March 2002 issue of the Journal of Clinical Systems Management, formerly CurtinCalls, an “occasionally irreverent” scan of nursing and health care in the United States. The author, Leah Curtin, is a Registered Nurse who has been internationally recognized for her work in nursing ethics for over two decades. For more information, visit
www.curtincalls.com.
Staffing and Mandatory RN ratios
Now that California has published its mandatory staffing ratios (February 2002), the time for comment and input is practically over. California was the first state to do it, but several other states have ICU ratios, and another 17 are thinking about it. It is legislatively mandated RN/patient ratios -- an eminently predictable result of the overenthusiastic re-engineering efforts of the 90s....
With a system in the midst of chaotic change, a far sicker patient population was placed in the care of an ill-prepared, poorly supervised health care workforce - and, among the results, is a dramatic increase in the number of serious errors made in the care of patients. ... Thus, hospitals began hiring rather than firing RNs, creating a selective shortage of experienced nurses.... So, California's nurse-to-patient ratios for all nursing units in acute care hospitals should surprise no one! The full list of ratios is as follows: -Intensive/critical care unit: 1:2 -OR: 1:1 -Neonatal ICU: 1:2 -Intermediate care nursery: 1:4 -Well-baby nursery: 1:8 -Postpartum (when multiple births, the number of newborns and number of mothers shall never exceed 8 per nurse)1:8 (1:4 couplets); 1:6 (mothers only) -Labor and delivery: 1:2 -Post-anesthesia care unit: 1:2 -Emergency departments (triage, radio, or other specialty nurse are to be added as additional workforce and are not included in the ratio): 1:4 -Critical care: 1:2 -Trauma: 1:1 -Burn unit (a critical care unit): 1:2 -Pediatrics: 1:4 -Step-down/telemetry: 1:4 -Specialty care (oncology): 1:5 -Telemetry unit: 1:5 -General medical-surgical: 1:6 (initial); 1:5 (phased in 12-18 months after effective date of regulations) -Behavioral health/psychiatric units: 1:6 -Mixed units: 1:6 (initial); 1:5 (phased in 12 to 18 months after effective date of regulations) This is happening NOW. And the more part-time nurses there are, the more FTEs left vacant. This, coupled with the aging of the workforce, legislatively mandated RN/patient ratios, and multiple studies tying patient safety to richer mixes of RNs serve as a clarion call to health administrators in other states: change your ways before its too late!
The Ethics of Staffing
... With California’s publication of its mandatory staffing ratios for all hospital units, law stepped into the staffing arena in a big way! And in the USA, the law is often thought of as determining what is the right thing to do in a given situation (which, interestingly enough, is the definition of practical ethics!). If an organization has met ‘all the requirements of the law’ then it should be safe from allegations of neglect, malpractice, malfeasance and so forth. However, while meeting the requirements of law is a necessary precondition for responsible staffing, the question remains, is it sufficient to define safe staffing? I would argue that it is not, and I’ll tell you why: Safe staffing is not determined by the numbers of personnel, including registered nurses, per patient. While a certain minimum - such a dictated by the staffing ratios -- is a starting point, it is nothing more than that: a starting point. Other considerations include (but are not limited to): patient acuity, ancillary help available, competence of the nurses themselves, level of familiarity with the setting, physical architecture of the unit, the level of technology, back-ups available for staff, the immediate presence/absence of a unit manager, and the ubiquitous problems of staff morale. I bring these up in the context of ethics because ethics almost always deals with responsibilities that are over-and-above law (unless, of course, the law is the problem). In a nutshell, the ethical responsibilities of anyone managing health service delivery are (in order of priority): 1. the safety of the services delivered; 2. the safety of the personnel who report to them directly and indirectly; 3. No institution, and no manager is above the law. Manager have a duty to follow all applicable laws governing practice and personnel management. Among the most intractable of staffing problems today is the issue of ‘mandatory overtime’ - in any of its various interpretations. I shall abstract information from The Economic Policy Institute’s Briefing Paper, Time After Time: mandatory overtime in the U.S. economy Golden and Jorgenson (1/2002).* and juxtapose it with manager’s ethical obligations. # 1. How Safe is this practice for patients? - overtime resulted in impaired performance in attention and executive functions. - accident rates increase during overtime hours (Kogi 1991). ... - Overtime is a factor contributing to safety incidents at nuclear power plants (Baker et al. 1994), confirming what researchers had previously found at manufacturing plants (Schuster 1985) and among anesthetists (Gander et al. 2000). - after nine hours at work, the accident rate begins to rise; in the 12th hour the accident rate was twice as high as the rate for the first nine hours (Hanecke et al. 1998). - Medical residents cited fatigue as a cause for their serious mistakes in four out of 10 cases (Boodman 2001), - two studies linked infection outbreaks at hospitals to overtime work (Arnow et al. 1982; and Russell et al. 1983). - An Australian study found that sleep deprivation has the same effects as being drunk. As the number of hours increased without sleep, the study's testers took a longer time completing a task, made more mistakes, and had problems with concentration and memorizing information. After 17-19 hours without sleep, the testers' performance and alertness suffered notably, and "performance levels were low enough to be accepted in many countries as incompatible with safe driving" (Williamson and Feyer 2000, 653). #2. How safe is mandatory overtime for staff? - The social costs associated with the growth in work hours and persistent overtime are particularly worrisome when the long hours are involuntary.” (Golden and Jorgenson 2002) - Accident rates increase during overtime hours (Kogi 1991). - Workers who work overtime face a greater risk of injury and illness (Aakerstedt 1994; Duchon et al. 1994; Rosa 1995; Smith 1996). - Long work hours also multiply repetitive motions and exposure to harmful chemicals. Further, frequent overtime and compressed work schedules that produce long workdays can be a major cause of the stress and chronic fatigue reported by many workers, as well as the ensuing occupational burnout or serious health conditions (Sparks et al. 1997; Spurgeon et al. 1997; Martens et al. 1999; Barnett et al. 1999; Shields 1999; Fenwick and Tausig 2001). - Stress can result in increased blood pressure and cardiovascular diseases, which in some cases can have fatal consequences. # 3. What does the law require? In the United States, unlike in most European countries, employees who refuse to work overtime can lose their jobs or face other reprisals including dismissal. However, this is changing rapidly. Legislative initiatives at both the federal and state levels would regulate mandatory overtime. Bills have been introduced in the 107th U.S. Congress that would limit the amount of forced overtime that nurses and other licensed health care providers could work. The Safe Nursing and Patient Care Act of 2001 was introduced in the Senate (S-1686) and House (HR 3238 ). It aims to amend the Social Security Act by limiting the number of mandatory overtime hours a nurse may be required to work among providers of services to which payments are made under the Medicare program. On the state level, many states either have banned, or have legislation introduced to ban mandatory overtime. Among them are California, Connecticut, Hawaii, Maine, New Jersey, New York, Ohio, Oregon, Pennsylvania, Rhode Island, Washington, West Virginia and Wisconsin. There are, of course, exceptions, stipulations and limits set into the laws. There certainly is recognition that employers need some flexibility -- but there are some stiff penalties for violating the spirit as well as the letter of the law. To put matters succinctly, mandatory overtime policies generally violate the ethical duties of managers. However, next month’s column will deal with the specifics of legislation, and the legal and ethical exceptions to this general statement which, while succinct, is lacking in subtly!
March 2002 issue of the Journal of Clinical Systems Management, formerly CurtinCalls, an “occasionally irreverent” scan of nursing and health care in the United States. The author, Leah Curtin, is a Registered Nurse who has been internationally recognized for her work in nursing ethics for over two decades. For more information, visit
www.curtincalls.com.
Staffing and Mandatory RN ratios
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