Nursing Notes

July 1, 2011

Patient Classification Systems Address Nurse Staffing Balance

Here is an interesting article from Health Leaders Media that I found.  I have read this article several times, because I am impressed with the information it contains.  It is not often that you come across an article that actually gives nurses and nursing in general any credit for lowering bottom line costs and increasing productivity, while improving customer satisfaction.

As a nurse who has worked in the Sharp system as a travel nurse, I can say that their use of electronic staffing equipment far and away leads the nation.  The nurses working for this system really are satisfied and relatively happy with their current employment.  There is the ordinary stress-related bickering, but if asked, these nurses will mostly tell you that they like where they work.  That is a far cry from the responses I have gotten at other hospitals.

Please read this article and then let me know what you think.  Visit the original site, too, because there are many wonderful nursing articles available there.


Susan Stone, PhD, RN, and Ruth Plumb, MSN, RN, for HealthLeaders Media , May 24, 2011
Determined to achieve meaningful use of electronic health records (EHR), hospitals and health systems will increasingly adopt clinical information technology between now and 2015. This is certainly a welcome development for our economy and patient health. However, because providers are putting larger investments into EHR systems, they are overlooking other strategies to quickly enhance clinical and financial performance and support their pending transformation to accountable care.

While EHR technology is key to reducing costs and improving care quality, safety, and outcomes, providers also can achieve these goals by leveraging patient classification software and managing nursing staff more effectively. When used in parallel or integrated with an EHR, these combined resources give organizations extra tools to realize even greater clinical and financial benefits. This is a lesson that San Diego-based Sharp HealthCare has learned and benefited from over the past two decades.

Since 1990, Sharp HealthCare has used a nursing staff management solution to assign nursing staff and resources appropriately, improve care, and manage RN labor costs and department budgets. Every hospital faces these common challenges, but addressing them successfully is especially difficult for California-based providers struggling to survive the Golden State’s unique and pervasive capitated environment.

Though health systems in other states have not been exposed to capitation, this will change soon with the Patient Protection and Affordable Care Act allowing the Centers for Medicare & Medicaid Services (CMS) in early 2012 to use payment models such as partial capitation. Under this particular model, providers and accountable care organizations will bear some but not all of the financial risk.

In addition to helping organizations better manage their bottom line in a risk-based reimbursement environment, a patient classification system makes it easier for hospitals to comply with nurse-to-patient ratio regulations. Fifteen states and the District of Columbia have passed nurse staffing legislation, according to the American Nurses Association. But with hospitals admitting a higher volume of sicker patients and cutting nursing budgets across the country, RNs and others are increasingly urging lawmakers in other states to pass laws to ensure sufficient staffing to meet patients’ needs.

Having the right skill mix and nurses with the necessary skills readily available to take care of the right patient at the right time is essential to quality of care, patient safety and financial health. Still, it is common for nurses, unions, and state regulators to question hospitals’ staffing level decisions. An intensive care unit RN, for instance, may contend that a patient’s acuity demands his or her sole attention or the services of an additional nurse. This questioning or complaint about inadequate staffing, which tends to increase when facilities institute layoffs in poor economic times, is often emotional.

A patient classification system enables hospitals to remove emotion from the equation by demonstrating through hard data that its decisions are valid, not arbitrary. The tool applies an evidence-based approach to assign, match, and schedule nurses where they are needed the most based on patient acuity level.

Institutions that use the technology to assess acuity on every shift across all patient care units are able to provide objective documentation showing they are not understaffed, which of course places patients at risk. This proactive assessment of patient acuity helps ensure business continuity when regular charge nurses are out sick or on vacation. Replacements typically are less familiar with a unit’s policies and procedures, which can result in poor patient outcomes and higher costs.

A patient classification system promotes operational consistency by offering data on fill-ins that can be used to run a department efficiently in the absence of the regular charge nurse. More importantly, the process of assessing acuity on every shift gives health systems the ability to act immediately to prevent understaffing and overstaffing, both of which result in higher costs from potential malpractice lawsuits, disputes with employees, lost productivity and overtime.

Lack of awareness among many nurses about the budget process, healthcare financial management principles and how assignments are determined is a major reason for those costs. When bedside RNs are unaware of the financial role they play in managing and determining the fiscal health of their employer, nurses and administrators are pitted against each other.

To eliminate damaging infighting and wasteful spending, Sharp HealthCare, which serves 1.3 million residents of San Diego County in southwest California, has made it a priority to educate nurses how to use the patient classification system to analyze, track, and monitor staffing, productivity, and nursing budgets. Its leaders discuss the critical role that technology, patient acuity, and appropriate nurse assignments play. Every Sharp HealthCare facility shares annual financial targets and justifies its department budget. Hospital executives and RN leadership emphasize that their budget development is comparable to how RNs manage their household finances. In other words, the health system deploys the funds it has to provide care in the most efficient and cost effective manner possible. Like nurses—or anyone else—Sharp HealthCare cannot spend money it does not have.

Today, RNs understand staffing decisions are based on patients’ best interests as opposed to driven by an effort to save money at the expense of quality care. The results are fewer misunderstandings, misconceptions, and conflicts that distract Sharp HealthCare hospitals and nurses from their core clinical mission.

Sharp HealthCare sets goals for facilities partly based on the location and the size of an institution’s nursing staff. As a not for profit healthcare system, the organization’s long-term viability is dependent on its financial health and well being.

Increased nurse awareness and the nurse staffing management system have helped Sharp HealthCare not only weather a weak economy for the past three years, but also post impressive financial results during the same period.

The outreach also gives nurses a clearer view of the economic picture at the facility and enterprise levels, and how their institution compares to local and national peers. Whenever a financial variance occurs in their unit, RNs now can easily pinpoint it and determine the reason why. The software enables Sharp Healthcare to:

  • Deliver accurate patient acuity, skill mix, and census data in real time, ensuring charge nurses and nursing managers have the information necessary to optimize clinical and financial outcomes
  •  Analyze retrospectively whether nursing assignments were a factor in near misses that harmed or placed patients at risk
  • Aggregate information to enhance clinical, financial, and operational decision-making
  • Benchmark internal evidence-based data against national standards for acuity
  • Develop and successfully manage nursing budgets

To further increase time savings for nurses and validity and reliability of data, Sharp HealthCare now is working to integrate the software with its EHR.

With health reform altering reimbursement models and the first of 78 million baby boomers beginning to turn 65 years of age in 2011, staffing, clinical, and financial pressures on providers will only intensify. Since RN labor costs represent providers’ single largest controllable expense and a significant percentage of their operating budget, it is critical to use nursing resources more efficiently and enlist RNs as strategic assets and financially oriented managers. Providers following this path will find it easier to navigate the rapidly changing healthcare ecosystem and meet their goals.

Susan Stone, PhD, RN, is chief nursing officer and Ruth Plumb, MSN, RN, is an acuity nurse specialist at Sharp HealthCare, which comprises four acute care and three specialty hospitals in southwest California.

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March 30, 2010

Nursing Workforce Getting More Diverse, Older

This is another take on an article I posted previously about nursing getting older.  I like this article because of the statistics that really make a point.  I also really like the site this comes from,  According to this article, if we are not truly having a nursing shortage right now (and we all know we are) then we will have a doozy of a shortage in about 10-15 years when the 50ish nurses all get ready to retire and not enough new nurses have come down the pipeline to replace them.  Gives you something to think about, huh?

Let me know if you have any suggestions that we can implement to prevent such a massive shortage.


Joe Cantlupe, for HealthLeaders Media, March 29, 2010

An extensive federal survey of nursing trends from 2004 to 2008 shows a growing diversity of backgrounds in an increasing registered nurse workforce.

The report—entitled The Registered Nurse Population: Initial Findings from the 2008 National Sample Survey of Registered Nurses—also reveals a trend of more highly educated, male, and foreign-trained nurses.

The trends, however, showed dramatic increases among older registered nurses, prompting concerns from officials about retirements impeding the growth of the nursing workforce.

The Health Resources and Services Administration (HRSA), a division of the Department of Health and Human Services, released the report this month. Published every four years by HRSA’s Bureau of Health Professions, the National Sample Survey of Registered Nurses is what officials describe as the preeminent source of statistics on trends over time for the nation’s largest health profession.

The report also includes comparisons from eight recurring surveys, 1980 through 2008.

The report showed that:

  • The number of licensed registered nurses in the U.S. grew to a new high of 3.1 million between 2004 and 2008.
  • 16.8% of nurses in 2008 were Asian, Black/African-American/American Indian/Alaska Native, and/or Hispanic—an increase from 12.2% in 2004.
  • An estimated 170,235 registered nurses (RN) living in the US received their initial nursing education in another country or a US territory, comprising 5.6% of the US nursing population, compared with 3.7% in 2007. About half of the internationally educated RNs living in the US in 2008 were from the Philippines, with another 11.5% from Canada, and 9.4% from India.
  • Women outnumber men by more than 15 to 1 in the overall number of RNs, but among those who became RNs after 1990, there is one male RN to every 10 women, the report stated.
  • The average age of all licensed RNs increased to 47 years in 2008 from 46.8 in 2004; this represents “stabilization after many years of continuing large increases in the average age,” the report stated.

Nearly 45% of RNs were 50 years of age or older in 2008, a dramatic increase from 33% in 2000 and 25% in 1980. “The aging trends in the RN population has raised concerns that future retirements could substantially reduce the size of the US nursing workforce at the same time the general population is growing older and the proportion who are elderly is increasing,” the report said.

Overall, Dr. Mary K. Wakefield, the HRSA administrator, said officials are “encouraged by growth in the numbers and diversity of registered nurses and HRSA is committed to continuing this trend to ensure an adequate supply and distribution of nurses in the future.”

Reacting to the findings, the American Nurses Association said it was “pleased to note the increasing diversity of the nation’s population of registered nurses.”

“More and more nurses have advanced training; more than half of American registered nurses have a bachelor’s degree or higher,” the ANA said. “Registered nurses in the US exhibit an increasing diversity of origins.”

“By gender, race, and ethnic origin, US nurses are also increasingly diverse,” the ANA said. “In the 2008 data, there were more male nurses, more non-white nurses, and more Hispanic nurses than ever before.”

“Greater minority involvement in the health professions, including nurses, is critical,” Wakefield said in a statement to HealthLeaders Media. “Numerous studies indicate that underserved communities benefit from the service of minority providers, who are more likely to choose to practice in these communities,” she said.

The National Council of State Boards of Nursing reported that there was a large increase in the number of internationally-educated nursing graduates who passed the National Council Licensure Examination, from 5,000 nurses in 1998 to more than 22,000 nurses in 2007.

“The growth in the number of internationally-educated nurses passing the NCLEX is consistent with the substantial growth in the number of internationally educated RNs living in the US,” the report stated.

Additional findings included:

  • There are also wide variations across states in the number of employed nurses per 100,000 people. The lowest numbers of employed RNs per 100,000 were in Utah, (598), Nevada (681), and California (638), while the largest numbers were in the District of Columbia, (1,868), South Dakota, (1,333), and North Dakota, (1,273).
  • Half of RNs have achieved a baccalaureate or higher degree in nursing or a nursing related field in 2008, compared to 27.5% in 1980.
  • The number of RNs with a master’s or doctor’s degree rose to 404,163 in 2008, an increase of 46.9% from 2004, and up from 85,860 in 1980.
  • Average annual earnings for RNs in 2008 were $66,973, an increase of almost 15.9 % from 2004, a figure that slightly outpaced inflation.

Joe Cantlupe is a senior editor with HealthLeaders Media Online. He can be reached at

Here’s the link to the original article

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March 12, 2010

Nurse Staffing and Quality of Patient Care: Evidence Report

I know I keep talking here about staffing issues, and I do believe that staffing is the #1 problem facing the profession, but I really want to talk about patient care and patient safety.  That these two issues seems intricately interwoven only underscores the importance of solving this problem to the betterment of our patients.

Speaking only for myself, I can only do so much in a shift.  I can only be in so many places during the day.  So, what do I do when that is not enough and my patients suffer due to my inability to be all and be everywhere?

Please read the article below and let me know what you think.


Objectives: To assess how nurse to patient ratios and nurse work hours were associated with patient outcomes in acute care hospitals, factors that influence nurse staffing policies, and nurse staffing strategies that improved patient outcomes.

Data Sources: MEDLINE® (PubMed®), CINAHL, Cochrane Databases, EBSCO research database, BioMed Central, Federal reports, National Database of Nursing Quality Indicators, National Center for Workforce Analysis, American Nurses Association, American Academy of Nurse Practitioners, and Digital Dissertations.

Review Methods: In the absence of randomized controlled trials, observational studies were reviewed to examine the relationship between nurse staffing and outcomes. Meta analysis tested the consistency of the association between nurse staffing and patient outcomes; classes of patient and hospital characteristics were analyzed separately.

Results: Higher registered nurse staffing was associated with less hospital-related mortality, failure to rescue, cardiac arrest, hospital acquired pneumonia, and other adverse events. The effect of increased registered nurse staffing on patients safety was strong and consistent in intensive care units and in surgical patients. Greater registered nurse hours spent on direct patient care were associated with decreased risk of hospital-related death and shorter lengths of stay. Limited evidence suggests that the higher proportion of registered nurses with BSN degrees was associated with lower mortality and failure to rescue. More overtime hours were associated with an increase in hospital related mortality, nosocomial infections, shock, and bloodstream infections. No studies directly examined the factors that influence nurse staffing policy. Few studies addressed the role of agency staff. No studies evaluated the role of internationally educated nurse staffing policies.

Conclusions: Increased nursing staffing in hospitals was associated with lower hospital related mortality, failure to rescue, and other patient outcomes, but the association is not necessarily causal. The effect size varied with the nurse staffing measure, the reduction in relative risk was greater and more consistent across the studies, corresponding to an increased registered nurse to patient ratio but not hours and skill mix. Estimates of the size of the nursing effect must be tempered by provider characteristics including hospital commitment to high quality care not considered in most of the studies. Greater nurse staffing was associated with better outcomes in intensive care units and in surgical patients.

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The article Nurse Staffing and Quality of Patient Care: Evidence Report is provided by Manual Nurse and Health Guidelines. The article from Medical site is freely distributed for non-commercial purposes to include the source for the article and does not alter the content.

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March 9, 2010

Nurse to patient ratios: lies, damned lies, and statistics.(Legislative Updates)

This is an old article, but I want to publish it here just to show that this problem has been going on for quite some time and still is no further along towards any resolution.  I am sure that if the hospital administrators had to work the floors as nurses, there would be a fast action, but since that will never happen I expect little to no headway to be made along the lines of mandated nurse-to-patient ratios.

Nurses will just continue to get frustrated and burned out and drop out of nursing altogether and we will continue to hear about the “horrible” nursing shortage.  If the nurses who currently hold RN licenses were to all come back to the profession right now due to better staffing and nurse to patient ratios, would we even still have a “nursing shortage”?

This article just lets you know that we have been fighting this battle for a long, long time.


By Lillian Gonzalez | August, 2007

The data is in. The fewer patients assigned to nurses, the better the patient outcomes. So why does Nevada, particularly Southern Nevada, have high nurse-to-patient ratios?

Some argue that it’s all about the money. After all, it is logical that fewer nurses caring for more patients could yield higher revenue for hospitals. It can also ensure a cycle of repeat business by way of “frequent flyers.” For example, a male patient is hospitalized to get a knee replacement. Because his nurse has ten other patients, the nurse is unable to adequately protect him from acquiring an infection. Thus, the patient must stay an extra few days for antibiotic therapy. He is rushed out of the hospital because of the HMO factor and receives little to no discharge teaching because the nurse is putting out fires for the other nine patients. The patient returns a week later with a bowel obstruction because he didn’t understand that the pain killers he took home could cause constipation. So much agony could have been avoided if a nurse had had the time to adequately address his needs during his first admission.

So are high nurse-to-patient ratios about the money? Or is it unavoidable because of the highly publicized nursing shortage? Let’s get right down to the stats.

The American Hospital Association (AHA) reported in April 2006 a national registered nurse deficit of 118,000 RNs “to fill vacant positions nationwide.” (1) In the December 2003 issue of Health Affairs, distinguished nurse researcher, Peter Buerhaus, published interesting statistics supporting our nation’s increased dependence on “foreign born” nurses. (2) However, this same data appeared to indicate a surplus of 600,000 registered nurses in the U.S., not working as nurses. A surplus of 600,000 nurses could well eliminate the AHA’s reported 118,000 deficit.

When questioned by email about this surplus, Buerhaus responded, “There are roughly 500,000 individuals who are licensed to practice as an RN in the U.S. today, but who are not currently working.” He then speculated that perhaps many of these nurses are retired, too old to work, independently wealthy, or have chosen to stay home with children. But nurses working in the hospital trenches of Nevada, where some of the highest ratios in the country exist, need not speculate why Nevada has the worst shortage of nurses in the country. To them the reason is: burnout.

Another argument challenging ratio enforcement is the hypothesis that ratios would be impossible to meet and would therefore cause hospitals to shut down. But according to Deborah Burger, President of the California Nurses Association, where mandatory ratios are in full force, “After many dire predictions about closing hospitals and wards by the California Hospital Association, there were in fact NO hospital closures let alone unit closures in California due to the ratios law. It is not just my wishful thinking but actual facts reported to the Department of Health Services.”

Did California have an abundance of nurses to support mandated ratios? Before ratios were imposed, California ranked last in numbers of nurses per capita and Nevada ranked second to last. Today, California has increased its numbers of nurses per capita, now leaving Nevada in last place.

The California Nurses Association has embraced nurses is Texas and other States to help them achieve mandated ratios as well. In a report by The Texas Observer, “Even Schwarzenegger’s office has acknowledged that California’s law has produced some benefits. For one thing, it’s lured thousands of nurses back to work, easing that state’s shortage.” (3)

How did the California Nurses Association manage to beat the odds and attain ratio legislation? Ms. Burger reports, “Since we left the ANA [American Nurses Association], we have accomplished more in the last 12 years than in the previous 50 years with ANA. Since then we have put forward safe staffing legislation (ratios and whistle blower protections) in Illinois, Maine and Texas. In all states, ANA has opposed the bill, but we are moving forward because nurses (just ask any traveler who has worked in California recently) know this will make a difference.”

California has set the standard for hospital nursing care. There, medical-surgical nurses are assigned a maximum of five patients, while here in Nevada it is customary for nurses to have twice as many.

So the next time someone offers statistics supporting a particular view, recall what Mark Twain said, “There are three kinds of lies: lies, damned lies, and statistics.”




Lillian Gonzalez, BSN, RN

Las Vegas Agency Nurse

Here’s the link to the original article

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March 8, 2010

Overworked and understaffed

Here’s an article I found that is an opinion of Dennis Kosuth.   Although I am usually not rabid in my push for improved nurse staffing, I do find myself looking around and thinking, “There has to be a better way to do this.”

I search out and find numerous articles about staffing ratios, staffing laws, etc.  I read them all.  What stands out in my mind is the fact that hospitals are a business and will continue to act just like every other business in the world.  The bottom line is God.  Hospitals, so far, have escaped the notice of the public–who still view hospitals as a haven of safety and help.  When will the public realize that patients and patient care are not that important to the hospitals except in the way they affect the bottom line?

Please read this article and then come back and let’s talk.  I sometimes feel that I am out her alone, but I know that can’t be right, can it?


Dennis Kosuth, an ER nurse in Chicago and member of the National Nurses Organizing Committee, makes the case for laws mandating nurse-to-patient ratios.

March 8, 2010

AMONG NURSES who work in the emergency room, there’s an understandable fear that when you go to check on one of your patients, they may have stopped breathing. Because many people come in with undiagnosed conditions, it’s sometimes impossible to predict the direction they’re headed before it is too late.

In a public hospital, this concern is compounded by a waiting room bursting at the seams, where sick patients with nowhere else to turn sometimes sit for 18 hours before being seen by a doctor. While waiting for tests or a bed upstairs, patients are routinely wheeled into the hallway to make room for the next one, so the pressure building out front can be relieved.

Depending on the day, this can result in one nurse having seven or eight patients, and when their covering nurse goes on lunch, the number doubles. All this endangers the patients that nurses are responsible for–not to mention straining nurses to their physical limits.

Every day, in hospitals across the country, this ticking time bomb is wound up, and everyone crosses their fingers, hoping that nothing bad happens to themselves or their loved ones. According to an investigative feature in the San Francisco Chronicle, “[A]ll of the available research indicates that the death toll from preventable medical injuries approaches 200,000 per year in the United States.”

The profit-driven health care system has no interest in getting to the bottom of these numbers, mainly because it would involve investigating itself. It simply stands to reason that an overworked nurse with too many patients is not an accident waiting to happen, but a guarantee that accidents will happen.

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ON A Friday evening in February in Chicago, almost 50 registered nurses gathered at a forum sponsored by the National Nurses Organizing Committee (NNOC) to discuss the need for safe nurse-to-patient ratios in the state of Illinois.

Bills (known as SB0224 and HB5033) have been introduced in each chamber of the Illinois legislature to establish a maximum number of patients per nurse, depending on the level of care. In the ER, for example, the legislation would mandate a maximum of four patients per registered nurse (RN), and this ratio would have to be maintained during breaks as well.

The Illinois bills are modeled after California, the only state to have such regulations. In 1999, Governor Gov. Davis signed the legislation, which mandated compliance by 2004. It was twelve years between the legislation first being introduced to a law going into effect.

Throughout the process, significant resistance was organized by the hospital industry, aided by their friends in state government. Even after the bill was signed into law, Davis’ successor, Arnold Schwarzenegger, was particularly obstructive, helping to wage a legal battle against the new law. So the California Nurses Association (CNA) protested him wherever he went, inside the state and out.

The Illinois Hospital Association (IHA) is vehemently opposed to nurse-patient-ratio legislation. One complaint is that in California, the new law raised health care costs by more than $1 million per hospital, “with 23 percent attributable to increase in nurse wages,” the IHA claimed in a statement.

But the hospital owners don’t say is that having more nurses will actually save medical costs by reducing errors and recovery time–not to mention other insignificant questions like saving some of the 200,000 lives lost to medical error every year. The focus on profits blinds the IHA to measures that would actually improve patient care.

Another excuse for opposing the new legislation is that Illinois already has the “Nurse Staffing by Patient Acuity Act,” which took effect in January 2008 and was supported by the IHA, as well as the Illinois Nurses Association (INA), a professional organization that also represents some Illinois nurses through collective bargaining agreements.

But this existing law only requires hospitals to have a written plan for nurse-to-patient ratios, which is designed by a committee made up of at least 50 percent nurses. There is nothing about monitoring, regulation or enforcement of the wishes of bedside nurses. This is a toothless bill that leaves ratios in the hands of management.

There are currently 136,000 RNs in the state of Illinois, making for a definite nursing shortage. This leads to another IHA claim–that mandating nurse-to-patient ratios would further exacerbate the shortage.

The fact is, however, that many nurses don’t stay in the field because working conditions are so stressful.

According to one study in 2007, for example, the average voluntary turnover rate for first-year nurses was 27.1 percent. The federal government’s quadrennial survey found that only 83 percent of people with a license to work as an RN chose to do so in 2004. With the total number of RNs at 2.9 million, that means there were almost 490,000 nurses nationwide who didn’t work in the field.

Ratio laws can actually turn these trends around. In the short time since ratios went into effect in California, the state has seen an increase in the number of nurses being retained, an influx of nurses to California and a greater interest in nursing as a job. Once conditions were improved, nurses went back to work at the bedside, started moving to California from out of state, and more people have enrolled in nursing school.

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THE REAL reason the hospital industry opposes the Illinois ratio proposals and similar national legislation is profit, flexibility and speedups. A recent article in Becker’s Hospital Review listing “10 Best Practices for Increasing Hospital Profitability” starts with “reducing staffing costs” through flexible scheduling and reducing benefits for full-time employees.

While health care was one industry that created jobs during the recession, this hasn’t lessened the corporations appetite to improve their bottom lines. Profits returned at large community hospitals in the first quarter of 2009, partly due to an improved stock market, but also from a decrease in hospital labor costs. Many employers were able to gain significant concessions from workers by playing on their economic fears.

For example, Mount Sinai Medical Center, a large Chicago hospital that serves the poor, has not only gotten away with wage freezes for the past couple years, but has also been on a campaign to get employees to make donations to the hospital. This is the same “not-for-profit” institution that spent significant resources to successfully fight off a unionization drive by nurses three years ago.

On the federal level, Sen. Barbara Boxer of California recently introduced legislation to institute nurse-to-patient ratios nationally. This national bill and other state legislation could produce important improvements in patient care and working conditions.

But this isn’t the only path to ratios. Union nurses at Saint Mary’s Regional Medical Center in Reno, Nev., recently won contract language that mandates the same nurse-to-patient ratios as exist in California.

The introduction of these bills is a good first step, but it’s only the beginning. If the mammoth resistance to even the tepid measures promoted by Barack Obama and the Democrats in their “reform” legislation is any indication, the health care industry will stop at nothing to fight mandating ratios.

As one public health nurse said at the Chicago forum last month, “I’ve been to Springfield, written letters and called my representatives. We need to start thinking about protest actions that are just on the other side of the law if we’re going to get the change we need.”

Ratios themselves won’t solve the ongoing health care crisis in this country, but organizing around this issue can bring nurses together with patients and others to address one of the more glaring aspects of it–and force the issue of the present nursing shortage higher on the agenda.

Here’s the link to the original article

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February 12, 2010

States Consider Merits of Mandated Staffing Ratios

As a member of my hospital’s Staffing Effectiveness Committee, I found this article to be a welcome sight.  My experience on this committee, that is mandated by the state legislature, has not been positive.  This meeting is the first thing to be cancelled or moved back to accommodate administration schedules.  During these meetings, we have rarely talked about staffing.  We hear about everything else, but not one word about current staffing problems and ways to fix them.  My hospital has an involved and cumbersome acuity system that is on the computer and requires the charge nurses to input information three times each shift.  There has to be a better way because we just don’t have that kind of time, even though we want to provide accurate data for staffing.
I don’t think it is wrong to be thinking about mandating some type of nurse-patient ratio.  At a time when we need to provide nursing with great PR to entice more people to consider this profession due to the shortage, we need to be able to show that the job is not impossible.  Staffing ratios improve nurse satisfaction and keep nurses nursing.  What part of that does not compute?
I’ve worked in California with the mandated ratios, and I have to say that I did enjoy the work there more than any where else I’ve worked.  I was able to spend time with my patients and provide education that was needed.  That cannot be a bad thing.
By Cathryn Domrose
Wednesday February 10, 2010

Kathy Dennis, RN, has worked in the float pool for nine of her 11 years at Mercy General Hospital in Sacramento, Calif. She firmly believes the state’s mandatory nurse staffing ratios — in place since 2004 — allow herself and her colleagues to provide better patient care. She can’t imagine going back to the days when she sometimes managed care for seven patients at a time, including some with complicated conditions.

“I wonder how I was able to provide the adequate education, the appropriate assessment,” says Dennis, who belongs to the California Nurses Association, the labor organization that helped push a law through the state legislature, making California the only state with mandatory staffing ratios.

But to the surprise of Dennis and many others, data from the first two years after ratios were enacted so far show no improvement in certain nursing-related outcomes in California hospitals. Though some studies show ratios have increased the number of nurses in the state’s hospitals, improved the skills mix, and may have contributed to greater nurse satisfaction, the jury still is out on whether ratios actually improve patient care, researchers say.

“It takes a lot of data and years of data to do the kind of analysis that demonstrates whether or not a policy works,” says Matthew McHugh, RN, PhD, JD, MPH, CRNP, assistant professor of nursing at the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing in Philadelphia. McHugh works with researcher Linda Aiken, RN, PhD, FAAN, FRCN, professor of nursing and sociology at the University of Pennsylvania, who has published widely cited studies linking nurse staffing to outcomes. Aiken’s most recent report in Health Affairs associates reduced nursing workloads with greater patient satisfaction.

About a dozen states are considering some version of a mandatory ratio law, and national legislation has been introduced in the U.S. House of Representatives and the Senate. Most nursing labor groups see mandatory ratios as the only way to reduce potentially dangerous workloads and increase nurses’ time with patients, thus improving patient care. Hospital organizations fear mandatory ratios will exacerbate an expected nursing shortage and put an economic strain on already stressed facilities, forcing them to cut services or even close units.

The Research
Many studies have shown a strong correlation between staffing levels and patient outcomes. A 2002 report, published in the Journal of the American Medical Association, found surgery patients faced increased risk of mortality and failure-to-rescue in hospitals with high patient-to-nurse ratios. A 2007 report by the Agency for Healthcare Research and Quality showed hospitals with higher levels of nurse staffing had lower hospital-related mortality, decreases in failure to rescue, and shorter hospital stays, though it did not prove a causal relationship between the number of nurses and fewer adverse events.

When California enacted ratios five years ago — after a lengthy battle between unions and hospitals — the state became a testing ground for how mandated nurse staffing levels would work. The California law requires one nurse for every five patients in med/surg units; one for every four patients in telemetry, pediatrics, and emergency care; and one for every two in labor and delivery and intensive care. It also requires hospitals to staff beyond the ratios if patient acuity demands it.

In February 2009, the California HealthCare Foundation released a report on the California ratios that found ratios had increased the number of RNs, as well as the nursing skills mix (number of RNs versus licensed vocational nurses and aides) in California hospitals. It could not identify any impact on hospital finances, particularly because hospitals faced other demands, such as seismic requirements and changes in Medicare and Medi-Cal payments, although some hospital administrators reported having to reduce services and cut auxiliary staff in order to hire more nurses. Many administrators also said it was especially difficult to meet ratios “at all times,” including breaks and meals.

But most important, the CHCF report found nothing suggesting ratios changed the average length of hospital stay nor the number of certain nursing-sensitive adverse events, including pressure ulcers and failure to rescue.

“So far, there is no evidence that the ratios have improved patient outcomes,” says Joanne Spetz, PhD, associate professor at the UCSF School of Nursing, associate director at the Center for California Health Workforce Studies, and one of the authors of the CHCF report. Other reports have linked the California ratios to greater nurse satisfaction and higher nurse salaries, but none so far — and researchers emphasize there haven’t been many — have shown improved nursing-sensitive outcomes.

Researchers speculate there could be any number of reasons for this. Some outcomes, such as falls and pressure ulcers, may have depended as much on care from aides as from nurses; and if aides were cut, there may have been no improvement, Spetz says. Two years may not have been enough time to improve outcomes. Outcomes related to certain nursing duties possibly affected by the ratios, such as assessment and teaching, have not been measured.

Some believe hospitals that hired adequate numbers of nurses may have done other things to improve patient care, and that these things, as much as or more than the number of nurses, contributed to better patient outcomes in earlier studies. “There’s so much more to it than hours of care and skill mix,” says Nancy E. Donaldson, RN, DNSc, FAAN, clinical professor and director of the Center for Research and Innovation in Patient Care at the University of California, San Francisco School of Nursing.

McHugh says he expects further research will show mandated higher staffing levels do affect outcomes. Based on previous research, he believes they are an important — though not the only — factor in safe patient care. Aiken’s team expects to publish further research based on interviews involving more than 100,000 nurses in more than 800 hospitals in California, Pennsylvania, New Jersey and Florida. Spetz and Barbara Mark, RN, PhD, FAAN, a professor and researcher at the University of North Carolina, Chapel Hill, also are working on more comprehensive studies comparing a wider variety of nursing-related patient outcomes in California with those in other states.

Legislators Take Action
National legislators aren’t waiting. They say there is enough evidence to show inadequate nurse staffing impacts both patient care and nurse satisfaction. “We need minimum standards to ensure patient safety and help retain nurses,” Sen. Barbara Boxer, D-Calif., says in an e-mail response to questions. Boxer is sponsoring a Senate bill for a national ratio plan similar to California’s. “Patients do not get the quality of care they deserve when nurses are overstretched.”

National ratios are supported by nurse labor groups and opposed by hospital associations and some nursing groups, including the American Nurses Association. The ANA instead supports national legislation similar to that enacted in Washington, Oregon and other states, which requires nurse staffing committees to set staffing limits according to nurse skills mix, patient population and acuity.

In Washington, the committees — made up of half staff nurses and half nurse leaders and administrators — have received mixed reviews since they were put in place two years ago. “Even at this early juncture, it is clear that the commitment of hospital leadership is essential to the success of the committees and their work,” says Gladys M. Campbell, RN, MS, MSN, executive director of the Northwest Organization of Nurse Executives.

One possibility, says Julie Sochalski, RN, PhD, FAAN, associate professor at the school of nursing and a senior fellow at the Leonard Davis Institute of Health Economics, University of Pennsylvania, is to enact legislation requiring hospitals to set safe staffing goals through nurse committees or other means, and if those goals aren’t met, to automatically trigger mandatory ratios.

“If you can’t get hospitals to ensure there will be a sufficient number of staff, then [ratios] need to be done,” Sochalski says. “They are a starting point. The question is, are they able to improve patient safety? I don’t know if we have the answer to that.”

Cathryn Domrose is a staff writer for Nursing Spectrum.

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February 11, 2010

Whistleblower Trial Update Galle’s Case Dismissed; Mitchell’s Trial Proceedings Begin

Here’s another article on the two West Texas nurses facing felony charges.  I know that I keep posting about this but this is a serious precedent and one we nurses should all be following closely.  This article is from Advance for Nurses, which is  a nursing magazine distributed to registered and licensed nurses.  The scope of the damage this incident can cause for nurses is unimaginable.  On the one hand, you will be held accountable to your licensing board for your efforts or lack of efforts to advocate for your patients.  On the other, you can be held legally liable and can be prosecuted for being a patient advocate if in doing so you happen to step on the toes of someone with more power than you.  You will not be protected by the Whistle-blower laws that protect others who come forward with proof of dangerous actions by persons and businesses.

I can see that there may be some type of history between this nurse, Ann Mitchell, and the doctor, Dr. Arafiles.  That may be playing a part in this scenario, but is bad blood a felony?  When this was reported to the Medical Board, was the information taken seriously and investigated by that board?  Did they take any action?  Aren’t there federal laws that prevent doctors from steering patients to some other business in which the doctor has involvement and stands to make monetary gains?

I am still very worried about this outcome and I hope you are too.


By Amy McGuire

Last updated on: February 9, 2010 | Posted on: February 5, 2010

In what may be considered a surprise move, prosecutors filed a motion Feb. 1 to dismiss the criminal case against Vicki Galle, RN, in the Winkler County nurse whistleblower trial. “Prosecutor’s discretion” was the sole reason given for the dismissal.

At press time, the other defendant, Anne Mitchell, RN, continued to face felony charges. Her trial proceedings began on Feb. 8.

Mitchell is being tried by the state for “misusing official information” by allegedly obtaining details as a Winkler County Hospital employee to jointly report, with Galle, what they considered to be sub-standard care provided by hospital physician Rolando Arafiles, MD. They filed the report to the Texas Medical Board April 7. In June, both nurses were indicted on the criminal charge, a third-degree felony that carries potential penalties of 2-10 years’ imprisonment and a maximum fine of $10,000. Mitchell and Galle, both long-time nurses at the hospital, were subsequently fired from their positions.

Nursing Community Responds
The case has brought the attention of both the Texas Nurses Association and the American Nurses Association officials who claim the nurses had a duty to act in the best interests of their patients. The groups are concerned that the case will set a legal precedent regarding nurse whistleblowers, sending a message to healthcare practitioners that there are adverse affects to reporting improper care.

TNA general counsel Jim Willmann, JD, told ADVANCE the dismissal of Galle’s case was a positive step.

“It appears the county attorney finally agreed that Galle’s duty as a nurse required her to report the physician and by doing so, she was fulfilling her duty,” said Willmann, who also serves as TNA director of governmental affairs. “It’s unfortunate that it took him 8 months to make that decision.

Still, Willmann is unsure why the prosecution thinks they can convince a jury that Mitchell acted with bad motives.

“I do not understand why [the prosecution] believes Texas courts would ever hold that a nurse who uses information in fulfilling her or his duty to patients by reporting a physician for substandard care to the Texas Medical Board is committing the crime of ‘misuse of official information,'” he said. “Whether the county attorney has ‘non-legal’ reasons for continuing against Mitchell is open to speculation.”

At the Oct. 21 pretrial hearing, the county attorney described the state’s position: “It doesn’t matter whether the underlying care was good, bad or indifferent. If the motive for reporting was something other than good faith, then they’re guilty of the crime.”

Depending on the state’s case, Willmann believes the nurses’ attorneys may decide to: 1) not put on a defense and call no witnesses because they believe the state has not proved its case beyond a reasonable doubt, 2) put on a limited case and call only the witnesses needed to refute specific evidence put on by the state, or 3) put on a full case.

Federal Civil Suit Mediation Failed
Despite her case’s dismissal, Galle will have a felony indictment on her record, an issue that Willmann called “outrageous.”

“For Galle, it means the state criminal case is over. Unfortunately, the indictment will probably stay on her record. Her federal civil suit against the county, county attorney, hospital, et al. remains alive.”

The court-ordered mediation in the federal civil suit was held Dec. 17, but failed to produce any agreement by the parties, said Willmann.

“Consequently, the federal civil case filed by the nurses will proceed,” he said.

The nurses’ federal suit alleges not only illegal retaliation for patient advocacy activities, but also civil rights and due process violations. The suit names a number of defendants, including Winkler County Memorial Hospital, the hospital administrator, the physician, Winkler County, the district and county attorneys, and the county sheriff.

A change of venue was court-ordered in October to move the criminal trial from Winkler County to Andrews in Andrews County.Willmann told ADVANCE he plans to attend the trial and provide updates on a daily basis through the TNA Web site at

Amy McGuire is regional editor at ADVANCE.

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January 5, 2010

Ohio lawmaker to propose harsher penalties for assault of nurses in workplace

I cannot believe that this is up for discussion.  As a nurse, and especially as a psychiatric nurse, I can tell you stories from first hand experience–both my own and others on my team–of violence against nursing staff.  I have even seen nursing staff killed by a patient.  Why is it deemed okay to assault someone who is trying to help you?  Why is it seen as “part of the job” to have your patient assault you with the intent to do major bodily harm to you?  It doesn’t really matter if we are talking psychiatric or medical patients.  Neither scenario is acceptable.

When the recent topic of the WWF fighter in the ER assaulting all those staff was being everywhere–online and on television, I really felt for the staff who had to deal with such an experience.  I can only hope that the hospital got them some support and treatment–at no cost to them–for such a violent exposure in the workplace.


December 30, 2009 by Brandon Glenn

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Rep. Denise DriehausRep. Denise Driehaus

COLUMBUS, Ohio — A state representative plans to introduce in early 2010 legislation that would increase the punishment for assaulting nurses in the workplace.

Rep. Denise Driehaus, D-Cincinnati, said she plans to introduce the legislation in January or early February, though many details remain to be worked out.

Last month, the newly elected president of the 8,800-member Ohio Nurses Association called the proposal the organization’s highest legislative priority in an interview with MedCity News.

Currently, the punishment for assaulting a nurse in the workplace ranges from a misdemeanor to a “lesser felony,” Driehaus said. The new proposal could reclassify the crime as a fourth-degree felony, though Driehaus said she has not yet decided on the level of punishment she’ll seek. Those convicted of fourth-degree felonies are subject to fines of up to $5,000 and prison terms of between six and 18 months, according to the Cleveland Law Library Association.

It’s unclear how much of a problem workplace violence against nurses in Ohio actually is. Neither Driehaus nor the Ohio Nurses Association were aware of any statistics on the matter. Also unclear is how many states have passed laws that deal specifically with workplace violence against nurses. Massachusetts lawmakers proposed a law earlier this year making such crimes punishable by a fine of up to $5,000 and jail time up to two-and-half years, or both, the Gloucester Times reported.

Adam Sachs of the American Nurses Association did not respond to multiple requests for comment.

Regardless, Driehaus said the law would act as a deterrent. “Not only is it about the increased penalty, it also means something to [the Ohio Nurses Association] that it protects them,” she said.

A 2004 study in the Online Journal of Issues in Nursing called workplace violence “one of the most complex and dangerous occupational hazards facing nurses.”  The study said that stems in part from a culture in the health industry that is “resistant to the notion” that providers are at-risk for violence at the hands of patients.

Driehaus said she’s still considering whether to propose the legislation as its own separate bill, or tack it on as an amendment to House Bill 265, which she sponsored. That bill seeks to impose the same criminal penalties for assaulting a resident participating in a uniformed police volunteer program as are imposed for assaulting a peace officer.

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November 14, 2009

Forensic nursing–CSI anyone?

Filed under: Nursing — Shirley @ 8:43 am
Tags: , , , ,
Below is an article about a nurse who expanded her practice in a rather unusual way.  Usually a coroner is a doctor, but not always.  Sometimes in smaller rural areas the coroner may even be the funeral parlor director.  What is different here is that this coroner is a nurse, but even more interesting, she is a forensic nurse.
Forensic nursing is a relatively new field.  It seems that there are many ways to utilize this credential besides by being a nurse.  I am always interested in new avenues for nurses, so when I found this article I was pleased.
I hope you are too.
Let me know what you think about Forensic nursing or about a nurse as a coroner, won’t you?

Jacobson hopes to restore trust in office

Death no mystery to county coroner

By JOSHUA WOLFSON – Star-Tribune staff writer | Posted: Saturday, November 7, 2009 12:00 am

Formally worked at the Wyoming Medical Center,Connie Jacobsen took over as the County coroner in Sept. (Tim Kupsick/Star-Tribune)


Connie Jacobson has been asking questions about death for almost her entire life.

Growing up, she’d quiz her father about his work embalming bodies at a funeral home. She wanted to know things, like where all the blood went.

“It wasn’t dinner table conversation, but I had curiosities,” she said. “I had questions when I got old enough to know what he was doing.

“Her interest would eventually lead to the top job in the Natrona County Coroner’s Office. Death, she says, has never been a mystery to her.

“I guess what intrigues me is my job of finding out why that patient died, or that person died, and putting all of those investigative pieces together,” she said.

As coroner, Jacobson is responsible for investigating accidental, violent or unattended deaths, as well as suicides. The 57-year-old assumed the job in September, replacing Dr. James Thorpen, who retired after nearly three decades in office.

Jacobson took the job in the midst of the criminal prosecution against former chief deputy coroner Gary Hazen, who has admitted to taking prescription drugs from the office for his own use. Jacobson, who plans to seek re-election next year, said she has taken steps to prevent a similar situation and restore the public’s faith in the office.

“Because of this last year’s history … my concern and my focus is to regain trust and credibility with the community, and to be more open with the community,” she said.

Forensic nurse

Jacobson came to the coroner’s office after more than two decades as a nurse. She most recently served as Wyoming Medical Center’s trauma nurse coordinator.

Her speciality is forensic nursing, in which nurses, in addition to caring for patients, also collect evidence and serve as liaisons between the medical and law enforcement communities. She feels her experience — including training in criminology — helped prepare her for the coroner’s job.

“My nursing background … is probably the best background to have as a coroner, if you are not a physician,” she said.

Compared with other specialties, the field of forensic nursing is relatively new, only gaining official recognition from the American Nurses Association in 1995. At one time, Jacobson said, she was the only forensic nurse in Wyoming. Even now, there are only a handful, with most specializing as sexual assault examiners.

“I kind of felt like the Lone Ranger, striking out, doing things that other nurses aren’t usually or normally doing,” she said.

While finishing up her education for forensic nursing, Jacobson had her first experience with the Natrona County Coroner’s Office, where she served as an intern. When the internship ended, she told Thorpen she’d like to work for him if a position every opened up.

“So he hired me,” she said.

From 1998 to 2001, Jacobson worked as a coroner’s investigator when she wasn’t at her job in the Wyoming Medical Center emergency room.

“There is nothing really glamorous about the job,” she said. “It’s man’s work. You do a lot of heavy lifting, hauling around. You are out in the weather.”


Jacobson resigned from the hospital this summer and sought the coroner’s office after Thorpen submitted his formal letter of resignation.

The Natrona County Commission selected her as coroner in August after interviewing her and one other candidate. Thorpen lauded the selection, calling Jacobson a “top-drawer person.”

New leadership has led to several changes at the coroner’s office. Because she’s not a physician like Thorpen, Jacobson has to rely on doctors in Montana, Colorado and Nebraska to perform autopsies.

Another notable difference, especially in light of Hazen’s crime, is the new prohibition against investigators collecting drugs from death scenes. That task is now left to the police, who are also responsible for storing the evidence and destroying drugs when they are no longer needed.

“We count, log and store all medicines over there,” Jacobson explained.

Jacobson also plans to increase communication between her office and the public.

“There are no secrets here,” she said. “There is nothing in our process that we can’t share with anybody else, as long as it is not still under investigation.”

That increased communication extends to the families of those who have died. Jacobson wants her office to spend more time with family members, because she believes they can help investigators take better care of the deceased.

“Families need to be involved in what we do and help us make decisions and feel a little bit of control… ,” she said. “We don’t stop taking care of people just because they died.”

Reach reporter Joshua Wolfson at (307) 266-0582 or at Visit to read his blog.

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