MASSACHUSETTS NURSE NEWSLETTER :: April 2008

Author Suzanne Gordon raises a series of compelling issues in her soon-to-be released book “Safety in Numbers: Nurse-to-Patient Ratios and the Future of Health Care.” Utilizing survey data, interviews and additional original research, Gordon and healthcare workforce researchers John Buchanan and Tanya Bretherton weigh the cost, benefits and effectiveness of ratios in California and the state of Victoria in Australia, the two areas where RN staffing levels have been mandated for the longest length of time. Gordon, also the author of “Nursing Against the Odds: How Health Care Cost Cutting, Media Stereotypes, and Medical Hubris Undermine Nurses and Patient Care” and “Life Support: Three Nurses on the Front Lines” recently sat down with the editorial board at MNA to discuss her latest book.

For someone who has spent the better part of two decades writing about nursing and nursing issues, what has led you to focus an entire book on the issue of safe staffing legislation?

The answer is both personal and professional experience. I wrote my first book about nursing, “Life Support: Three Nurses on the Front Lines” which profiled three nurses at the Beth Israel hospital in Boston in the early 1990s. I spent almost three years at the BI and was constantly impressed with the quality of the nursing care. There was no talk about staffing ratios then – things looked really good for nurses and patient care in the late 80s and early 90s as hospitals were trying to resolve the last nursing shortage. I never asked about ratios and no one mentioned them. Why? Because they were excellent. On med/surg the ratio was probably 1 to 4 and remember this was a time when nurses were working eight hour days, were younger and patient acuity was much lower. The care was superb.

Enter managed care – or as I call it mangled care – and hospital restructuring. And I could see with my own eyes and hear with my own ears how bad things were getting and continued to become. I watched nurses scrambling. I heard their stories. I saw the despair and weariness etched on their faces. And I saw and heard what happened to patients. My mother, mother-in-law and father-inlaw were some of those patients. Nurses were rushed and brusque; some seemed downright callous and uncaring. They got the basics done – sometimes – but when it came to emotional connection, education, advocacy, forget it; they simply did not have time.

What is more, before restructuring, when I’d done interviews with patients and family members about nursing care, or when I appeared on call-in shows about nursing on the radio, all I heard were great stories about nurses. “Oh the nurses were so terrific…oh, they made such a difference.” Those were the comments I would hear. Then I began to hear something entirely different. “We barely saw the nurse.” “Where were the nurses?” “Oh they were so rushed; I didn’t want to bother them. Poor things.” So you had patients trying to nurse the nurses. Or you had patients actually blaming the nurses for system problems – like understaffing and work intensification because after all, most patients and families aren’t sophisticated enough to tell the difference between the nurse who’s required to enact bad policies and the people who make those policies – people with whom the patient never comes in contact.

So it was becoming clear that there was something drastically wrong. And then of course, as I was reporting on what was wrong, we started hearing about efforts to implement staffing ratios. I spent a great deal of time in California and several months, on and off, in the state of Victoria in Australia. I wrote about staffing ratios in “Nursing Against the Odds” but I could only deal with the subject in brief. It seemed impossible not to explore this issue more thoroughly.

I decided I wanted to write a book about the issue for the series of books on The Culture and Politics of Health Care Work that I co-edit with Sioban Nelson, who is now the dean of the University of Toronto School of Nursing and who was, until several years ago, the dean at the University of Melbourne School of Nursing. I knew that I could not possibly research the situation in Victoria – the other major spot where ratios have been enacted – from this distance. Fortunately, I was able to hook up with two wonderful health care workforce researchers –John Buchanan and Tanya Bretherton at the University of Sydney. They had documented and analyzed work intensification or overload in nursing and other areas of work. They had conducted a number of excellent studies on nurses’ problems in Victoria for the Victorian Branch of the Australian Nursing Federation. I was so thrilled that they agreed to partner with me and look at the history, struggle for, and outcomes of ratios in Victoria.

Having spent years studying this policy initiative in California and Australia, the most important question nurses and policymakers would want to have you and your colleagues answer is simply this…are the ratios working?

First, let me say that John, Tanya and I are not cheerleaders for ratios. We support ratios but we do not think they are a panacea for the many ills besetting nursing. But we are convinced that other solutions will simply not work without the control of the nursing workload. If nurses come to work not knowing whether they will take care of four patients or 14 patients, then they will simply burn out and either quit or detach from their work.

The dirty secret of work overload is that if you overburden nurses with too many patients who are as sick as they are in hospitals today, patients will become a problem, an undesirable, and not a challenge to them…and the challenge is the reason why they became nurses in the first place. Nurses will want to flee their patients and their workplaces, not embrace patient care and their work. And that’s exactly what we are seeing. We are seeing nurses facing unacceptable levels of stress. We are seeing patients Safety in numbers: nurse-to-patient ratios and the future of health care MNA goes one-on-one with award-winning health care journalist Suzanne Gordon April 2008 Massachusetts Nurse Advocate suffer, and we are seeing new recruits fleeing the hospital because they just can’t take the work overload.

We have seen all this occur in California and in Victoria, which is why the ratios solution seemed to these nurses the only way to begin solving a whole host of problems. And yes, also as a solution to work overload; to unbearable levels of job stress; and to burn out…the ratio solution is clearly working. In Victoria, more than 7,000 inactive nurses were brought back into the systems. Nurses we have interviewed have said they cannot imagine how they managed without ratios and have fought – in two sets of subsequent contractual negotiations – to fight to retain and improve ratios that were implemented in 2000.

In California, nurses fought for over a decade to win ratios and all the nurses I have interviewed say things are better because of those nurses. Linda Aiken and Sean Clarke at the University of Pennsylvania have done research on the ratios there and have concluded that they are indeed improving recruitment, retention, job satisfaction and reducing burn out.

Are they solving every problem? No. Can they solve every problem? No. But when it comes to patient care we have to be very careful not to let the perfect become the enemy of the good.

Did you detect key differences in approach between California and Victoria that other states like Massachusetts can learn from?

Yes, I think it makes a lot of difference when you have a tax supported universal health care system – as they do in Victoria – and a largely for-profit private system as we do in the US. For example, because they actually do health care planning in Victoria, ratios are a funded mandate.

It also makes a difference when you have a union that represents 65 to 70 percent of nurses in the system, a union that additionally represents nurse unit managers and even CNOs. What is really interesting about the situation in Victoria is that so many nurse managers understood what, tragically, nurse managers fail to understand here. Ratios make it easier to manage care. Ratios protect the nursing budget. With ratios, doctors and medicine and administration cannot keep poaching from the nursing budget. Also the Victorian ratios are not 1 to 4 on med/surg but 5 to 20, an interesting twist which merits exploration.

You focus an entire chapter in your book on the research that has been done concerning this issue. In summary, what did your review of this research tell you about the efficacy about regulating staffing levels?

The research is unequivocal. Staffing – particularly understaffing – makes a significant difference in patient mortality and morbidity. That’s unarguable. We don’t know what the perfect number is… is it 1:3, 1:4, 1:5? We just don’t know. But we sure know what it isn’t. And it isn’t 1:7, 1:8 or 1:15. What these studies also suggest is that if people want to hone in on a more precise number above which it is unsafe to staff, then do the research and figure it out. It’s tough but it ain’t rocket science. Plus, we need to look not only at patient outcomes but to also consider the impact of work overload on nurses’ health. It’s time we stopped considering nurses as some sort of disposable medical equipment. You use it, you break it, you throw it out and well, we know nurses are self-sacrificing angels of mercy, so they won’t be bothered when their health suffers. That kind of thinking must stop.

You also featured an entire chapter in your book on the arguments the hospital industry and others have used against this type of legislation. You even used arguments taken directly from Mass. Hospital Association ads against the MNA bill. How do the industry’s arguments stand up against the experience with ratios you studied in California and Victoria?

The issues made by many opponents to ratios are serious ones. It is because we take them so seriously that we have dedicated an entire chapter to them. We believe, however, that any debate about ratios should be based on a realistic view of how nursing care is provided in an unregulated environment in which considerations of cost tend to predominate. Much of the anti-ratio propaganda is, unfortunately, based on a fantasy of how care is currently delivered and a fictional view of how much power nurse executives have in the current environment.

In studying how these laws were achieved in other places, what advice would you give our readers about what is needed to make this law pass here in Massachusetts?

It’s absolutely critical to mobilize the public, nurses, and patients and families around these issues. I have long been a proponent of ratios because of my professional observations and because I have observed the care close friends and relatives receive. I have become even more concerned about staffing arguments since my own unfortunate experience with hospital care a year and a half ago.

I had an emergency appendectomy in Vermont. It was Columbus Day weekend, not the best time for such an event. The unit was clearly understaffed. Things were particularly hectic at night. I realized then, what a myth it is that patients aren’t as sick at night and therefore you don’t need as many nurses on the unit. I was operated on at around 8 p.m. on Sunday night and got back to the unit near midnight. It was nighttime and I was sick.

When I was alert enough to observe things, what I realized was that new graduates and even people still in nursing school were my primary caregivers. Some of them had four year degrees in other subjects. They were very smart, but they had no experience in nursing and clearly no mentoring. They had way too many patients. I could see them fall apart in front of my eyes as things got more hectic. One of them thrust a basin and washcloth in my hands and told me, “Here, wash yourself.” I was on pain meds and hadn’t pooped for three days. No one even mentioned a bowel regimen. I ended up with two serious complications, one which still bothers me. And I almost ended up with an impacted bowel and am thankful I didn’t get an infection because one of the nurses didn’t wash her hands. When I describe my experience to people, they say, “I can’t believe that happened to you.” Well, let me tell you, I wasn’t shy, I politely told them I was a journalist and that I wrote about nursing. And it mattered not a jot. If you’re taking care of seven patients – some of who were a lot worse off than I was – you just can’t deliver good care. When I lay in that hospital bed, in pain, frightened, and far from home, all I could think about was, “how can anyone (pardon my French) screw around with nurse staffing.” What are they thinking?

Please visit National Nurses Day Event for to sign up for her speaking engagement with the MNA.

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