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Nurses Urge State to Increase Mandated Staffing Levels at Hospitals

Unions say it would improve patient safety, but hospital managers say they must have flexibility to assign staff to according to circumstances

Ann Twomey, Mary MacDonald, and Elfrieda Johnson
From left, Ann Twomey of the Health Professionals and Allied Employees union, Mary MacDonald of the American Federation of Teachers’ Healthcare Division, and Elfrieda Johnson of the JNESO nurses union testify about a proposal to increase mandatory nurse-staffing levels at hospitals.

Whether New Jersey hospitals should be required to have more nurses – and whether this would lead to improved safety or less flexibility for hospital managers – is at the center of a policy debate brewing in Trenton.

A coalition of labor unions is pushing the state to revise its minimum nurse-staffing rules for the first time since 1987, and to add teeth to the mandates by including penalties for hospitals that don’t follow the rules. They point to studies finding a link between improved patient safety and lower patient-nurse ratios.

But hospital representatives and nursing managers question these studies and instead argue that patient safety could be harmed by reducing hospitals’ flexibility to adjust nurse staffing levels to meet patient needs.

They portray the experience in California, the only state to institute strict nurse staffing minimums, as a “failed experiment.”

Nursing unions and their legislative allies have pushed for the increased minimum staffing levels for 10 years.

But a hearing yesterday in the Senate Health, Human Services and Senior Citizens Committee was the first public discussion in years of a bill, S-1183/A-647, that would increase nurse staffing levels.

While union officials expressed optimism that the hearing was being held, they face a lobbying challenge, as state senators from both parties are skeptical about increasing the burden on hospitals.

Mary MacDonald, former executive director of the American Federation of Teachers’ Healthcare Division, said that having more nurses can help prevent hospital-acquired conditions like infections.

She noted a Journal of Patient Safety estimate that medical errors are the third-leading cause of death in the United States and a Lancet study that found that increasing the number of patients that each hospital nurse serves by one apparently results in a 7 percent increase in patient mortality.

She also noted that 88 percent of medical-surgical nurses in California report caring for five or fewer patients, while only 19 percent of such nurses in New Jersey said the same, according to a study that estimated that raising New Jersey’s nurse staffing to California levels could save 222 lives annually.

“How many more people have to die before the evidence is irrefutable?” MacDonald said.

However, Inspira Health Network senior nursing executive Elizabeth Sheridan pointed to other measurements of hospital quality in which New Jersey scores well, including having the fourth-best Leapfrog Group’s Hospital Safety Scores. She said having flexibility in staffing levels has contributed to this.

Sheridan estimated that adding one nurse in a hospital unit would cost each hospital $500,000 annually, since they would have to cover 24 hours per day.

“The real question is financial survival,” she said. “How many more hospitals in New Jersey will be forced to close, after adopting higher nurse-patient ratios that’s being proposed?”

She added that the additional cost of forcing hospitals to have more nurses would lead to them trimming other positions -- including nursing specialists, case workers and nursing assistants – to offset the costs. This would then require the remaining nurses to engage in menial tasks that would otherwise be done by nursing assistants.

Sen. Jim Whelan (D-Atlantic) questioned the practicality of specifying the nursing staff levels of each unit in a hospital, noting that patient numbers in each unit can vary over the course of a day, and the staffing mandates could leave some nurses with nothing to do.

“The level of detail here is well beyond what we traditionally do,” Whelan said of the bill.

The current version of the bill would require anywhere from one nurse per patient in surgery and under anesthesia to up to six patients per nurse in psychiatric units. It would mandate having one nurse for every two patients in intensive-care units, compared with three patients per intensive-care nurse under current state rules.

Ann Twomey, president of the Health Professionals and Allied Employees union, said current state regulations only mandate one nurse for the entire emergency department, while the proposed bill would mandate anywhere from one ER nurse for every one to four patients, depending on the patients’ condition.

Elfrieda Johnson, board president for JNESO, New Jersey’s other large nurses union, said the state could no longer accept the current staffing levels.

“Every person in the state of New Jersey should be able to walk into a hospital, (and) expect the same standard of care regardless of where they live and what hospital they visit – let’s make that a reality,” she said.

Communication Workers of America Local 1036 President Adam Liebtag called for the bill to be amended to require – and fund – more state inspections of hospitals to enforce staffing levels. His union represents state Department of Health inspectors.

“Quite frankly, over the last few years, the (state) Department of Health has shifted from a proactive inspection model to a reactive complaint investigation model,” said Liebtag, who described that change as “bad medicine.”

Health Department spokeswoman Donna Leusner noted that the state is one of 48 that rely on inspections by federally approved accrediting agencies like the Joint Commission in lieu of state inspections. She said this allows the department to focus its resources on incident or complaint investigations.

Sen. Robert W. Singer (R-Monmouth and Ocean) questioned Liebtag’s proposal for more state inspections, saying that county-level boards of health are better positioned to inspect local facilities.

Nurses describe situations in which there weren’t enough nurses. Maria Refinski, president of the New Jersey Nurses Union, said she’s seen situations where five nurses were caring for 13 ICU patients. “These patients received adequate care, but barely, and certainly not the type of intensive care that they should have received that night,” she said.

But Virtua Health Nurse Director Kim Edson said it’s unfair to apply strict staffing ratios without considering the individual needs of patients. “We’re assuming that it’s a one-size-fits-all approach …That every patient is the same patient, that there’s nothing unique about each patient,” Edson said.

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