Feb. 6, 2006 – When California Governor Arnold Schwarzenegger tried to roll back legislation passed in 1999 that required specific nurse-to-patient ratios in California hospitals, the California Nurses Association (CNA), went to war. The unionâ€™s 65,000 members launched an extensive campaign, insisting that such standards were vital to providing quality care.
After staging more than 100 protests and hounding the governor at events all over the country, the union defeated Schwarzeneggerâ€™s initiative in November and elevated the issue of working conditions for nurses to a national level.
Now, nurses across the nation are pushing legislation to relieve overworked and inadequate nursing staffs. Legislation has been introduced in Illinois and Massachusetts. Arizona has already adopted a minimum-ratio law for nurses in intensive care units, and the National Nurses Organizing Committee (NNOC) says nurse-to-patient ratio laws are being discussed in about a dozen other states.
Advocates for nursing professionals say that mandatory staff ratios are not only more fair to employees, but are invaluable when it comes to protecting health and safety. Up to 20,000 patient deaths per year can be linked to errors by medical personnel, including nurses, according to an October 2002 article in the Journal of the American Medical Association. That article also reported that for each additional patient assigned to a registered nurse, the likelihood of death occurring within 30 days of treatment rises by 7 percent.
Proponents of the nurse-ratio initiatives say that the problem of understaffing is one that hospitals themselves could address.
The Illinois bills, introduced in late January, would mandate one nurse for every five patients in rehabilitation units, one nurse to two patients in critical care units and one nurse for each patient in operating rooms and trauma emergency units.
The sponsors of the Illinois legislation, State Senator Iris Martinez (D) and State Representative Mary Flowers (D), predict the ratios would result in better patient care and reduce medical errors. The proposed bills also prohibit hospitals from retaliating against nurses who refuse to accept assignments which they think compromise patient safety.
Diane Ellis, a registered nurse in the pediatric intensive care unit at John H. Stroger Jr. public hospital in Chicago, said nurses are stretched too thin to provide the kind of follow-up care and emotional support patients need.
"There has to be quality time to deal with their emotions and fears; having the time and patience to do that is important," she said. "But we canâ€™t do that unless we have more hands. Youâ€™ll get patients coming back to the hospital because they didnâ€™t get the follow-up treatment and information they needed the first time. Theyâ€™ll end up back in the [emergency room]."
The National Nurses Organizing Committee won a major organizing victory at Stroger when a majority of the 1,800 nurses voted to leave the Illinois Nurses Association and join NNOC. The union is looking at organizing other not-for-profit and private hospitals in Illinois and other states, taking on staffing ratios as one of their main issues.
A study published in the January-February 2006 issue of the journal Health Affairs predicted 1,801 patient deaths per year could be avoided if the proportion of nurses to patients at all hospitals was raised to match the levels at the top 25 percent of the countryâ€™s hospitals.
But some critics of mandatory ratios say that these rules fail to address a deeper resource issue. Hospital officials in California and Illinois have argued that the staffing ratios are unrealistic because there simply are not enough nurses in general.
"These ratios wonâ€™t result in a single extra nurse at bedside," Illinois Hospital Association spokesperson Danny Chun told The NewStandard. He said hospitals are already trying hard to recruit new nurses, but a shortage of nursing faculty and aspiring nurses is making it difficult.
Indeed, the federal Health Resources and Service Administration estimated that in 2000, there were 1.89 million registered nurses available to work, while hospitals needed 2 million -- a shortage of 110,000. The Administration projected that due to drops in the number of nursing school graduates and the aging of the existing work pool, the shortage would deepen through 2020.
"Patients wonâ€™t be served by forcing hospitals to comply with rigid regulations rather than using their best judgment about where nurses are needed," said Chun. "Units will have to close since they canâ€™t meet the ratios."
Neither Chun nor NNOC spokesman Chuck Idelson could give an estimate of how many more nurses would be needed in Illinois to comply with the proposed statewide staffing ratios.
Proponents of the nurse-ratio initiatives say that the problem of understaffing is one that hospitals themselves could address. According to the union, poor working conditions â€“long hours, high stress and the constant risk of harming patients due to an intense workload â€“ is resulting in fewer new recruits and high turnover among younger nurses.
"[The hospital associationsâ€™ argument] makes sense if you ignore the reason for the nursing shortage," said NNOC spokesman Idelson. She commented that over the past decade, leaders in the hospital industry have "driven [working conditions] down to the point that nurses are being forced to leave." Idelson added, "We need to create a situation where nurses feel it is safe for them to practice, where theyâ€™re not going home at night thinking patients might have died on their watch."
A study published in the January-February 2006 issue of the journal Health Affairs predicted 1,801 patient deaths per year could be avoided if the proportion of nurses to patients at all hospitals was raised to match the levels at the top 25 percent of the countryâ€™s hospitals. If the number of practicing nurses increased, and provided that the proportion of nurses who are RNs compared to those with lower licensing was also increased to match the ratios at the top 25 percent of hospitals, an estimated 6,754 patient deaths could be avoided, according to the research. The study was funded by the Commonwealth Fund, a centrist private foundation.
The Health Affairs study, based on a survey of 799 hospitals in 11 states, also predicted that patientsâ€™ hospital stays would be greatly reduced by increasing the nurse-to-patient ratio. It also found that pneumonia, shock, cardiac arrest, upper gastrointestinal bleeding, sepsis, or deep vein thrombosis resulting from surgery would be significantly reduced.
The study acknowledged that such staffing increases would be accompanied "significant" cost hikes to hospitals, estimated at 1.5 percent of US hospital budgets. But the article deemed the higher costs would be partially offset "by the monetary and non-monetary benefits" of improving conditions for patients. Researchers predicted the bulk of savings from higher nurse-to-patient ratios would come from patient stays made shorter by higher quality care.
The California ratio law did not take effect until January 2004 because of legal challenges. But after the first year, administrators at several major hospitals â€“ including Catholic Healthcare West, Kaiser Permanente and the University of California â€“ reported they were able to meet the ratios and experienced positive outcomes.
"Nurses say they canâ€™t provide quality care unless the number of patients for each nurse is significantly reduced," said Kaiser Permanente spokesperson and nurse Alix Sabin, noting that the Health Maintenance Organization worked with the union to institute the ratios even before the California law took effect. "We have better care and happier nurses. What more could we ask for?"
Sabin said the cost of hiring more nurses did not prove to be an undue burden. Since Kaiser is an integrated system that combines insuring and treating patients, she noted, better front-end care is ultimately cost-effective.
"The more we keep you healthy, the cheaper it will be," she said. "Paying and treating nurses well fits into that preventative model."