN, ANP, regional director for the North East region of Show Me Your Stethoscope and founder of HireNurses.com, went even further when she stated, “I think what we’re seeing in the hospital is verging on the level of we are choosing which patients are going to live and which patients are going to die every day when we come in and deal with the ratios that we are dealing with.”
In fact, Kelsey Rowell, RN, thinks that staffing ratios may be leading to some of the other problems that face nurses. “I think we’re spread so thin that it’s really causing nurses to experience compassion fatigue and feel tired. I think ratios are something that’s going to be ultimately good in a long haul.”
Ratios are the most important issue in nursing because it is about the patients. There is no way to get around that fact, and that is why this legislation is so important. Nurses need to stand up and be heard. People can and will die when nurses are spread too thin, and that not only hurts patients, but it severely impacts the psychology of the nurse.
The general public doesn’t even know this is an issue because they don’t know what nurses do. “Nurses need to speak about the value of their work,” says Sandy Summers, RN, MSN, MPH, founder and executive director of The Truth About Nursing, and coauthor of Saving Lives: Why the Media’s Portrayal of Nursing Puts Us All at Risk. “Moving their heads up high and saying, ‘I can’t possibly take care of four ICU patients, someone is going to die. I can barely take care of two.’ So working on safe staffing issues is ultimately joining our mission of working to educate the public about the value of nursing, the work that nurses do to save lives.”
The hubbub at the Capitol was due to the legislation that is now in the House of Representatives called HR 1602. There is also a Senate bill for nurse to patient ratios, but it is still in its very beginning stages. Like the California laws, this bill calls for mandatory ratios across the country. Here is what the bill proposes hospitals will have to offer nurses who work for them:
“[A] hospital’s staffing plan shall provide that, at all times during each shift within a unit of the hospital, a direct care registered nurse may be assigned to not more than the following number of patients in that unit:
- One patient in trauma emergency units.
- One patient in operating room units, provided that a minimum of 1 additional person serves as a scrub assistant in such unit.
- Two patients in critical care units, including neonatal intensive care units, emergency critical care and intensive care units, labor and delivery units, coronary care units, acute respiratory care units, postanesthesia units, and burn units.
- Three patients in emergency room units, pediatrics units, stepdown units, telemetry units, antepartum units, and combined labor, deliver, and postpartum units.
- Four patients in medical-surgical units, intermediate care nursery units, acute care psychiatric units, and other specialty care units.
- Five patients in rehabilitation units and skilled nursing units.
- Six patients in postpartum (3 couplets) units and well-baby nursery units.”
Nurses posing with Congresswoman Jan Schakowsky
This bill was proposed by Congresswoman Jan Schakowsky (D-Illinois), a woman of great charisma and passion for nurses and ratios alike. She is moved by health care and the plight of nurses everywhere. “If we really want to improve patient care, we have to improve the nurse staffing ratio,” says Congresswoman Schakowsky. “There’s just no question about it. It is nurses that are on the frontlines. If they have too many patients, then nurses just can’t do the job that we need done.”
In the House, different representatives can agree to co-sponsor a bill, or lend their support to its cause. Two of those representatives are Congresswoman Donna F. Edwards (D-Maryland) and Congresswoman Joyce Beatty (D-Ohio), and both are passionate about the cause.
After a rousing speech to the nurses assembled, Congresswoman Beatty spoke with similar eloquence as to why she supports the bill: “It makes a difference in the lives of not only nurses but in the lives of patients. It’s good for patients. It’s good for health care. I want to say thank you for being out here because getting a bill passed and moving it along the way is standing up for what you believe in. I can go back to the house floor and I can say I believe in nurses.”
Congresswoman Edwards was similarly supportive of the bill and of nurses. “We want to make sure that our patients and our nurses are operating in the kind of environment that allows them to provide quality health care,” she explains. “That quality is jeopardized when nurses have so many patients to care for when they have some other responsibilities that don’t involve direct patient care.”
Nurses and Health Care
It’s great to talk about getting more nursing at the bedside, but nurses cost money. With the rising cost of health care, it may not be feasible to expect that the system could support better nurse ratios. The Affordable Care Act aims to get more people health insurance, but how does this impact nurses? More patients mean more work, higher ratios, and more stress. What is the solution?
Nurse talking to Congresswoman Donna F. Edwards
Congresswoman Edwards doesn’t see this as a problem: “It’s really clear that even under the Affordable Care Act, we’ve always known that we’re going to be in an environment where we need more nurses, more qualified care in medical settings, and that’s going to be really important with so many more people coming in to the system requiring care that staffing ratios are [an] important component of that kind of quality care.”
Obviously, this will need to be addressed if more patients are coming into the system. If there are no ratios in place, this could lead to very unsafe staffing in most facilities. That makes it even more important to pass this legislation . . . and to find ways to get more nurses to the bedside.
Congresswomen Schakowsky also wants more nurses: “We need to make sure that health care providers are also increased to make sure that we can actually deliver the care to these millions more people.”
“We’re trying to marry the two of the insurance and having good medical services,” says Congresswoman Beatty. “I don’t see them on separate ends. You can’t be for health care and be against good nursing. You can’t be for good nursing and be against health care.”
Despite the positive talk, the increase in patients will trickle down to nurses. This legislation needs to pass so that the facilities can’t just continue to add to the nurse workload because there are more patients than they know what to do with.
Ways to Improve Ratios
Ratios are obviously a problem, but legislation cannot possibly be the only solution. For starters, there are some flaws in the bill proposed, but laws can take a very long time to come into effect. Patients are dying now. Nurses are suffering now. There has to be something else nurses can do to impact this issue.
Rowell has a few ideas. “I think it’s going to start with awareness,” she says. “Maybe it’s going to be starting with people standing out and voicing everything going on and the severity of it. If we continue to let the business of the profession run what we do, we will focus on profit over patients’ safety, and that is a big deal.”
There are other factors that stand in the way, as well. Love points out that “I think that there are powerful interests at play that oppose this kind of change. Largely insurance and health care and hospital administrators because nursing costs money and the only way that we’re going to be able to fight that is when we state we will have mandated safe staffing levels.”
It is certainly true that insurance isn’t going to support staffing ratios. The more they keep costs down, the better. Unfortunately, this often comes at the expense of patients and nurses. With the Affordable Care Act, insurance companies will look to cut costs even more, and that is a dangerous precedent for the movement.
It is also true that facilities don’t tend to listen to nurses. They are seen as complainers, but even then, nurses can find a way to maneuver themselves into a better situation. “We have to encourage patients and their families, and caregivers to start questioning a lot more,” says Andrew Lopez, RN, president and CEO of Nursefriendly.com. “We have to feed them the information they need. Social media is an excellent vehicle. We can do that. Social media gives us a platform where we can go on to Facebook, we can go on to Twitter, and go on to communities where we will be welcomed as nurses, as ambassadors of health.”
Deficiencies to the Bills
One of the problems with the bill is that it doesn’t provide for an acuity scale. Although it is mentioned, a scale is not specifically written out. This can leave the door open for facilities to exploit it by giving nurses the required number of patients but swamping them with patients requiring a great deal of care.
“We want the hospitals to be working with the nurses to figure out exactly what number needs to be there,” says Congresswoman Schakowsky. “Obviously, when there’s greater acuity, we need to have even more nurses that are available. It’s clearly a big factor. We haven’t put a number in the bill but we want that taken into clear account.” However, leaving the negotiation to the hospitals may not be the best idea.
Congresswoman Beatty agreed and showed a remarkable knowledge of what nurses experience every day. “I think that’s one of the things we’re going to work through. Certainly when you know if a patient is sicker than another patient, they require more care. If you’re in intensive care or if you get an infection, the requirements are that it takes more work.”
Another glaring oversight of the bill is the lack of ratios for those in long term care and rehabilitation. In these specialties, registered nurses can have up to 40 patients with minimal support staff under them.
Summers stated that this was one problem with the bill that needed to be addressed. “A nurse told me in her rehab center, there are two nurses for every 17 ventilated patients. That is so reckless. But taking care of ventilated patients is hard. Their tubes always get blocked up. They get secretions and coughing. Eight and a half patients each? That’s reckless. She thought that wasn’t as bad as they have on the floor which is 40 patients each or 50, I think.”
Clearly, this is a problem, and it needs to be addressed in the bill. It is an oversight that has caused many to withdraw their support. For this reason and others, national groups like the American Nurses Association are not as supportive. “The ANA is not supportive of the current legislation, but that does not necessarily mean that they’re not supportive of us,” explains Garner. “I think they’re in general supportive of a grass root effort, but they certainly do not back the current legislation that we’re supporting.”
Although there are some flaws with the bill, the future may rely on its passing. This is why nurses support it—it is the best thing out there for the problems they face. What is the future of nursing and this bill?
Caroline Thomas from EmpowerRN states, “I think you know the future of nursing is very bright obviously. Statistically, we have a huge gap in the amount of nurses that we have and the amount of nurses that we’re going to need in the future. Having a degree in nursing, it opens up a lot of doors other than just the traditional. I definitely recommend it; I think it’s a great time to get in to it.” Despite the flaws, nursing still remains a profession that is worthy of pursuit.
Love has a completely different take on the future of nursing and of ratios: “I believe what’s going on, is that we are becoming so overburdened with the amount of patients that we are caring for that it is driving down the quality of care. It’s forcing nurses out of the profession and eventually we are going to end up with nobody by the bedside to care for patients. I think the future of nursing and the future of health care are at risk.”
Where is Show Me Your Stethoscope going from here? Garner is optimistic. “We’re going to continue to do nurse advocacy. We’ll also continue to do patient advocacy. Mostly, I see us doing what nurses want us to do because we’re a nurse’s organization. I don’t want to unionize the world. All we want to do is do what nurses want to do.”
In the end, nurses are fighting for their patients and themselves when everyone else doesn’t understand the struggle or even knows it exists. Advocacy for nurses is needed. Education of the public is also necessary. Legislation is only one road. Starting a dialogue and standing up for nurses is the way to lasting change. This is the future of the staffing ratio debate, and with this rally, nurses are off to a great start.
But it is only the start.
The Director from the National Institutes of Health (NIH), Francis S. Collins, MD, PhD, has appointed Patricia Flatley Brennan, RN, PhD, as the new Director of the National Library of Medicine (NLM). She is expected to begin the new role in August 2016.
Dr. Collins appointed Dr. Brennan for her background as a pioneer in the development of patient information systems. Her experience in developing patient information systems includes developing ComputerLink, an electronic network to reduce isolation and improve self-care for home care patients. She also directed two projects, HeartCare, a web-based information and communication service for helping home-dwelling cardiac patients recover quicker, and Project HealthDesign, an initiative to stimulate the next generation of personal health records.
Dr. Brennan is currently a Lillian L. Moehlman Bascom Professor in the School of Nursing and College of Engineering at the University of Wisconsin-Madison, as well as a leader for the Living Environments Laboratory at the Wisconsin Institutes for Discovery where new ways for effective visualization of high dimensional data are developed. Her background includes her MSN degree from the University of Pennsylvania and her PhD in industrial engineering from the University of Wisconsin-Madison. After completing school, Dr. Brennan went on to work seven years of clinical practice in critical care nursing and psychiatric nursing before taking on several academic positions at Marquette University, Case Western Reserve University, and her current role at the University of Wisconsin-Madison. She is also now a fellow of the American Academy of Nursing, the American College of Medical Informatics, and the New York Academy of Medicine.
The National Library of Medicine is the largest biomedical library in the world with a wide print collection and electronic information resources on a wide range of searchable topics that are available to people all across the globe. They support and conduct research, development, and training in biomedical informatics and health information technology used by scientists and health professionals worldwide. The NLM is a branch of NIH, the nation’s primary medical research agency which includes 27 Institutes and Centers as a component of the US Department of Health and Human Services. The NIH conducts and supports clinical and translational medicine research, investigating causes, treatments, and cures for common and rare diseases.