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Topics About 'Safe Staffing'.

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  1. TL;Dr: Nursing needs some help. What do you think will help improve the profession? Nursing as a profession is in definite need of improvement as we go forward into the future. Many additional tasks are thrown at us, sicker patients are assigned to us, and we’re always asked to do more with less and do it faster. There has been a palpable push toward tasks over people, a decidedly different path than historically and from what is taught as nursing in schools. Based on your experience, what would you change or do to improve the profession? I’m going to preempt some answers here and say go beyond better staffing/ratios, higher pay, ancillary staff, unionizing, etc. Think about the profession itself and how you think nursing fits within healthcare as a whole now and five years from now.
  2. Nurses comment every day on social media about staffing issues. I just wish they’d take it one step further. Words matter—but action is your true power. Action—as in organizing to educate yourselves. Action— as in showing up to a 2-day event, NursesTakeDC, a Conference with CEs and a Rally/Lobby Day on April 21-22, 2020. Action— as in then meeting with your legislators to convince them why they must pass federal legislation to support nurses staffing ratios—and acuity. Because the complaining on social media just becomes background noise. And I want you to —ROAR. Then you will be heard. Professor Linda Aiken's Study on Nurse Staffing Another way to take action is happening right now in Illinois and New York—nurses pay attention! Could you tell all your Illinois and New York APRN, RN and LPN colleagues to complete Professor Linda Aiken's study survey on the quality of nurse staffing in Illinois and New York? Did YOU complete it? Only 8,361/180+k nurses in IL and 14,226/334+k in NY responded to the email survey as of December 20th. Less than a 5% response rate. I’m quite shocked. And angry. And this is why. Why Should You Respond to a Survey? In Illinois, we’ve had the Nurse Staffing by Acuity Act since 2008 - A law that states hospitals must purchase an acuity tool and form staffing committees comprised of bedside nurses and management. A law without any penalty to somehow enforce hospitals to comply. As a result, few hospitals do in fact comply. In fact, the ANA-IL collected data from nurses to show just how unsafe staffing is in Illinois. And NursesTakeDC completed a survey concurrently with ANA-IL which duplicated similar results for Illinois. How Can Nurses Fight for Safe Staffing Laws? So what is the answer to move us forward? How can nurses fight for safe staffing laws? I believe it’s by mandating safe staffing ratios that include patient acuity and penalties if hospitals do not act in good faith. The ANA and the AHA state its laws are like Illinois’s. Illinois nurses say—No way! We are attempting to pass the Illinois Bill HB2604 Safe Patient Limits Act, similar to California nurse to patient ratio legislation from 2004. Illinois and New York nurses must tell their state legislators their unsafe staffing stories—like I did with the NPR affiliate interview with Philadelphia's WHYY and Chicago's WBEZ. However, how can nurses impact on safe nurse staffing if nurses in Illinois and New York choose NOT to be a part of Professor Aiken’s survey study? An evidenced-based nursing study— which we, as nurses, have a responsibility to participate in. We are expected to advocate, impact and improve patient safety, as well as our own profession of nursing— on healthcare policy in Illinois and New York. These 2 states have pending legislation, HB2604/S.1908 in Illinois and A2954/S1032 in New York. Illinois and New York Nurses Should Complete the Survey All Illinois and New York nurses should complete the email survey, not just hospital-based nurses. Even currently inactive and retired nurses who are holding an active license to practice. Please remember—it as an independent, objective research project— to inform the policy debate about patient to nurse ratios in Illinois and New York. Additionally, a large part of the study is to link your responses with actual patient outcomes. Please complete the study survey, your voice does count. Search Your Email The email survey is from the National Council on State Boards of Nursing and the respective state’s Board of Nursing—IDFPR in Illinois and NYSEOP in New York. Make sure you search your email— all folders including, the junk folder for NCSBN. It was sent to the email you used when you renewed your license. Please do this and be a part of history—evidenced-based research on the quality of nurse staffing in Illinois and New York. You Can Affect the Future of Nurse Staffing Finally, your participation may have implications for the future of nurse staffing in all states. Imagine that. You will be a part of evidenced-based research on healthcare policy and nurse staffing. Here’s your chance now. So—what’s stopping you? And get yourselves to NursesTakeDC. Now. Your inaction is deafening. It silences your voice. Make it heard. Doris Carroll BSN, RN-BC, CCRC Illinois Nurse https://www.congress.gov/bill/116th-congress/house-bill/2581/text https://www.congress.gov/bill/116th-congress/senate-bill/1357/text https://www.congress.gov/bill/116th-congress/senate-bill/1357/all-inf allnurses.com Illinois Nurse Staffing Survey https://www.yumpu.com/en/document/fullscreen/62266590/the-nursing-voice-december-2018/ Bill Status Illinois State House Bill HB2604 NPR - Why Mandated Nurse-to-Patient Ratios Have Become One of the Most Controversial Ideas in Health Care Illinois Nurses Push for Safe Patient Limits, Working Conditions New York State Senate Bill S1032
  3. 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.
  4. SafetyNurse1968

    Just Say “YES” to Nurse Staffing Laws

    In my Just Say "No" article, I listed the evidence from California against mandated nurse-to-patient ratios, the only state to have a safe staffing law. Despite a reduction in patient mortality, California hospitals are struggling with the cost burden of mandated ratios, and nurses are busier than ever, just not with direct patient care. All you have to do is read the articles and comments posted on allnurses for a few minutes to confirm what you already suspect. We need some kind of change. A recent New York Times article reported on thousands of nurses on strike in California, Arizona, and Florida. They were striking for better patient care, improved working conditions and higher pay. Their No. 1 demand: better nurse-to-patient ratios. In a survey of nurses, only 20% felt staffing levels were safe.1 Rules and Regulations Fourteen states currently have official regulations for staffing ratios: CA, CT, IL, MA, MN, NV, NJ, NY, OH, OR, RI, TX, VT, and WA. Seven states require nurse-driven staffing committees: CT, IL, NV, OH, OR, TX, WA. California is the only state with a law that requires minimum nurse to patient ratios to be maintained at all times by unit. Massachusetts passed a law specific to the ICU that requires a 1:1 or 1:2 nurse to patient ratio depending on stability of the patient. Minnesota requires a CNO or designee to develop a core staffing plan with input from other nurses, similar to Joint Commission standards. Five states require some form of disclosure and/or public reporting: IL, NJ, NY, RI, VT. New Mexico has asked stakeholders to recommend staffing standards to the legislature. The department of health will collect information about the hospitals that adopt recommended standards and report the cost of implementing oversight programs.2 Federal regulation 42CFR 482.23(b) requires with Medicare certification to "have adequate numbers of licensed registered nurses, licensed practical nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient." However, no figures are mandated. Each state determines how to meet the Medicare requirement.3 Illinois passed the Nurse Staffing by Patient Acuity Act in 2007. The Illinois Health and Hospital Association cites the law as sufficient for governing nurse staging. But the law isn’t enforceable. Though it requires a committee to be formed to make up staffing plans based on acuity, less than a third of respondents to a 2018 survey by Nurses Take DC said their hospital had a staffing committee. Of the hospitals that did, less than half include enough nurses, or committee recommendations weren’t followed.4 The Price of Nursing I’m going to refute the argument that a shortage of nurses will cause hospitals to close units or limit services if mandatory ratios are enacted. At issue here is that there are plenty of nurses. In Arizona 37,000 licensed, active RNs are not currently working as nurses.5 Why is that? The issue isn’t that there aren’t enough nurses, the issue is how poorly nurses are treated. A survey in 2014 demonstrated that nearly 1 in 5 nurses leave the first job within a year, and 1 in 3 leave within the first two years.6 Nurse turnover costs hospitals a lot of money, so why wouldn’t they want to keep us happy? Because we are expensive. Nurses make up almost 40% of operating costs for healthcare facilities. Hospitals would prefer to find a less expensive way to improve patient outcomes.7 California paints a vivid picture of this problem. Critics of AB394 were concerned about its increased financial burden on hospitals, especially safety-net hospitals, to maintain a mandated ratio. Economists found that the mandated ratio resulted in financial pressure on hospitals and declining operating margins in CA hospitals compared with other states.8 Current Nurse-to-Patient Ratios What is the national benchmark when it comes to nurse-patient staff ratios? Pinning down a specific number is hard to do, given the legal vagaries from state to state. California RN-to-Patient staffing ratios range anywhere from 1:2 in intensive/critical care, PACU and L&D, to 1:6 in postpartum women only, med surg and psychiatric.3 Aiken and colleagues found that in England, the average patient-to-nurse ratios for all hospitals was 8.6 but varied 5.6 patients-per-nurse to 11.5 patients per nurse. They found a similarly wide variation in patient-to-nurse ratios across hospitals in every country studied.9 The Evidence In 2002, Aiken, Clarke, Sloane, Sochalski, and Silber found that adding an additional patient per nurse was associated with a 7%increase in the likelihood of dying within 30 days of admission and a 7% increase in death resulting from a complication.9 In 2007, Kane and colleagues conducted a meta-analysis of 28 studies. They found that increased RN staffing resulted in lower hospital mortality and adverse patient events. They hypothesized that patient and hospital characteristics, including the hospital commitment to quality care contributed to the causal pathway.10 In 2008, Aiken analyzed data from 10,184 nurses and 232,343 surgical patients in 168 Pennsylvania hospitals. When staffing ratios were optimized, nurses reported more positive job experiences and fewer concerns with care quality. Patients had significantly lower risks of death and failure to rescue in hospitals with better care environments.9 CMS began the Hospital Readmissions Reduction Program under the Affordable Care Act in 2012. At the time, researchers found that higher levels of RN staffing were associated with lower readmission rates.8 In a systematic review of 43 articles, Lang et al. (2013) showed better nurse staffing is associated with lower failure-to-rescue rates, lower inpatient mortality rates and shorter hospital stays.11 In 2018, Driscoll et al looked at 35 studies in a metareview and found higher staffing levels associated with reduced mortality, medication errors, ulcers, restraint use, infections, pneumonia, higher aspirin use and greater number of patients receiving percutaneous coronary intervention within 90 minutes. They looked at 175,755 patients from six studies and found that high nurse staffing levels decreased the risk of death in the hospital by 14%.12 Aiken has looked at patient outcomes in both California, which passed its ratio law in 1999, and Queensland, Australia, which passed one in 2015. She said the result for patients has been fewer complications, fewer infections, fewer injuries — and even lower mortality.9 The Solution The American Nurses Association has a position statement on safe nurse staffing, stating, “We all agree that there should be safe staffing. Safe staffing is essential to patient and nurse satisfaction and for safe patient outcomes. What we need is evidence of what those safe staffing practices are. Eliminating unsafe practices will improve our healthcare system.” The ANA supports that appropriate staffing levels reduce mortality rates, length of patient stay, number of preventable events like falls and infections.7 The ANA states that fixed staffing levels are problematic. Staff levels should depend upon: Patient complexity, acuity or stability. Number of admissions, discharges and transfers. Professional nurses’ and other staff members’ skill levels and expertise. Physical space and layout of the nursing unit. Availability of technical support and other resources. The ANA supports a legislative model in which nurses create flexible staffing plans for their unit. What is needed is greater nurse involvement. Take action by writing Congress to support safe staffing. Share your story about being an everyday advocate with Janet Haebler, Senior Associate Director, State Government Affairs, janet.haebler@ana.org, (301-628-5111). You may also be interested in The Safe Patient Limits Act (H.R. 2581/S. 1357). This bill is currently sitting with committees in the senate and house. The bill sets limits on the number of patients a nurse can be assigned, depending on the hospital unit. Any facility that fails to comply could be subject to a fine of up to $25,000 for each day it is out of compliance. The bill factors in a plan for acuity adjustments that need to be made for patients and staffing. The goal of Nurses Take DC is to get the legislation passed to the Senate and House of Representatives where they can be put up for a YES vote. For more information, click NURSESTAKEDC.1 REFERENCES 1. NursesTakeDC 2. Update on nursing staff ratios 3. The Importance of the Optimal Nurse-to-Patient Ratio 4. Why mandated nurse-to-patient ratios have become one of the most controversial ideas in health care Tung, L. (Nov 29, 2019). 5. Nurses in Four States Strike to Push for Better Patient Care Ortiz, A. (Sept. 20, 2019). 6. Nearly 1-in-5 nurses leaves first job within a year, survey finds Becker’s Hospital Review (Sept 5, 2014). 7. American Nurses Association (n.d.). Nurse Staffing Crisis 8. Effects of Public Reporting Legislation of Nurse Staffing: A Trend Analysis deCordova, P. B. & Riman, K. (2019). 9. Aiken, L. H., Clarke, S. P., Sloane, D. M., Lake, E. T. & Cheney, T. (2018). Effects of Hospital Care Environment on Patient Mortality and Nurse Outcomes. Journal of Nursing Administration, 38(5), 223-229. 10. Kane, R. L., Shamliyan, T. A., Mueller, C., Duval, S. & Wilt, T. J. (2007). The Association of Registered Nurse Staffing Levels and Patient Outcomes. Medical Care, 45(12), 1195-1204. 11. Lang, T. A., Romano, P. S., Hodge, M., Kravitz, R. L. & Olsen, V. (2004). Nurse-Patient Ratios. The Journal of Nursing Administration, 34(7/8), 326-337. 12. Driscoll, A. et al. (2018). The effect of nurse-to-patient ratios on nurse-sensitive patient outcomes in acute specialist units: a systematic review and meta-analysis. European Journal of Cardiovascular Nursing, 17(1), 6-22.
  5. NursesTakeDC

    How many more decades?!?

    How many more decades must we continue this fight for safe nurse to patient ratio staffing?!?! Remember the “mandated ratio” legislation INCLUDES patient acuity and nurse skill mix adjustment. #SafePatientLimits indeed saves lives. “Nightingale rigorously researched the impact of the introduction of trained nurses on mortality in military hospitals. Once having established an association between trained nurses and reductions in patient deaths, she spent much of her life advocating for these findings to be widely translated into practice to improve the quality and safety of hospital care. The International Year of the Nurse and Midwife in 2020 in recognition of the 200th anniversary of Florence Nightingale’s birth is a fitting time to take action based on the preponderance of evidence to date that good professional nurse staffing results in safer and higher quality hospital inpatient care. “ “All three papers confirm—at least with respect to mortality—that low RN staffing increases the risk for poor outcomes for patients. What is especially important about the confirmation provided by the Needleman et al 4 11 and Griffiths et al 13 papers is that they show longitudinal associations between RN staffing and patient outcomes at the patient level, within hospitals, which suggests that the cross-sectional associations found in studies that use hospital-level RN staffing data and compare outcomes across hospitals, such as the RN4CAST study, are more likely to be causal than artefactual and reflect differences in patient exposures to different staffing levels as well. We provide additional evidence of this in our own recent work” “The findings of the RN4CAST paper on the outcomes of nursing skill mix are closer to those of Griffiths et al than to Needleman et al, showing, for example, that substituting one nursing assistant for an RN for every 25 patients is associated with a 21% increase in the odds of dying”. Credit to authors: Linda H Aiken and Douglas M Sloane Nurses Matter: More Evidence #NursesTakeDC www.nursestakedc.com
  6. SafetyNurse1968

    Just Say “NO” to Nurse Staffing Laws

    You’ve worked on a busy Med Surg unit for almost a year now. You were so excited to be hired right out of nursing school to the day shift, but it’s been so much harder than you ever thought it could, and so different from what you expected. It only took a few days to discover that no one does anything like they taught you in nursing school, there’s just no time. Recently you’ve been cringing every time your phone buzzes, worried it’s the nurse manager asking you to come in for an extra shift. It’s so hard to say no. You want to be a team player, but you’re just so tired. You’ve been wondering if you’re cut out to be a nurse, but maybe this is just how it is. Today is your fourth day in a row. You arrive on the unit to discover that not one, but two nurses have called in sick, and one of your nurses is a floater from labor and delivery. Normally you have five patients, but today you see with a sinking heart that you’ve been assigned seven. You sit at the computer next to your nursing mentor, trying to wrap your brain around your day, trying not to cry. He’s a good nurse and seems to notice everything. He turns to you and says, “Are you okay?” You point at the seven patients on your computer screen and reply, “How can this be safe? How can they do this to us…to our patients?” He says, “It’s a right to work state, and the hospital can do whatever they want.” You say in disbelief, “So there’s no law against this? There’s no maximum number of patients we can be assigned? They could give us twenty next time?” He shakes his head ruefully and says, “Medicare has guidelines for patient ratios, but this hospital has never followed them and we’re still running.” He looks over his shoulder before he turns back to you and says under his breath, “We shouldn’t talk about this at work, but there’s a group you can join to fight for safe staffing laws. Check it out when you get home, it’s called NursesTakeDC. It’s a dot org. But don’t talk about it here, you could get in big trouble.” Mandated Nurse-to-Patient Ratios Does this conversation seem familiar? Have you ever felt like you were working in unsafe conditions and wondered, “Isn’t there a better way?” As a patient safety specialist, I’ve always been a huge advocate for safe staffing laws as a solution to so many of the problems nurses face. But, then I read a recent article, Why mandated nurse-to-patient ratios have become one of the most controversial ideas in health care and I had to give my position a second look.1 How Can There be Controversy Over Something So ... Obvious? Opponents say ratio laws would exacerbate nursing shortages across the country, limit access to care, and take important staffing decisions out of the hands of nurses. Danny Chun is a spokesperson for the Illinois Health and Hospital Association (IHHA), a leading advocacy group for hospitals. He states that safe staffing laws are “a deeply flawed, inflexible, rigid approach to setting staffing levels that do not improve quality, safety or outcomes, but in fact would adversely affect patients.”1 The IHHA is against the Safe Patient Limits Act, a bill recently introduced in Illinois (House Bill 2604, Senate Bill 1908). Under the Safe Patient Limits Act, no nurse working in a hospital could be responsible for more than four patients at a time. The ratio would be even lower for special units like L&D, ICU and the ER. If passed, any facility that fails to comply could receive a fine of up to $25,000 per day. Critics of the bill say that the consequences could be catastrophic, causing shortages of nurses and money. There may be increased wait times for patients in the ER, and hospitals may have to turn away patients because they don’t have enough nurses to meet the ratios. In addition, an unexpected influx of patients due to epidemics, mass shootings or other disasters could make it impossible to meet the ratios. Small hospitals operating in regional areas could be forced out of business. Chun says in Illinois, “more than 40% of hospitals across the state are losing money or barely surviving.” The cost to the hospital could be passed on in the form of higher healthcare costs. The biggest criticism being offered is that mandated ratios don’t work. Chun says, “The evidence is not conclusive that ratios improved quality, safety or outcomes,”1 The Evidence Here is where I get excited. I went to Google Scholar and typed in “Safe Staffing Laws, nursing” and got 44,400 hits. I love digging into the research to find the truth (like the X-files, the truth is out there…) I found multiple review articles that speak to the state of the science on safe staffing ratios. One by Olley (2017) suggests that there is a significant research gap to support claims of increased patient safety in the acute hospital setting with improved ratios (for all the REST of the evidence, check out my Just say "YES" article on this topic).2 California is the only state in the union with a safe staffing law. AB 394 was passed back in 2004 after a massive effort by the California Nurses Union. The result of the bill is that nurses in California have approximately one less patient than the national average. Multiple studies have shown that the standard mortality rate decreased by more than 33% after the enactment of the bill.3 This seems like pretty good evidence…evidence that the law that California enacted is working in California. See where I am going here? The biggest criticism of bills in other states (and this comes from organizations like the American Nurses Association) is that there is no empirical evidence supporting specific ratio numbers. Passing legislation without sufficient evidence is potentially dangerous since legislation is difficult to change. Critics say the laws currently proposed also don’t take into account nurse education, skills, knowledge and years of experience. In Bill 394, only 50% of the mandated nurses must be RNs. Some say these laws ignore patient acuity, required treatments, length of stay, team dynamics, environmental limitations, variations in technology and availability of ancillary staff. And last but not least, these laws are inflexible and don’t allow for the changing needs of patients.4 The Bottom Line $$$ The mortality rate may have decreased, but the finances are problematic. To meet mandatory staffing ratios, hospitals in California have had to cut funding for supplies, upgrades and education and holding patients longer in the ER. The result is increased economic costs for employers, with the unanticipated side effect of an increased workload for nurses in non-patient tasks as ancillary staff are dismissed. 4 & 5 The PRO Side I’m not actually telling you to say “NO” to mandatory staffing laws. I want to get a conversation going, so please comment! To learn more about Nurses Take DC and what you can do to make a difference, take a look at my second article on the topic. Most importantly, before you speak up about safe staffing laws, make sure you are knowledgeable on the topic. We must be well educated on all sides of a topic if we want to weigh in on shaping the future of patient care. References Why mandated nurse-to-patient ratios have become one of the most controversial ideas in health care Systematic review of the evidence related to mandated nurse staffing ratios in acute hospitals. Statewide and National Impact of California’s Staffing Law on Pediatric Cardiac Surgery Outcomes Effects of Public Reporting Legislation of Nurse Staffing: A Trend Analysis Mandatory Nurse-Patient Ratios
  7. 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
  8. Nancy Blake, PhD, RN, CCRN-K, NEA-BC, NHDP-BC, FAAN has been at the forefront of healthy work environments since its inception. She has been very involved at both the national and local levels. Mary Watts, BSN, RN, allnurses.com’s Content and Community Director was fortunate to visit with her recently. There have been research studies and several papers published that state improving communication is key. What Defines a Healthy Work Environment? Hospitals recognize that a healthy work environment encompasses six points: Communication - between all levels in the facility, from the Chief Nursing Officer to the transporters to housekeeping to dietary Collaboration - among all teams in the hospitals Staffing - adequate and individualized staffing matrixes Effective decision making - researching the problem and bringing a variety of solutions to the table for discussion Authentic leadership - managers and leaders who come to the bedside to talk to staff Meaningful recognition - for all members of the team Safe Staffing Those are the primary elements. Nancy Blake then honed in on safe staffing. Acuity tools need to be used to ensure the experience level of the nurse as well as their training matches the patient acuity. “Also ensuring nursing competency is very important,” she continued. How is the Safe Number of Nurses Determined? She went on to state there are many different factors to consider when using an acuity tool. This involves making sure you have the right numbers for the right patient acuity. Patient acuity means making sure you have the right number of patients to the right nurse. The nurse needs the skill set to care for a particular patient as it relates to their medical condition. There are times where a patient needs two or three nurses. “It's really important that nurses get refreshed during their shift - take their breaks.” Staffing is not a one-size-fits-all matrix. Even in an ICU, patient acuity must be taken into account. “I’m not a fan of ratios, it needs to be individualized.” “Actual acuity depends on the patient.” What Can Nurses Do to Improve the Work Environment? They next discussed what nurses can do to improve the care situation: Have a positive attitude that the situation can be changed. Provide feedback to administration regarding concerns. Talk with your manager and then go up the chain of command if needed. Be a team player. Important to realize that you are not alone - you are part of a group. For managers - please listen to the bedside nurses. Help them to succeed and ultimately provide the care your patients need. Realize that you need to consider many factors when determining what nurse or nurses are taking care of which patient. How does your facility work to provide you with a safe work environment? What could be done to improve the situation? Do you feel comfortable going to your leadership team to try to find solutions? Here is the complete interview: References: Programs that Support a Healthy Work Environment The Healthy Work Environment Standards, Ten Years Later Appropriate Staffing for a Healthy Work Environment
  9. 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.
  10. Health Commission meetings are generally not too exciting. However, a session held at the Zuckerberg San Francisco General Hospital on May 28th was full of energy when nearly 150 nurses strode in to make their concerns known. The commission is in current contract negotiations with the close to 2,100 unionized nurses across the city. Without an agreement, a possible strike is on the horizon, set for July 1st. The commission believed they have met the nurses’ needs and felt satisfied with an offer they placed on the table during a May 24th meeting. However, the description provided by The Mission Local, about the May 28th meeting left us thinking of many words other than satisfied to describe the nurses. Aaron Cramer, a cardiac catheterization lab nurse, shouted, “We are chronically understaffed” in the meeting. He made the only public comment during the meeting, which he followed by telling the commission that he held a petition of no confidence with the Department of Public Health with over 1,300 nurses’ signatures. Cramer then began reading the list of signatures as other nurses chanted, “safe staffing now.” The cardiac cath nurse was about 15 minutes into reading the names on the petition when the health commissioners picked up their belongings and left the room. The nurses were attempting to provide a clear picture to the commission of what an actual strike would look like if a mutually agreed upon contract isn’t found soon. Zuckerberg San Francisco General Hospital isn’t new to being in the press. Earlier this month, several current and former nurses protested the Zuckerberg name change that happened in 2015 after a $75 million donation from Mark Zuckerberg and his wife. The name change was approved by the Board of Supervisors shortly after the donation was made. However, some nurses feel that the 147-year-old hospital shouldn’t be named after Zuckerberg due to privacy issues that faced Mark’s company, Facebook. Today, the hospital is under scrutiny related to a chronic state of understaffing. While the commissioners report that the nurse staffing levels of the hospital are safe and in compliance with codes, they failed to comment further on the issue. This claim is that 40 percent of all nursing hours are assigned and completed by per diem staff. The Mission Local tracked down the financials and were able to confirm that since 2016, the Department of Public Health has far surpassed their budgeted dollars for per diem nurses. For the fiscal year 2016-17, the department paid out $58.4 million in wages for per diem nursing staff. This far outreached the budget for the same year of $16.9 million. The following year, 2017-18 was a similar story with $17.3 million budgeted and $62.3 million spent. For the current fiscal year 2018-19, the department has spent near twice the amount they budgeted for per diem staff nurses for the entire year while they are only seven months into the period. They have spent $34.3 million to date. As tempers rise, the idea of a striking seems to be looming on the horizon. The unionized workers allege that hospital administration won’t add more full-time positions, but in the light of the numbers above, it might seem that the commission isn’t making fiscally sound decisions regarding the issue. How do you feel? Should the nurses strike? Does the Department of Public Health have it all wrong and should shift their budgeted dollars from per diem nurses to full-time staff? And, if they do, who would want to work in a facility with this current reputation? Would you? Let us know by commenting below.
  11. Nurses are desperate for safer staffing. Which is more impossible: Asking a Genie in a bottle to grant your wish or getting State and Federal legislators to pass safer staffing laws?
  12. "We are short again today" - A daily phrase used by nursing staff that summarizes the consistent inadequate nursing staff ratios that healthcare facilities seem to continue to support. Inadequate nursing staffing ratios greatly diminish the likelihood of achieving positive patient health outcomes, as well as significantly decreases nursing staff job satisfaction and retention across our nation. Having an upwards of eight or more patients per Registered Nurse, and 15 or more patients per Nursing Assistant in an acute healthcare setting, such as a hospital, has been the norm for far too long now. As our healthcare marketplace expands and becomes more demanding of nursing staff by offering more treatment options, more medications, more technology, longer working hours, more complex patient illnesses, more computerized documentation, etc., healthcare facility staffing procedures should be reconfigured to include more nursing staff resources, rather than remaining unsafe. According to an article posted in The American Nurse - an official publication of the American Nurses Association, when it comes to achieving high standards of care, optimal patient outcomes and institutional financial growth, adequate nursing staffing ratios should be considered as a necessity. Unfortunately, many healthcare facilities have not set standards for adequate nursing staff ratios. Instead, they continue to base their nursing staff to patient ratios off of a grid that only reflects patient body count - not taking into consideration RN experience levels, patient acuity, or available resources. In a nursing led effort to provide adequate nursing staff ratios across our country, the American Nurses Association, each individual State's Nursing Association, and Nurses Take DC, have introduced Bills to improve staffing in a variety of care settings. The ANA proposed The Safe Staffing for Nurse and Patient Safety Act (S. 2446, H.R. 5052) to the House and Senate for consideration. According to the American Nurses Association (2018), this proposed legislation would require Medicare-participating hospitals to create a committee, composed of at least 55% direct care nurses, to develop nurse staffing plans that are specific to each patient care unit. The idea of having these committees is to utilize the expertise of the direct care nurses, who are best equipped to determine the adequate staffing levels to safely meet the needs of their patients. For example, many charge nurses get report from the bedside nurses regarding how much care their patients need. Someone who is completely bed bound, incontinent, has multiple wounds, IV lines, oxygen, and may be confused, would require the assistance of three nursing staff members. This could be a combination of nurses and nursing assistants. The unfortunate reality is that the charge nurse currently collects this information so that they do not assign five of these high acuity patients to the same nurse. Instead of getting additional nursing staff to help with the increased acuity, they try their best to split up the acuity among the nurses and nursing assistants - which rarely works in regards to maintaining adequate and safe nursing staff ratios. However, if the charge nurse were able to bring on an additional nurse, or nursing assistant to help manage the increased acuity, then patient safety and nursing staff job satisfaction would improve significantly. The ANA states that to date, seven states have enacted nursing staff ratios legislation that closely resembles the American Nurses Association's recommended approach to ensure safe staffing, by utilizing hospital-wide staffing committees, where direct care nurses have a voice in creating appropriate staffing levels. A total of 14 states have implemented laws that address nursing staffing ratios. These states include: CA, CT, IL, MA, MN, NV, NJ, NY, OH, OR, RI, TX, VT and WA. For more information on these efforts, you can visit the Nurse Staffing page on the American Nurses Association website. Nurses Take DC have proposed the RN Ratio Bill S. 1063/HR 2392, which goes further by mandating that each nursing speciality has their own mandated patient to nurse ratio, and places great consideration on other staffing issues such as mandatory overtime, averaging, video monitoring, and keeping nursing administration, such as charge nurses, out of the direct patient care staffing numbers. To see a side by side comparison of the differences among the ANA's Bill and the Nurses Take DC Bill, you can click here. As of this very moment the fight for adequate nursing staff ratios continues. With all of our continued dedication and service to improving nursing care and standards of practice, I am certain that we will prevail in obtaining legislation for adequate nursing staff ratios. For articles in this series, go to: Inadequate Staffing: Patient Safety in Today's Healthcare Marketplace Inadequate Nursing: Patient Safety in Today's Healthcare Marketplace Alarm Fatigue: Patient Safety in Today's Healthcare Marketplace Compassion Fatigue: Patient Safety in Today's Healthcare Marketplace
  13. 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. Another nurse's patient load immediately increases to twelve patients; or 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. House of Representative Bill (H.R. 2392) (Schakowsky, Illinois) Senate bill (S.1063) (Brown, Ohio). 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. 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: According to some sources, medical errors account for up to a third of patient deaths. 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. 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 (HR 2392/S.1063). Driven by grassroots nurses. 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: 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: Please join in putting patients over profits. Be sure to check out more from the first issue of allnurses Magazine.

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