National Nurses United

Nurse Practice 6/11/06 9:08 AM Page 19 commitment to striving for true excellence in patient care and outcome. Validation of condition deterioration comes from collaboration with a charge nurse, CNS, or resource nurse. As for reporting or referring, in our patient advocacy role, we must at times wake up an attending physician or intern/resident in the middle of the night and report the patient's condition, and secure treatment that will stabilize the patient. Contrast this with California Safe Staffing Standards. These standards are clear as to their priority: (1) Staffing standards based on individual patient acuity for which the RN ratio is the minimum; (2) additional licensed and unlicensed staff based on direct-care RN assessment and a documented patient classification system; (3) ratios apply at all times including meals and breaks, and authorized absences from the unit. This means that all California acute care hospitals must first budget for a sufficient number of direct-care RNs to meet the mandated direct-care RN-to-patient ratios and the additional RN and non-RN staff needed to meet the patient's requirements and needs. Next, the budget must provide for a float/meals and break relief team. Let's review relevant laws regulating RN practice. The primary activity performed by registered nurses in acute care hospitals is ongoing patient assessment, sometimes referred to as ongoing patient surveillance or monitoring. Under California law, such assessment requires direct observation of signs and symptoms of illness, reaction to treatment, general behavior, or general physical condition, and a determination of whether the signs, symptoms, reactions, behavior, or general appearance exhibit abnormal characteristics (Nursing Practice Act). Furthermore, RNs must formulate/design and implement a care plan based on observed abnormalities and then evaluate the patient's response. According to the Institute of Medicine (IOM), assessment is "an important mechanism for the detection of errors and the prevention of adverse events." Studies have shown that errors typically result from problems within the system (e.g. acute care hospitals or nursing homes) where people work. In its publication To Err is Human, the IOM endorses the systems approach to understanding and reducing errors and notes that failure in large systems, such as hospitals and their various patient care units, are mostly due to unanticipated events or factors occurring within multiple parts of the system. JUNE 2006 Direct-care registered nurses, typically, do not control the system. The corporation controls the system. It determines budgetary priorities, expenditures, and cost containment schemes based on its philosophy, mission, and vision. Direct-care RNs are inseparably linked to patient safety. Minimum staffing ratios and staffing up based on the patient's acuity is a safety standard that allows the direct-care RN to observe subtle changes in the patient's condition and recognize the early signs and symptoms of the beginning of a patient's decline. These can only be detectible through the direct-care RN's physical presence and her/his ability to directly observe the changes in the patient's physical and cognitive status. This Rapid Response Team approach has not been scientifically validated. It is based on assumptions and so called "best-practices," also known as "just in time" nursing and medicine. It blatantly disregards scientific studies and findings, which all indicate that RN staffing levels are associated with the rescue of patients with life-threatening conditions and also suggest that RNs contribute importantly to the surveillance, early detection, and timely interventions that save lives. In this instance, it is the direct care RN at the bedside, not the RRT, that meets the legal staffing mandate. CLEAR AND PRESENT DANGER (continued from page 11) where an entire group of professional employees would be deemed supervisors . . .the answer is undoubtedly yes." Similar arguments are made in a companion brief submitted for the Ohio Hospital Association which argued that "when a professional employee exercises judgment in the execution of (certain) functions—including the giving of directions to others—that employee is properly classified as a supervisor." With Oakwood, and many similar cases, hospitals, abetted by the employer-leaning labor board, now have the pretext to trample on the rights of tens of thousands of other RNs. If the Constitutional ideals of free speech and freedom of association are discarded along the way, that appears to be little more than collateral damage to those pushing these policies. As more RNs are joining unions at a more rapid pace today than any other employees, due in no small part to CNA/NNOC, other employers hope to deal a blow to all of labor by blunting the right of RNs to achieve and maintain representation rights. It's no accident that the Ohio Hospital Association brief was also submitted on behalf of the Chamber of Commerce, the main trade association of large corporations. ■ have been percolating for years before the labor board. The cases have been backlogged until the Bush Administration completed its overhaul of the NLRB and stacked it with board members who are hostile to unions. That process is, sadly, now complete. The most recent threat can be traced to a 2001 Supreme Court ruling in a case commonly known as Kentucky River. In a 5-4 vote, the high court said an RN's professional judgment in assigning clinical tasks must be considered as possible supervisory judgment. The court's ruling left a final determination of how to determine supervisory status in the hands of the NLRB. Since then, the anti-union consultants and attorneys have been piling on challenges in anticipation that they could redefine all RNs as supervisors. The tipping point could come in a case known as Oakwood Healthcare Inc. in which a Michigan hospital corporation is seeking to have charge nurses classified as supervisors. As outrageous as it would be to deprive charge nurses of their representation rights, avaricious employers want far more. In its brief on the case, the hospital attorney writes that as to whether the basis has now been laid to "contemplate a situation W W W. C A L N U R S E S . O R G REFERENCES Aiken L.H., Clarke S.P., Sloan D.M., Sochalski J., Silber J.H. "Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction." Journal of the American Medical Association 288(16); 1987-1993. Institute of Medicine (IOM) 2000. To Err is Human: Building a Safer Health System. Washington, DC. National Academies Press. Institute of Medicine (IOM) 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC. National Academies Press. ■ Hedy Dumpel, RN, JD is Chief Director of Nursing Practice and Patient Advocacy for the California Nurses Association. Rose Ann DeMoro is executive director of CNA/NNOC. REGISTERED NURSE 19

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