Should Hospitals Set Workloads for Nurses?

[Melissa Mills, BSN]

In a recent Chicago Sun-Times Letter to the Editor, nurse Mary Nnene Okeiyi responds to the need for safe workloads in Illinois hospitals and current legislation that lawmakers are reviewing.

Illinois House Bill 2604

Illinois House Bill 2604 provides the maximum number of patients that can be given to a registered nurse in specific situations. Under the bill, hospitals will be able to assign the nurse with fewer patients during their shifts, but never more. The legislation also limits the ability of facilities to pull nurses to units they haven’t previously received training to ensure the nurse has the essentials needed to provide care to this specific type of patient.

One Administrator’s Point of View

Mary wrote her letter following a letter from A.J. Wilhelmi, President and CEO of the Illinois Health and Hospital Association. In Wilhelmi’s letter, he states that “While supporters of ratios say it (mandatory nurse staffing ratios) will help patients, it will do the opposite.” He contends that the state of Illinois doesn’t have enough nurses as it is, quoting a 21,000 nurse shortage with another one-third of RNs planning to retire within five years. He went on to say that the ratio legislation will only deepen the shortage of nurses in the state and create safety issues for patients.

Wilhelmi’s solution? Leave staffing in the hands of hospital administration, not lawmakers.

One Nurse’s Point of View

Let’s go back to Okeiyi’s letter for just a moment to gather an understanding of her perspective. She says that she went into nursing for a career that “inspires, educates, and advocates for others.” She went on to say that unfortunately, she is often expected to assume the care of an unsafe number of patients. Mary contends that the ‘big business’ mentality of hospitals is more about money than safe patient care and that administrators are often more worried about their bottom line. She closed her letter with a simple, yet powerful statement, ”What we cannot trust hospitals to do on their own, we ask politicians to do by passing HB 2604.”

Breaking Down the Issue

Illinois won’t be the first or the last state to consider and possibly pass nurse staffing ratios. Let’s take a look at a few nursing staff ratio laws in states across the nation.

There are currently fourteen states with official staffing regulations. Another seven states require hospitals to have staffing committees for nurse-driven ratios and staffing policies. California is the only state that provides a minimum nurse to patient ratio. Massachusetts passed a law specific only to the staffing ratios in the ICU. Minnesota requires that a CNO or designee develop a staffing plan for ratios, and the state of New Mexico has given powers to specific stakeholder groups to recommend staffing standards.

Staffing issues have long been a source of contention between nurses and administration. This is why many have turned to lawmakers to take the role of mediator to create policies that must be followed. While a federal regulation (42CFR 482.23(b) has been in effect for some time, without a law backing it up, there isn’t a way to hold hospitals and other facilities to the rule. The dangers of not having enough nurses, like medication errors, patient mortality, and hospital readmissions, should be enough to make any administrator consider their staffing ratios. However, it seems that it just isn’t enough.

Who Should Decide?

So we come down to one simple question - who is in the best position to decide how many patients any one nurse should be assigned to care for during their shift? As nurses, we know the dangers of having too many patients, but can we be objective and offer this information for the good of all involved? Or, should this be up to administrators or even lawmakers?

Tell us how you feel about Mary’s letter and who you think should be in charge of making nurse staffing ratio policies.

[subee, MSN, CRNA]

Institute stage ratios in Illinois and the nurses will come.

[OUxPhys, BSN, RN]

Staffing should bot be in the hands if supervisors and administrators, it should be in the hands if the nurses and nurse managers of the floors.

The problem is a lot of the nursing supervisors and administrators havent worked the floor in decades....yes decades. Other administrators are just concerned with making themselves look good so they get that next bonus/pay raise.

[Forest2]

Patient care nurses should make the decision.

[Hematocrit13]

6 hours ago, Melissa Mills said:

She closed her letter with a simple, yet powerful statement, ”What we cannot trust hospitals to do on their own, we ask politicians to do by passing HB 2604.”

I'm with her.

[Daisy4RN]

In a perfect world we would not need politicians to do this, hospitals would do it on their own. We need mandated ratios along with Charge RN and bedside RN making the decisions. Acuity tools do not usually work IMO because there are very time consuming (patient) factors that are either not on them or not on them appropriately. When I first did Charge (20 yrs ago) it was the Charge who (after getting report form the nurses) assigned the next shift's patient list based on approp. acuity and time factors. If ratios did not match what was intended (by admin) the Charge wrote a mini report explaining why and that was that. Also both shift Charge could change if need be. It worked well.

[Nurse Beth, MSN]

Nurse patient ratios have been in the hands of hospital administrators and the AHA (American Hospital Association), a powerful lobby.

It seems they have had ample opportunity to ensure safe staffing.....but have they?

Lawmakers speak on behalf of constituents- nurses and patients are constituents.

[beekee]

I’ve told my charge nurse twice in three years that I felt it was unsafe for me to accept another patient due to the acuity level of my current patients. In both instances, I was told I had no choice; my next admission was on their way.

Twice. I don’t cry wolf.

I was ignored.

We need more protections. Patients need more protections. How would you feel if you found out your loved one’s nurse was overwhelmed and ill-equipped to handle her assignment?

And to do this because there’s a nursing shortage? Well, make the job more appealing, not less!

[Leader25, ASN, BSN, RN]

12 hours ago, Melissa Mills said:

The legislation also limits the ability of facilities to pull nurses to units they haven’t previously received training to ensure the nurse has the essentials needed to provide care to this specific type of patient

This is the part I take issue with.It looks good on paper but in practice it can lead to even worse abuse of nurses.They tried similar ways to circumvent the union contract when had language to prevent forced floating to unlike areas.Some nurses would not listen about the fight we had on our hands: the need to stop all floating to unlike areas.We are not furniture nor pawns on a chess table for managements pleasure,so they could fill the blanks with "complete" staff,united properly staffed on paper and they could go home and forget about the mess they created and get a good nights sleep.

An RN is not an RN jack of all trades.Part of job satisfaction is also working in the specialty you desire when you are on duty.

What they would do is force cross training on nurses from one specialty to another.When the time came to perform as oriented many would break down in tears and overwhelming fear of being forced to function in a area they had no interest and only limited knowledge.

Next they changed all the positions to a multi-specialty job number,so now if you wanted a job,you had to accept this.Now after sometimes many weeks the nurse would be told go to the other unit,by now she is sort of stale and does not feel comfortable in that long forgotten unit.You can not assign the sickest patients and most called the supv to complain as soon as the arrived on the different unit.

The only good solution that sometimes solved the staffing problem was having a float team that was truly interested in being in different units ,had a talent /certification for doing so and enjoyed the mobility.

I could go on ,it is endless the bag of tricks administration has.

[Leader25, ASN, BSN, RN]

5 hours ago, Daisy4RN said:

Also both shift Charge could change if need be. It worked well.

Until it didnt.The outgoing supv would put it all on the outgoing charge nurse and ask if staffing was ok,regardless of whether it was or was not.When the next incoming charge nurse would protest the poor staffing,the answer was always .."well, your co-worker/charge nurse said it was ok ."

This happened over and over again.The lying,supv,management with no accountability.

[Wendy65]

Management does not care about high acuity for Nuses or safe patient ratio's. Not until some dire incident. We as Nurses have to advocate for our patients and ourselves and it is frustrating to no end feeling unsafe on a daily basis. Then as Nurses, we get reprimanded for poor HCAP scores like we are some kind of hotel.

Even when we state we feel unsafe with certain assignments we are looked at as if we can not handle our load? I had to fight my Charge Nurse because he wanted to give me a new patient at the same time I was getting a post-operative patient. I refused to take the new patient. This was at the change of shift. ( which to me is unsafe to allow post-operative patients or new admissions to occur) My post-operative patient ended up having complications that may have been missed if I was so busy trying to juggle two patients during the change of shift and ended up being transferred to ICU.

My point is, we need safe patient ratios. And they need to be out of the hands of Administrators who only care about the bottom dollar. It is not their license on the line. And they are not the patient in the bed trying to get good Nursing care. Hospitals are losing Nurses at the bedside at a fast rate because Nurses are no longer willing to put up with the treatment or dealing with poor patient care. We as Nurses go into Nursing because we enjoy caring for people. At least that is the reason I went into Nursing. There is no joy in struggling through your shift, not taking any breaks, unable to drink any fluids because of JACHO and never even having time to use the restroom. Twelve to fourteen hours straight. Who else would be willing to do our job??? Something needs to be done in every State.

[Tdmoudry, BSN, RN]

It is baffling to me that states can dictate how many perfectly healthy children a daycare provider has in their care at any given time. Yet when we're speaking in terms of medically unstable individuals, requiring frequent assessments and interventions ranging from zero days to 100+ years old we are just gonna wing it and hope these money hungry CEOs do the right thing by our loved ones?