The Politics of Staffing

Two federal bills would hold hospitals accountable for safe staffing levels for nurses.

By Pam Chwedyk Last updated on: March 22, 2013 | Posted on: March 12, 2012
Editor's note: This special Job Watch article is a reflection of a desire by many nurses to enter or advance within specialty areas. You helped guide the theme through your enthusiastic reception of information we've published throughout the past year. Use our online exclusive articles and related content in our print editions to help guide your career to the next level. In 2011, no fewer than 15 states introduced nurse staffing bills into their legislatures. And according to the American Nurses Association (ANA), 11 states introduced staffing legislation in the first 2 months of 2012 alone. Meanwhile, not one but two federal bills that would hold the nation's hospitals accountable for providing safe, appropriate nurse staffing levels were introduced in the U.S. Congress for the 2011-12 session: The Registered Nurse Safe Staffing Act (S. 58/H.R. 876) would require Medicare-participating facilities to create unitby-unit staffing plans establishing adjustable minimum numbers of RNs for each unit, based on such factors as patient numbers and patient acuity. These plans would be developed by staffing committees that must be comprised of at least 55 percent direct care nurses. The National Nursing Shortage Reform and Patient Advocacy Act (S. 992/H.R. 2187) would amend the Public Health Service Act to require hospitals to implement a staffing plan that includes minimum RN-to-patient ratios as well as minimum LPN staffing levels. The bill also allows for adjustments above the minimum ratios "under appropriate circumstances." Although demand for legally mandated staffing requirements that will ensure a safe hospital environment for both patients and nurses appears to be rising rapidly, this issue isn't new. Since the passage in 1999 of California's historic ratio-based staffing legislation, 15 states plus Washington, DC, now have some form of staffing laws or regulations on their books. But why is there still no national safe staffing law despite the publication of study after study showing a direct correlation between insufficient nurse staffing and adverse patient outcomes, including death? A Matter of Time Staffing legislation is catching on at the state level, said Janet Haebler, MSN, RN, associate director of state government affairs at ANA, "because nurses, as patient advocates, are still expressing their concerns about unsafe staffing levels and patient safety. And legislators are responding." But whether nurses' voices can command the same attention from federal lawmakers is another matter. Both of the national staffing bills brought before Congress last year have been referred to committee, where legislation can languish for years. In fact, the Registered Nurse Safe Staffing Act, which ANA helped craft and continues to endorse, was first introduced in the 2003-04 session of Congress and has had to be re-introduced repeatedly since then. "Realistically, it probably won't happen in this session," Haebler admits. However, she notes, "the average bill, at either the state or federal level, takes 5-10 years to get passed. The challenge is always that these bills are competing with thousands of other bills each session." "In California, it took us 12 years to get safe staffing legislation passed," said DeAnn McEwen, MSN, RN, president of the California Nurses Association/National Nurses Organizing Committee. She is also vice president of National Nurses United (NNU), the nation's largest nursing union, which endorses the National Nursing Shortage Reform and Patient Advocacy Act. "Once the public understands the reality that a lack of safe RN-to-patient staffing ratios has an unconscionable effect on patients' health outcomes, the chances are good that this national legislation will gain a foothold," McEwen

believes. But to make that happen, she added, "nurses must use the advocacy we exert at the bedside to educate the public and influence the legislature to enact a transparent, enforceable safe staffing standard." Ratios vs. Committees Although these two proposed federal laws are similar in many respects, there's one big difference. It's a hot-button issue that engenders heated debate within the nursing profession: Which approach to safe staffing mandates is more effective, the staffing committee model or the ratios model? Nurses unions, such as NNU and AFT Healthcare, are passionate proponents of numerical ratios. "Ratios are like a speed limit," McEwen explained. "The research shows that there's a certain nursing workload level above which it's inherently dangerous for patients,: she said. "You can't enforce vague, undefined references to 'appropriate staffing levels.' There has to be a specific, evidence-based minimum numerical standard." Patricia Eakin, BSN, RN, CEN, president of the Pennsylvania Association of Staff Nurses & Allied Professionals (PASNAP), agrees. The union helped craft a ratios bill that's currently being considered by Pennsylvania's legislature. "Safe minimum ratios are a floor, not a ceiling," Eakin argued. "If patients need more nurses, it's certainly built in that they can have more," she said. "But this way you ensure that there's at least a minimum amount of protection for the patients and the nurse." But some nursing professional associations, such as ANA, believe preset ratios don't allow nursing departments enough flexibility to tailor their staffing plans to the needs of their particular institutions and patients. "Having nurse-to-patient ratios is a more concrete approach," Haebler said. "But it fails to recognize that each hospital, and even each unit within a hospital, is different," she said. "The committee approach empowers nurses to be able to reflect those differences and adjust staffing levels accordingly." In Connecticut, which passed a committee-based staffing law in 2008, the Connecticut Nurses Association played a key role in developing the legislation. "We didn't feel that ratios were the best way to go," said Mary Jane Williams, PhD, RN, the association's government relations committee chair. "When you have a staffing committee in which half of the members are nurses who are working every day with these patients, you have a better indicator of the number of nurses needed to meet the acuity level of the patients." Where Will the Nurses Come From? While it may take years for a national safe staffing standard to become law of the land, efforts to regulate nurse staffing at the state level are likely to pick up even more steam in 2012-13. But given the economic realities of shrinking hospital budgets and the lingering nursing shortage, how can staffing managers make sure they have enough nurses on board to stay ahead of changing legal requirements? "At this point, there really isn't a shortage of nurses," Eakin responded, "because there are nursing graduates who can't find jobs. From all the studies I'm reading, it does seem that there are adequate numbers of nurses out there."

As McEwen puts it, if you build a safer workplace, nurses will come. "Since the signing of the law in California, RN vacancies in hospitals here have plummeted dramatically," she reported. "We've had a big influx of nurses back into the profession, nurses who had left because their workloads were unsafe and they had burned out." As for the argument that hospitals can't afford to hire more nurses because of the recession, Haebler doesn't buy it. "Increasing the number of RNs can yield a cost savings," she emphasized. "It reduces overtime, turnover and even patients' length of stay," she said. "If there's sufficient staffing to let nurses focus on better patient outcomes, it will cost the facility less money." Taking a more creative approach to scheduling is another cost-effective strategy, Haebler continued. "I remember the days when float pools were common," she said. "It may be time for hospitals to start reaching out to experienced RNs who have left nursing because they couldn't get a part-time position, couldn't be part of a float pool and don't want to work 12-hour shifts." Pam Chwedyk is a frequent contributor to ADVANCE.