Nurses Rally in DC for Patient Safety
Today is the anniversary of the birth of Florence Nightingale — the founder of modern nursing and on Capitol Hill, a thousand nurses used the occasion to call for worker and patient rights. Demonstrators want
increased staffing ratios, collective bargaining rights and improved patient care which they say are missing from the health care reform law. FSRN’s Karen Miller has more.
Nurses Rally Renews Debate Over Mandatory Staffing Ratios
Robert Lowes
May 12, 2010 — Nearly 1000 registered nurses rallied today outside the US Capitol in support of legislation that would set adequate ratios of nurse-to-patient staffing in the nation’s hospitals to ensure good care and prevent nurse burnout.
Virtually everyone agrees that hospitals need more nurses on duty, but when it comes to a solution, the 1000 voices in Washington, DC, during National Nurses Week were not speaking for their entire profession.
These nurses were members of the 150,000-strong National Nurses United (NNU), a union formed from the recent merger of the California Nurses Association/National Nurses Organizing Committee, the Massachusetts Nurses Association, and United American Nurses. Ambitious, aggressive, and ready to take up bullhorns and protest signs, the NNU aims to unionize every nurse in the country.
"We should all be under the same roof," NNU copresident Karen Higgins told Medscape Medical News.
In contrast, another powerful force in the profession, the American Nurses Association (ANA), stands opposed to lawmakers regulating how many nurses work a given shift, which has already happened in California. The ANA would rather see Congress follow in the footsteps of other state legislatures and pass a law requiring hospitals to develop customized staffing plans with strong input from nurses.
In a way, the disagreement between the NNU and ANA should come as no surprise. The California Nurses Association and the Massachusetts Nurses Association are former ANA affiliates who left the fold, and the United American Nurses used to be the ANA’s official labor arm. So the clash over staffing regulations reflects a battle for the loyalty of individual nurses.
"The Study Shows We Were Right All Along"
The nurses that gathered in Washington, DC, today had several messages to deliver to lawmakers. One was a sense of frustration about the new healthcare reform law, which fell short of the NNU’s vision of a single-payer system. In a recent article in the Huffington Post, NNU executive director Rose Ann DeMoro characterized the law as "wimpy" and geared to the needs of health insurers rather than patients. For example, the law will allow insurers to sell their products across state lines, motivating them to "set up in the least-regulated states in a race to the bottom, threatening public protections won by consumers in various states," according to DeMoro. In addition the law lacks a competing government-sponsored health plan — the public option — that would keep private plan premiums under control.
Worse yet, lawmakers who drafted reform legislation did not seek the input of frontline nurses on how to improve the quality of patient care, said NNU copresident Higgins. "We were not involved in this discussion. We were pretty much left out."
Other items on the NNU agenda were a bill that would restore the collective bargaining rights of nurses in the Department of Veterans Affairs and another that would eliminate manual lifting of patients by nurses in most circumstances and require hospitals to do the job with mechanical devices.
Arguably the most controversial agenda item was a bill on staffing levels titled the National Nursing Shortage Reform and Patient Advocacy Act. The bill is modeled after a landmark California law passed in 1999 and implemented in 2004 that sets nurse–patient ratios for various hospital settings. A nurse may not care for more than 5 patients on a medical-surgical unit, 2 patients in an intensive care unit, or 3 patients in a labor and delivery unit, for example.
The American Hospital Association is on record as opposing any law that would limit a hospital’s flexibility to determine the appropriate staffing levels for its employees. Left unsaid is the additional expense such laws would impose. However, hospitals can afford to hire extra nurses because improved patient outcomes will lower their overall costs, according to Higgins. "You cut down on infections and injuries. Patients come home earlier."
The NNU is touting a study published last month in Health Services Research reporting that mandatory staffing levels in California have helped reduce mortality rates among general surgery patients while improving nurse job satisfaction. The study, which came out of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing, Philadelphia, stated that if hospitals in Pennsylvania and New Jersey were to institute California-style staffing levels, deaths among surgery patients would decrease by 10.6% and 13.9%, respectively.
"The study shows we were right all along," said Higgins. "The more nurses you have, the better off patients are."
Mandatory Ratios Have Their Critics
Although the NNU points to the study in Health Services Research, not everyone agrees that nurse staffing ratios in California have lived up to expectations. In February 2009, the philanthropic California HealthCare Foundation published a study finding that although the California law put more nurses to work, it had "at most a marginal impact" on hospital financial stability, and "there was no evident change in patient length of stay or adverse patient safety events."
One critic of taking the California law national is Peter Buerhaus, PhD, RN, a professor of nursing at Vanderbilt University, Washington DC. Mandatory staffing arrangements, Dr. Buerhaus told Medscape Medical News, will lead inevitably to greater inefficiency and higher costs without the likelihood of improved care. His solution for undernursed hospitals smacks more of a free-market philosophy: Give these institutions a sufficient financial incentive to improve patient safety, and they will figure out a way to do. Some hospitals would be forced to address nurse–patient ratios, some would not.
"Not all patient safety problems have to do with staffing," Dr. Buerhaus said.
He worries that by failing to deliver what it promises in terms of patient care and lower costs, mandatory staffing ratios could hurt the reputation of his profession. The public, he said, might suspect such regulations were designed only to keep nurses off the unemployment line.
He also warns that the push for mandatory ratios could divide the profession. In an article in the March-April issue of Nursing Economic$, Dr. Buerhaus writes that nursing leaders should consider other solutions that "have less chance of fracturing relationships within the nursing community."
"Our Approach Doesn’t Treat Nurses Like Numbers"
The ANA solution to a shortage of bedside nurses is a compromise between imposing across-the-board standards on hospitals and dangling incentives in front of their noses. The bill it supports, titled the Registered Nurse Safe Staffing Act, would require hospitals to work with direct-care RNs to determine the number of RNs needed on each shift and in each unit. Staffing systems must reflect, among other things, recommendations from specialty nursing organizations, as well as the skill sets of individual RNs. Hospitals that ignore the law are subject to fines.
The ANA stresses that its plan puts a premium on flexibility and a nurse’s good judgment.
"We believe in having nurses who are the frontline workers — who know their patients best and who know their units best — develop the best staffing ratios," said Rose Gonzalez, RN, ANA director of government affairs. "Our approach doesn’t treat nurses like numbers (in a ratio), but as an individual responsible for care."
For its part, the NNU views the ANA plan as an open door for widely varying and potentially harmful staffing levels among hospitals. "Why shouldn’t you get the same level of care at one hospital vs another?" asked Karen Higgins. She also distrusts the source of the plan.
"The ANA is now mostly hospital administrators," she said. "It’s basically an organization that works for the hospitals."
Rose Gonzalez counters that the ANA is very "staff-nurse driven," with many of its members belonging to nurses unions. Higgins’ characterization of the ANA, said Gonzalez, is merely "a way to create a difference between us and them."
Gonzalez, however, draws some differences between the 2 groups as well. "We’re a professional organization," she said. "We’re not just about rallies. We’re about advancing issues."
The participation of the 2 groups in the healthcare reform debate highlighted these differences, according to Gonzalez.
"The NNU was looking for a single-payer system, and once they didn’t get it, they were very frustrated and they stepped away from the table," said Gonzalez.
"We have a position that supports single-payer, but we’re also pragmatists. We know at times you have to move toward incremental reform. So we stayed at the table. We didn’t say it was single-payer or nothing. We worked to get a compromise."
Say They Won’t Sign Concessionary Contracts
During National Nurses Week, registered nurses from across the country May 11 put health care employers on notice that they do not intend to sign concessionary collective bargaining agreements that are “injurious” to their patients or their profession.
Some 1,000 nurses attending the first annual National Nurses United Staff Nurse Assembly enthusiastically adopted a resolution to promote “national collective bargaining standards for all NNU contract agreements” that emphasize improvements for patients, nurses, and the nursing profession.
In introducing the resolution, NNU Executive Director Rose Ann DeMoro contended that there is an “orchestrated campaign across the country by employers to lower nurses standards in their contracts” as well as replace nurses with everything they can, including technology.
“We need to tell employers it’s a new day in America and registered nurses are going to stand up and not take it anymore,” DeMoro said.
NNU, which is the first national union of direct care registered nurses, was formed in December through the merger of the California Nurses Association/National Nursing Organizing Committee, the United American Nurses, and the Massachusetts Nurses Association. The union has some 150,000 members across the country.
Prior to voting on the resolution, the nurses heard from a panel of colleagues who recently have been engaged in fierce contract fights with their employers.
Patty Akin, a member of the NNU affiliate Pennsylvania Association of Staff Nurses and Allied Professionals said she and her colleagues engaged in a 28-day strike against Temple University Medical Center and were successful in fighting off a “gag clause” sought by the employer that would have prevented nurses from criticizing the institution in public at any time. Despite the fact that the employer hired 850 “scabs” from 42 different states and spent $20 million on the strike, at the end of the strike, 93 percent of the members were still on strike walking the picket lines, she said.
Strike Vote Scheduled in Minneapolis
Linda Hamilton, the president of the Minnesota Nurses Association, told the conference that some 12,000 nurses in the Twin Cities are scheduled to take a strike vote May 19 in their contract negotiations with six hospital systems that own 13 hospitals and they could strike June 1. The major issues are staffing and safe workplaces, she said.
If the strike occurs, it would be the largest nurses’ strike ever in this country, according to MNA.
In introducing the panel, Jill Furillo, the NNU national bargaining director, said that in collective bargaining across the country nurses are seeing management proposals on the table “like we have not seen in 20 years.” The employers’ goals, she said, are to take away the hard fought standards nurses have achieved through their unions, such as better staffing, higher wages, pensions, and health care benefits.
Furillo contended that health care employers are “attacking us with the same takeaways almost word for word” across the country, with the same proposals being put on the table from Philadelphia to Minneapolis to Kalamazoo, Mich. “We are seeing proposals to eliminate our unions,” she said, adding that management is hiring “union busters” to conduct the employer’s campaign against units that have been organized for more than 30 years. Previously, she said, “union busters” were only hired when nurses were engaged in organizing campaigns.
“If they can extract concessions out of any one of us, then they have a foot in the door to go after all of us,” Furillo said.
According to the resolution, health care industry employers are demanding concessions in RN professional practice and patient care standards “in pursuit of a greater economic bottom line and increased control of its nurses, other staff, and patient care practices.”
National Standards Outlined
The nurses agreed that national RN standards need to be established throughout the country in order to promote the retention of experienced RNs and assist in recruitment of new nurses. Among the standards NNU affiliates will strive to achieve in all their collective bargaining contracts are:
- enhanced staffing based on individual patient acuity with minimum, specific nurse-to-patient ratios and contract language to enforce ratio standards;
- restrictions on unsafe floating to units where nurses are not experienced;
- a ban on mandatory shift rotation and mandatory overtime;
- mechanisms to contain exposure of patients and nurses to pandemics and other communicable diseases;
- improved retirement security through defined benefit pension plans and employer-paid retiree medical benefits;
- limits on the introduction of new technology that displaces nurses or RN professional judgment;
- workplace safety protections to provide for health and safety for nurses; and
- provisions that enhance and promote unity and collective strength for unionized nurses.
- The nurses also agreed that NNU affiliates will not sign concessionary agreements that undermine RN contract standards including:
- takeaways in compensation, health and retirement benefits, or work hours or schedules;
- two-tier plans that establish reduced pensions, lower pay, or other reduced standards for new hires;
- merit pay agreements or other proposals that erode seniority or years of service as an RN; and
- layoffs of RNs or displacement of RNs with other staff.
Solis Now ‘Secretary of Workplace Safety.’
Labor Secretary Hilda Solis told the conference that “so much has happened in the last two months” that she wants to change her title to be called the Secretary of Workplace Safety. She said that 14 people a day die at work, and more than 4 million are seriously injured. “Most of those fatalities and injuries are easily prevented,” she said, adding “this can no longer go on. We have to stop the madness.”
Solis said she is committed to making sure that workers’ health and safety is protected. “All workers deserve a safe workplace,” Solis said, adding that worker protection laws “apply to every single person who works in the United States.”
Solis told the nurses that they are on the “front line of patient care” in this country, and “we need to make sure that [your] health and safety is protected.”
The labor secretary said her department is working on new standards that will protect nurses, including one on infectious diseases. Currently, the Occupational Safety and Health Administration only has a standard to cover bloodborne pathogens, she said, but it now is working on a standard that will protect nurses against infectious diseases.
Earlier this month, OSHA announced in the May 6 Federal Register that it was requesting information on occupational exposure to infectious diseases in health care settings (86 DLR A-11, 5/6/10). OSHA is considering what measures to take, including rulemaking or guidelines, to protect workers against infectious diseases.
Solis also noted that DOL has announced rulemaking on an Injury and Illness Protection Standard that would require all employers to “find and fix” every hazard in their workplace.
OSHA said in its latest regulatory agenda that it plans to hold stakeholder meetings in June 2010 on a forthcoming injury and illness prevention program rule (79 DLR C-2, 4/27/10).
Solis told the nurses that in 2008 the Bureau of Labor Statistics reported more than 36,000 health care workers were injured by lifting and transferring patients. In addition, she said, 12 percent of nurses who plan to leave the profession cited back injuries as a contributing factor.
“What a waste when the career of an experienced nurse is ended years or decades too early because of an easily preventable back injury,” Solis said. “In these days of ever-rising health care costs, what a waste of money to pay workers compensation and disability for easily preventable back injuries.”
Solis applauded the introduction in Congress of legislation (S. 1788, H.R. 2381) that would require OSHA to issue a standard requiring health care workers to use mechanical lift equipment when moving patients. The legislation also would require facilities to implement safe patient handling and injury prevention plans, train workers on safe patient handling, and authorize $200 million in grant dollars for acquisition of safe patient handling equipment (94 DLR A-7, 5/19/09).
That legislation is one of a number of bills the nurses will be marching and rallying around May 12, before they go off to lobby their members of Congress. Sponsors of the bills are scheduled to address the nurses.
Another bill the nurses are supporting is the National Nursing Shortage Reform and Patient Advocacy Act (S. 1031, H.R. 2273), which would establish minimum ratios of nurses to patients for all hospitals in the country (91 DLR A-8, 5/14/09). Introduced by Sen. Barbara Boxer (D-Calif.) and Rep. Jan Schakowsky (D-Ill.), the bill is modeled after nurse-patient staffing ratio legislation adopted in California, which has been in effect since 2004.
Text of the resolution on national contract standards may be accessed at http://op.bna.com/dlrcases.nsf/r?
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