Issue link: https://nnumagazine.uberflip.com/i/198066
Ratios:4 3/18/09 4:10 PM Page 15 "Before, nursing felt more like an assembly line: Get 'em in, get 'em out. You became like a robot and shut down emotionally. If you spoke up before, you were considered to be whining, complaining, and told to just 'suck it up.' Now having proper staffing is really more respected, and nurses know it."—Rita Batchley, RN Batchley explained that it's not simply the work and pace that's different; nurses' expectations of the kind of care they give and how they are treated have been raised, and the dynamic between nursing and management at her hospital has changed. Like many other RNs, Batchley reports that she can devote more time to teaching patients how to take care of themselves and, in her case, their newborns. "Before, nursing felt more like an assembly line: Get 'em in, get 'em out," she said. To survive, "you became like a robot and shut down emotionally. If you spoke up before, you were considered to be whining, complaining, and told to just 'suck it up.' Now having proper staffing is really more respected, and nurses know it. There's more open communication with managers. If we get a sick call and they don't remedy the situation, you can bet the managers will hear about it. Nurses are a lot happier because, guess what? If we're treated more humanely, we act more human." Darby also agreed that working in California under ratios made him realize how, back in Pittsburgh, he had numbed himself to abysmal conditions. Darby said that staffing was so bad at his old hospital that it wasn't uncommon for RNs to discover that a patient had died, but nobody knew the exact time of death. "Looking back now, I realized how callous and hardened I had become, because something like that was no big deal," he said. Marla Liberty, an RN at Marina Del Rey Hospital near Los Angeles is glad that she can once again spend five minutes to hold a patient's hand and comfort him if he needs it. Before ratios, she would not have had five minutes to spare. "We're still busy, but before you were just running around nonstop trying to get your patients their medicines," Liberty said. "You had no time to view them as individual people at all." A question that surfaces repeatedly over staffing ratios is whether they directly translate to better patient outcomes. Overall research about the subject so far points to yes. Various studies have shown that lower staffing is a key cause of preventable deaths and the spread of antibiotic-resistant infections. Higher staffing is associated with a reduction in hospital-related mortality, failure to rescue, and lengths of stay. When hospitals add patients to an RN's patient load, the risk of hospital-acquired pneumonia, respiratory failure, and medical complications goes up. Kathy Carder, an RN who works in CNA/NNOC's nursing practice division and often compiles patient care reports based on assignment despite objection (ADO) forms submitted by nurses, says she has observed a dramatic drop in the number of sentinel events after ratios went into effect. "It seems that with lower ratios, the nurses are catching it before a patient goes south," said Carder. "We're seeing fewer numbers of falls and disconnections from ventilators. The ADOs are now more about potential bad things that could happen rather than something that actually happened." Of course, registered nurses are not the only ones with reason to support ratios. Ultimately, it's the patients who benefit from better nursing care, and many savvy ones are not only expecting, but demanding it. Christina Swift, a medical-surgical RN at Kaiser Permanente in Fresno, Calif. and a CNA/NNOC board member, says that quite a number of MARCH 2009 patients have started conversations with her about whether the hospital is meeting ratios and whether the nurses are satisfied with staffing levels. "Every now and then, a patient will ask me how things are on the floor," said Swift. "They're curious and ask me, 'Kaiser staffs to ratios, don't they?' They pay attention to that and appreciate it. They know that they're going to get better care, and a nurse who's less stressed." Even though RNs and patients know mandatory staffing ratios are a must to ensure safety and quality care, the hospital industry is continually trying to undermine the standards. As early as 11 months after ratios were first implemented, Gov. Arnold Schwarzenegger issued an emergency order to delay the improvements scheduled for Jan. 1, 2005, and to exempt emergency departments from ratios. Hospitals also did not, and some still do not, adhere to the rule that ratios apply "at all times," meaning that hospitals must provide additional RNs to relieve coworkers during meals and breaks to avoid doubling up of patient loads— a violation of the ratio law. CNA/NNOC RNs launched a massive public campaign against the governor to defend ratios, and also won a number of decisions in court to uphold the ratio law as passed. A Sacramento judge decided that no state of emergency existed to justify Schwarzenegger's order, and another ruled that "at all times" did indeed mean 24/7, aroundthe-clock applicability. "The ratios are great, but I always say they're only as good as the nurses who are willing to report violations" and speak up, said Batchley. As the economy worsens and hospitals are looking to cut even more corners to reduce costs, registered nurses also warn that employers may try to get away with staffing only to ratios and not acuity, as the law actually prescribes; reducing ancillary help; not providing dedicated meal and break relief RNs; using lower-licensed staff; or even playing with the names and mix of units in order to sneak by with lower staffing. "Just because we have ratios doesn't mean it can't be taken away," cautioned Darby. "We have to fight for it and to improve upon what we have." They say a good defense is a strong offense, so one of the ways CNA/NNOC is protecting ratios is by expanding ratios to other states. In past legislative cycles, it has introduced ratio bills in Illinois, Maine, and Texas. This year, CNA/NNOC has submitted or plans to sponsor ratio legislation in Arizona, Nevada, Texas, Pennsylvania, Illinois, and Ohio. Nurse leaders are also preparing to push for a national ratio and nursing rights bill. "Nurses in California have a duty to protect what we have and share what we have with other nurses and make them understand that they can have it too," said Darby. He also pointed out that he wants ratios to protect his family and loved ones back in Pennsylvania and Ohio. Recently, when his grandmother was hospitalized for heart problems, he flew to Cleveland to stay by her bedside. "Without ratios, I wasn't sure she would have an advocate at the bedside. And, eventually, I would like to be able to go home and work." ■ Lucia Hwang is editor of Registered Nurse. W W W. C A L N U R S E S . O R G REGISTERED NURSE 15