The Working Conditions of Registered Nurses and Their Relation to Patient Safety

Nurses Activism



September 24, 2002

Statement on Behalf of the United American Nurses, AFL-CIO

to The Institute of Medicine Committee on Work Environment for Nurses and Patient Safety

regarding The Working Conditions of Registered Nurses and Their Relation to Patient Safety

September 24, 2002

"Good afternoon, Madame Chair and members of the Committee. My name is Jeanne Surdo. I am a registered nurse and secretary-treasurer of the United American Nurses, AFL-CIO, the collective bargaining arm of the American Nurses Association. The UAN through its 26 constituent members (state nurses associations) represents approximately 100,000 registered nurses for collective bargaining throughout the United States. Our members include staff nurses working in a variety of health care settings. I myself have more than 30 years experience as a staff nurse and currently work in the pediatric cardiology/genetics unit of Children's Hospitals and Clinics in St. Paul, Minnesota.

In addition to my work at the national level, I am first vice president of the Minnesota Nurses Association. In that capacity I represent the concerns and voices of staff nurses at both the state and local levels. The United American Nurses (UAN) appreciates the opportunity to present its views to the Institute of Medicine (IOM)committee on the working conditions of registered nurses and their impact on patient safety.


Today, health care institutions across the nation are experiencing a crisis in nurse staffing, and we are standing on the brink of an unprecedented nursing shortage. Without doubt, the current staffing crisis and the emerging national shortage of RNs pose a real threat to the nation's health care system. As the single largest group of health care professionals, registered nurses are the backbone of the U.S. health care system. With more than 1.3 million registered nurses working in hospitals throughout the country, we underpin the entire health care delivery system. Having a sufficient number of nurses is critical to the nation's health. In the wake of disastrous experiments in health care restructuring, downsizing and displacement of RNs by unlicensed staff in the mid-1990s, registered nurses have been and continue to sound the alarm about patient safety.

RNs across the country tell us there are too few nurses taking care of too many patients. Nurses report they have less time to care for their patients who are increasingly ill, and they are deeply concerned that the quality of care they deliver is deteriorating. And, as shown in survey after survey, more and more registered nurses are voicing dissatisfaction with their high-risk, high-stress working conditions, some even voting with their feet and leaving their profession entirely.

IOM Committee Questions:

The IOM Committee on Work Environment and Patient Safety, at the request of the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, identified two areas that are the focus of its study:

key aspects of the work environment for nurses that likely have an impact on patient safety; and potential improvements in health care working conditions that would likely increase patient safety.

Key Aspects of the Work Environment:

The UAN believes there are several major areas of the registered nurse's work environment that must be addressed in a comprehensive manner in order to improve working conditions and thus enhance patient safety. These include:

* Staffing

* Health and Safety

* Decision-making

* Respect

* Compensation

Potential Improvements:

1. Staffing

Staffing is the single most important issue UAN members are addressing in our collective bargaining negotiations. The UAN believes that the safety and quality of care provided in the nation's health care facilities is directly related to the number and mix of direct care nursing staff. More than a decade of research shows that nurse staffing levels and skill mix make a difference in the outcomes of patients.

The recent study of nurse staffing levels and the quality of care in America's hospitals, which concludes that "a higher proportion of hours of nursing care provided by registered nurses and a greater number of hours of care by registered nurses per day are associated with better care for hospitalized patients," confirms the UAN's long-held belief that more care by RNs means better care for patients in hospitals. (Needleman, Jack., et al. Nurse-Staffing Levels and the Quality of Care in Hospitals," N Eng J Med, Vol. 346, No. 22 (May 30, 2002), pp. 1715-1722)

UAN members have bargained contract language that calls for a written hospital-wide patient staffing system, based upon acuity classification, for determining and measuring the effectiveness of nurse staffing. The required nursing care is based on patients' aggregate and individual needs and is the primary consideration in determining the number and categories of nursing personnel needed. The staffing system provides for minimum numbers of RNs per unit and shift, and is regularly evaluated using patient outcome indicators and data from staffing request documentation forms.

Other UAN contacts provide for RN-to-patient staffing guidelines based on patient acuity levels and the number of RNs and non-RN personnel available to staff the unit, enforceable through arbitration. UAN members have also won agreements that require the hospital employer to involve the union in proposed changes to nurse-to-patient ratios or staffing skill mix changes before changes are made. Changes made unilaterally by the hospital are subject to the grievance process.

The Minnesota Nurses Association is setting the pace in patient care initiatives. In a recently concluded collective bargaining agreement, registered nurses won the right to temporarily close a unit to new patients when too few RN staff are available to care for more patients. This contract innovation has helped our nurses cope with excessive workloads. We secured this language only after our nurses put their lives on hold and went on strike last summer to fight for quality nursing care for their patients and better working conditions for themselves and other nurses around the nation.

Mandatory Overtime:

The UAN believes that mandatory overtime must be abolished.

Our concerns about the use of mandatory overtime are directly related to patient safety. Nurses report that fatigue can contribute to medical errors and other consequences that compromise patient safety, and that mandatory overtime is driving nurses away from the bedside.

The UAN supports enactment of national legislation (the "Safe Nursing and Patient Care Act of 2001") that prohibits the use of mandatory overtime for nurses except in the case of a declared state of emergency. Mandatory overtime would be a requirement that a nurse work in excess of any of the following:

the scheduled work shift or duty period of the nurse;

12 hours in a 24-hour period;

80 hours in a consecutive 14-day period, and which, if refused by the nurse, may result in an adverse employment consequence to her or him.

The UAN supports enactment of state mandatory overtime legislation. The Minnesota Nurses Association led the successful fight for passage of the "Mandatory Overtime Protection Act" which the Governor Jesse Ventura signed into law on March 25, 2002. The legislation prohibits certain healthcare facilities from taking action against a nurse who refuses to work overtime when in the nurse's judgment doing so may jeopardize patient safety.

The law makes clear that the nurse, not the employer, must make this judgment call. To date, UAN member states that have enacted mandatory overtime laws include New Jersey, Minnesota, Oregon and Washington.

2. Health and Safety

The UAN believes that when nurses are protected from health and safety hazards, patient safety is likewise enhanced. When nurses can work in an environment of care that is free from unnecessary safety and health risks, patients benefit because nurses can then do what nurses do best: advocate on behalf of their patients and provide them their first line of support.

In today's presentation, I want to focus on one health and safety issue vital to nurse and patient safety: ergonomics. The UAN is committed to the goal of pursuing a strong Occupational Safety and Health Administration (OSHA) ergonomics standard which will prevent disabling back injuries and other musculoskeletal disorders among registered nurses.

Over the past two years, UAN and ANA elected leaders and injured nurses have testified in support of such a standard at OSHA public hearings and at Department of Labor ergonomic forums. The UAN believes that scientific evidence strongly supports the relationship between worker exposure to biomechanical risk factors and the resulting musculoskeletal pain and injuries. Comprehensive ergonomics programs can greatly reduce employee risks and prevent injuries. Every day nurses are exposed to disabling, career-ending and life-altering injuries when taking care of patients.

The U.S. Bureau of Labor Statistics reported that nursing personnel had the second highest rate of days away from work due to musculoskeletal disorders of all occupations. "Registered nurse" as an occupation ranked sixth among U.S. occupations at risk for strains and sprains, outranking construction workers and stock handlers. Of these disorders, the back is the body part most frequently injured, and patient lifting and transfers are the major sources of the injury. What ergonomics really means for nurses is encouraging safe ways to lift, move, reposition and provide essential and safe care - safe for the patient and safe for the nurse.

Well-designed patient lifting and transfer devices pay for themselves by preventing back injuries. Additional measures like job hazard analysis, lift teams and employee training can reduce injury risks even further. The UAN supports a strict, enforceable ergonomics standard that requires employers to protect their nurses from preventable injuries. Nurses need a federal ergonomics mandate because, although effective control measures exist to reduce these risks, few health care employers have voluntarily implemented them. Without a federal mandate, there will always be higher priorities in health care than preserving the health and safety of workers.

The voluntary ergonomics guidelines issued in April 2002 by the Bush administration's Department of Labor for the OSHA fall far short of what is needed. The UAN further believes that the absence of enforceable ergonomics regulations is a contributing factor in the decision of many nurses to leave the profession. In an ANA health and safety survey conducted last year, 60% of nurses surveyed cited a disabling back injury as ranking among their top three health and safety concerns. Additionally, nurse respondents stated that more than half the facilities in which they worked did not have lifting and transfer devices readily available for moving patients.

3. Decision-Making

The UAN believes that staff nurses must be fully involved in all decision-making related to nursing practice and patient safety. Staff nurses must participate fully, for example, in establishing staffing effectiveness standards at their facility. They must participate in implementing these standards, in collecting and analyzing nursing-sensitive outcome data, and in measuring and evaluating their effectiveness. Staff nurses should also be involved in assessing and purchasing patient-focused technology as well as the efficacy of proposed capital improvements and cost-containment decisions. As the frontline professionals caring daily for patients, staff nurses are uniquely positioned to understand the issues surrounding patient safety. Their voices need to be heard and their authority recognized when decisions are made in any area related to nursing practice.

4. Respect

The UAN believes that hospitals and other health care facilities must create and maintain a supportive workplace culture that values registered nurses. This is key to patient safety. Respect at the workplace is a standard that staff nurses deserve. Unfortunately, all too often the reality staff nurses experience does not reflect that standard. Disrespect in the forms of verbal abuse or other disruptive behaviors has a negative affect on nurse satisfaction levels and morale. Nurses must be recognized for their competence and valued for their experience.

Respect also includes having the necessary assistance and resources that allow staff nurses to spend more time delivering direct patient care. Hospitals must not reduce the number of support personnel needed for safe care delivery and then expect the registered nurse to perform those added responsibilities. As the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) recently reported, the high cost of high RN turnover is not only higher patient costs and lower profitability but greater patient mortality.

5. Compensation

As the leading union OF registered nurses FOR registered nurses, the UAN believes that RN compensation must reflect the important role nurses play in the nation's health care system. Appropriate RN compensation is essential to patient safety in that it would help ensure the nation of an adequate supply of registered nurses to meet the demand for health care services. Findings from the 2000 National Sample Survey of Registered Nurses indicate that staff nurses need to continue their struggle for appropriate pay and benefits.

According to the survey, average annual earnings of registered nurses employed full time as "staff or general duty" nurses was $42,133. Adjusted for inflation, RN wages for much of the 1990s have been essentially flat, barely keeping pace with the rising cost of living. The UAN also believes that significant improvements must be made in non-wage compensation, particularly in the areas of health insurance and pension benefits. Employers are pressing nurses to shoulder an increasingly larger part of their health insurance premiums as they try to shift the costs of care. And more and more employers are moving away from defined benefit pension plans toward financially riskier defined contribution plans.

The UAN is in the forefront of negotiating non-wage compensation issues and educating nurses about the need for career-long financial planning. Appropriate compensation is also essential to a viable recruitment and retention strategy. If nursing is to attract new women and men into the profession and retain its experienced staff nurses, it must offer a level of compensation that can compete with other professional occupations.


The UAN maintains that the current staffing crisis - and the danger to patient safety that goes with it - will remain and likely worsen if changes in the workplace are not addressed immediately. The profession of nursing will be unable to compete with other career opportunities available today unless we improve RN working conditions. Registered nurses, hospital administrators, other health care providers, health system planners and consumers must come together to create a system that supports quality patient care and the nurses who provide that care. We must begin by improving the environment for nurses.

Madame Chair, members of the subcommittee, the UAN looks forward to working with you to make the current health care environment more conducive to high quality nursing care. Improvements in the environment of nursing care, combined with recruitment and retention efforts, will help ensure a stable nurse workforce and promote better health care for all Americans. Thank you." # # #

The United American Nurses, AFL-CIO, the labor arm of the American Nurses Association, is the nation's largest RN union with 100,000 nurses and is made up of state nurses associations or collective bargaining programs from 24 states, the District of Columbia and the U.S. Virgin Islands.

Comments may be addressed to:

Suzanne Martin




1 Article; 5,758 Posts

This is great. Is it not interesting that a union representative can hit the nail on the head and give the story from the shoes of the staff nurse when so many just don't get it.


2,709 Posts

Whats interesting is that so may RNs still will say "I dont believe in nurses unions". Now who isnt getting it?

Additional testimony:

ANA, UAN, AAN Representatives Testify Before IOM Committee on Nurses' Work Environment, Patient Safety Concerns


"Nurses should never be threatened with patient abandonment and potential loss of license when they are afraid that working additional hours will endanger patient safety," ANA President Barbara Blakeney, MS, APRN,BC, ANP, told the Institute of Medicine (IOM) Committee on Work Environment for Nurses and Patient Safety with regard to the unsafe practice of mandatory overtime. Testifying on behalf of the United American Nurses (UAN) was UAN Secretary Treasurer Jeanne Surdo, RN, BSN, MA; testifying on behalf of the American Academy of Nursing (AAN) was AAN Secretary Linda Burnes Bolton, DrPH, RN, FAAN. The committee's role is to identify key aspects of the work environment for nurses that likely have an impact on patient safety; and potential improvements in health care working conditions that would likely increase patient safety...

Link to ANA President Blakeney's testimony:


1 Article; 5,758 Posts

Can't help wondering if nursing professors still tell their students that "good nurses don't join unions because it is unprofessional". I heard this same statement during LPN and ADN training. I think some of the resistance might hark back to those statements don't you -jt? I never bought it for a moment.


2,709 Posts

I dont know. I NEVER heard that statement in my nursing school. I went to a city college in NYC (big union town - we have a union for just about any job you can think of - its the way of life here - you finish school, you get a job, you join the union....).

Our instructors were also still nurses at the bedside (part time, per diem or night shift) & practically all of our hospitals are unionized. Most staff RNs in NYC are unionized with the state nurses assoc, so my instructors were probably union nurses too. We were taught to always carry our own , never rely on the employer to do what was best for us himself, join our state nurses assoc & the ANA, be active in them & speak for ourselves because nobody was going to do it for us.

They NEVER said nurses dont belong in unions.

At last years NYSNA Lobby Day at the state capitol, several nursing schools & their instructors were there with over 300 student nurses they brought by bus to participate. I cant imagine those students would be hearing they dont belong in a nurses union either.

Our state nurses assoc supplies nurses with many things & one of them is red-white-&-blue bumper sticker that says "AN RN'S PLACE IS IN AN RN'S UNION" -- and our state nurses assoc includes members who are nurse managers, nurse educators, nurse executives, advanced practice nurses, nurse entrepeneurs, retired nurses, disabled nurses, as well as the majority of members who are staff nurses.

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