The Culture and Politics of Health Care Work

Nurse-to-Patient Ratios and the Future of Health Care

Suzanne Gordon, John Buchanan, Tanya Bretherton

• Publisher: ILR Press
• Year: 2012
• ISBN:
  9780801465017
• Topic: Medicine
• Subtopic: Nursing

Legally mandated nurse-to-patient ratios are one of the most controversial topics in health care today. Ratio advocates believe that minimum staffing levels are essential for quality care, better working conditions, and higher rates of RN recruitment and retention that would alleviate the current global nursing shortage. Opponents claim that ratios will unfairly burden hospital budgets, while reducing management flexibility in addressing patient needs.

Safety in Numbers is the first book to examine the arguments for and against ratios. Utilizing survey data, interviews, and other original research, Suzanne Gordon, John Buchanan, and Tanya Bretherton weigh the cost, benefits, and effectiveness of ratios in California and the state of Victoria in Australia, the two places where RN staffing levels have been mandated the longest. They show how hospital cost cutting and layoffs in the 1990s created larger workloads and deteriorating conditions for both nurses and their patients—leading nursing organizations to embrace staffing level regulation. The authors provide an in-depth account of the difficult but ultimately successful campaigns waged by nurses and their allies to win mandated ratios. Safety in Numbers then reports on how nurses, hospital administrators, and health care policymakers handled ratio implementation.

With at least fourteen states in the United States and several other countries now considering staffing level regulation, this balanced assessment of the impact of ratios on patient outcomes and RN job performance and satisfaction could not be timelier. The authors' history and analysis of the nurse-to-patient ratios debate will be welcomed as an invaluable guide for patient advocates, nurses, health care managers, public officials, and anyone else concerned about the quality of patient care in the United States and the world.

PART I

California: Managed Care, Hospital Restructuring, and the Ratio Response

1

Hospital Restructuring and the Erosion of Nursing Care in California and the United States

As a young recruit new to nursing, Summer Vanslager is both a statistic and a phenomenon. As a modern young woman she has an entire professional world open to her and could have decided to be a doctor, lawyer, or banker. Instead, she chose nursing because she wanted a career in which she could make a difference and be close to patients. Unlike her nursing foremothers, however, she is unwilling to put up with relentless self-sacrifice. During both her nursing school apprenticeship and her first year on the job, Vanslager found that the ratio of satisfaction to sacrifice was less than reassuring. In spite of this, Vanslager fell in love with oncology nursing and got a job on an oncology unit at Dominican Hospital in Santa Cruz, California, after graduation. By November 2004, she had been working for a year, which was enough time to convince her that unless something changed for the better, there was no way she would stay at the hospital working at the bedside for more than a couple of years.

When she was a student and learned from nurses on an oncology floor, she says, conditions were nothing short of “barbaric.” “We were working with seven or eight patients. It was gruesome.” Her patients had breast, lung, colon, or other cancers. They knew they could die. She knew they could die. They were getting heavy-duty chemotherapy. They were terrified. “You couldn’t get any sense of who they were. There was no way to know the patients, let alone know what was the right equipment or medications and how to use it,” she says. Had she entered the wrong profession, Vanslager wondered? Or was it just hospital work that was the problem?

The questions continued to mount when she graduated and went into the hospital workforce. Would she move on to less stressful work after a year or two or stay at the hospital bedside and thus contribute to ending California’s—and the nation’s—serious nursing shortage? Many newly graduated nurses shared Vanslager’s dilemma. In fact, just as she was entering the workforce, several studies, including one conducted by Julie Sochalski, a University of Pennsylvania nursing workforce researcher, were quantifying the experiences of new graduates entering the hospital setting. Sochalski, for example, found that “raising particular concern is the increasing proportion of new RNs who are not working in nursing.” More new male nurses than female nurses were leaving the profession, but “the proportion of female entrants who were not working in nursing also increased.”1

At the time of this writing, new recruit Vanslager, going against the odds, had at least for the time being decided to remain at the bedside. Why? Because she believed that working conditions were changing for the better in California’s acute care hospitals. In 1999, the California legislature passed AB 394, a statute introduced years earlier by Assemblymember Sheila Kuehl establishing minimum patient-to-nurse ratios in all acute care hospitals in the most populous state in the United States. After a complicated three-year process, the California Department of Health Services (CDHS) set minimum staffing ratios that would be phased in starting in January 2004. On medical/surgical floors and specialty units such as oncology (which account for the majority of patient capacity in any hospital), no nurse could be asked to care for more than six patients at any time, day or night. Other ratios applied to additional units. Moreover on January 1, 2005, the ratios would be even “richer.” On medical/surgical and specialty floors, the ratio would be set at 1:5. By 2008, oncology units like Vanslager’s would have a 1:4 ratio.

When Vanslager started work the ratios had just been implemented. “It was like a breath of fresh air,” she said, as if just inhaling. “We could actually read charts. We could find out about our patients and deliver safe care.”

She said her hospital abided by the ratios most of the time. In November 2004, they were planning to staff up to the 1:4 ratio that would have been implemented in January 2005. Then on November 12, 2004, just a few days after President George W. Bush was reelected, California governor Arnold Schwarzenegger announced that he was suspending the phase-in of the next stage of the ratios, which would have assured nurses like Vanslager that they would not be asked to take care of more than four patients at a time. He argued that the nurse-staffing ratios had created a health-care “emergency” and that the ratios were responsible for hospital and bed closures, staff cuts, and undue financial strain on California’s hospitals.

Vanslager, like thousands of other nurses in California, remembers feeling stunned at this news. “I just wondered if he’d ever actually visited a hospital. If he knew what it’s like to have so many patients and to try to take care of them,” she recalled. The California Nurses Association, the union that led the battle for the staffing-ratio bill, immediately filed a suit against Schwarzenegger. The suit alleged that the administration had exceeded its authority, and the union demanded that the ratios be implemented as scheduled. Even though the public supported the bill, Vanslager worried about the outcome of this legal action. The governor had received campaign contributions from a state hospital industry that was a powerful force in California politics and adamantly opposed the implementation of the staffing-ratio bill.

In March 2005, however, Sacramento Superior Court Judge Judy Holzer Hersher issued a decision that rejected every claim the governor and the California Department of Health Services had made. The judge ruled that the phasing in of the ratios must continue. Later that year, the CNA, along with other unions representing public-sector workers, again battled the governor. Governor Schwarzenegger was pushing a statewide referendum, which, if passed, would limit public-sector unions’ ability to use members’ dues for political lobbying. When this referendum was soundly defeated in November 2005, the governor immediately stated that he would forego any further efforts to fight the implementation of the phasing in of the nurse-to-patient staffing ratios.

For nurses like Summer Vanslager, this was welcome news. “Thank God,” she said. When I asked her what she would have done if the phase-in had not continued, she sighed. If things had not continued to change for the better in California hospitals, she said, she would have left hospital nursing. “Absolutely!” she asserted. “I would have gone into home care or hospice. I would not have been able to continue in such stressful work. I would have gone to work someplace where there is less physical labor and more time with patients.”

We Can’t Cut ‘Em Fast Enough

Whether they are new nurses or more experienced and older ones, RNs who are involved in direct care throughout California have marched and rallied, stood in vigils in the cold and rain, and engaged in letter-writing campaigns and door-to-door political canvassing in support of ratios. During the mid to late 1990s nurses began to argue that they were working in an increasingly money-driven, rather than quality-oriented, health-care system in which managers were forced to focus more on the bottom line than on quality care. As Californians, moreover, they lived and worked in a state that has been hit by one of the most extreme forms of U.S.-style managed care.

After a decade of cost cutting and hospital restructuring in which nursing had been deskilled and deprofessionalized, organized nurses insisted that staffing ratios represented their attempt to assert professionalism. They did this through a legislated mechanism that they believed would give them greater control over their workload. As nurses involved in the fight for ratios in California and elsewhere in the United States emphasized to the public and policymakers, they believed that legislation was one of the only ways they could ensure patient safety and their own professional integrity. It was, moreover, a vehicle to protect their own health and well-being in the face of an epidemic of workplace injuries and stress-related illnesses. Indeed, they argued that patient safety and worker safety are interconnected. Nurses won’t be there to take care of patients if they leave the bedside because of intolerable stress, stress-related illnesses, and increasing levels of occupational injury. They can’t be attentive to patients’ needs if chronic workplace stress leaves them so burned out that they are unable to muster empathy for their patients’ pain and discomfort.

Many nurses in California believed that the only way they could gain a measure of professional control over their work was to make government an ally. They chose this path because they had tried everything else. They had tried appealing to their professional managers, the nurse middle-level and high-level managers who throughout the staffing-ratio debate declared themselves to be the guardians of nursing’s professional integrity. Yet, when nurses begged hospital nurse managers for workload relief, they said they were told they were being alarmist, resisting change, and acting selfishly. Although managers argued that they were not cutting nursing care to the bone, in the twenty-first century many admitted that that’s just what they did. As Jeanette Ives Erickson, senior vice president for patient-care services and chief nurse executive at Massachusetts General Hospital, said of the restructuring of hospital nursing in a recent U.S. public radio series on the nursing crisis, “We just couldn’t cut ‘em fast enough.”2

In California, as floor nurses registered growing concerns about unit staffing, they say they agreed to work to implement patient acuity systems (sometimes referred to as patient acuity or dependency systems) that would computerize decisions about their workload and determine how many hours of nursing care patients would receive. As we shall see, hospitals did not abide by the data on acuity that their own systems generated. The legislative solution to eroding working conditions was, many bedside nurses argue, a last-ditch response to conditions that few contest were untenable and the existence of which even high-level executives have come to ruefully acknowledge.

The struggle for staffing ratios as a solution to the nursing crisis in California is one that engages some of the thorniest issues in U.S. or even global health care. When compared with the story behind and the state of ratios in Victoria, it becomes even more interesting—illustrating the differences between workplace transformation in Australia’s highly unionized, public national health-care system and the privatized, market-driven system in the more politically polarized United States.

The key actors in this drama are the three nursing unions that fought for ratios; the California Healthcare Association, which fought against them; the Department of Health Services, which implemented (and then opposed) the law; and three California governors. Heading up this cast of characters is the California Nurses Association, an all-RN union that, until 1995, was part of the American Nurses Association. Because members of the collective bargaining arm of the CNA believed that the ANA was not acting assertively enough in the face of managed-care and health-care cost cutting, the unionized nurses split from the ANA in a bitter divorce whose reverberations are still felt today. Its twenty-four thousand members formed their own independent labor organization, which led the battle for ratios.

The other unions involved were the Service Employees International Union (a national union that was at that time affiliated with the AFL-CIO) that represented RNs and LVNs, many in public-sector hospitals. Finally, another union player was the United Nurses Association of California, which represents RNs in Southern California and which is affiliated with the American Federation of State County and Municipal Employees.

On the opposing side of the ratio dispute stood the California Hospital Association—later to be renamed the California Healthcare Association (CHA)—whose members include over four hundred, or over 85 percent, of the state’s acute care hospitals. The CHA has been and still is opposed to ratios. In addition to the California Department of Health Services, which regulates the state’s hospitals, critical players included California governors Republican Pete Wilson, who served from 1991 to 1999, Democrat Gray Davis, who was elected in 1998 and served one and a half terms from 1999 to 2003, and Republican Arnold Schwarzenegger, who replaced Davis in a special recall election in 2003 and was reelected in 2006.

The Reemergence of Ratios

Although the ratio legislation was enacted and signed into law in 1999, the story of California nurse-staffing ratios actually began with the passage of what came to be known as Title 22 in the 1976–77 state legislative session. This mandated a standard for a nursing presence on at least some units in acute care hospitals. It stated that “there shall be registered nurses, licensed vocational nurse and operating room technicians in the appropriate ratio to ensure that at all times a registered nurse is available to serve as the circulating nurse.”3 Although the appropriate ratio was not defined for the operating room, it was specified for intensive care units and intensive-care nurseries: “A ratio of one registered nurse to two or fewer intensive care patients shall be maintained” in intensive care, newborn nursing, and in ICUs “the nurse:patient ratio shall be 1:2 or fewer at all times. Vocational nurses may constitute up to 50% of the licensed nurses.” Similarly, on perinatal units, the regulations mandated that “a ratio of one licensed nurse to eight or fewer infants shall be maintained for normal infants.”4

Throughout the 1980s and early 1990s there was no movement to expand the use of ratios to include other acute care hospital units. With the advent of health-care cost cutting and hospital restructuring in the mid-1990s, nurses’ work changed dramatically, and the idea of extending ratios to other hospital units surfaced.

After the election of President Bill Clinton and the failure of the Clinton health reform proposal, managed care produced a rash of hospital cost cutting and belt tightening that had an enormous impact on nursing.5 Nursing care was restructured or reengineered, as hospitals replaced experienced and expensive registered nurses with what became known as “unlicensed assistive personnel” (UAP). Reports of staff cuts became common in the mainstream and industry media. Publications such as the weekly Modern Healthcare ran stories reporting that “from 1993 through January of 1996, 140 hospitals or systems laid off a total of 23,910 workers, or an average layoff of 171 workers per hospital.” Their article “Jobs Go First,” based on a survey of hospital administrators, revealed that more hospital executives said they would save money by cutting staff than by limiting capital improvements or research and development.6

California, which had the highest “penetration” in the nation of managed-care health plans, was the hardest hit of all the states. It thus had the dubious distinction of ranking fiftieth in the nation in terms of the nurse-population ratio.7

The hundreds of nurses laid off from California hospitals was not the only factor creating disaffection among the state’s nurses. Work overload quickly became a major problem, not only because fewer nurses were taking care of the same number—or more—patients but also because patients themselves were becoming more intensely ill while in the hospital. This increase in patient acuity was a by-product of one of managed care’s most significant cost-cutting strategies—reducing the length of hospital stay for patients.

Under the traditional fee-for-service coverage that managed-care plans aimed to replace, both doctors an...

Table of contents

• Acknowledgments
• Introduction
• Part I California: Managed Care, Hospital Restructuring, and the Ratio Response
• Part II Australia: Nurses and Work Intensification in Public Hospitals in Victoria— Context, Response, and Legacies
• Part III Arguments and Alternatives
• Conclusion: Ratios and Beyond
• APPENDIX: Decision of the Australian Industrial Relations Commission on Nurse-to-Patient Ratios
• Notes