Nurses Storm the U.S. Capitol to Demand Safe Staffing Ratios

Nurses Storm the U.S. Capitol to Demand Safe Staffing Ratios

“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.

Why Ratios?

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 Legislation

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.”
Congresswoman Jan Schakowsky

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?

Congresswoman Donna F. Edwards

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.”

The Future

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.

Patricia Flatley Brennan, RN, PHD, Appointed as New Director of the National Library of Medicine

Patricia Flatley Brennan, RN, PHD, Appointed as New Director of the National Library of Medicine

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.

Safety in Numbers—of Nurses

How many patients can a nurse reasonably care for at one time? This is perhaps the biggest issue facing the nursing profession right now. In fact, there are two bills in Congress right now that seek to decide just this, not only to protect patients but also the nurses who care for them.

California is the only state in the United States that regulates the number of patients a nurse can have under his or her care. The safe staffing law was passed there in 1999 (more than 15 years ago!) and it went into effect in 2004. The law breaks down the maximum number of patients for a nurse by acuity and type of care.

But in 49 other states and in the District of Columbia, there is no mandated limit to the number of patients a nurse can safely or reasonably be expected to care for.

What does this mean? This means on busy days in an emergency department, nurses may be caring for 4-6 acutely ill patients, some of whom need to be transferred to the intensive care unit, to a telemetry unit, or to the OR. This means a psychiatric nurse could be expected to care for more than 10 patients at a time, or that on a low-staffed unit at night, a med-surg nurse may be caring for up to eight or more patients.

A nurse’s name on a patient’s chart confers ultimate responsibility for that patient’s safety and well-being. The expectation is that the nurse will prevent a patient from harm and will keep a patient safe. It is the nurse who will discover a medication error before it gets to the patient (whether it be an error on the part of a resident or the doctor or the pharmacist); she or he will keep a patient from falling should they try to get up out of bed unassisted, and he or she will medicate, assess, chart, document, comfort, and care. But what happens when that nurse is stretched so thin there is no possible way for her to ensure a patient’s safety? The patient is at risk, and so is the nurse’s license. How can she be everywhere at once when she is caring for five or even six patients at a time?

Unfortunately, this is an issue that is unlikely to be resolved in the near future, despite the two bills currently before Congress. Over the next decade, the number of aging baby-boomers continues to increase while the number of new nurses entering the workforce decreases (not to mention those nurses leaving the profession altogether as a result of burnout and fatigue). Administrators still incorrectly fear the cost ramifications of nursing mandates. Specifically, the bill would require hospitals to write a staffing plan, and “allows a nurse to object to, or refuse to participate in, any assignment if it would violate minimum ratios or if the nurse is not prepared by education or experience to fulfill the assignment without compromising the safety of a patient or jeopardizing the nurse’s license.” Importantly, the bill also carries an anti-retaliation clause. The bills are a start, but are not a panacea by any means. And, they have yet to pass.

Earlier this week, a report released by Johns Hopkins purports that medical errors are the third leading cause of death in the United States each year. The high number of deaths relating to errors point not to bad doctors or to mistakes, but more to systemic problems, a lack of standardization, a lack of reporting and data collection about mistakes, and issues with medical staff turnover, burnout, and fatigue. Many people are quick to point out the myriad studies correlating positive patient outcomes and higher levels of nurse staffing, as well as the decrease patient lengths-of-stay.

It’s not that data don’t exist, as hundreds of studies demonstrate the positive relationship between patient safety and nurse staffing. Moreover, studies also show that increasing nursing staff does not contribute to higher hospital costs. A longitudinal study by the Agency for Healthcare Research and Quality concluded that it actually decreased costs over time, including a decreased patient length-of-stay. Additionally, increased nurse staffing has been shown to decrease patient mortality, increase patient satisfaction, and decrease nursing turnover and job dissatisfaction.

Safe staffing is an issue that is not likely to fade, and many nurses are eagerly tracking the legislation before Congress. A rally to demonstrate support of safe staffing is planned in Washington, DC, for May 12th. More information can be found here.

The Nurse’s Role in Preventing Ransomware Attacks

The Nurse’s Role in Preventing Ransomware Attacks

In April, the MedStar Health system of 10 hospitals and hundreds of physician-affiliated offices around the Maryland and Washington, D.C., area became the latest hospital system targeted by ransomware. Ransomware is a type of virus or malware that blocks access to a computer system until a payment is rendered. The hospital system was reportedly without access to its electronic medical record (EMR) system for days, including restricted access to e-mails, imaging software, and scheduling systems. Many physicians had no access to patient medical records or labs and test results, and most locations resorted to a system of paper charting.

Clearly, losing access to the EMR is debilitating. “Think about it—we couldn’t even print patient armbands,” said a MedStar employee who agreed to discuss the situation with me on the basis of anonymity. “It was a systematic breakdown both for patients and staff, with safety at the forefront,” he said.

Another MedStar nurse told me about the drastically increased wait times in the ER and numerous patient safety issues. “I had a patient who was possibly having a heart attack, but it took hours to get labs results, and I had no way to compare the EKG [electrocardiogram] to any previous EKGs to look for changes,” she said. “The other problem was that [MedStar] kept telling people we were under ‘normal operations,’ so people walked through the door expecting a functioning department.”

Many nurses are inexperienced with paper charting because EMRs have been in use longer than their tenure. “We were boarding patients, no one knew how to paper chart, and the lab was backed up more than six hours for a stat result,” said one nurse.

MedStar is not the first hospital system to be affected by malware: In February, a hospital in California paid $17,000 in bitcoin ransom. Is this the start of a frightening new trend? Hospitals seem like a perfect target because regaining EMR access is time-critical. Systems are very likely to pay up, and quickly, in order to access the hostage information. Patient safety is on the line.

Every hospital employee is familiar with the importance of patient privacy and protected health information because of the HIPAA privacy rule. However, at many hospitals, nurses do not even log into shared workstations—they are all unlocked—and passwords often have lax requirements. In hospital orientation, the focus is on patient privacy, not network security.

What can you do as a nurse to make sure you aren’t contributing to a possible security threat?

1. Be a “discriminating clicker.”

If something seems fishy on your computer, do not click it. Be wary of e-mail attachments specifically, and utilize the “hover-over” feature many programs and browsers use to help verify the legitimacy of the sender or link. Never click a suspicious link, even if it appears to be sent from a friend.

2. Call the help desk if anything strange pops up on your screen.

If a pop-up asks for you to provide log in credentials to a workstation you are already using, be suspicious. Third, immediately report any e-mails you receive from unknown senders. Forward a questionable e-mail to the help desk only if requested, because doing so can help the virus “spread.” Some web sites are able to create a pop-up that asks you to call a certain phone number; do not call these numbers and report this to a help desk.

3. Do not attempt to fix a suspicious problem yourself.

In some cases, turning off a machine altogether can exacerbate a problem or even eliminate potential forensic evidence that could be helpful to law enforcement. When in doubt, check it out with the help desk.

The recent ransomware attack on the D.C. hospital system is unlikely to be the last. Familiarize yourself with the systems information policy at your organization. Even these guidelines will not prevent ransomware, because based on FBI reporting, certain pieces of ransomware can attack application servers directly. However, these tips can help vigilant nurses remain well informed, and can help ensure malware infection attempts through e-mail or browsing are unsuccessful.

AANP heads to Capitol Hill today to urge Congress to improve health care access

AANP heads to Capitol Hill today to urge Congress to improve health care access

The American Association of Nurse Practitioners (AANP), the nation’s largest professional organization representing nurse practitioners (NPs), is asking Congress to strengthen patient access to vital health care services. Over 300 members will be in attendance, serving as the voice of 205,000 nurse practitioners around the nation.

In today’s meetings with Congress, AANP’s present members will be providing personal insight on health care challenges being faced all over the US. They will bring awareness to the members of Congress to support health care priorities in combatting chronic disease, substance abuse, and patient access to primary, acute, and specialty health care services in rural and urban communities.

Currently only 21 states and the District of Columbia grant full practice authority to NPs. Nurse practitioners are growing in popularity, but it hasn’t been enough to grant them full practice authority nationwide. In states where licensed and fully trained NPs are not being allowed to practice at their full education and training levels, many citizens are missing out on access to care. At a time when primary care shortages are so prevalent, every capable provider is needed to reach patient needs.

By 2025, the number of licensed nurse practitioners in the US is expected to rise from 205,000 to 244,000, a statistic released by AANP. This growth prediction is based on the increase in baby boomers and the millions of new patients who have entered the American healthcare system under the Affordable Care Act. With 80% of NPs being educated in primary care programs, and 49% of those entering into family practices, nationwide full practice authority will increase access to care everywhere, especially for underserved communities.

Across the country nurse practitioners serve as primary, acute, and specialty care providers. They have a wide range of abilities including assessing, ordering, and interpreting diagnostic and laboratory tests; making diagnoses; initiating and managing treatment plans; prescribing medications and nonpharmacological treatment; and counseling patients and their families.

AANP is also involved in providing legislative leadership at local, state, and national levels. Their legislative involvement allows for advancing health policies, promoting education and research, and establishing best practice standards for nurse practitioners and their patients. The role of AANP is to provide a networking platform for nurse practitioners and advocate for their role as providers of high quality, cost effective, comprehensive, patient-centered, and personalized health care all over the country.

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