Tip of the Iceberg: Amid a sea of hot-button issues, staffing ratios rise to the surface

Tip of the iceberg
Amid a sea of hot-button issues, staffing ratios rise to the surface

By Mary Elizabeth Hopkins
October 23, 2000
Photo: Artville

Gov. Gray Davis has charged the California Department of Health Services with developing minimum nurse staffing ratios by Jan. 1, 2002. The regulations are expected to be written with plenty of oversight.


	You've read the article. Now tell us what you think. Related sites California Nurses Association American Nurses Association\California California Healthcare Association More nurses, please Dorel Harms, RN, of the California Healthcare Association, emphasizes the importance of recruitment at nursing schools to fill the slots that AB 394 – a fairly complex bill – will mandate. The California Nursing Outcomes Coalition is addressing the image of nursing and how nurses are recruited, Harms said. Often, she said, we talk about the "best and the brightest" when medicine is involved. But it’s difficult these days to get the best and brightest interested in nursing, she said. "We have to do an imaging campaign," said Patricia McFarland, MN, RN, executive director of the Association of California Nurse Leaders. "We need to work with young people to dispel a lot of myths about nursing. Television doesn’t help." High school counselors are overburdened, Harms said, so it’s probably asking a lot for them to promote nursing in the last year of high school. "We need to attempt to bring [prospective students] in before the freshman year in high school," she said. "I think we need to educate counselors as well," McFarland said. "The role of a nurse is to assess, evaluate and plan patient care. It’s a distinct role. "In every interaction, the nurse needs to be in an advocacy role. He or she needs to be aware of the situation." ~ Mary Elizabeth Hopkins

For good or ill, California became the first state a year ago to pass a law that will mandate setting minimum nurse staffing ratios and assessing acuity after every shift in acute care hospitals. Similar bills so far have failed in Virginia, New Jersey, Hawaii and Missouri.

Gov. Gray Davis has charged the California Department of Health Services with developing staffing ratios by Jan. 1, 2002.

The verdict on those ratios will arise not from a legislative vacuum in the DHS, but from a filtered brew of warring voices in the nursing world.

Gina Henning, implementation coordinator of AB 394 for the DHS licensing and certification program, will write the regulations with a lot of oversight. "Folks have been invited to submit proposals, concerns and experiences, and people who are supplying us with thoughts are being answered now by mail," Henning said.

Emotions run high on this Pandora’s box. Talk to anyone, on any side, and staffing ratio controversies perch on the tip of the iceberg, while other hot-button issues jockey for position: Nursing retention and recruitment. Funding for nursing schools. Mandatory overtime. Patient acuity. Managed care. Bottom-line thinking vs. quality care. Nursing shortages.

The connections are like tangled roots of a tree, whose tendrils are so long a college course called "Staffing Ratio Controversies 101" might merely introduce students to their complexities.

"When you look at ratios, you have to look at all the other issues," said Kay McVay, RN, president of the California Nurses Association.

Rick Wade, vice president of the American Hospital Association, said that hospitals are the toughest places for nurses to work because they are under the greatest financial pressure and are the most costly health care delivery setting. "Everyone wants to pay them less. Managed care companies and HMOs are low pay, no pay or slow pay," Wade said.

"The staffing ratios argument goes all the way back to the controversy we’ve had for 10 years: What’s a nurse? Is it someone with a two-year degree, four-year, master’s, Ph.D.? When you set staffing ratios, what does that mean? Trying to legislate them is probably a bad idea, because how do you get it right? When you start dictating ratios, you may have met them, but that doesn’t mean the patient is getting the same standard of care," he said.

Staffing ratios are more of an emergency measure than a permanent solution to all woes within the nursing world, said Jan Emerson, spokeswoman for the California Healthcare Association. The proposed ratios are only minimums, she emphasized. "Of course, we don’t want nurses taking care of too many patients," she said.

"It’s beyond me how anyone can argue about staffing ratios," said Tricia Hunter, MN, RN, legislative advocate of the American Nurses Association\ California. "They’re to ensure that you don’t find a nurse in a unit by herself with six patients. That is not safe. As RNs, we are required to take care of patients."

McVay, a 43-year veteran of ICU, med/surg units and cardiac care, said, "We really do believe we need to have ratios, because the kind of patient we have now wouldn’t have made it to the hospital years ago. When I came out of nursing school, there were no ICUs. No transplants. No bypasses. We can’t keep using ratios from the 1950s."

Pro and con
At least three questions bubble up in conversations with opponents of the bill:

Who will manufacture the nurses needed to fill the slots when the ratios appear?
Will the ratios merely serve as a Band-Aid?
How will numbers alone ensure that nurses on the same shift have equivalent clinical experience?

A group of 12 patients might have three nurses, Wade said. Two of the nurses might have a two-year degree, but the first might have two months of clinical experience, while the second might have been on the job for 37 years. The third nurse might have a four-year degree and two years’ experience.

"You can’t say a nurse is a nurse is a nurse," McVay said, although as president of the CNA she strongly favors ratios.

History of the bill
The California Nurses Association drafted and supported the bill in light of managed care’s cost-cutting measures, which may put one med/surg nurse in charge of as many as 16 patients and figure a housekeeper trained to take vital signs can pick up the slack.

"There’s no longer such a thing as a hospital patient who just needs vital signs read," Hunter said.

Most everyone in favor of staffing ratios wants them in relation to establishing a floor, said Patricia Benner, Ph.D., RN, a professor of nursing at the University of California, San Francisco.

"The problem is that the standard ratios might be used as the ceiling or as ironclad criteria. In some situations, even a one-to-one nurse-to-patient ratio isn’t enough. You would hope an institution would make the adjustments they need," Benner said.

"But, sadly enough, some sort of legal arm is necessary because of market pressures and destabilization of staffing levels. Maybe people are asking more of the law than it can deliver. The [market pressures] come from hospitals trying to be competitive and survive in a really competitive market. [Staffing ratios] are a legal counter to extreme market pressures."

If hospitals are not aggressive enough in recruiting for openings now, then how will they increase staff according to legislative guidelines? asked Poul Eriksson, RN, who works in oncology medicine at California Pacific Medical Center in San Francisco.

"The way I come down on it is I feel sorry for anyone who has to set down ratios," Eriksson said. "You would almost invariably work with acuity in making calculations, and figure it all out by the next shift.

"I favor simplicity; it gives us room to negotiate. If the guidelines are too broad, the hospital could feel justified in compliance with levels that were inherently unsafe. I completely agree that you should not ever, ever, ever saddle a nurse with 12 patients. If you did, you should tell the patients, ‘We are now in gross excess of safe staffing levels,’ because the patients should be informed that their care will be compromised.

"Usually, though, the hospital is more inclined to say everything is fine."

Nursing is a lot more complex today, said Dorel Harms, RN, of the California Healthcare Association. "It used to be that a physician needed to know 300 major drugs, but that’s turned into 3,500," she said. "As a nurse, I haven’t been working in a hospital for quite some years, but I was responsible for lots more patients then. We now have fewer patients, but caring for them is much more intense."

Patients still top priority
McVay had planned to be a nurse until she was 75. "Contact with patients gives me such a good feeling," she said.

But layoffs in the ’90s created an unsafe patient load, she said. "People like myself said, ‘I’m outta here,’" McVay said. "It was harmful not only to me, but mainly to patients."

Nurses have left in droves, she said. "There’s no respect for nurses and no loyalty for nurses. We’ve lost a lot of them to sales of pharmaceuticals and nice, clean dot-coms."

Wade also puts patients at the head of the line. "It’s all about the people who walk trustingly, hopefully into hospitals, who want RNs to care for them," he said.