|
What Works?
|
|
What Works?
|
|
You've read Previous Stories Kid
Stuff Pharmaceutical products for children Does
Walking During Labor Help? Instilling
Hope Working with ALS patients Rx
Y2K Turf
War Don't
drop the ball
Charting your way
Crossing
the Line
Alternative
Therapy Genetic
Testing Related
Sites American Organization of Nurse Executives National Institute of Nursing Research
|
By
Barbara Tone, RN Nurses throughout the country are speaking more and more publicly about their concerns that patient safety is being jeopardized by continuing cuts in nurse staffing. On April 20, nurses at two New York City hospitals held an "informational picket" to protest working conditions that included RNs’ working 24 hours straight, and 16-hour days five days in a row. And the issue is getting national media attention: ABC’s "20/20" is working on a segment on nurse staffing. The issue is in the foreground in California because of a bill before the Legislature that would set minimum nurse-patient ratios in all hospital units. Currently, Title 22 requires a one to two nurse-patient ratio in critical care units only. According to the American Nurses Association, 25 states have legislation in process that relates to nurse staffing, though not all bills would mandate ratios. Legislating quality? The bill offering the mandatory ratio solution, Assembly bill 394, is sponsored by the California Nurses Association (CNA) and enthusiastically supported by members who have been on the front lines of the staffing cuts and increases in patient acuity. "When something that is tied to public safety is being run for profit, you really need regulatory benchmarks." said Debbie Bayer, RN, a pediatric ICU nurse at Children’s Hospital Oakland and CNA a board member. "Hospitals will continue to compete, but there will be a bar under which they cannot go." Hospitals and nursing executives, however, oppose the legislation, saying the current requirements for acuity staffing are sufficient to ensure patient safety. "We believe a valid and reliable acuity system is the best way to put patients first," said Pat McFarland, MSN, RN, executive director of the Association of California Nurse Leaders. "Ratios are about putting nurses first." "There has been no documentation linking ratios with quality of care," said Deloras Jones, MS, RN, director of divisional nursing services for Kaiser Permanente Medical Care Program of California. "The language in Title 22 is very effective language. If a hospital is in compliance with Title 22, they should have no problem." Looking for more Many staff nurses, however, do not feel protected by the mandates of Title 22. "The majority of nurses I talk with believe the acuity system is ineffective or manipulated," said Katherine Kany, RN, senior labor relations specialist in the department of health and economic policy of the American Nurses Association. " And the reason they believe this is that the staffing that comes out of it is, in their minds, inadequate." Martha Kuhl, RN, a nurse at Children’s Hospital Oakland, does not feel supported by the acuity system. "A lot of activities are not captured, and it’s often a system of ‘averages,’ " she said. "We have to check and clear IV pumps once an hour, for example. The checking and clearing is stated as one activity, whether we have one pump or six pumps to check. I’m a much better predictor of the hours of care needed than the acuity system is." Hospital officials say its policies are in line with Title 22. "We use the same tool as every children’s hospital in California," said spokesperson Carol Hyman. The computerized system uses data entered by nurses to establish a staffing baseline. Hyman said the hospital feels the acuity tool is reliable, but an annual study will assess the system. Mary Lee Streitwieser, MSN, RN, a nurse at Good Samaritan Hospital in San Jose, believes that ratios will do a much better job of ensuring patient safety and points to the number of "assignment despite objection" forms filed in her hospital. Since 1995, the number of ADOs has more than quadrupled, going from 60 in 1995 to 265 in 1998. "Columbia/HCA bought the hospital in 1995," she said, "and we have seen a significant increase in pressure on the med/surg nurses. Of the 265 ADO forms [in 1998], only 17 of them came from intensive care units where specific ratios are mandated. We lost five med/surg RNs and an LVN in one six-week period. All of them left because the workload was so bad." ADOs can give a picture of trends, said Pat Davis, MS, RN, chief nursing officer at Good Sam. However, "Some are about individual comfort levels, not necessarily about competency or safety," she said. Some of the increase in ADOs recently may because multiple reports can be done on the same situation. She also said that most nurses have worked hard to cover patient needs during a very busy time, "often going the extra mile to make sure patients have good care." Most of the nation’s hospitals do rely on some form of acuity-based staffing. In a recent survey by the American Organization of Nurse Executives, 61 percent of hospitals reported at least partial use of acuity-based staffing systems. The survey also reported that 50 percent of hospitals now use temporary agencies to help fill staffing requirements. Not enough nurses Hospitals complain that there are simply no nurses to fulfill the needs of any staffing system. "California has fewer nurses per capita than any state, and we are the biggest importer of nurses," Jones said. "The average age of nurses in California is 47, 30 percent are over the age of 50, and half plan to retire by 2003. Our educational system is prepared to replace only half of them." There do seem to be people interested in going into nursing. "There is a backlog of people wanting to get into nursing schools," said Dorel Harms, MS, RN, vice president of professional services for the California Healthcare Association. "There is a bill [AB 655] that will hopefully open more slots into AA programs and for those who want to go from an AA to a BSN." Others discount this argument. "This is a shortage manufactured by the industry," said Jill Furillo, RN, director of government relations for the CNA. "It goes back to the conditions in hospitals. A lot of nurses were downsized and left. They are wary about coming back because they don’t trust hospitals to provide safe working conditions. We hope this [staffing ratio] bill will attract nurses back to the profession." Creating the right setting Acuity systems and ratios are the most discussed, but not the only, answers to the staffing problems. A variety of methods are being used at hospitals throughout California. The UC Davis Medical Center is designated by the American Nurses Credentialing Center as a "magnet" facility for its ability to attract and retain nurses, one of only 13 in the country. UC Davis maintains an all-RN nursing staff throughout the entire acute care hospital, with the small exception of five long-time LVNs and the use of technicians in the emergency department and the operating room. The facility’s turnover rate is 5.7 percent, compared with a national average of 11 to 16 percent; its vacancy rate is usually about 3 percent, compared with a national average of 7 to 12 percent, according to Carol Robinson, MPS, RN, associate director of hospitals and clinics, patient care services division for the UC Davis Health System. "I think a major contributing factor to our retention is the all-RN staff," Robinson said. "I know this may not be a very popular opinion, but I don’t think hospitals are the place for unlicensed people." In addition, Robinson says the medical center really looked at what it means to be a professional and what is needed to meet the needs of a professional nurse. One of the most important answers is research, and a center of nursing research was developed. "We encourage all the nurses to follow through if they have an idea or question," she said. "We have 30-some research projects being conducted by staff, and at least 70 have gone to specialty conferences to present their findings." Other hospitals have used less dramatic, but often effective, methods for maintaining staffing levels. Many have kept or reinstituted per diem pools or "on call" nurses for staffing overloads; some have "p.r.n. teams" who spend the whole shift responding to any unit that needs additional assistance; others have instituted careful cross-training or float pools of nurses educated for particular specialties. Getting the facts All sides agree that there needs to be more research to guide these crucial decisions about staffing adequacy. A 1996 report by the Institute of Medicine titled "Nursing Staffing in Hospitals and Nursing Homes: Is It Adequate?" noted the scarcity of "objective research on the relationships among restructuring, nurse staffing, and quality in hospitals" and strongly recommended that the National Institute of Nursing Research and other agencies fund "scientifically sound research on the relationships between quality of care and nurse staffing levels and skill mix." David Schildmeier, director of communications for the Massachusetts Nurses Association, welcomes any new research. "We’ve been fighting for [better staffing levels] for five years, and we always hear that our information is ‘only anecdotal.’ It’s difficult to keep hearing that, particularly when we see these dramatic changes in staffing mix and the repeated downsizing—with none of those changes researched for their impact on patient care." Research into patient outcomes and staffing is accumulating, but much more needs to be done. Until hard data clarifies some of the issues, nurses will continue to be on the front lines of the patient safety issue. "Unless we speak up, the patients are going to be the ultimate losers," Streitwieser said. "We’re all going to end up in that bed at some time—I want to be sure there’s a nurse there for me when that time comes." |
