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The Patriot News: Nurses seek voice in staffing levels, citing patient safety

Nurses seek voice in staffing levels, citing patient safety

By DAVID WENNER, The Patriot-News

View full sizeJOE HERMITT, The Patriot-News The Carlisle Regional Medical Center.

How many nurses does it take to keep hospital patients safe and comfortable?

It’s a long-running source of tension between nurses and hospitals.

It’s also one that will intensify as hospitals head into a perhaps-unprecedented era of financial strain.

Some argue the solution is government-mandated nurse-patient ratios. Others say the key is to give nurses the loudest voice regarding their staffing.

Something approaching a worst-case scenario might have occurred recently at Carlisle Regional Medical Center, where the state painted a frightening picture of conditions that allegedly existed over several weeks in May and June.

Insufficient nurse staffing was the root of the problems, according to the state Department of Health.

For example, the investigation report cites times when as few as three nurses had to care for 30 medical-surgical patients.

It said patients commonly were kept for hours in the emergency room — even after they were officially admitted — because there weren’t enough nurses staffing inpatient units.

It depicts assorted instances of the nurse manager calling nurses at home to fill holes but finding no takers.

Beyond that, the report quotes employees who said nurses who spoke up about low staffing were labeled “troublemakers” and feared losing their jobs.

Carlisle Regional officials, who must obtain state approval on a plan of correction, said they already have started to address items contained in the report, although they maintain the report contains inaccuracies.

Hospital officials dispute the state’s contention that staffing problems might have contributed to deaths of two patients in June, and insists that quality of care at the hospital is excellent.

Carlisle Regional is part of a 59-hospital for-profit chain based in Florida.

Some people familiar with the hospital blame its troubles on tight cost controls dictated by its parent, Health Management Associates.

But it’s likely most if not all hospitals will face unprecedented cost-cutting pressure related to the economic downturn and government cutbacks.

“It’s been there, it’s just incredibly enhanced. … There have been massive reductions in nursing budgets,” said Betsy Snook, a registered nurse and CEO of the Pennsylvania State Nurses Association.

Dr. David Nash, a nationally known health care-quality expert employed at Jefferson
Medical College in Philadelphia, cautioned against hospitals cutting too much.

“In our current environment, we have to be more vigilant than ever about nurse staffing ratios,” Nash said. “A natural cost-cutting avenue is cutting people. We have to be very careful not to cut nurses to save money. It’s a penny-wise, pound-foolish strategy.”

Research has shown proper nursing care increases the likelihood of patients having the fastest possible recovery, while lack of sufficient nursing care can result in problems such as infections and even death.

Some states have mandated nurse-patient ratios.

In Pennsylvania, a bill that sits in a state Senate committee would mandate nurse-patient ratios. For example, intensive care units would have a one-to-one or one-to-two nurse patient ratio, depending on the situation, and a unit for people recovering from general illnesses and surgeries would have a one-to-four ratio.

The bill was introduced by state Sen. Tim Solobay, D-Washington County, who has been pushing similar legislation for a decade.

Yet many nurses oppose mandated ratios.

Snook said her association fears some hospitals would stick with the lowest allowed ratios, and possibly cut staff such as nurse assistants to pay for mandated nurses.

Her organization is pushing a bill that would require hospitals to form a committee, with registered nurses making up at least half its members, to set nurse staffing levels. The nurses also would approve who heads the committee.

The correct staffing level would be based on factors including the sickness levels of patients and skill levels of nurses.

Hospitals would be fined if they didn’t have a committee and accept its input.

Beyond that, the bill would require information about current staffing levels to be posted in view of patients and visitors.

There’s a widespread belief among nursing experts that the key to ensuring adequate nurse staffing, and high-quality hospital care, is to give nurses the most important voice in setting staffing levels and nursing policies.

This concept is best exemplified by “magnet” hospitals.

Magnet status requires a hospital to excel in areas such as preventing infections and falls, while also giving nurses a major voice in matters ranging from staffing levels to how medical treatments are carried out.

In magnet hospitals, administrators don’t dictate to nurses how many of them should be present or how nurses should carry out their work.

Nor do nurses fear speaking up about staffing levels or any other matter they feel detracts from top-quality medical care.

“That’s the magnet culture. They know what’s happening at the bedside. They have a say. … Those of us in administration are further from the bedside, further from what really works,” said Sheri Matter, the chief nursing officer and vice president of nursing for PinnacleHealth System.

Pinnacle has attained magnet status at its Harrisburg and Community General Osteopathic hospitals.

Other magnet hospitals in central Pennsylvania are Penn State Milton S. Hershey Medical Center, Geisinger Medical Center, Lancaster General Hospital and York Hospital.

“You absolutely have to work with your nurses. They know what they do and see every day,” said Sue Hallick, the chief nursing officer at Geisinger.

Matter said Pinnacle uses a complicated process to figure out the right staffing levels of nurses.

Some of it is based on national benchmarks and data that allow hospitals to compare their units to successful units in other hospitals.

While benchmarks form a guideline, actual staffing levels are based mostly on the sickness levels of patients in a given unit and the skill levels of nurses that will care for them, Matter said.

There’s room for variation based on the medical needs of patients being cared for, Matter said.

For example, in Pinnacle’s intensive care unit, a ratio of one nurse for two patients might be adequate at certain times.

Yet on a recent weekend, nurses decided an extremely ill patient required the full attention of two nurses.

“It was really the nurses making the call of, ‘Do you know what? This doesn’t feel quite right, and we need another nurse,’ ” Matter said.

Two nurses remained assigned to the patient for 48 hours, she said.

She cited another occasion, several years ago, when a unit had an especially young contingent of nurses. Pinnacle upped the number of nurses per patients until the experience level of the nurses had risen, she said.

The magnet culture has other benefits, including low nurse turnover, which results in lower recruiting expenses, Matter said.

And although Pinnacle has a pool of 60 floating nurses, it strives to keep nurses in a specialized area, such as cardiology. One benefit is that patients end up with nurses who are highly experienced in the care they need.

Matter acknowledged the system isn’t perfect. When nurses ask for more staffing, managers sometimes question the need.

Sometimes predictions concerning patient mixes and staffing needs are off the mark. A nurse manager occasionally must fill in as a regular nurse.

But Matter also said such high-quality nursing care leads to efficiencies that can offset other economic pressures.

She’s convinced that adequate nurse staffing and quality can be maintained, regardless of economic pressure.

“Our nurse-patient ratios are the best they’ve ever been,” Matter said. “We don’t cut corners when it comes to patient care. Patient care is what we do. It has to be our focus.” 
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