Texas Legislature to Consider Staffing Ratios
Texas, one of the first states in the nation to adopt nurse-staffing plan regulations, will debate the merits of nurse-to-patient staffing legislation during the 2009 session.
The National Nurses Organizing Committee (NNOC), founded by the California Nurses Association (CNA) in 2005, plans to work with lawmakers to introduce the Texas Hospital Patient Protection Act of 2009. The bill would establish minimum staffing levels, similar to those implemented in California in 2004. The union pushed similar Texas legislation in 2007, which died in committee.
This is our opportunity to create a workplace we went into nursing to have, says Joanne Thompson, RN, BSN, in Houston. It will give us a chance to touch someone rather than rush in and out of a room.
The act proposes one nurse to four patients on med/surg units, the emergency room, postpartum women only and psychiatric units. Intensive care units, NICUs, post-anesthesia recovery and the newborn nursery would have to staff one nurse for every two patients. It suggests one-on-one staffing in the operating room, conscious sedation, labor and delivery and with trauma patients in the ED. In rehabilitation units and skilled nursing facilities, the ratios would be one nurse for every five patients. Hospitals violating the ratios would be subject to civil penalties.
More than 200 nurses from all over the state donned red shirts, then marched and rallied at the capitol November 13 in support of minimum RN-to-patient ratio legislation.
We need ratios so we can adequately take care of patients, says Beverly Leonard, RN, one of the participants. Its not unusual to have six or eight patients, and things get missed.
Leonard also expects ratios would draw nurses back to the bedside. CNA reports actively licensed registered nurses in California have increased by 80,000 following enactment of its ratios law.
Not everyone agrees that the state needs a ratios law.
We dont think we need a bill along the direction of California, says Claire B. Jordan, RN, MSN, executive director of the Texas Nurses Association (TNA). Bedside nurses can best predict how much nursing care is needed, not legislators.
TNA supported legislation, enacted in 2001 and 2005, which requires hospitals to develop a written nurse-staffing plan for each unit and adjust staffing from shift to shift, based on intensity of patient care, scope of services provided, the geography of the unit, nurse experience and other factors. A nurse staffing advisory committee, comprised of up to 50% direct care nurses is responsible for soliciting input from other nurses, and developing, monitoring and evaluating the plan, which includes consideration of nurse-sensitive outcomes. The law protects whistleblowers and requires reporting of variances to the committee.
Texas was one of the first states to get on the bandwagon with holding hospitals accountable with nurse staffing plans, says Nancy Rout, RN, MBA, CNAA, FACHE, CPHQ, president of the Texas Organization of Nurse Executives and chief nursing officer at Las Palmas Medical Center in El Paso. There is no research that gives a definitive staffing level.
Rout adds that the committees bring staffing issues forward and allow registered nurses to make staffing decisions rather than the one-size-fits-all ratios.
I feel very comfortable we have in place what we need to have in place for a culture of patient safety and staffing, Rout says.
Texas hospitals agree.
The Texas Hospital Association believes mandated fixed ratios are not the answer to address the nursing shortage, says Elizabeth Sjoberg, RN, JD, associate general counsel for the THA. Through our nurse staffing rules we have the flexibility to provide safe patient care and for staff nurses and patients to be sure the right nurse, at the right time, with the right equipment is taking care of the patient.
The American Nurses Association also supports unit-based, nurse-led staffing policies rather than legislator-mandated ratios, says Cynthia Haney, American Nurses Association senior policy fellow for nursing practice and policy.
Thompson disagrees and believes in minimum staffing ratios, because nurses are trying to care for too many patients.
The legislation they have has no meat and has no teeth, Thompson says. It leaves it to the hospital to come up with a staffing plan.
Suzanne Gordon, visiting professor at the University of Maryland School of Nursing, assistant, adjunct professor at the University of California, San Francisco School of Nursing and co-author of the 2008 book Safety in Numbers: Nurse-to-Patient Ratios and the Future of Health Care, which examines the California and Australia experience with ratios, recognizes a need for ratios to deal with work overload.
What we are seeing in health care is what we are seeing in the economy, Gordon says. Unregulated hospitals dont work, just like unregulated Wall Street has not worked.
Gordon points out that the ratio legislation sets minimums. It does not take away nursing managements ability to modify skill mix or schedule additional nurses on a particular shift.
Jordan says that mandated ratios could give nurses and patients a false sense of security, since research has not shown improvements in nurse-sensitive outcomes.
Linda Burnes Bolton, DrPH, RN, FAAN, a California Nursing Outcomes Coalition (CalNOC) senior investigator and vice president and chief nursing officer of Cedars-Sinai Health System/Burns & Allen Research Institute, and colleagues have compared staffing and nurse-sensitive outcomes before and after California implemented its ratio laws, using data collected by CalNOC from more than 185 hospitals in the state. In a 2007 paper, the investigators reported the ratios have increased the number of licensed staff, however, the incidence of falls and prevalence of hospital-acquired pressure ulcers did not change.
Joanne Spetz, PhD, associate professor in the Department of Community Health Systems at the University of California, San Francisco (UCSF) School of Nursing, has studied various aspects of ratios. In a 2008 paper published by Policy, Politics, & Nursing Practice, she reported a significant improvement in nurse satisfaction between 2004 and 2006, before and after ratios took effect, particularly with the adequacy of RN staff, time for patient education, benefits and clerical support. Spetz also completed a financial analysis and found in a forthcoming study for the California HealthCare Foundation no empirical relationship between finances and ratios.
While the California Hospital Association has not collected data as to the affects of ratios on its members, Jan Emerson, vice president of external affairs, says ratios have not caused but could have contributed to closures of financially unstable hospitals.
In a March 2008 American Journal of Nursing article, Jean Ann Seago, RN, PhD, an associate professor in the Department of Community Health Systems at the UCSF School of Nursing, said she feels it is doubtful that ratios can be blamed for hospital closures. She acknowledges for those facilities operating in the red and not solvent, ratios could have been the final straw. In November 2008, Seago says she still considers that the case.
Gordon suggests enough money exists to pay for the staffing that would be required by the legislation, especially if dollars spent on advertising were reallocated to patient care. She also believes not having enough nurses at the bedside increases the risk of financial peril, with pay-for-performance initiatives.
With the new CMS (Centers for Medicare & Medicaid Services) rule, how will they manage never events without an adequate supply of nurses? Gordon asks. Hospitals are not acting in their own best interests, and government has to step in.