Nursing Notes

February 26, 2010

Nurse Staffing Laws: Should You Worry?

Nurses At Work - ChangAn Hospital
Image by voxeros via Flickr

Here’s an interesting article about staffing laws.  As a member of my hospital’s Staffing Effectiveness Committee, I read this article with enthusiasm.  However, it quickly became evident that my experience with the state mandated committee was about par for the course.  It seems that as long as hospitals are not mandated to staff according to safety standards and acuity, they will continue to say that there is no problem with their staffing levels.

I have talked about my experiences working in California before and I have said that there are pros and cons to a legally mandated ratio system.  Now, working in Texas, I see very few pros and many cons with this states mandated staffing committees.  The only pro I can see is in allowing staff nurses to actually hear some of the issues around staffing from upper management; but the con to that is making nurses feel they have some power over the staffing when in reality they do not.

Please read the article below and comment on your take on this difficult topic.  I know I would love to hear from someone else about this.


By Terese Hudson Thrall
For hospitals, bills range from onerous to OK

Illinois legislators last year approved a bill mandating that hospitals form committees to create nurse staffing plans—and that 50 percent of committee members must be direct care nurses. The legislation was spearheaded by the Illinois Nurses Association and, to the surprise of some, was strongly supported by the Illinois Hospital Association.

“This bill was the result of many years of prescriptive ratio bills,” explains Cathy Grossi, IHA’s assistant vice president of health policy and regulation, “and a lot of criticism that nurses did not have a voice at their hospitals.”

The law requires the new committees to use a patient acuity model—which takes into account patient conditions and nurse experience—to guide adjustments to a hospital’s staffing ratio.

Illinois is not alone. Texas and Oregon already require hospitals to create staffing committees with half the members being direct care nurses. The Washington State Hospital Association expects similar legislation to pass in 2008 and the Ohio Hospital Association supports a bill introduced earlier this year.

It’s all part of a nationwide trend, says Stephanie Dodge, a labor and employment attorney and partner at Drinker, Biddle and Reath, Chicago. She’s busy these days, flying around the country to educate hospitals and hospital associations about state efforts to regulate how hospitals make decisions on nurse staffing. Legislation varies from state to state; some bills, like Illinois’, are intended to make sure nurses sit on staffing committees; some would require hospitals to make their staffing plans public or file them with state agencies; others, such as California’s controversial nurse ratio law, set staff-to-patient numbers; and some include a combination of mandates.

“I predict within five years, we’ll have staffing legislation at least introduced in all 50 states, with a significant number having passed some type of legislation involving staffing plans,” Dodge says.

To date, nine states have passed laws or adopted regulations addressing nurse staffing. In 2007, 16 states had some type of staffing legislation introduced. In the first two months of 2008, an additional four states saw legislation introduced. Bills in 13 states would mandate nurse-staffing ratios. (see map)


Leading Advocate

Nursing groups nearly always lead the legislative charge. Zenei Cortez, R.N., traces the efforts back to the 1990s when cash-crunched hospitals cut back their nurses and hired more unlicensed personnel. Nurses have been trying to gain more say on the staffing issue ever since, says Cortez, a member of the President’s Council created by the Oakland-based California Nurses Association and the National Nurse Organizing Committee.

On the other hand, Jean Moore, director of the Center for Health Workforce Studies at the State University of New York’s Albany School of Public Health, says pressure to improve quality of care, bolstered by reports from the Institute of Medicine and others that indicate a relationship between staffing and outcomes, has made staffing a priority with state legislatures. “When you cut to the chase, it’s about preserving quality and not putting nurses in a situation where they are likely to do harm,” she says.

The ongoing shortage of nurses also has focused attention on the staffing issue.

To Mandate Ratios or Not

The California Hospital Association disputes Cortez’s assertion that mandated ratios have brought nurses “back into nursing” by improving salaries and working conditions. “While the numbers of nurses in California have increased, many of those are traveler nurses,” says Jan Emerson, CHA vice president of external affairs.

The National Nurse Organizing Committee sent out a mass mailing to nurses in all 50 states earlier this year to drum up support for more ratio laws. Cortez says the group is now working for ratio laws in Arizona, Illinois, Maine, Massachusetts, Missouri, Ohio, Pennsylvania and Texas, with additional plans to target Kentucky and Nevada. In Minnesota and elsewhere, state unions have pressed for ratio bills.

The issue has been an effective one for organized labor, Dodge says, as unions target the 85 percent of the nation’s nurses who are not dues-paying members. “Here’s an opportunity for the unions to take the high road,” she says. “It’s a way to communicate to nurses, ‘We are interested in what you are interested in. You can trust us to do what is in your best interest.’ ”

But state nursing groups—even those that are unions—don’t uniformly embrace staffing ratios. Last year, the Oregon Nurses Association, an 11,000-member union, came out against a ratio bill backed by another state union. “We believe it is difficult to establish a single staffing standard for hospitals in Oregon or any other state because the great variable between hospitals,” says Susan King, ONA executive director. “The nurses at the facility are the experts on how staffing should be managed.”

The union had spearheaded legislation—strongly supported by the Oregon Association of Hospitals and Health Systems and passed in 2005—that created staffing committees whose members are evenly split between direct care nurses and nurse management.

“Our message to the legislature was ‘Give our plan a chance to work,’ ” King says. “We’d been working with the legislature since 1997 for nursing to have the authority at hospitals, and we had it. I didn’t see the advantage of abandoning our legislation.”

Gwen Dayton, the hospital association’s vice president and general counsel, notes that the union’s opposition to ratios “put them in a difficult position with other labor groups. It wasn’t easy for them, and we understand that.”

Attorney Dodge points out that staffing laws like those in Oregon and Illinois won’t preclude ratio bills from being considered; Illinois has seen one introduced during each of the last seven legislative sessions. However, ratios are much harder to pass when nurses and hospitals agree on another method.

Even with both the Oregon Nurses Association and Oregon Association of Hospitals and Health Systems committed to the 50-50 staffing committees, getting them up and running took a lot of work. The groups hashed out  guidelines to suggest ways the committees could operate, including how to select committee members, expectations for attendance, how to make decisions, and what to do when the committees reach an impasse. “It’s not always easy because it’s a new way of doing things,” Dayton says. “It might require a new hospital culture.”

When the Rubber Meets the Road

That’s just what Ruby Jason, R.N., found when she started to work on her organization’s new staffing committee. Jason is division director of pediatrics at Oregon Health & Sciences University, Portland. The 500-bed medical center had a history of rocky relations between management and the more than 2,000 nurses who work there. Heavily unionized by the Oregon Nurses Association, the nurses went on a 56-day strike six years ago.

“When the state law came out with provision for equal representation, a lot of nurses thought it was a labor-management committee,” Jason says, “but the union doesn’t have a place at the table.”

The eight committee members spent two months working with an outside consultant to set aside their hospital roles and change their frames of reference. “We had to learn that staff nurses weren’t responsible to the union and the nurse managers weren’t responsible to the administration,” Jason explains, “that we were all responsible for making sure that this law was equitably applied to nursing staff.”

Eventually, the committee found common ground. “We realized we are all nurses and every one of us wanted to be safe,” Jason says. “We wanted patients to receive safe care, and we wanted the organization to stay safe.”

When the committee started work 18 months ago, it met twice a week, all day, going through the law line by line, agreeing on what the provisions meant. The staffing plan took eight months to devise, but Jason says it was worth it. One big payoff: More nurses strongly support the staffing plan.

The committee has granted direct care nurses more information and insight about the budget. “When you work on staffing it isn’t always about the money, but sometimes it has to be,” Jason says. “We all want to get paid and have benefits, and we all want to get new equipment.”

She has been surprised by the reaction of staff nurses on the committee when confronting certain problems. For instance, the committee found that one medical center unit was sometimes understaffed because the nurses were setting their own schedules. One day the unit would have 17 nurses, the next day only 11. “That was a hard sell to that unit,” Jason recalls. “We had to say, ‘We are not going to hire more nurses just so you can have the schedule you want,’ and the staff nurses on the committee agreed.”

Susan Campbell, R.N., chief nursing officer at OSF Saint Francis Medical Center, Peoria, Ill., says she’s had a similar experience with her 12-member committee, which is just getting started. “I have found very few nurses want an unreasonable thing; they are pretty comfortable with normal staffing levels, 1-to-5 for med-surg and 1-to-2 or 1-to-1 for intensive care,” she says. “What they want is more guidance when it’s not an average day.”

State laws vary on how strictly hospital executives must follow whatever proposals come out of the staffing committee.

For instance, Illinois’ law does not require hospitals to act on a committee’s recommendations but says only that the recommendations must be given “significant regard and weight.” To Campbell, that means a hospital’s administration would need a strong reason, backed up with data, to show why it rejected the committee’s advice.

Dodge urges her Illinois clients to take that part of the law very seriously. “You want to show these nurses they had an impact. The worst thing that can happen is that the nurses do this work and hospitals turn up their noses at it.”

Oregon, on the other hand, requires hospitals to act on committee recommendations, although the administration can ask for changes. Theoretically, nurses could hold up the staffing plan if they can’t get some provision they want, although Dayton has not heard of any such instance so far.

Next Steps

Even in states with no staffing legislation in the works, Dodge urges hospitals to pay attention to the trend. She recommends that all hospitals start staffing plan committees with nurse input. “Staffing committees are a great opportunity for hospitals to engage their nurses. Get them involved in the process and the solution on individual units,” Dodge says. “You’ll make your nurses happy, remain competitive, be better able to recruit nurses. And a union is not likely to come knocking if your nurses are touting your hospital.”

At Ohio Health & Sciences University, Jason says the hard work of setting up staffing committees could bear even more fruit. Committee members might next consider reengineering bedside care to improve nurse performance. “What is making the nurses so busy? Is it how they interact with doctors? The documentation they prepare?” she asks.

Like Dodge, Jason recommends hospitals set up the committees simply for the good of the nurses and the hospitals. “The nurses really drive the business,” she says. “For a long time, hospitals have focused on doctors and patients they admit, but beds don’t take care of patients, nurses do.” And if hospitals don’t proactively involve nurses in workplace decisions, she warns, “they will find themselves with mandated ratios.”

Here’s the link to the original article.

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