National Nurses United

Ratios:4 3/18/09 4:09 PM Page 14 INDUSTRY USING BAD MATH TO UNDERMINE RATIOS California's historic RN-to-patient ratio law, sponsored and defended by CNA/NNOC, is marking the tenth anniversary of its passage in 2009, but that's not stopping the hospital industry and its allies from gearing up for another attack. Two recent studies purport to offer an academic analysis of the impact of the ratios. But both are politically-motivated works, intended as ammunition for the industry campaign. The first study, "California's Minimum-Nurse-Staffing Legislation and Nurses' Wages," published in Health Affairs, examines what happened to RN wages in metropolitan areas of California compared to non-California metropolitan areas from 2000 through 2006, and attributes higher RN wages in California solely to the requirement for safe staffing ratios in hospitals. California RNs do have the highest wages in the United States because of the dramatic success of CNA/NNOC in winning negotiated improvements to raise standards for RNs as well as passing the ratio law, points deliberately ignored by the study's authors. But the authors' intent seems to be to lay the groundwork for attacks on ratios due to the alleged costs to supposedly impoverished hospitals. In fact, during this same time period cited in the study, metropolitan hospitals in California enjoyed a 13.2 percent increase in their real profits, also ignored in the article. Moreover, the methodology for the report is, at best, sloppy. For example, RNs in California may work more overtime, but the authors dismiss this factor as their data does not allow for a precise measurement. Further, the authors do not account for different changes in cost of living across various metropolitan areas, assuming for example that expenses in Los Angeles were the same as in Topeka, Kansas. The second study, "Assessing the Impact of California's Nurse Staffing Ratios on Hospitals and Patient Care," published by the California HealthCare Foundation, is also littered with methodological errors. The purpose of this study is to attempt to discount any improved patient outcomes resulting from ratios. The authors talked with administrators at 12 hospitals for their thoughts on the ratios. Surprise, the administrators do not like ratios. The authors did not interview RNs or their patients who, presumably, would not fit neatly into the authors' agenda. Regarding quality of care, the authors self-selected five of 27 "nursing-sensitive" measurements, cited by the Agency for Healthcare Research and Quality (AHRQ) as quality indicators. These indicators are actually listed as "patient safety indicators," not nursing sensitive indicators. According to the AHRQ website, the five chosen are "relatively inexpensive to use," meaning they are used because they are cheap to measure. Ironically, even by the authors' own methodology, three of the measures are in the good range, one is on the edge of good, and the last one has been improving. Yet the authors inexplicably allege that quality has not changed. —Dan Johnston 14 REGISTERED NURSE step-down unit. RNs in his unit typically juggled seven to nine patients per shift. One night in August 2004, Darby had nine patient assignments on top of acting as charge nurse, and everybody else had 10 or more. The entire unit objected, but no help came. He remembers, regretfully, telling one of his more alert patients that he should call him if he really needed anything, but otherwise "I probably won't see you." At the end of his shift, Darby told his supervisor "either you shred my license, or the state's going to shred my license, but I can't do this anymore." When she asked what he planned to do, he replied, "I'm going to California. They have ratios." By October, he was working in the neuro ICU at UCSF Medical Center. Many other RNs from around the country followed Darby's lead, flocking to California for work and often permanently relocating there. Within the state, nurses who had left hospital work dusted off their licenses and returned to the bedside. And young people, as well as people looking for second careers, flooded nursing programs as nursing became once again not only a viable, but desirable, career. According to October 2008 data from the California BRN, about 98,800 more actively licensed RNs are working in the state since the ratio law was signed in 1999. "We always said, 'If you make it safe, nurses will work,'" said Zenei Triunfo-Cortez, a post-anesthesia care unit RN at Kaiser Permanente South San Francisco and a member of the CNA/NNOC Council of Presidents. "And it's come true." Staffing ratios have so revolutionized the practice of nursing that RNs might as well call the days before ratios "B.R." and the time after ratios "A.R." "I think through the past few years, it's really changed everything," said Rita Batchley, a labor and delivery RN at Ventura County Medical Center in Ventura, Calif. and chief nurse representative at her facility. "Before ratios, when I worked in med-surg, I never had less than a six to eight patient load and we just ran and ran. It's just so much better than before."

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