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  1. South Dakota’s House of Representatives approved a bill, on February 29th, that would criminalize physicians who treat transgender children with hormones and sex reassignment surgeries. The Vulnerable Child Protection Act will now be sent to the state’s Senate for a committee hearing. Rep. Fred Deutsch, the bill’s primary sponsor, explains the legislation will protect vulnerable children who “are being chemically castrated, sterilized and surgical mutilated. South Dakota’s House of Representatives is the first state to pass a bill to restrict medical treatment for trangender teens. However, more than half a dozen state houses are considering similar bills. House Bill 1057 Under the bill, it would be a Class 1 misdemeanor for a physician to prescribe hormone replacement therapy or perform sex reassignment surgery to youth under the age of 16. This includes: Performing a mastectomy Gender affirming surgery (vasectomy, penectomy, vaginoplasty and others) Prescribing, dispensing or administering puberty blocking medication, supraphysiologic doses of testosterone to females and supraphysiologic doses of estrogen to males Removing any healthy or non-diseased body part or tissue. The penalty would be a maximum of 1 year in jail and a fine of $2,000. Nurses would be exempt from prosecution. The Debate Republicans and Democrats debate represent a larger culture war with conflicting values, beliefs and practices. The debate is bigger than just the medical issues and extends into parenting and the role of physicians. Opposition to the Bill Parents, many members of the medical community and advocates of transgender youths make the following arguments (although there are many more) in opposition to House Bill 1057: The bill is a form of discrimination that would withhold life saving treatment The bill is unconstitutional and the decision about gender expression should be between the youth, parent and doctor. Sex assignment surgeries and are rarely performed on youth Puberty blockers, requiring parental consent and extensive counseling, are reversible Libby Skarin, policy director for the American Civil Liberties Union of South Dakota, issued a statement after the vote, stating “By blocking medical care supported by every major medical association, the legislature is compromising the health of trans youth in dangerous and potentially life-threatening ways.” A conservative Christian organization, Liberty Counsel, has offered legal counsel to defend bill, at no cost to state taxpayers. Proponents of the Bill Lawmakers supporting the bill make debate these points (among others): Need to protect youth from making life altering changes until they are old enough to consider all available options Too young to understand the potential consequences Sex-reassigment surgery and administration in youth are harmful, abusive and criminal acts The website https://hb1057.com/, promotes Deutsch’s bill and features resources and videos from the Heritage Foundation, the Minnesota Family Council, a Christian organization. For Thought In 2018, the American Nurses Association released a position statement, Nursing Advocacy for LGBTQ+ Populations and applied the nursing code of ethics to this population. ANA Position Statement: Nursing Advocacy for LGBTQ+ Populations How do you think this ethical duty of nursing fits into the debate around limiting transgender healthcare for youth? Let us hear from you!
  2. Nurse Beth

    CEO Says More Nurses Won't Improve Care

    The fight for safe patient staffing is being waged right now in Illinois. The Safe Patient Limits Act, HB 2604, which calls for safe nurse-patient ratios, will be voted on this week in Springfield, Illinois in the House of Representatives. The bill requires: One nurse for every four patients in Med Surg One nurse for every three patients in Stepdown, ED, or intermediate care units One nurse for every two patients in ICU If it passes, Illinois will be on its way to joining California as the only state with mandated safe staffing (nurse-patient ratios). It won’t pass if the American Hospital Association (AHA), hospital CEOs, and even the American Nurses Association (ANA) have their way. Doris Carroll, Vice President of the Illinois Nurses Association, flatly states that “Not one CEO (in Illinois) is in favor of the safe staffing legislation”. It has a good chance of passing if Illinois nurses call their legislators (see below) today. Mark Gridley, CEO of FHN Memorial Hospital, raised the ire of Illinois nurses in a public statement opposing the bill. He used predictable arguments and unsubstantiated claims that are intended to mislead nurses and the public. More Nurses Won’t Improve Patient Care The CEO, who says that he worked as an LPN prior to becoming a CEO, declared that “increasing the number of nurses won’t improve care”. Does Mr. Gridley really believe that fewer nurses result in improved care? At what ratio does he determine that "more nurses won't improve care"? One nurse to six patients? One nurse to eight patients? It has been proven over and over in the literature that lower ratios are associated with significantly lower mortality. It is concerning that evidence can be ignored in lieu of sweeping statements. Especially when rhetoric is valued over evidence by a hospital CEO. There are Not Enough Nurses According to the Illinois Center for Nursing Workforce Survey, there were 176,974 registered nurses in Illinois in 2016. According to the federal Health Services and Resources Administration (HRSA), an agency of the US Department of Health and Human Services, 139, 400 registered nurses will be needed in Illinois by 2030. HRSA projects an overage of registered nurses in Illinois, yet the CEO of Fairhaven hospital claims that Illinois has an “anticipated shortage of 21,000 nurses in 2020”. While different numbers and predictive models can be used to support different arguments, mandated safe staffing ratios in California not only improved staffing, it alleviated the severe nursing shortage at the time (Aiken,2010). There’s Not Enough Money Mark Gridley then states that staff would have to be cut in other areas. This is intended to frighten nurses, and perhaps to serve as a veiled warning, but it is unfounded. HB 2604 specifically prohibits cutting staff. Dall and colleagues (2009) determined that ” hospitals with greater nurse staffing levels resulted in cost savings due to reductions in hospital-acquired infections, shorter lengths of stay and improved productivity”. Hospitals with a higher nurse-patient ratio that focus on retaining nurses have a competitive edge. Nurses report less burnout and job dissatisfaction when the quality of care is higher, as in hospitals with safe staffing ratios (Everhart, et al., 2013). Staffing Committees Are All We Need “Illinois already has laws...to ensure safe, optimum nurse staffing levels”, Mark Gridley. Illinois nurses strongly disagree. Seven states, including Illinois, have legislation in place that requires hospitals to have staffing committees. Staffing committees are to include bedside nurses as well as management to create staffing plans specific to each unit. Staffing plans are to take into consideration: Intensity of patient care Admissions, discharges and transfers Level of experience of staff Physical layout of the unit Availability of resources (ancillary staff, technology) It sounds good in theory, and theory is where it remains. According to the ANA-Illinois, over 70% of nurses say the staffing plans are not being used. Nurses say that staffing committee meetings lack accountability, are hijacked by management, are not taken seriously, and serve as lip service only. Hospitals with staffing committees are free to staff 1 RN for every 6-7 Med Surg patients, or 8, or however many they see fit. Ratios Are Inflexible Ratios are not inflexible. On the contrary, nothing in the Safe Patient Limits Act precludes the use of patient acuity systems and nothing precludes a facility from assigning fewer patients that the Act requires. As an example of how flexible ratios are, a Med Surg nurse in a mid-sized CA hospital who is assigned a patient with continuous bladder irrigation will only have 3 patients, even though ratios call for 5 patients. Ratios are not inflexible unless hospital administrators want them to be. It would be interesting to know the staffing assignments at FHN Memorial, and for Mark Gridley to give examples of the staffing flexibility in his facility. Hospitals Will Close or Reduce Services Critics say hospitals will close or reduce services. Acquisitions, takeovers, mergers and closures are taking place in all of the 49 states that do not have mandated nurse-patient ratios. Hospitals all over the country have merged or closed due to decreased reimbursement and low patient volume, for example, a 25-bed hospital in Celine, TN, that recently closed on March 1, 2019. According to Linda Aiken “There is no evidence that hospitals closed as a result of the legislation (in California). Indeed, there is very good scientific evidence that staffing improved even in safety-net hospitals that long had poor staffing.” Consider this- if the surgery department had surgeries scheduled but didn’t have adequate nursing staff, should they cancel cases? The answer is yes. Only safe services should be provided. Illinois nurses, the time to speak up is today. If you are reading this, call your legislator now. Leave a voicemail. You are a constituent, and your opinion matters. Call to Action The Illinois Who is your State Rep? Follow this link and enter your address information into this link: https://bit.ly/2FtE2A3. Here is a script (thanks to Doris Carroll): Hello Representative _________, My name is ___________, I have been a constituent in your district for ___ years. I’ve been a nurse for ___ years. I am calling today to ask that you please vote Yes on the Safe Patient Limits act, House Bill 2604, which ensures that there is a maximum number of patients any one nurse can be assigned depending on her unit. Unsafe staffing costs patients their lives. Please put patients over profits. Please Vote Yes on HB 2604! 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. Dall T, Chen Y, Seifert R, Maddox P, Hagan P. The economic value of professional nursing. Medical Care. 2009;47(1):97–104. [PubMed] [Google Scholar] Everhart, D., Neff, D., Al-Amin, M., Nogle, J., & Weech-Maldonado, R. (2013). The effects of nurse staffing on hospital financial performance: Competitive versus less competitive markets. Health care management review, 38(2), 146. U. S. Department of Health and Human Services, Health Resources and Services Administration (201) Supply and Demand Projections of the Nursing Workforce:2014-2030.
  3. Everyone Deserves the Best Care Possible Nurses are often put in impossible situations pushed to care for more patients than is safe. It is fair to say everyone deserves the best care possible. In order to ensure this, safe staffing for nurses and patients should be established. Just think of it, you are a registered nurse tending to a patient with a heart rate sustained above 160 when your other patients’ blood pressure suddenly becomes dangerously low. Soon after, another patients’ arterial line malfunctions making blood pressure readings inaccurate. No, this is not an exam question on prioritization; this is the less detailed version of an understaffed stressful 12-hour shift I had in the intensive care unit. These types of situations can lead to health risks for both patients and nurses. In addition, these situations can drive nurses from their profession. Safe staffing ratios cultivate a healthcare environment that increases optimal health outcomes, nurse retention, improves quality of care and lowers healthcare costs. Hospitals are supposed to be safe institutions to treat and care for patients. Unfortunately, staffing shortages in hospitals nationwide compromise the safety of patients. According to the Department for Professional Employees (2013), correlations in several studies between inadequate nursing staff and poor patient outcomes are found to be associated with an increase in medical errors, patient infections, bedsores, pneumonia, Methicillin-resistant Staphylococcus aureus, cardiac arrest, and accidental death. Most bedside registered nurses have experienced the result of this study first hand trying to keep patients safe while understaffed. For instance: Turning and repositioning are not performed every two hours as recommended to prevent bedsores. Blood work may not be drawn on time. Oral care, for ventilator-associated pneumonia prevention is often skipped. Clave changes on central lines may not get done to prevent central line-associated bloodstream infections. These preventative measures are often not performed because the bedside nurse is understaffed and has to prioritize care for the unstable situation at hand. Inadequate staffing and working long hours don’t just affect the health of the patient, but the health of the nurse. The Department for Professional Employees (2013) lists associated risks with inadequate nurse levels to musculoskeletal disorders, commonly back, neck and shoulder injuries. Workplace related injuries are costly to hospitals. The study also found other health risks to nurses including hypertension, cardiovascular disease, and depression. Being understaffed and overworked can easily lead to these issues. As nurses we are frequently placed in unsafe and stressful working conditions and if recurrent, can lead to burnout. The cost of hiring more nurses to staff adequately should not be a concern for hospitals. Hospital institutions must consider the fact that nurse turnover rates are just as costly. Abraham (2018) gives details on burnout-related turnover rates among nurses already costing hospitals in the United States an estimated $9 billion per year. It must be considered that once a large amount of staff is lost, hospitals are willing to pay travel nurses a large sum of money to replace the lost staff. Adequate nurse staffing would improve nurse retention rates and help prevent the ill effects of nurse burnout and turnover. Mandating staffing ratios provides better outcomes for patients, nurses, and hospitals. Currently, some states have laws that address safe staffing. The Department for Professional Employees (2013) lists Connecticut, Illinois, Nevada, Ohio, Oregon, Texas, and Washington as states that require hospitals to have committees responsible for staffing policy, and the states of Illinois, New Jersey, New York, Rhode Island, and Vermont to require hospitals to publicly report staffing ratios, but California is the only state to implement a ratio mandate. Studies show that after legislators enacted California safe staffing ratios, patient mortality events within thirty days of hospital admission decreased notably, and nurse-patient interaction improved significantly (Department for Professional Employees, 2013). Another study showed that California nurses experienced less burnout compared to nurses in states without minimum staffing ratios such as New Jersey and Pennsylvania (Department for Professional Employees, 2013). Additionally, for each nurse added to the staffing pool, patients spent 24 percent less time in intensive care units and 31 percent less time in surgical units (Department for Professional Employees, 2013). The safe staffing ratio law improved patient care, patient outcome, and nurse retention. As nurses, we play an essential role in health care. We can help improve health care in America simply by supporting important issues as nurses. Carlson (2017) provides a list of actions a nurse might consider taking to ensure we are heard, to allow for improvement. Actions include: Gaining an understanding of the legislative process in your state and become familiar with current legislation being enforced, Attend training and days of action related to lobbying your legislators and meet with legislators as well in regards to issues of importance to nurses and patients. Discussing ratios and nurse staffing with others for support, document situations that show the challenges faced by nurses providing patient care to discuss observations and concerns with those who can help make a change (Carlson, 2017). The issue of safe staffing levels has been around for years and we must continue to support safer staffing levels. Nurses and patients deserve a healthcare environment that increases optimal health outcomes, nurse retention, and improves quality of care. Therefore, we must stay informed and get involved. References Abraham, T. (2018). Fight for mandated nurse to patient ratio heats up. Retrieved from https://www.healthcaredive.com/news/fight-for-mandated-nurse-to-patient-ratios-heats-up/525225/ Carlson, K. (2017). Nurse-Patient Ratios and Safe Staffing: 10 Ways Nurses Can Lead the Change. Retrieved from https://nurse.org/articles/nurse-patient-ratios-and-safe-staffing/ Department for Professional Employees. (2013). Safe-Staffing Ratios: Benefiting Nurses And Patients. Retrieved from http://dpeaflcio.org/wp-content/uploads/Safe-Staffing-Ratios-2013.pdf
  4. On Saturday, June 8th nurses, doctors, and medical students stood side-by-side to protest the American Medical Association’s (AMA) annual meeting in Chicago. The AMA, which was founded in 1847, is a large, powerful, and wealthy lobbying group. However, it seems that many young physicians and medical students don’t agree with the work done by the group. In fact, in 2016, it was reported that the AMA only represented about 25 percent of practicing physicians. This decrease was a significant change from just a few decades ago when nearly 75 percent of all physicians were members. #AMAGetOutTheWay If you perform a quick social media search for #AMAGetOutTheWay, you will find support from many healthcare professionals fighting for Medicare for all. Experts believe that adopting a Medicare for all system in the United States would allow us to join the ranks of the rest of the industrialized world where health coverage is universal. They also feel that this would save money and improve health outcomes. Protesters feel that the AMA isn’t fighting for the right initiatives. Adam Gaffney, President for Physicians for a National Health Program and an instructor at the Harvard Medical School, made his feelings known at the rally. “The AMA is not fighting for their patients, they’re not fighting for the uninsured, and they’re not fighting for the underinsured. We’re here today because the AMA is again on the wrong side of history.” Other groups well-represented at the rally included Students for a National Health Program (SNaHP), National Nurses United, People’s Action, and The Center for Popular Democracy. SNaHP published on their website that showing up at the rally showed support by “taking a stand AGAINST corporate greed, misleading advertising, and the profit motive of health care.” National Nurses United is the largest union and professional association for registered nurses and supports Medicare for All. What is HR 1384? Medicare for all isn’t just a catchy slogan used by Democrats like Bernie Sanders. It’s a legislative proposal, HR 1384, that would create a nationwide health insurance program for all U.S residents. A single-payer system such as this would replace the current mixed healthcare system which includes private and public health programs. It also has a provision to allow people to purchase public coverage during a transitional period to this new system. Who Would Be Covered? HR 1384 aims to provide coverage to all U.S. residents, documented immigrants, and even undocumented people. The program would prohibit anyone from being excluded because of citizenship status. How Would it be Funded? This single-payer system would not require premiums to be paid. However, it would require new federal taxes for both businesses and individuals. What Would Be Covered? All medical care would be covered under this system. Those who support HR 1384 proudly boast that it would also cover reproductive health services. This would include maternity and newborn care. The Power of Unity Regardless of your opinions about HR 1384, the rally in Chicago is an example of what could happen when healthcare workers come together. It’s estimated that there over one million physicians and nearly three million nurses in the U.S. Imagine how workplace problems and care deficiencies could be approached with this type of unity. Would we be able to solve some of the top problems that plague healthcare? Just think for a minute how discussions about safe staffing, workplace violence, and long working hours might change if these two “strong-in-number” groups stormed the offices of administration and lawmakers across the nation. Where Do You Stand? There are so many different conversations that could come from this one event. Do you support a Medicare for all system? And, what do you think about the unity that was displayed at this protest? Oh, and what other issues do you think a unified front could impact? Let’s start there for now. Tell us what you think!
  5. In 2018, TIna Suckow, a 49-year old nurse, was brutally beaten by a patient at a state mental facility in Iowa. Suckow had been employed there for over 4 years when the incident occurred. A “code red” alert was issued, and multiple staff members responded, one of whom was Suckow. A patient, who is said to have been in a manic episode, was throwing furniture and threatening physical violence. Staff members brought in a “turtle shield,” an assault-protection device the facility had recently purchased, but not yet trained staff to use. Shortly after this device was brought out, Suckow became trapped between the shield and the patient. She was then beaten unconscious and hospitalized with injuries to her shoulder, knee, and head. She has undergone several surgeries and continues to need medical treatment today. Share Your Thoughts via Video During the incident, officials at the facility didn't call law enforcement to investigate the situation, which has left Suckow feeling like a target. “I’m not the criminal here,” said Suckow, “I didn’t do anything wrong.” The Nursing Director at the facility, Georgeanne Cassidy-Westcott sent an email two days after the incident informing staff about the opportunity to use the “turtle shield” and stated that while they had not trained on the use of the device, it was “fairly effective” when used in this situation. Suckow contends that during her time off, she was not treated fairly. She reports that other staff who were off for medical reasons were allowed to send in paperwork electronically. However, Suckow was required to make a two-hour round-trip drive to deliver her paperwork in person. After her federally mandated time-off ended, Suckow made two requests. First, she requested catastrophic leave, which would allow other employees to donate sick time so that Suckow could extend her time on payroll. This was denied. Her second request was for time off without pay. However, the state rejected this request as well and is protected to do so under a 2017 state law that limits government employee unions to negotiate on the employees’ behalf for anything except pay. According to a ucomm blog article, the union reports that terminations and forced resignations have tripled since the 2017 law went into effect. Some people in Iowa believe this number is low because it doesn’t account for state workers who have been forced to resign and others who like Suckow, have been injured on the job. In fact, Suckow’s state employment record doesn’t even list her as being terminated. Another result of this legislation is that hospitals are now struggling more with being understaffed, which places patients and workers at risk of more safety concerns. Danny Homan, president of the American Federation of State, County, and Municipal Employees Iowa Council 16 told the Des Moines Register, “Any reasonable human being should have concern because if it’s OK for the state of Iowa to treat workers this way, then Casey’s can do it, Ruan can do it, any employers in the state of Iowa can do it.” Even in light of this horrific situation that Suckow has endured, lawmakers still support the 2017 law. State Rep Steven Holt, helped to get the bill passed. He believes the changes have created a fairer balance between workers’ rights and government operations. He told the Des Moines Register, “There are plenty of horror stories to go around in the old system as well.” Holt also believes that a connection between unfair treatment by managers can’t be tied to the law. Should lawmakers and citizens of Iowa accept the 2017 law because it’s not “worse” than the previous law? Or, should the union and the employee have more rights in this situation? What do you think? Share Your Thoughts via Video
  6. Melissa Mills

    Safe Staffing in Illinois: Not Over Yet

    Legislation to set maximum nurse-to-patient staffing ratios is a hot topic these days. Currently, California is the only state to enforce a staffing ratio mandate. However, several other states have some sort of legislation in place regarding safe staffing. The laws vary from telling the hospitals they must have committees to set the ratios to have standards for specific nursing units. Last week, nurses across the state of Illinois were hopeful that their state would join the ranks of California and become a state which placed patient and nurse safety as a priority. The Safe Patient Limits Act, House Bill 2604, was before lawmakers to mandate how many patients could be assigned to one nurse, depending on the setting. The bill would require med-surg units to only assign up to four patients to each nurse, three-to-one assignments in intermediate care units, and intensive care units would be limited to two patients per nurse. The bill has similarities to the California law that was passed in 2004. However, HB 2604 was the first of its kind to provide minimum staffing ratios for ambulatory surgical centers and long-term acute hospitals, too. The bill passed through a committee, then stalled in the final week of session. Ultimately, it never came to a full vote before the House. Alice Johnson, executive director of the Illinois Nurses Association, told Herald & Review in a recent article, “Of course we want to see the bill passed into law because we know it’s going to save lives, but we’re looking at it like….it’s not the law yet. We’re going to keep advocating and keep working on this until we get it done.” The Opposition Hospital administrators across the state weren’t supportive of the proposed legislation. Many felt that hiring more nurses to meet the mandated ratios would strap the hospitals financially. Danny Chun, a spokesman for the Illinois Health and Hospital Association, told Herald & Review that the bill could cause some hospital units to close and negatively impact patient care. Chun also called the bill a “one-size-fits-all” approach that wouldn’t meet the needs of the different hospital settings across the state. The interesting thing about this position is that without nurses, hospitals would be more than financially strapped to provide care. These healthcare facilities would be without care. Nurses are the epitome of patient care, and without them, hospitals are nothing more than a large building where people who are ill, recovering, and dying would go to commiserate in the knowledge that nobody is there to do the hard work that must be done 24-7. The Support If you’re like 99% of the nurses I know, you probably went into nursing intending to help others. Maybe you wanted to help the sick, be there to support new moms as they deliver babies, or ease the discomforts of death for people as they die. Regardless of why you went into nursing or where you work now, you should support nursing staff ratios. Inadequate nurse to patient ratios create adverse outcomes for patients. It can also prolong hospital stays and increase the risk of hospital-related complications, including death. Adequate staffing has shown to decrease the following: Medication errors Hospital readmissions Length of stay Preventable adverse events Cost of care One of the most comprehensive studies that support safe staffing compared hospitals in California, who have mandates on staffing, to hospitals in Pennsylvania and New Jersey. This study came out in 2010 and reviewed data from 22,336 nurses in all three states in 2006, as well as the state hospital discharge databases. It also compared nurse workloads and patient outcomes. The facilities in California boasted better health outcomes for similar patients, lower surgical mortality rates, and fewer inpatient deaths within 30 days of admission. Along with this study and others, several organizations support safe staffing initiatives, too, although they don't all agree on how to achieve this. A few of these organizations include the America Nurses Association, many state nursing organizations, NursesTakeDC, and the Department for Professional Employees, AFL-CIO (DPE). Nurses on the Move This isn’t the last lawmakers in Illinois will hear about HB 2604. Johnson said that there are plans to meet with lawmakers this summer to provide more education on the impact of the bill. They will work with the sponsors to get it back in front of the session this fall or at the start of 2020, if necessary. If you take a look at the Illinois Nurses Association Facebook page, you’ll notice that the support of nurses doesn’t seem to have waned in light of last week’s events. The active nursing advocacy group isn’t only worried about staffing ratios, but they continue to support other issues in Illinois like the Howard Brown Health employees who are fighting for a fair labor contract. How to Get Involved If you’re interested in helping nursing initiatives in your state and across the country, there are a few ways you can get involved. Look up your state nursing association or search for their social media page on Facebook. You can also join movements supported by national organizations like NursesTakeDC to stay up-to-date. Do you have any other unique ways to move staffing ratios forward in your state or facility? I would love to hear how you support this critical healthcare issue.
  7. Melissa Mills

    Should Hospitals Set Workloads for Nurses?

    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.
  8. House Bill 793 passed in the state of Virginia in 2018 and went into effect in January of this year. The legislation allows nurse practitioners (NP) in specialty practices to open a private practice and work without the oversight of a medical doctor. Since nearly half of the states across the country have similar legislation, this appears to be a win, but also possibly just part of the natural progression for NPs. Marsha Stonehill, a psychiatric NP recently opened her own practice, Melt the Ice. Her doors opened in March, just a few months after the bill went into effect. She described her practice and why she decided to go out on her own in a recent Fredericksburg.com article. Stonehill has previously worked in large health systems that required her to see many patients in a day and even cut sessions short. Today, she truly is a one-woman show who answers her own phone and emails and even set her times directly with her clients. She leaves extra time between patients in case there are emergencies or care issues that need further discussion beyond the scheduled appointment limits. She has chosen to be a private pay practice to avoid some of the limitations set by health insurance plans. While Stonehill is enjoying the freedoms of her practice, not everyone in Virginia or even across the nation agrees that nurse practitioners should be allowed to practice alone. The Debate Virginia’s law requires NPs to have a minimum of five years of full-time clinical practice. They must submit documentation from a physician who can attest that there was collaboration between the two during that time. If an NP wants to go out on their own but doesn’t meet this qualification, they must provide a plan to the state detailing how they will refer complex cases and emergencies to a doctor or other provider. Some doctors, like Dr. Davis Liu, who practices in California and runs a start-up called Lemonaid Health doesn’t feel that nurse practitioners should be allowed to practice on their own. He was quoted saying, “It boils down to training. Primary care is a cognitively challenging specialty. The amount of training doctors receive is far greater than that of nurse practitioners.” However, Lui might be in the minority for a few reasons. And, it’s not just nurses who question if his opinions are correct. Understanding the State Practice Environment According to the American Association of Nurse Practitioners, across the U.S., there are three categories of practice that governs the care provided by NPs. Full practice states allow the clinician to evaluate, diagnose, order and interpret diagnostic tests and start and manage treatments. They can also prescribe medications, including controlled substances under their license. This model of care is supported by the National Academy of Medicine and the National Council of State Boards of Nursing. States in this category include Washington, Hawaii, and Iowa. Reduced practice states include Ohio, Utah, and New Jersey. NPs in these states have a reduced ability to engage in at least one element of the NP practice. They must have career-long collaboration with a provider under a set agreement. The final category is restricted practice in which the NP have a restricted ability to engage in at least one element of the NP practice. They also must maintain career-long supervision, delegation, or team management by another provider. States who continue to restrict NP practice to the fullest include California, Texas, and North Carolina. What’s Next? Using NPs as an integral part of the healthcare team has been proven successful many times over the years. They’re a cost-effective solution to the shortage of physicians, and many patients prefer the care they provide. As more states adopt similar laws to Virginia will the naysayers finally believe in the value of NPs at work? What’s your opinion?
  9. Nurses Celebrate Nurses across the state of Washington celebrated last week when House Bill 1155 passed, creating new break and overtime laws for nurses and other healthcare professionals across the state. You probably first heard about the bill when video clips of Senator Maureen Walsh hit the internet that showed her opposing the legislation by making a comment that some nurses “probably play cards for a considerable amount of the day.” While her comment received tons of publicity and backlash from many nurses and nursing organizations, it wasn't enough to stop the bill from being passed. Understanding House Bill 1155 The bill passed on April 24, 2019, and should go into effect on January 1, 2020. It currently sits with the governor, who will sign it for final approval. This legislation will implement new restrictions on hospital staffing. It removes a mandatory eight-hour cap on nurse shifts and also offers provisions that nurse’s breaks can’t be interrupted to address patient care needs. This means that nurses will receive uninterrupted meal and rest breaks, with the only exception being patient care emergencies. SHB 1155 also provides changes to the use of mandatory on-call for regularly schedule shifts and excludes pre-schedule on-call nurses from being used to cover staffing needs for reasons like census or high acuity. Finally, the bill protects nurses and other healthcare workers from not receiving rest breaks between consecutive shifts that will put them into overtime hours. While the initial changes will affect nursing staff, other healthcare workers will be included in these rules beginning in July 2021. The list of workers that will join in on the provisions of SHB 11155 includes radiology technicians, cardiovascular invasive specialists, certified nursing assistants, surgical technologists, and respiratory care practitioners. While everyone knows Senator Walsh made a statement that was insensitive to the long hours and hard work nurses do each day, other lawmakers and hospital associations in the state agree that this bill could be detrimental to critical access hospitals. The fear is that these small, rural hospitals, who have less than 25 beds, might have difficulty complying with the newly passed regulations because of staffing constraints. However, critical access hospitals have been given additional time to comply and won’t join the law until July 1, 2021. Washington Nurse Speaks Out in Support The Spokesman-Review interviewed ICU nurse, Sara Rice just after the passing of the bill. Sara reported that in her 10 years as a nurse she has never worked a full week where she was able to take her allotted breaks. She went on to explain that it wasn’t a knock at her employer, but rather a cultural issue that’s prevalent to both nursing and hospitals. Rice feels that the bill is a “big win for nurses” even though lawmakers and the hospital industry remain in opposition. Rice went on to say in the interview that, “We just want patients to get quality, safe care. In a perfect world, we wouldn’t need laws for that.” Could More States Follow? While Senator Walsh shuffles through the more than 1,700 decks of cards she received in the past week, you might be wondering how the passing of SHB 1155 could affect other states. You may have even considered how your current laws about breaks and lunches work and if your employer could meet the standards of rules like this. If this would happen in your state, how would you feel? Do you agree that SHB 1125 a win for Washington nurses? Or could it even be a win for nurses across the country? Let us know how you feel about the passing of this law below.
  10. NursesTakeDC

    Illinois Nurse Staffing Survey

    Illinois Nurse Staffing Survey Catherine Stokes BSN, RN, Jalil Johnson PhD, APRN, Ruth Neese PhD, RN, CEN, Doris Carroll BSN, RN-BC, CCRC, Pamela S. Robbins MSN, RN, Deena Sowa McCollum BSN, RN A national survey was completed from October 1, 2018- October 31, 2018. Survey responses were collected via SurveyMonkey.com. Online outreach occurred through several social media outlets including Allnurses.com, Facebook nursing communities, Medscape Nurses, Show Me Your Stethoscope, and Twitter. The national survey produced 9,498 responses nationwide. These results will show information collected from 508 Illinois nurses. Inclusion criteria for the survey were that nurses should have an active license and be working as a bedside clinician. Demographic information was obtained from the participants. Units identified in the survey include: ED, ICU, NICU, pediatric ICU, PCU, intermediate step down, telemetry, med-surg, mother/baby, labor/delivery, pediatric floor units, float pools, and psych units. Educational demographics include responses of diploma nurses 4.72%, ADN/ASN 31.10%, BSN 55.12%, MSN 8.46% DNP 0.59%. The clinical settings identified by the respondents include: Tertiary/Academic hospitals 23.62%, community hospitals 57.28%, critical access hospitals 10.83% and 8.27% marked the type of hospital they work at as other. Information obtained as to whether the facility that they work at is a Magnet accredited hospital or not include: 45.08% nurses responding yes and 54.92% responding no. The intent of this survey was to see if nurses who work in a state with state staffing legislation which mandates utilization of acuity tools and staffing committees comprised of 50% or more RNs, who provide direct patient care at least 50% of the time, is implemented properly and if nurses think staffing is safe. The survey also explored the differences in nurse staffing between Magnet-designated facilities and facilities without that designation. The state of Illinois has had state legislation for nurse staffing in place since January 1, 2008. The basic premise of that law includes the following: Facilities must post and implement the staffing plan recommended by a committee of nurses (at least 50% direct-care nurses), with broad representation. The plan must include the complexity of nursing judgment required, patient acuity, number of patients, ongoing assessment, unexpected patient needs, time for documentation, and staffing flexibility. Committee minutes must be stored for five years and must be given significant regard in the adoption and implementation of the plan. The plan must outline the process for submitting the committee’s recommendations to administration; the process for providing feedback to the committee regarding unresolved or ongoing issues, which must be addressed at the next meeting. Nursing Performance and Quality data must be reviewed by the staffing committee semiannually. (Shin, Koh, Kim, Lee, & Song, 2018) Data Results for questions pertaining to bedside nurse knowledge of their staffing law are as follows. Nearly 15.87% of Illinois nurses knew their state had acuity based and staffing committee legislation. The rest of the respondents marked “no” or “I don’t know” to the question of having knowledge of the state law that had been in place since January 1, 2008. Over 28% of nurses reported working in a hospital with a staffing committee, 38% of nurses worked in hospitals that do not have staffing committees, and 33.54% of nurses did not know if their hospital has a staffing committee. Composition makeup of the committees was asked of the respondents to further assess proper implementation. More than 20% of respondents work in facilities that are composed of 50% or more RNs who work direct patient care at least 50% of the time. Seventy-nine percent of the respondents either marked “no”, “I don’t know”, or that their hospital did not have a staffing committee. Sixty-two percent of the participants marked their staffing committee does not encourage feedback from nurses related to staffing issues. When asked if their staffing committee re-evaluates the effectiveness of the staffing plan semi-annually, 28.97% of respondents marked “no”, 56.90% marked they do not participate in the staffing committee process. Sixty-nine percent of respondents marked that their staffing committee does not re-evaluate variations between the staffing plan and actual daily staffing. We asked the respondents if the staffing recommendations determined by the staffing committee were implemented in the daily staffing census and 25.34% marked “yes.” The other respondents either marked “no” or “I don’t know” to implementation of staffing committee recommendations. Almost 43% of respondents indicated their hospitals use an acuity tool. When asked if staffing is based on the needs of the patients in the units, 68.26% of respondents said “no”. In response to a survey item asking if adjustments in staffing occur in response to patient acuity on different shifts 65.15% reported “no.” Over 81% of respondents reported their unit does not have a plan for when a patient’s care needs unexpectedly changes and exceeds the direct care nurse resources. More than 60% of the nurses who responded marked that retaliation is feared for nurses who provide input about staffing. Nurses were asked if their nurse to patient ratio in their unit is adequate/safe and 82.09% of them reported “no.” Thirty-nine percent experienced unsafe staffing 50% of the time, 31.95% experienced unsafe staffing 75% of the time, 20.23% experienced unsafe staffing 25% of the time, and 8.74% marked that they experienced unsafe staffing 100% of the time. More than 93% of responses indicated charge nurses were providing direct patient care on their unit. When asked if the charge nurses had a patient assignment, 34.01% of respondents marked “yes”, 28.31 marked “no”, 27.70% marked “sometimes but less than 50% of the time”, and 9.98% marked “sometimes more than 50% of the time.” Nurse staffing based on Magnet hospital status vs non-Magnet status was assessed to determine if there was a significant difference in the relationship between the designated facilities vs non-designated facilities. Over 37% of nurses in Magnet hospitals reported having a staffing committee in contrast to 20.97% of non-Magnet hospital nurses. A significant difference was noted between nurses at Magnet-designated hospitals and non-Magnet facilities, with more nurses at Magnet hospitals 37.33% being aware of the existence of a staffing committee, than nurses at non-Magnet facilities 20.97%. Additionally, nearly 30% of Magnet facility nurses reported “no” to having a staffing committee in comparison to 45.32% of nurses at non-Magnet facilities. A significantly higher difference in non-Magnet hospital nurses saying no at 45.32% vs 29.33% was determined. Respectfully 33%, of nurses in both magnet and non-Magnet did not know if a staffing committee was used. Thirty-three percent of nurses in both Magnet and non-Magnet designated hospitals did not know if a staffing committee were used. In Magnet accredited hospitals, 26.29% of nurses reported that the staffing committee was composed of 50% or more RNs who work in direct patient care 50% of the time. In contrast, in non-Magnet hospitals, 15.31% of nurses reported that the staffing committee was composed of 50% or more RNs who work in direct patient care 50% of the time. Slightly more than 51% of Magnet hospital nurses did not know if the hospital staffing committee was composed of 50% or more RNs who work in direct patient care; compared to 36.73% of non-Magnet hospital nurses. There were no significant differences found between Magnet hospital nurses and non-Magnet hospital nurses in regards to staffing based on the needs of the patients in the unit. Seventy percent of non-Magnet hospital nurses reported that staffing is not based on the needs of the patients. In Magnet accredited hospitals, 66.08% of nurses reported that staffing is not based on the needs of the patient. Magnet hospital nurse response: 82.97% report that their nurse to patient ratio is not safe. Non-Magnet hospital nurse response: 81.36% report that their nurse to patient ratio is not safe. Almost 60% of nurses who work in a Magnet accredited hospital feared retaliation for providing input for staffing. Over 62% of nurses that fear retaliation for providing input on staffing work in non magnet-designated hospitals. There is no significant difference found between Magnet and non-Magnet nurse responses and fear of retaliation. Of the total 508 responses, 496 respondents marked they do have ancillary services including certified nursing assistants (CNAs), patient care technicians (PCTs), unit secretaries, phlebotomy, electrocardiogram technicians, and respiratory therapists. When asked if licensed vocational nurses (LVN) or licensed practical nurses (LPN) were used to provide team nursing, 92.13% of participants reported “no”. Seventy-three percent of respondents indicated that they do not have to stay over their shifts as “mandatory overtime” to cover scheduling gaps. Conclusions Slightly more than 85% of nurses responding to this survey did not know Illinois had legislation in place requiring hospitals to develop staffing committees for safe staffing. Over 68% of nurses reported patient needs were not used to determine staffing in Illinois. There was no significant difference between how nurses perceived Magnet and non-Magnet hospital nurse staffing; and nurses did not believe staffing was based on actual patient needs. Almost two-thirds of nurses in Illinois feared retaliation if they provided input about staffing. Magnet accreditation did not make a significant difference regarding fear of retaliation. Magnet hospitals utilized staffing committees more than non-Magnet hospitals, with 26.29% of nurses in Magnet-designated facilities reporting the staffing committee is comprised of 50% or more RNs as compared to 15.31% of nurses in non-Magnet hospitals. Despite this finding, 82% of nurses felt their assignments were unsafe; and Magnet designation did not make a significant difference in this perception. A law mandating hospitals to utilize a staffing committee to determine nurse staffing has been in place in Illinois for 11 years. Magnet status is considered an important benchmark for the quality of nursing care. However, findings from this survey study show nurses report unsafe staffing consistently occurring in both Magnet and non-Magnet hospitals in the state of Illinois. Reference: Juh Hyun Shin, Jung Eun Koh, Ha Eun Kim, et al. (2018) Analysis of professional health provider need in East Nusa Tenggara until 2019. Health Syst Policy Res Vol. 5 No.1:67
  11. jeastridge

    STOP Measles: Nurses on Alert

    Looking through my Facebook posts the other night, I noticed our friendly local pediatrician had posted a photo of herself in the protective garb associated with examining someone with measles. It looked a little like a space suit and reminded the viewers of her site of the potential dangers associated with the current active measles cases in our country. The outbreaks of measles around the country, particularly in the New York area and in California are alarming. “From January 1 to April 26, 2019, 704 individual cases of measles have been confirmed in 22 states. This is an increase of 78 cases from the previous week. This is the greatest number of cases reported in the U.S. since 1994 and since measles was declared eliminated in 2000.” (https://www.cdc.gov/measles/cases-outbreaks.html) Mostly related to unvaccinated youngsters, this outbreak highlights with devastating clarity the problems that the unvaccinated portion of our population creates for the greater population. In 2018, the United States suffered 17 outbreaks, 3 of which were in New York State, New York City and in New Jersey. A variety of other pockets of infection accounted for the remaining cases, many related to travel abroad. A simple rash and runny nose are now viewed with a heightened sense of caution and alert. It is striking how contagious measles is. In fact, it is hard to believe that after an infected person sneezes or coughs, the airborne virus stays active in the air or on surfaces for two hours and anyone that passes through who is unvaccinated stands a 90% chance of becoming infected. The period of contagion is from 4 days before the outbreak of the rash until 4 days after, making for a long window of infectious opportunity. The efficiency of the contagion of this particular virus makes in a public health menace and a national scourge, set to upend many lives. Besides being highly contagious, the measles virus is also responsible for severe illness. The cough, coryza , conjunctivitis and high fever (up to 104 F) develop after an incubation period of 7 to 14 days. Before the rash breaks out, patients may exhibit Koplik spots (tiny white spots) inside the mouth. The rash usually begins 3-5 days after initial symptoms and spreads down from the head until it reaches the feet, gradually becoming more contiguous until many of the spots are joined. Medical care is supportive but complications are frequent and include ear infections with potential for permanent hearing loss, pneumonia and encephalitis. Children under 5 and adults over 20 are most at risk for developing problems related to measles infection. Nurses are on the front line when it comes to addressing the current cases and providing information. What do we need to do? Stay informed and provide patients and families with accurate sources of information: CDC.gov or your local health department. Encourage vaccination. This is a “well, duh” point but it has to be on the list. There are, however, a surprising number of questions to be answered. If you are not working directly with children or immunizations you may not be completely familiar with the protocol: The MMR (measles, mumps, rubella) is given at 12-15 months with the second dose at age 4-6. If the child will be traveling, the parents have the option of considering an accelerated schedule so as to avoid contagion. Adult vaccinations- There is lots of “fine print” related to the need for vaccination in adults, but bottom line: look at your immunization records to be sure you have been vaccinated. If you are traveling to an area with a current outbreak, you may want to consult with your doctor about your individual needs. One dose is 93% effective in protecting the recipient from measles and 2 doses are 97% effective. The Oregonian reports regarding its recent outbreak: "Between Washington and Oregon, 77 people got sick. The outbreak also forced schools to exclude unvaccinated students and teachers, disrupted local business in the Vancouver area and prompted a public health emergency declaration in Washington state.” The article went on to clarify that most of the cases were in children who were completely unvaccinated. Additionally, one person had to be sequestered in Hawaii and another in Georgia where they traveled before developing symptoms. Authorities are looking into the possibility that the outbreak was related to a child that traveled to the area from Ukraine. In our mobile world, where long-distance travel is increasingly easy, accessible and inexpensive, we will continue to see increased rates of spread of infection. As nurses, it is part of our work to stay abreast of the current events and to help transmit accurate information regarding vaccinations and their effectiveness to combat disease.
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