Should Hospitals Set Workloads for Nurses?

[Melissa Mills]

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.

[SmilingBluEyes]

Should the fox guard the henhouse?

[NursesTakeDC]

On 5/5/2019 at 1:30 AM, SmilingBluEyes said:

Should the fox guard the henhouse?

No they most certainly should not!!!

[Silent No More Foundation]

Hospitals have had all the time in the world to get this right. They are the ones making the choices now, and they choose WRONG. We (SNMF) are huge believers in setting maximum patient ratio limits, not just because I, personally, have felt the terror that comes with realizing a patient is going to die because we’re understaffed (to date, that’s still the worst shift I have ever had in my entire life), but also because the risk factors for violence toward us include short staffing, and problems resulting from short staffing (long wait times, etc.). Since hospitals can’t do what’s right, legislation is something we support. In fact, we typically endorse proposed legislation with ratios matching those recommended by NNU.

So to answer the question, “who should determine this?” I think clinical bedside staff should be creating the staffing matrix. Only the floor staff knows the workload they are being given through patient care, documentation, and typical orders for their specialty. Bedside staff should set this ratio. Unfortunately, nothing like that is happening, so the maximum allowable number of patients per nurse per specialty should be limited by legislation in the interests of protecting those patients who might otherwise fall victim to a medical mistake or injury, and the staff who are at higher risk of assault because of lack of staff.

[Silent No More Foundation]

On 4/30/2019 at 8:46 PM, beekee said:

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.

This makes me so angry I could scream. My old hospital decided to take a med surg CN with no ICU experience and float her to ICU. She refused. They actually fired her. I couldn’t believe it! From then on out, we all knew we weren’t allowed to say no, regardless of safety. It’s hard to ensure your first duty is to the patient and your license when your employer is the ONLY employer for quite a number of miles. I’m so sorry this happened to you.

[OUxPhys, BSN, RN]

18 hours ago, Silent No More Foundation said:

Hospitals have had all the time in the world to get this right. They are the ones making the choices now, and they choose WRONG. We (SNMF) are huge believers in setting maximum patient ratio limits, not just because I, personally, have felt the terror that comes with realizing a patient is going to die because we’re understaffed (to date, that’s still the worst shift I have ever had in my entire life), but also because the risk factors for violence toward us include short staffing, and problems resulting from short staffing (long wait times, etc.). Since hospitals can’t do what’s right, legislation is something we support. In fact, we typically endorse proposed legislation with ratios matching those recommended by NNU.

So to answer the question, “who should determine this?” I think clinical bedside staff should be creating the staffing matrix. Only the floor staff knows the workload they are being given through patient care, documentation, and typical orders for their specialty. Bedside staff should set this ratio. Unfortunately, nothing like that is happening, so the maximum allowable number of patients per nurse per specialty should be limited by legislation in the interests of protecting those patients who might otherwise fall victim to a medical mistake or injury, and the staff who are at higher risk of assault because of lack of staff.

This would be amazing if congress actually adopted this but the hospital lobby is too strong.

[frenchtoastwaffles, BSN, RN]

Staffing needs to be determined by people who work with patients. Bedside nurses should be able to speak with their managers and charge nurses about the acuity of their assignments to determine safe staffing ratios, and it should be implemented accordingly. Because of budgetary restraints, this is not occurring. Hospital administration does not allocate adequate funds for this to happen, and it is in the name of profit margins. It is in the name of upper and exec management salaries. Hospital CEOs making millions per year plus bonuses is at the expense of bedside nurses and patients. Unfortunately, greed is at the center of this; and the nursing shortage is perpetuated by hospitals that do not hire ADNs, and there are not enough BSN programs to support hospital demands. Positions are left open because it's cheaper to do so. Hospitals will not act in the best interest of patients or nurses without their hands being forced, and in order to do this, we must become political. It's not easy or safe for us to unionize, and many of us are not so lucky to have union representation. Most of us are at-will.

By becoming politically involved and having more nurses in office, we can work towards changing the way "health" care is run in this country. Reimbursements would be changed from being based on patient satisfaction and on acuity and clinical outcomes instead. Errors and missed documentation would not be fireable offenses, but rather root cause analyses would be performed to find out why errors or misses occurred in the first place- if clinical staff feel safe in documenting with integrity, we can find honest answers to the causes of the problems that are being faced. Nurses are fleeing from the bedside in pursuit of work that is possible for a human to do with less risk of litigation and less moral injury. What we are enduring now is not sustainable.

[Forest2]

On 5/18/2019 at 11:56 AM, OUxPhys said:

This would be amazing if congress actually adopted this but the hospital lobby is too strong.

I think that we should remember that some of these units, need aides as well, and if you have one nurse to 5 patients and no aide, then that nurse is responsible for bathing, dressing, toileting, feeding them because they can't get a spoon to their mouths, meds, treatments, and everything else that the pt. demands, some of these people are 100% total care and can't even wipe themselves, much less sit up on their own, and if you have someone who is 400 plus pounds, well just saying one person can't do all that work. For every nurse there should be an aide to help. NOW we can take care of people.

[panurse9999]

On 4/30/2019 at 7:50 PM, Nurse Beth said:

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.

I remember having 6 patients at a local hospital, then 60 on nights at a SNF, and I felt much better about the job / safety/ issue, with 60 on nights. Until staffing is taylored around tasks and acuity, we will continue to have a disproportion of work assigned.

I come back to my favorite example...6 patients on med surg, each patient has 100 check boxes per shift in total, times 6, that equals 600 check boxes, divide by 8 , its 75 tasks per hour, which is >1 per minute.

When we start staffing based upon tasks, instead of treating patients like inventory 6-1, then we can have a better staffing system overall. And, if the government gets itself involved, like it does everywhere, the decision should be made by a panel of current bedside nurses. Not politicans. Not corprations. Not lobbyists. Nurses.

[panurse9999]

On 5/18/2019 at 9:21 PM, sarolarn said:

Nurses are fleeing from the bedside in pursuit of work that is possible for a human to do with less risk of litigation and less moral injury. What we are enduring now is not sustainable.

entire post, very well said. Since I am one of those ADNs who was locked out of hospitals due to lack of a BSN here in PA, my choices are home care or SNF. What I am seeing in SNF is getting more frightening by the month. These are nation wide (sometimes) corporate conglomerate chains of skilled nursing facilities, that have turned nursing into geriatric warehousing. Their propensity to cut, cut, cut to bolster the bottom line is sickening. I have personally seen some of these homes run like a mom and pop grocery store, not a nursing home. And yes, this is why nurses are leaving the profession in droves.