Landmark Ruling is First to Align Staffing Decisions with RNs’ Professional Standards and Their Ability to Meet Those Standards
View the full text of the arbitration decision
In a landmark victory for unionized registered nurses and their patients at North Adams Regional Hospital in North Adams, Mass., an independent arbitrator has found that the hospital can no longer admit "more patients than nurses can safely care for." As part of a ruling released in early March, the arbitrator issued an order for the hospital to "cease and desist" from these practices. For a fax copy of the decision, call 781.249.0430.
"The nurses of North Adams Regional Hospital have made history with this decision and, if the hospital complies with arbitrator’s order, we believe it will make this hospital one of the safest in the region by guaranteeing every patient first-rate nursing care," said Robin Simonetti, RN, co-chair of the nurses’ union at NARH.
The ruling is the first of its kind to deal with the issue of RN staffing and a hospital’s obligation to assign patients based on nurses’ ability to meet their professional practice standards, according to the Massachusetts Nurses Association, the union which represents the nurses at the facility.
In his 30-page decision, Arbitrator Michael Stutz ruled that the hospital violated the nurses’ rights because "unsafe staffing was allowed by the hospital to occur without cropping admissions or transferring patients and without adding another nurse. Individual nurses were injured by having to work under unsafe conditions."
"The nurses of this hospital are thrilled with this ruling but the biggest winners of all in this decision are all the future patients of NARH," said Mary McConnell, RN, chair of the nurses’ union at NARH. "This ruling protects nurses from being forced to care for too many patients at once and places decisions about the safety of patients in the hands of those ultimately accountable for that care."
According to Ruth O’Hearn, RN, a long-time nurse at NARH and one of the nurses whose grievances over unsafe staffing incidents in May-June 2002 were the subject of the decision. "While a long time coming, I see this decision as a very positive step towards the improvement in the quality of care at our hospital. While we all want our hospital to improve and be successful, at the same time, I want to make sure that it is providing safe patient care. Ultimately, this decision says it is up to we nurses on the front lines to determine what we can and cannot safely do and under what circumstances."
Mirroring problems faced by nurses across the state and the nation, the arbitration decision in favor of the RNs at NARH grew out of a multi-year struggle by the nurses to fight decisions by hospital management to cut registered nurse staffing levels in an effort to slash operating costs. This included a nearly unanimous vote by the nurses to authorize a strike over these issues in 1999, and followed later by a concerted effort to win revolutionary contract language in 2001 that protected RN’s professional judgment and to protect patients from unsafe conditions. A provision in the NARH MNA contract states, "[T]he hospital would only keep and admit the number of patients that registered nurses can safely care for." It also calls upon the hospital to promulgate and adhere to staffing policies and procedures that comply with "professional standards of nursing practice."
The problems with staffing and patient care at NARH came to a head in November 2001 when the hospital, on the advice of a consultant, cut the RN staffing, resulting in a dramatic increase in the number of patients assigned to each nurse. The hospital also eliminated its "float" pool of nurses who were to be on hand to staff units experiencing a spike in census or sick call. At the time of that decision’s announcement, the nurses’ union held a press conference announcing its objection to the plan and warning the public of deterioration in the quality and safety of patient care.
True to the nurses’ predictions, as a result of these decisions, many nurses, particularly on the night shift, began to see their patient loads double, from being responsible for five or six patients, before the changes, to often being assigned 10–12 patients after the staffing cuts.
Numerous grievances, in the form of unsafe staffing reports, were filed by many nurses throughout the winter and spring of 2002, with nine of those grievances filed between May and June of 2002 ultimately selected to be put forward for review by the arbitrator.
The arbitrator, after hearing evidence from the hospital and the RNs, found that in all nine (9) incidents cited by the RNs, the hospital violated the contract by requiring RNs to care for too many patients and found each instance to represent an "unsafe" situation. The testimony of the nurses was supported by a nurse administrator at the time, who testified that "she repeatedly expressed concern about staffing levels to higher management because she believed that the level of care was insufficient to meet the patient needs." The arbitrator writes that the administrator testified that "she was later forced to resign, told that she was ‘not the leader’ that management wanted for the Hospital."
The arbitrator’s decision focuses great attention on the scope of nursing practice and the numerous responsibilities that comprise their role. Stutz wrote, "Nurses are subject to established professional standards that define proper nursing practices. The Standards of Clinical Practice, for example, include ….assessment, diagnosis, outcome identification, implementation and evaluation. These standards of care include measurement criteria and documentation. In order for nursing practice to meet these professional standards, it is beyond dispute that nurses must have a patient assignment load, including number and acuity that allows sufficient time to meet all the basic standards of care."
Referring to the hospital and the union, the decision states, "The parties expressed intent to assure nurses that their professional standards will be respected and that nurses will not be assigned to a greater number or acuity of patients than they can safely care for. Should census or acuity threaten to become too high, then management must correct the situation by adding nurses, stopping admissions or taking other measures to ensure that nursing assignments remain within safe parameters."
The decision cites the fact that under Massachusetts law, registered nurses are held responsible for their patient care, while also citing nursing research, particularly a study published in the Journal of the American Medical Association, which demonstrated the negative impact of unsafe patient assignments on the safety of patients. "Patients in hospitals with the lowest nurse staffing levels (eight patients per nurse) have 31% greater risk of dying than those in hospitals with four patients per nurse," the ruling states.
While ordering the hospital to cease and desist from forcing nurses into situations that endanger patients, the arbitrator stopped short of accepting the MNA’s request that NARH be required to hire more RN staff. While citing recent improvements in staffing and the fact that these incidents occurred more than three years ago as reasons for holding off on requiring a staffing increase, the wording of the decision holds open the possibility that this could be a remedy in the future.
"It is our sincere hope that our administrators have learned a lesson through this process and will now heed nurses’ judgment in these situations," McConnell explained. "However, we intend to spend a great deal of time educating our members of the importance of documenting very carefully their objections to unsafe staffing assignments so that we have a detailed record to take back to the arbitrator should that ever become necessary."
The MNA points out that the ruling not only represents sound labor law, but also complies with recommendations regarding RN staffing and decision making promoted by the nation’s leading experts on nursing and patient safety. In fact, in late 2003, the prestigious Institute of Medicine of the National Academies of Science issued the most extensive and exhaustive report on the issue of nurse staffing and patient safety, which recommended that ultimate decisions regarding RN staffing should lie with direct caregivers. It recommends that hospitals "overstaff" units to account for fluctuations in census, that float pools be utilized and that hospitals should transfer patients from units where nurses are overburdened or working beyond 12 hours.
For O’Hearn, the arbitration process and its result underscores her faith in unions and the protection a union offers for nurses to speak out on behalf of their patients and their practice. "I can tell you that in this current health care environment, I would never work in a hospital that was not unionized."
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