With Nurses in Short Supply, Patient Load Becomes a Big Issue
By REED ABELSON
As hospitals struggle to fill nursing jobs, hospital executives and nurses around the country are squaring off over how many patients nurses can safely care for at once.
Hospital administrators say they are desperately searching for more nurses to staff emergency rooms, intensive care units and medical-surgical wards as 13 percent of hospital nursing jobs remain unfilled. But hospital nurses say they are being made responsible for too many patients and that hospitals are putting patients at risk and creating onerous working conditions.
The battle is making its way through the courts and several state legislatures as nurses push for new language in their contracts and lobby for regulations that would call for specific nurse-to-patient ratios. Some nurses have gone on strike over the issue, while others, like those at St. Vincent's Hospital in Manhattan, are holding protests to draw attention to their concerns.
Nurses say working conditions in hospitals are a major reason for the shortage.
"There are adequate nurses out there," said Mary Foley, president of the American Nurses Association. But many are choosing to work elsewhere, she said, noting that 41 percent of nurses work outside a hospital setting.
In California, nurses brought a lawsuit this month against Tenet Healthcare , the nation's second-largest for-profit hospital chain, saying they were working through meals and breaks without pay because the company did not employ enough nurses. Tenet denies the assertions.
The nurses have had some success. Late last month, registered nurses represented by the Service Employees International Union reached a tentative agreement with Northridge Hospital in Los Angeles, part of Catholic Healthcare West, a nonprofit hospital system in San Francisco, forming committees with nurses to address staffing concerns. The system reached similar agreements last year with the California Nurses Association at 17 other hospitals.
At Crouse Hospital in Syracuse, nurses and managers are working together to establish appropriate staffing levels, and the hospital pays nurses money in addition to overtime if managers consistently ask their staffs to work with too few people.
California has adopted proposed staffing ratios, which were unveiled in January. The proposals, which are expected to take effect next year, call for four patients for every nurse in a pediatrics unit, for example, and eventually five patients per nurse on a general medical-surgical floor. Similar laws are being debated in Massachusetts and Florida, and staffing legislation has been introduced in Iowa and Kentucky.
But elsewhere, nurses are meeting resistance from the hospitals, which are lobbying against legislation that would impose staffing requirements.
Hospital executives say that with so many nursing positions unfilled, there is little more they can do. "Legislating that you have so many nurses doesn't mean that nurses can appear," said Pamela Thompson, executive director of the American Organization of Nurse Executives and spokeswoman on nurses for the American Hospital Association.
Executives also argue that fixed staffing ratios are not useful because of differences among hospitals and the patients they treat and a need to be flexible in deciding how best to use employees.
The hospitals and the nurses find little agreement over how many nurses are needed. Many hospitals employ more nurses than they did a decade ago. The number of registered nurses working in hospitals increased to 1.3 million in 2000, the latest figures available, from 1.1 million in 1988, according to a federal survey.
But patients tend to be sicker today than they were in the early 1990's because managed care companies require many procedures to be performed outside the hospital. In addition, as hospitals have cut other staff members, nurses have picked up more of their work.
Hospitals typically do not disclose how many nurses they have in any individual unit, and little research has been done on what staffing levels are best. But many nurses point to the death of a patient in the liver-transplant unit at Mount Sinai Medical Center in New York in January as an extreme example of what can happen when nurses handle too many patients.
After reviewing the case, the State Health Department concluded that the unit "was inadequately staffed with nurses and physicians in charge of providing the necessary care for 34 transplant recipients and donors." Mount Sinai is adding more staff members to the unit, including nurses, although it noted that staffing was not the only issue involved.
Kaiser-Permanente, the country's largest nonprofit managed care health plan, is using a plan to increase staffing levels to recruit nurses and patients. Nurses on general medical-surgical floors, for example, will be responsible for only four patients. While Kaiser estimates that it may cost $200 million a year to employ the additional people, hospital executives say they expect to achieve savings through better patient outcomes and less turnover among its nurses.
"Our goal is to become the organization of choice for nurses," said Marilyn Chow, an executive at Kaiser, which is already advertising its planned staffing changes.
Other hospitals say the staffing law in California should not have a significant impact. "We already are or can easily be in compliance," said Harry Anderson, a spokesman for Tenet Healthcare. The company has no systemwide policies on staffing levels at its 116 hospitals.
But Kaiser and Tenet are exceptions. Other hospitals have argued that meeting the regulations could cost $400 million a year, according to the California Healthcare Association, when many hospitals are under severe financial stress. If the hospitals cannot hire enough nurses to meet the ratios, the association has warned, some hospitals may be forced to close units or cut services.