Nurses Advocate for Safer Staffing, Patient Safety, and Quality Care

CALLING ALL NURSES! Our voices will be heard in Washington, DC at the #NursesTakeDC on April 25th and 26th, 2018 as we address and show our support for the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2018 (HR 2392/S.1063). Nurses General Nursing Article Magazine

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Nurses Advocate for Safer Staffing, Patient Safety, and Quality Care

Nurses are stressed. Nurses are exhausted. And now nurses are speaking up for patient safety and against unsafe working conditions. But it's important that our voices be heard by the public and our policymakers. With your help, our voices will clearly be heard at #NursesTakeDC on April 25th and 26th.

The public does not know that hospital nurse staffing is at a crisis. In order to bring about change, our legislators and the public need to know what's really happening inside hospitals. They need to know that:

  • Hospitals send nurses home mid-shift at the drop of a hat the minute the census drops in order to save money
  • Patient call lights are not answered in a timely manner
  • Patient falls with injury continue to be a serious concern
  • Patient satisfaction scores appear to trump patient care
  • Nurses are given completely overwhelming patient loads and then reprimanded for five minutes overtime
  • Nurses routinely clock out for meal breaks but don't take meal breaks
  • Missing meal breaks is the norm, not the exception
  • Nurses routinely clock out at the end of shift and then continue working to finish charting while some managers look the other way
  • Nurses are blamed for overtime, doctors' failures to enter orders properly, re-admissions, low patient satisfaction scores, and more

News Flash: It's NOT a badge of honor to not get a bathroom break for hours on end, and sometimes (yes!) an entire shift. It's a wake-up call.

In many hospitals, nurses run the gauntlet every shift. Placed in unsafe situations, they simply try to make it through the shift without an error. After their shift, their sleep is interrupted by worries that make their way into their dreams- IV alarms going off, nightmares about patients forgotten, meds not given. New nurses cry on the way to work in dread.

If you are a nurse who has experienced any of the above, this article is for you.

Let's Talk Meal Breaks

Your representatives and the public probably don't know that when a nurse caring for six patients takes a meal break, one of two things happen.

  1. Another nurse's patient load immediately increases to twelve patients; or
  2. The nurse on "meal break" clocks out and proceeds to be on call/work throughout her/his unpaid meal break.

Under the proposed law, mandated minimum nurse-patient ratios are maintained at all times. Patients do not schedule emergencies around meal breaks, staff meetings, night shift, holidays, or potlucks. Patient safety cannot be in place only when it's convenient for the employer.

Every nurse knows what it's like to be paged, called, and interrupted while gulping down their food. If a doctor rounds while they are at lunch, they rush out to meet them. If a nursing assistant pops in and says someone wants something for pain, they run to give it.

By definition, this violates the intention and legal definition of a non-paid break which is "being relieved of all work duties". The proposed legislation protects against mandatory overtime and violation of labor laws.

Show Me Your Stethoscope (SYS)

By now every nurse knows the story of how the Show Me Your Stethoscope (SYS) movement came to be. In 2015, Joy Behar of the daytime TV talk show "The View" unwittingly mocked the Miss America contestant, Kelley Johnson of Colorado, (who also happens to be a nurse), by asking "'Why does she have on a doctor's stethoscope?"

Joy Behar was referring to nurse Kelley Johnson's monologue in which Kelley describes a poignant interaction with an Alzheimer's patient. In the monologue, Kelley wore scrubs and a stethoscope.

The backlash to Joy Behar's remark was immediate and strong. Show Me Your Stethoscope (SYS) was founded by Janie Harvey Garner, a Cath Lab nurse in Missouri. Tens of thousands of nurses posted pictures of themselves wearing their stethoscopes. Currently, the SYS facebook group has over 660,000 members and the non-profit SYS foundation sponsors the #NursesTakeDC event.

#NursesTakeDC Event

Nurse Beth and Keith Carlson Talk About Staffing Ratios & NursesTakeDC

Nurses from California to New York and every state in between are convening in Washington, DC on April 25th and 26th, united in their passion for patient safety.

#NursesTakeDC is a national nursing rally aimed at passing a federal law to protect patients by federally mandated minimum nurse-patient ratios.

This is the third year of the Show Me Your Stethoscope (SYS) sponsored #NursesTakeDC event and the number of nurses attending is growing each year.

Two bills mandating minimum nurse-patient ratios have been introduced into Congress. These two bills affect every nurse, every patient, and every person in the United States. As Nurse Keith Carlson says "Everyone of us will someday be a patient."

The bills are sponsored by National Nurses United (NNU).

What are the two bills? The Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act bills. The two identical bills call for federally mandated minimum nurse-patient ratios in all Medicare-participating acute care hospitals. One bill is in the House of Representatives (H.R.) and one bill is in the Senate (S.). A bill must be passed by both the House and the Senate in identical form and then be signed by the President to become law.

It's exciting that there are forty-three legislative co-sponsors for Congresswoman Schakowsy's bill! Check the list to see if your representative is one of the forty-three. If they are, call them and thank them. If not, call them and ask for their support.

Co-sponsors of Senator Brown's bill include the prominent Senator Elizabeth Warren (MA), Senator Bernie Sanders (VT) and Senator Tammy Baldwin (WI).

Here are the nurse-patient ratios in the proposed legislation. These bills require that hospitals put patients over profits.

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Source: NNU

#NursesTakeDC Keynote Speaker Dr. Laura Gasparis Vonfrolio

History repeats itself.

Back In 1998, over 3,000 nurses stormed Washington, D.C. in search of improved working conditions and patient safety. One courageous, outspoken, and forward-thinking nurse from New Jersey led the rally.

Dr. Laura Gasparis Vonfrolio is a living legend among many ICU nurses. Dr. Laura has prepared thousands of RNs for their CCRN certification exam. As a new nurse in the ICU, I attended Laura's CCRN certification prep course and she is one of the most dynamic and entertaining speakers in nursing.

She is a brilliant businesswoman and keynote speaker. A force to reckon with, she's down to earth, irreverent, and hilarious- and she calls it like it is.

At close to seventy years young, she is still going strong. I saw Dr. Laura Gasparis Vonfrolio in Las Vegas a couple of years ago at the National Nurses in Business Association (NNBA)* annual conference she was keynoting and asked her why she still works per diem in the ICU. Without missing a beat, she grinned widely and said "So I can still be a pain in (administration's) a**.

History repeats. Once again, Dr. Laura is commanding the podium in Washington DC. Other rally speakers include Janie Harvey Garner, Jalil A. Johnson (National Director- Show Me Your Stethoscope Foundation,) Kate McLaughlin, and Alene Nitzky. Here is a full list of speakers.

Nurse Keith Carlson and Beth Hawkes, will also be attending and speak at this all-important rally. Allnurses will be there in force representing their community of over 1 million nurses strong.

Why Mandated Minimum Nurse-Patient Ratios

Congresswoman Jan Schakowsky of Illinois introduced H.R. 1063 and says on her site:

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"According to the Institute of Medicine, up to 98,000 hospital patients die each year from preventable problems, many of which could be avoided with safe staffing levels. Further, the Joint Commission found that nurse-staffing shortages are a factor in one out of every four unexpected hospital deaths or injuries caused by errors. The Nurse Staffing bill would establish new minimum federal safety standards - including nurse-to-patient ratios - and require that hospitals work with direct care nurses to develop facility-specific staffing plans. It would also provide whistleblower protections for nurses who speak out to protect their patients' health and safety."

According to some sources, medical errors account for up to a third of patient deaths.

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Prior to mandated minimum nurse-patient ratios in California, a patient in ICU at a hospital known to me, the author, received the wrong blood and died as a result. It was an immediate anaphylactic reaction. Every nurse's worst nightmare.

The ICU nurse responsible for the lethal error was caring for 3 critically ill patients and was hanging blood on 2 of them at the same time.

The hospital did not change staffing practices as a result of this needless tragedy- they defended them and fired the nurse.

Today, in that same hospital and in all California hospitals, it is against the law for ICU nurses in California to have more than two patients. This is thanks to mandated minimum nurse-patient ratios.

Evidence Links Nurse-Patient Ratios and Patient Outcomes

*When health care systems cut corners on spending, they really cut corners on human lives*

We all know by now that nurse-patient ratios directly affect patient outcomes. The odds of patient death increase by 7% for each additional patient the nurse must take on (Journal of the American Medical Association, 2002).

Nurses know only too well that understaffing results in

longer hospital stays, increased infections, and avoidable injuries.

Understaffing also leads to lower nurse retention, higher rates of injury and burnout.

Dr. Ruth Neese, in her well-researched Talking Points for Safe Nurse Staffing, tells us:

Lower patient-to-nurse staffing ratios have been significantly associated with lower rates of:

  • Hospital mortality
  • Failure to rescue
  • Cardiac arrest
  • Hospital-acquired pneumonia
  • Respiratory failure
  • Patient falls (with and without injury)
  • Pressure ulcers

How it Works in California

As of today California is the only state to have safe, mandated minimum nurse-patient ratios. In California, patient safety is the law.

"Hospital nurse staffing ratios mandated in California are associated with lower mortality and nurse outcomes predictive of better nurse retention in California and in other states where they occur." (Aiken, et al. 2010. Implications of the California Nurse Staffing Mandate for Other States.

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In every state except California, the number of patients assigned to a nurse is entirely up to the discretion of the employer/hospital/manager/supervisor on duty. Or the hospital's "Staffing Committee".

Lack of federally mandated minimum nurse-patient ratios is why a MedSurg unit in Florida can have 1:7 nurse-patient ratios while an identical MedSurg unit in another state can have a 1:8, 1:5, or for that matter, any ratio.

Nurses in California successfully put an end to the madness in 2004 and legislated minimum nurse-patient ratios. They know that nurse-patient ratios are a matter of life and death. Safe staffing saves lives. They know that hospitals will not voluntarily decrease nurses' workload.

They took patient safety out of the hospital's hands and put it into the voter's hands. They advocated for patients over profits until it became the law.

Under mandated minimum nurse-patient ratios, ratios are upwardly adjustable based on patient acuity. Hospitals are free to change the assignment based on patient acuity as long as they do not violate the minimum nurse-patient ratio.

For example, in California, currently, the minimum nurse-patient ratio on MedSurg is 1:5 (it will change to 1:4 pending legislation). But a nurse with a high-acuity patient requiring frequent monitoring, such as a patient with a fresh continuous bladder irrigation (CBI), may be typically assigned only three patients (1:3) for a duration based on patient acuity and safety.

The American Hospital Association

Not surprisingly, there is fierce opposition from hospital executives. The powerful American Hospital Association (AHA) and its state chapters do not support federally mandated minimum nurse-patient ratios. The AHA wants hospitals to maintain control over all staffing assignments via "Staffing Committees".

There is a fear that mandated minimum nurse-patient ratios will affect their bottom line in the short-term. Of course, every nurse knows that reducing infections and increasing retention saves money in the long run.

The American Nurses Association (ANA)

So where is the ANA in all of this? Aligning with the AHA.

Sadly, the American Nurses Association, the ANA, the organization whose reason for being is to represent nurses, does not support this legislation to put patients over profits. They staunchly oppose it.

The ANA, along with the Association of Nurse Executives (AONE), chooses to stand with the hospital industry and not with its members, clinical bedside nurses. As a result, many nurses do not feel supported or represented by the ANA or their nurse executives...

ANA's Suspect Solution: Staffing Committees

Both the ANA and the AHA have blocked mandated minimum nurse-patient ratios legislation by initiating opposing legislation as a smoke screen.

Opposing legislation allows hospitals to continue to set arbitrary staffing levels under the guise of "Staffing Committees". These bills require hospitals to establish a "Staffing Committee" composed of at least 55 percent direct care nurses, to create nurse staffing plans that are specific to each unit.

The problem is that the hospital is the employer of the nurses serving on said "Staffing Committee".

The ANA claims that "Staffing Committees" empowers nurses.

But nurses working in hospitals with "Staffing Committees" say otherwise.

One such nurse is Deena Sowa McCollum. Deena Sowa McCollum has worked as a nurse manager in Texas in no less than three major hospital systems where "Staffing Committees" are in effect.

Deena says flatly that it's all about profit, not patients:

"The "Staffing Committee" is given budget constraints for each unit.

Let's say 5 West is budgeted to provide 6 hours of nursing care per patient day (HPPD), which translates to 10 registered nurses on duty every 24 hours when the census is full.

The committee can make recommendations for a staffing plan but may not increase the budget. For example, they can recommend allocating 6 nurses on day shift and 4 on night shift, or 5 and 5.

They could even recommend changing the skill mix by forgoing unit secretaries and instead have 11 nurses on duty -as long as if it doesn't put them over budget.

Still, it is usually a 7 patient load with an aide and a clerk for a 21 census in acute rehab and if there is an empty bed you will take 8 because your director says you can safely do it based off his or her evaluation of the unit at that time. Also, they say the grid is a GUIDE it is NOT set in stone. It's based on the unit director or manager's assessment of the unit. That is how this "safe staffing law" works in Texas."

As such, "Staffing Committees" do not provide accountability. Nurses are not fooled by the rhetoric of empowering nurses through "Staffing Committees", although congressional representatives are.

This is precisely why #NursesTakeDC needs you.

David and Goliath

As of this publication, the hospital industry has successfully blocked any proposed staffing regulations that could potentially affect their bottom line. What does this all this mean? It means clinical practice nurses are fighting a formidable foe. The foe is profits.

The deep-pocketed ANA and AHA employ well-spoken lobbyists to fight against mandated minimum nurse-patient ratios and for "Staffing Committees".

But maybe they forget that we are nurses, the most trusted profession in the United States. Maybe they forget what it's like to be on the front lines.

Remember that, we, too, are well spoken. In addition, we are voting constituents. Not special interest lobbyists. We can do this.

We must educate our legislators about the nonsense of "Staffing Committees' as put forth by the ANA and the AHA and ask them to vote as follows:

FOR The Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2018

FOR The Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2018 (HR 2392/S.1063). Driven by grassroots nurses.

AGAINST The Safe Staffing for Nurse and Patient Safety Act of 2018

AGAINST The Safe Staffing for Nurse and Patient Safety Act of 2018 (HR 5052/S.2446). Driven by the hospital industry.

Tip: The titles of the two bills sound the same. Remember the title of the legislation #NurseTakeDC supports has the word "Quality" in the title to differentiate. "The Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2018".

Stat: Calling all Oregon, Ohio, Hawaii, Washington Nurses

Do you know what some of your representatives did in February of this year?

They introduced opposing legislation- The Safe Staffing for Nurse and Patient Safety Act of 2018 ("Staffing Committees').

Oregon - Oregon nurses- reach out to Senator Jeff Merkley, who introduced the misguided Senate bill S.2446 ("Staffing Committees"). Ask why he introduced the bill, and who authored it. Who is really behind this bill? Respectfully educate him and explain that the ANA does not represent your views and your experience.

Ohio - Ohio nurses, please contact Representative David P. Joyce, who did a disservice to patients in your state by introducing H.R. 5052 ("Staffing Committees")

Note: By contrast, Ohio Senator Sherrod Brown stood up for patient safety and not big business by introducing the (good) bill S.1063. (Mandated Nurse-Patient Ratios). Thank you, Senator.

Ohio's own and activist RN Doris Carroll will be speaking in Washington, DC at #NursesTakeDC. Ohio nurses, come support her!

Washington - Washington nurses, Representative Suzan K. DelBene is co-sponsoring H.R. 5052 ("Staffing Committees")

Hawaii - Aloha! In Hawaii, Representative Tulsi Gabbard is co-sponsoring H.R. 5052 ("Staffing Committees")

What Can I do?

CONTACT Your Representatives.

Tell them you are a nurse, a voting constituent. Educate them to the fallacies of "Staffing Committees" and inform him about mandated minimum nurse-patient ratios.

There are passionate nurse activists working for the cause and speaking to their legislators daily; Doris Carroll (Ohio), Kate McLaughlin (New Jersey), Andrew Lopez (New Jersey), Cathy Stokes (Missouri), just to name just a few. But not enough. Your voice is needed.

Many of you can go to DC to support the #NursesTakeDC event on April 25th and April 26th this year. And all of you can do something.

Here's what you can do. First, find out who your representatives are by your zip code. Find Your Rep by Zip. Use this link to find your representative and Senators by your zip code. You have one representative and two Senators.

You should contact all three.

Your representatives want to hear from you, their constituents. Nurses are regarded as the most trusted profession. Tell them who you are, and how you'd like them to vote.

CALL Your Legislators

Everyone reading this can make three phone calls.

  • Call your representative. You are a voting constituent and trusted nurse. Your phone call counts. Your representative will be voting on H.R. 2392 (vote YES) and H.R.5052 (vote NO).
  • Call your two Senators. You are a voting constituent and trusted nurse. Your phone call counts. Your Senators will be voting on S.1063 (vote YES) and S.2446 (vote NO).

Yesterday I called Representative Kevin McCarthy's local office.

It's easy to find the phone number of your representative or your Senators.

When you contact your representative or senators, be clear and to the point. Here's an example:

"Hello, my name is Beth Hawkes, I'm an RN and a constituent of Kevin McCarthy. I am calling to ask that Representative Kevin McCarthy vote for HR bill 2392".

The secretary or administrative person answering the phone carefully tallies each and every phone call related to pending bills. As a voting constituent, your opinion is valuable.

WRITE Your Legislators

When you write or email, include your credentials. You are writing as a professional nurse on behalf of your profession and for your patients.

  • Write a letter. You are a voting constituent and trusted nurse. Your letter counts.
  • Send an email. You are a voting constituent and trusted nurse. Your email counts.

When you contact your legislators by email or by letter, address them in the salutation as "The Honorable" as in 'The Honorable Kevin McCarthy". Be respectful, and assume agreement. Never be argumentative or threatening.

Avoid form letters and include a personal story or example. Stories are remembered.Keep the letter to one page and ask for a response.

Keith & Beth Discuss How to Influence Your Legislators

MEET Your Legislators

Call your representative's local office and make an appointment. Your representative's office is located in your district, so make an appointment to meet him or her when they home and in their local office.

Face to face meetings are the most impactful. Take a friend or two, fellow nurses, and briefly explain why you'd like them to vote Yes on HR 1063.

How do I Discuss Nurse-Patient Ratios with Lawmakers?

Give a Short Story

Talk in stories. Stories are memorable. Here's an example:

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"My mother had just been transferred out of ICU to MedSurg and the nurse told me she had seven patients that day. I'm a nurse, too, so I understood and felt bad when I saw her rushing and racing from room to room. I know what it's like. The phone in her pocket rang constantly. I didn't want to bother her or act like I was telling her what to do.

But what scared me was when Mom got short of breath and needed a treatment. At that moment I was a daughter, not a nurse. I pulled the call light. No one came. My Mom was getting short of breath and more and more anxious. She looked at me. I felt helpless. How long should I wait?

I went out in the hall but could only see one person (not Mom's nurse). Her head was down as she was on the phone and typing into her computer. She looked intense and stressed, clearly radiating a "Do Not Disturb" vibe.

I ran by her towards the nurses' station and waited while a unit secretary finally looked up and said she'd page Mom's nurse. I went back to hold my Mom's hand. "They're coming, Mom. Someone is coming now".

I don't know how long it took. It seemed like forever. Finally, my nurse came in and apologized "I'm so sorry, I was at lunch". It was three thirty in the afternoon. She quickly paged Respiratory Therapy and Mom received the treatment she needed.

Do I blame her? No. I'm sure she was doing the best she could for each of her seven patients. What really struck me is that she didn't seem to have any time to think. She was clearly only reacting. Reacting to the IV alarm, then her phone, then the next call light...reacting, not thinking or planning.

If I hadn't gone to the nurse's station, or if I hadn't been there, would my Mom have just gone into respiratory arrest?"

The above scenario took place in a hospital in Florida. The nurse chooses to remain anonymous. It could not have taken place in California, a state with mandated minimum nurse-patient ratios because in California, a nurse on MedSurg can only have five patients (this will be changed to 1: 4 when pending legislation is passed).

States with Staffing Laws

Only California has mandated minimum nurse-patient ratios that are to be maintained in all units at all times(since 2004). Here is a synopsis of what other states are doing.

State law in thirteen states, other than California, currently addresses nurse staffing to some degree in their hospitals. These states are: CT, IL, MA, MN, NV, NJ, NY, OH, OR, RI, TX, VT, and WA.

  • CT, IL, NV, OH, OR, TX, WA. are required to have "Staffing Committees". "Staffing Committees" are the equivalent of the fox watching the hen house.
  • There is a law in MA mandating a 1:1 or 1:2 nurse to patient ratio in ICU. This is great and provides patient safety in the ICU. What about patients in other units?
  • Public reporting of staffing is required in the states of IL, NJ, NY, RI, VT. Public Disclosure is a good first step towards transparency. Mandated nurse-patient ratios are the next step.
  • The CNO or designee is required to develop a core staffing plan and includes input from others in MN. This sounds like the status quo in hospitals everywhere.

With the exception of California, none of these initiatives approach the comprehensiveness, patient safety and accountability of HR 2392 and S. 1063.

All patients deserve to have a nurse who has a manageable and safe workload.

All nurses deserve to practice nursing safely.

Conclusion

Many nurses are afraid to speak up for fear of retaliation or even for fear of losing their jobs. Nurses do not want to be labeled as "troublesome".

There are over 3 million nurses in the United States. If just half of us were to speak up, we can bring about needed change.

Activist and best-selling author Sonja M. Schwartzbach, BSN, RN, CCRN urges us:

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"NURSES: WE'RE ON A MISSION. IT'S TIME TO STOP GIVING IN, AND START GIVING A DAMN. We don't need another cup of coffee. We don't want another free pen. We want safe patient ratios: if not you, whom? If not today, when?"

Please join in putting patients over profits.

Be sure to check out more from the first issue of allnurses Magazine.

References

Aiken, L. H., Sloane, D. M., Cimiotti, J. P., Clarke, S. P., Flynn, L., Seago, J. A., & Smith, H. L. (2010). Implications of the California nurse staffing mandate for other states. Health services research, 45(4), 904-921.

Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Jama, 288(16), 1987-1993.

Cho, E., Chin, D., Kim, S., & Hong, O. (2016) The relationship of nurse staffing level and work environment with patient adverse events. Journal of Nursing Scholarship, 48 (1), 74-82. doi: 10.1111/jnu.12183

Cimiotti, J., Aiken, L., Sloane, D., & Wu, E. (2012). Nurse staffing, burnout, and health care-associated infection. American Journal of Infection Control, 40 (6), 486-490. doi: 10.1016/j.ajic.2012.02.029

Diya, L., Van Den Heede, K., Sermeus, W., & Lesaffre, E. (2012). The relationship between in-hospital mortality, readmission to the intensive care nursing unit and/or operating theater, and nurse staffing levels. Journal of Advanced Nursing, 68(5), 1073-1081. doi: 10.1111/j.1365-2648.2011.05812.x

Nicely, K., Sloan, D., & Aiken, L. (2013). Lower mortality for abdominal aortic aneurysm repair in high-volume hospitals is contingent upon nurse staffing. Health ServicesResearch, 48 (3), 972-991. doi: 10.1111/1475-6773.12004
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Nurse Beth

About Nurse Beth, MSN

Career Columnist / Author

Hi! Nice to meet you! I especially love helping new nurses. I am currently a nurse writer with a background in Staff Development, Telemetry and ICU.

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Specializes in Peds, Med-Surg, Disaster Nsg, Parish Nsg.

Thank you for the comprehensive coverage of the staffing issue and how nurses can take action.

Looking forward to hearing you speak more about this at the rally in DC.

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Specializes in Med/Surg/Infection Control/Geriatrics.

Question please: You mentioned MN has having some form of staffing laws. Would it be appropriate to contact my rep on this for the April vote? Or is it just pertaining to the states listed in the northwest and Hawaii? Please advise. Thank you.

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Wow. Lots of reading and information!! Awesome & Correct. Every working nurse has felt unable to care for someone who needs to be cared or has had an incident that could have been averted had they not been doing something else! I read the article. I have not read the proposed bill nor do I know how well CA is doing with the law they already have on the books and yet I am still going to reply. I will be reading the law proposal tonight. I can't say I agree with the poster in the standard number form to care for patients but I can agree with it being used to intelligibly staff those areas for a nurse count! Let me explain. Each person who commits to being a patient would be best served to be classified. Their location (like ICU vs school kid in school nurses office) would certainly help determine the patient classification. But so would many other factors be used to determine their classification which would determine nurse to patient ratio. Let's face it, we are talking about holding people/board of directors/administration accountable legally for decisions so we should make them very right & able to be completed. We have the science so let's put forth the rationale. Statistically speaking! A healthy 12yo standing fall statistically will not cause the damage (or require the amount of nursing care) of an 80yo. Nurse ratio for a patient requiring emergency care like CPR is not 2:1 or 3:1 like the ER assignment poster shows. I'm not saying we make ratios for every type of disease process or emergency just as I am not saying let's make assignments based on areas that people are patients (as on the poster). But we can assign a number to a person & decide assignments based on that number. Let's be honest, these short stories show need but should show the need for every nurse on duty in every environment. Examples: nurse at an outdoor camp with 6 alert kids at your feet. Sound simple? It is 100 degrees and they were all just stung by wasps and walked up at the same time. The camp doesn't have another nurse and you need support. We need to include expected responsibility of those who employ us when this happens. This isn't a school shooting. This is something the world would expect us to care for and have a GOOD outcome! Being prepared. ICU patient with Q1' blood sugar or lab draw who is on a balloon pump while in DIC. NOT a 2:1 assignment but could be with a 1:1 with appropriate 1:1 staff. Who does the ER waiting room ratio belong? One night on my way out after not eating, drinking, pooping or peeing for 14 hours of my 12 hour shift I decided to triage all the waiting room before I left. The designated triage nurse always had an assignment as well. This night everyone had an intubated patient & some had 2 or had RSI or a sedation to put a bone back or had a seizure that ended up intubated so nothing was going right and nothing was the normal expected. One of my 3 patients was a trauma who EMS could not intubate with head & face trauma along with BUE and chest trauma awaiting the trauma center ambulance because the helicopter couldn't fly and my other was an infant that resp & I took turns holding the ET tube because it seemed to migrate into the right main no matter what he did to secure it & we were waiting for the pediatric transport team for that patient. Those were just the 2 of mine I recall as I had the trauma room assignment that shift. After handing that assignment over (about 2 hours of the much needed 2 nurses working them and assisting the other nurses) I finally was able to leave but triaged the waiting room first as a nice gesture for those patients waiting hours already. Of the dozen waiting patients, 3 of them were ESI 3 so I brought them back and gave report to those nurses but one with back pain I decided to make sure her EKG was completed because her back pain couldn't be explained by injury and she ended up being a STEMI. The moral of this is incoming patients nurse ratios need special wording because those people are not classified yet. The unclassified, who is responsible? Like the guy sleeping in the waiting (so you thought) who has been dead for 2 hours. Now most ERs use nurses as greeters & a nurse places an ESI # to the patient. It partially works but care starts before a practitioner sees the patient & our nursing scope is WAY below our education and capabilities in every area nurses work! How many nurses do we really need for a pre-op area? If you have 21 people who arrive at 6am the ratio is gonna be much different than when they are ready at 8am. 6am they are walkytalky (generally or mostly independent). So one nurse could take care of all 21 if there are other staff but as IVs are placed & medicines are given & accuchecks for the NPO DM and such are done, the ratio should change to include many more nurses like the 3:1 or 6:1 but without patient classifications I don't think we can really place a ratio to an "individual" patient. Maybe to an area like you have done but that doesn't completely serve the individual patient who we ultimately serve and I know we can scientifically attribute "classifications" to patients with the "considerations" as to locations like schools, ERs, ICU, pre-op, intra op, camps, medical aids/urgent cares and all others who employ nurses. Patient classifications with "where you are" considerations for patient & nurse expectations is easy as Pi. So when a nurse goes on break or a patient codes - nurses already know who can pick up the extra load because statistically speaking we are prepared to meet the expectation "considerations" of an emergency, admission, discharge and general good outcome we desire for those we serve! To me, this is a start but I think our brilliant minded experienced and highly educated nurses can come up with perfection.. God bless.

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