Nursing Notes

October 12, 2011

Governor Signs Healthcare Law to Save Backs and Bucks

Service Employees International Union

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Here is an article about the new law in California to protect both patient and nurses from lifting injuries.  California has always been in the forefront of the public fight to protect both parties and improve nursing care for all patients.  Patient safety is the number one issue for all nurses; sometimes to our own detriment.  We, as a group, have the highest incidence of musculo-skeletal injuries.  We need some help, too.

This law that was just signed by the Governor is a good first step.  We can hope that the rest of the nation will follow suit; but that is not guaranteed–see the battle ongoing over nurse-to-patient ratios all over the country.

This is an article by the SEIU in California.


Posted by Michael Cox, 916-799-6784 on October 7, 2011

AB 1136 will help prevent workplace injuries among hospital workers

Sacramento, CA – Today Governor Brown signed landmark Safe Patient Handling legislation (AB 1136) to prevent a staggering epidemic of workplace injuries among hospital workers while improving patient care.

“The SEIU nurses here in California have long recognized the need for safe patient handling legislation and this was the year to finally get that accomplished,” said Ingela Dahlgren, RN, the Executive Director of the SEIU Nurse Alliance of California. “Too many of our nurses and other healthcare workers have been injured on the job while moving or repositioning the patients in their care.”

Due to excessive unnecessary manual patient lifting and transfers, healthcare workers experience some of the nation’s highest rates of disabling neck, back, and shoulder injuries. However for more than a decade, mechanical lifting and transfer devices have proven to be remarkably effective in reducing these injuries while reducing serious patient skin tears and patients being dropped.

“There isn’t a nurse that I’ve met that doesn’t have a story of experiencing an injury while caring for a patient that took them off work either temporarily or permanently or at the very least isn’t dealing with chronic pain in their back, neck or shoulders,” said Dahlgren. “With this important legislation, not only will our patients be provided safer care, but hospitals will have the guidelines to better protect their employees and prevent career ending injuries.”

California nurses and healthcare workers have always lead the charge for safer working conditions and patient care, whether through Nurse-to-Patient ratios, safer needle legislation or Airborne Transmissible Disease Standards, and now Safe Patient Handling isn’t just a hope, it’s a reality.

The nation’s first Safe Patient Handling law requiring the purchase of safe patient handling equipment and training programs was passed in Washington State in 2006. As a result of the implementation of this law, a January 2011 study found that neck, back and shoulder injuries to hospital workers caused by manual patient handling have decreased by more than one third.1

California now joins Washington State and a half dozen other states where SEIU members have succeeded in passing Safe Patient Handling state laws. SEIU is continuing to work with legislators in other states to pass more Safe Patient Handling laws while pursuing passage of a federal law.

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April 14, 2010

Nurse Staffing Effectiveness in 2010: The Interim Standards

Here is an article I found that I really was amazed to find.  It seems the Joint Commission is about to step up to the plate in the debate over patient safety and nurse-to-patient ratios.  Hmmmm………..

I’ve read those articles that say there is no correlation between staffing and positive patient outcomes and I don’t believe one word of them.  For every one that says nay, I bet I can find another that says “yes, there is a definite correlation.”  Statistics can be manipulated.  What the real decider should be is how many patients get better in the hospital and how satisfied are they with their care?

Please read this article and let me know what you think.  I will certainly be taking a copy of this with me to my next Staffing Effectiveness Committee meeting.


Briefings on The Joint Commission, April 13, 2010

Originally introduced by The Joint Commission to the standards in July 2002, staffing effectiveness is the appropriate level of nurse staffing that will provide for the best possible outcome of individual patients throughout a particular facility.

When first introduced, hospitals were required to track two human resource indicators and two patient outcome indicators, track data, and determine whether the variation in performance caused by the number, skill mix, or competency of staff.

“Hospitals collected the data, nurse leaders looked for correlations, and no correlations have been found,” says Susan W. Hendrickson, MHRD/OD, RN, CPHQ, FACHE, director of clinical quality and patient safety at Via Christi Wichita (KS) Health Network.

Hendrickson says even if hospitals did find what they believed to be a correlation between staffing and a patient outcome, when the information was examined more closely, it was not statistically valid.

Fast-forward to June 2009: The Joint Commission suspended these standards due to the debate of the results from across the country.

However, this suspension proved to be short-lived. In December 2009, The Joint Commission announced the approval of its interim staffing effectiveness standards for 2010.

The new standards will become effective July 1, and will remain in effect as The Joint Commission continues to research the issues of staffing effectiveness.

Interim standards at a glance
The first requirement affects LD.04.04.05, element of performance (EP) 13, and states that at least once per year, the hospital/organization must provide written reports on all system or process failures, the number and types of sentinel events, information provided to families/patients about the events, and actions taken to improve patient safety.

“In a broader sense, EP 13 ties staffing to outcomes and puts accountability at the leadership’s feet,” says Hendrickson. She suggests hospitals submit the reports to the board quarterly or monthly, rather than annually.

“Think about this: Every time a medical error occurs and you have to document it, this may be a long report for the board to get a grip on,” says Hendrickson.

Rather than compile an itemized list of failures, hospitals should instead classify the events and report on them statistically.

“Sentinel events, you will want to try to discuss the events as soon as possible, and disclose general information to the board,” says Hendrickson. “And if a sentinel event did occur, then disclose information on any action taken to prevent similar events.”

In addition to EP 13, the new interim requirements affect PI.02.01.01, EPs 12–14.

EP 12 states that any time the organization has an undesirable event, it must evaluate its staff and their effectiveness. EP 13 states that if a negative trend in the staff is noted, a report must be provided to the leadership.

In EP 14, a written report of the identified issues must be provided at least once per year to the leadership in charge of the patient safety program.

“The organization needs to have a process or policy that speaks to this so the surveyor can review the information,” says Hendrickson. “The Joint Commission believes that if you are not in compliance, this is an immediate risk to patient safety because there are few processes to intervene.”

Now if an organization is cited for any staffing effectiveness, a short-term resolution is given, and the organization is required to come up with a solution within 45 days.

Turning to patient-staff ratio
In addition to the new interim standards, a more intricate part of staffing effectiveness under examination is the patient-to-staff ratio. However, California is no stranger to this because a staffing ratio has been imposed on all organizations in the state since 2004.

To meet the patient-to-staff ratio, many hospitals in the state used traveling nurses from all areas of the United States. By doing so, many of the new nurses ended up taking residency in California, skewing the numbers of the nursing shortage elsewhere.

Despite the additional nurses, the ratios between patients and staff were not always met.

“Meeting the ratio at all times was difficult,” says Cyndie R. Cole, RN, MSN, CNO at the Ventura (CA) County Medical System. “Going from three RNs on the night shift to five RNs on the night shift added a tremendous cost, and then during the day shift staff were not used to being forced to take their lunch break at a specific time.”

Over time, however, nurses managed to work together with the administration to come to a better understanding.

For this year, a set ratio for each unit in the hospital must be met at all times, with no exceptions. The patient-to-staff ratios for each unit include:

  • Critical care: 1:2
  • Neonatal ICU: 1:2
  • Postanesthesia care unit: 1:2
  • Labor and delivery: 1:2
  • Postpartum (moms only): 1:6
  • Pediatrics: 1:4
  • Step-down: 1:3
  • Telemetry: 1:4
  • Med-surg: 1:5
  • Specialty care: 1:4
  • ED: 1:4, 1:2, 1:1

“In the ED, the patient census is always changing, so three different ratios are set up,” says Cole. “On an hour-by-hour basis, we are checking and making sure we are adequately staffed.” To help with the ED’s unpredictability, Cole developed two tools over a three-year period, to work together to help ensure that the patient-to-staff ratios are always met.

The first tool is an hourly census that requires the charge nurse to document the patients in the ED and those patients in the emergency room waiting area. By tracking the patients in the ED and those waiting, the tool helps determine when the ED census will be at its highest and helps the facility call more nurses to meet the patient-to-staff ratio.

In addition to the hourly census, facilities utilize an Excel spreadsheet that automatically determines variance in the ratios.

“This gave us a tool to show where our major hours of being under the ratio occurred, and allowed us to present to our fiscal people hard evidence the times when we need more nurses,” says Cole.

The importance of staffing effectiveness
Staffing effectiveness is being addressed at a national level, with the possibility of all hospitals one day being required to meet a nurse-to-patient ratio.

“Staffing effectiveness in a hospital, meeting ratios, and meeting acuity plans is a day-by-day process,” says Cole. “It is something we have all worked hard to do, but it is still not perfected.”

Even with time, Hendrickson believes that it is still important for hospital leaders to look at staffing issues. “We need to understand how staffing affects outcomes, because we are all held accountable for patient safety,” she says.

Most importantly though, Hendrickson says, it is necessary for organizations to develop the evidence for their own practices. “We need to work together in order to determine what practices will improve the outcomes. And then we have to spread that information across our profession.”

This article was adapted from one that originally appeared in the March 2010 issue of Briefings on The Joint Commission, an HCPro publication.

Here is the link to the article I found

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January 23, 2010

Many Nursing Jobs, But Only the Strong Need Apply

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Having worked as a travel nurse in California, I can say that ratio law has made a difference in how we nurse there.  When I left my permanent job and went traveling, I was the only RN on a unit of 22 adolescents working with an LVN, who gave meds and did treatments, and about 5-6 techs.  I charted on all the patients and assessed each and every one of them.  I also was responsible for the use of any intervention to alleviate out of control behaviors in such a volatile group.

Can you imagine my surprise, when I started my shift and found I had six patients?  I thought I had died and gone to heaven.  My supervisor actually relieved me for 15 min breaks and for 30 min lunches!  I kept thinking it was a joke until a colleague told me about the new law and the cost of infractions to the facility.  Boy!  That shut my mouth hard.

I continued to take assignments in California for the next two years and over time I saw  that there is an up side but there is also a down side.  Having a law that determines how many patients you are able to care for is at first a comfort, but eventually it becomes a binding and you become complacent.  True, I spent much more time with the patients and gave better care to my patients because I could.  However, I found myself with quite a bit of free time and nothing to fill it with–my patients were all well taken care of.  I began to ask to cover for breaks and lunches, then I would go around to see if anyone needed any help.  After that, I was on my own.

Granted, having down time is not a bad thing, but I was raised to believe that if you are getting paid to work, you should be working.  So, I cleaned and organized and kept busy.  The other nurses made fun of me.

Overall, I enjoyed working in California.  I would love to go back again but probably won’t.  I would love to see some type of mandate enacted across the nation that would allow nurses to give quality care to every patient, but not necessarily  a patient ratio law.  Maybe something more like a universal acuity system for patients in every hospital across the United States.  Hospitals will not staff appropriately until they have to–they are a business and need to make a profit.


Are you tough enough?

Filling open nursing positions is no easy task for hospital administrators these days, and there’s every chance the job will get tougher.
This country has a serious nursing shortage: The American Health Care Assn.’s most recent estimates from July 2008 show 116,000 open hospital nursing positions and more than 19,000 vacancies in long-term care settings.
The economic downturn has helped some hospitals as many nurses increase their hours and postpone retirement. But experts say that any lull in shortages is temporary.
A March 2008 report by Dr. Peter Buerhaus of Vanderbilt University Medical Center and colleagues predicted that national nursing shortages could balloon to 500,000 by 2025. Predictions from the U.S. Department of Health and Human Services are more dire: It anticipates a shortage of 1 million nurses by 2020.
A lack of faculty at nursing schools across the country is preventing many people from entering the profession, thereby exacerbating the shortage. Nearly 50,000 qualified applicants were turned away from professional nursing programs in 2008, according to the American Assn. of Colleges of Nursing.
In California, the outlook may be slightly less grim. It’s the only state with legislation requiring minimum nurse-to-patient ratios in acute-care hospitals. The law, which went into effect in 2004, limits the number of patients a nurse can care for on shifts depending on the type of medical unit and the patients’ degree of illness.
A nurse working on an intensive-care unit, for example, cares for no more than two patients per shift. A medical and surgical unit nurse cares for a maximum of five.
Linda Aiken, professor of nursing at the University of Pennsylvania, is studying effects of the legislation. She has found that nurses participating in the survey reported overwhelmingly that the ratio law has had a positive effect on their day-to-day work life.
The California Nurses Assn., which sponsored the legislation, credits the ratio law with helping to mitigate the effects of the nursing shortage and points to statistics that show an increase of 100,000 actively licensed registered nurses in California since the law was adopted.
Three nurses talk about what it’s like to be a hospital-based nurse today:
Mary Bailey RN, 59 years old, medical diabetic unit at Long Beach Memorial Medical Center; nurse for 21 years

Fifteen years ago, with a six- or seven-patient assignment, probably four of them could get up and about. A typical patient [today] has totally restricted movement, so we have to keep turning them as much as possible [to prevent] blood clots.
At the same time, this person can require IV medications every six hours and can be taking three different antibiotics every two to three hours and pain medicine every two hours. We are monitoring all of their lab results, making sure any tests that have been ordered have been followed through, and prepping patients for tests.
That’s just one patient — and I can have up to five.
It would be a good day if I had one patient who could get up and walk around and get to the bathroom and take care of washing up [on their own]. More often than not, I have at least three that require total care, meaning that everything has to be done for them.
It’s pretty hefty — a day with four patients is OK, five is pushing it. It only takes one extra person to push you over the edge in terms of trying to manage your day. They don’t get into the hospital easily nowadays. Insurance companies won’t cover the cost of hospitalization unless the patient is pretty ill.
About 20 years ago, I had nine patients. I think the ratios, by allowing us to only care for a certain number of patients depending on their acuity [degree of illness], has helped immensely. We have more time to see our patients and to do our job adequately.
Martha Kuhl RN, 57, pediatric cancer and hematology unit at Children’s Hospital and Research Center Oakland; nurse for 27 years

As a new nurse in the 1980s, my patient load was probably three to four patients, which is what it is currently in pediatrics, but the patients were not as sick as they are now. There’s been a definite change over time to a higher acuity [sicker] patient, requiring more technology, more paperwork, more intensive monitoring. If you had a patient assignment in the past, you might have one sick patient and several patients on the mend. But that has changed.
Ten years ago, before ratios, if I wanted to have a meal break, my employer didn’t have to provide additional care while I went for my meal. So you had to make a choice as a nurse: Do I stay and watch my patients? Do I leave somebody who is already really busy with their own patients to watch my patients? You know, a buddy system.
And so what you used to do is try to get everything done you possibly could, make sure everybody was comfortable and safe, and then you would run and take your meal break and ask somebody to listen out. Essentially, your patients would not get care while you were gone.
Whereas now, with the ratio law in effect at all times, the employer provides additional nursing care for breaks so that I can say, “OK, this child needs pain medication, can you give it and I can go to dinner?” That’s a huge difference for a family, to not have to wait to get care.
I [used to] go home and be falling asleep and would wake myself up thinking, “Oh my God! Did I do such and such? Did I tell the next nurse about this or that?” Because you’re so rushed you would be continually questioning, “Did I get everything done, was everybody safe?”
I didn’t consider leaving the profession, but I know a lot of nurses did. I know a lot of nurses told me they wouldn’t tell their sons or daughters to become a nurse. But I was one of the people who chose to work hard to get regulations and to make improvements in my collective bargaining agreements so that I could stay a nurse.
Because I like being a nurse, I want to provide patient care, I want to be a patient advocate.
Geri Jenkins RN, 59, intensive care unit nurse at UC San Diego Medical Center; nurse for 32 years

There are all kinds of complicated procedures and technology that the nurse is responsible for monitoring that didn’t exist 10 years ago. A lot of patients are on continuous dialysis with machines. A lot of labs and drugs have to be given on an hourly basis. There are very critical IV drips, and you’re titrating the drugs up and down based on the patients’ clinical picture, and there is constant bedside decision-making with each patient.
We also have [many more] patients who are on isolation precautions [because of infectious diseases] than we used to, which means gowning and gloving every time you walk into their room. That’s very time-consuming, but very, very necessary. There is a much greater risk factor for people who work in healthcare now and it makes the care more complicated. There are a lot of things that have changed over the years that make the delivery of care a lot more complicated.
I still enjoy what I do. I think people who go into nursing don’t go into it for the money but go into it for a sense of altruism and wanting to help and be in a caring profession. But it’s a very high-stress, physically, intellectually and emotionally demanding job, and that’s why I think the ratios are so critical, so that when people go to work they are reassured that they won’t have more than five patients, or more than two in the ICU. That may be a heavy load, but it’s better than it used to be.
Copyright © 2010, The Los Angeles Times
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