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Nurses Unions Ramp Up Staffing-Level Campaign

Nurse-to-patient staffing ratios should ease the burden on these professionals but some insist it's not the number, it's the workload

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Rank-and-file nurses have launched an aggressive campaign to boost staffing levels at New Jersey hospitals, confident that - after 15 years of trying to get the controversial requirements codified in law - Democratic Gov. Phil Murphy's support will help them reach the finish line.

During the gubernatorial campaign, Murphy pledged to sign legislation to create nurse-to-patient staffing ratios for all hospital departments - if it reaches his desk - something many nurses said is important to ensure better care. Proper staffing ratios have been shown to be a critical factor in patient outcomes and nurses have long made improving these levels a top priority.

"You have to make sure the nurse can be there to deal with all the patient's needs," said Ann Twomey, president of the Health Professionals and Allied Employees, the state's largest healthcare union, which is working with other labor groups on the campaign.

Some nurses question rigid system

But other nurses insist a rigid system would only hamper their flexibility to respond to patient needs. And hospitals are concerned about the significant cost involved and question the need for ratios, noting that Garden State facilities have been shown to provide high-quality nursing care.

"It's not about the number. It's about the workload," said Judith Schmidt, a nurse and CEO of the New Jersey State Nurses Association, which represents nurses in staff and managerial positions; while the association favors robust staffing, it does not currently support legislation to enact ratios. "It's all about the patients, and where they are in their continuity of care."

Sen. Joseph Vitale, (D-Middlesex) introduced a bill to establish legal staffing requirements earlier this month; the proposal, (S-989), would require the state Department of Health to set specific minimum ratios for all hospital departments and ambulatory-care facilities. An Assembly version is still pending.

An uphill battle

But if the past is any indication, advocates still face an uphill battle. Vitale and his Assembly colleagues, led by Assemblyman Paul Moriarty, (D-Gloucester), have proposed similar legislation each year since 2003, but only once - in May 2015 - did the issue get a hearing, let alone a full vote in either house. The concept has in the past been a target of fierce lobbying on both sides.

That said, the push for staffing ratios is gaining steam again, and not just in New Jersey. HPAE - which endorsed Murphy, in large part because he stated his support for the staffing ratios bill at a campaign event in March - is working with labor leaders around the Northeast to bring attention to the issue; in Massachusetts, the question will be put to a public vote in November.

"We're going to drive this this year," Twomey said. "And now that Gov. Murphy has indicated to us that he will sign it - that's the change in New Jersey."

Twomey said staffing levels have also become a critical issue in contract negotiations between nurses and hospitals, and in several facilities - including Cooper University Hospital, Englewood Hospital, and Jersey Shore University Medical Center - this has resulted in concrete ratios.

In New Jersey - where more than 140,000 nurses are licensed by the state - regulation requires hospitals to meet minimum staffing ratios for certain critical-care units, including the emergency department, intensive care, operating room, and labor and delivery. Hospitals must also file staffing plans, based in part on the condition of patients they are treating, and the state investigates complaints about staffing shortages and can cite facilities that don't meet these levels.

But Twomey and others note these regulations haven't been updated in more than four decades and don't address the struggles facing caregivers in other units; they also question the ability of the state to enforce the current rules. A DOH representative said the department conducts regular reviews and tracks staffing data frequently submitted by hospitals.

Drastic changes over time

But Maria Refiniski, a nurse with 40 years experience who is a leader in the New Jersey Nurses Union, part of the Communications Workers of America, said the nature of the care they provide has changed drastically over the years. Patients now have more serious needs and, as their workload increases, staff nurses are often forced to skip meals or scheduled breaks.

"There just isn't enough staff for the acuity of the patients," said Refinski, who works at Saint Barnabas Medical Center, in Livingston, where nurses have rejected the hospital's latest contract offer largely because the two groups haven't been able to agree on a process to resolve staffing disputes. "It has to do with the number of patients, but also the acuity," she said.

The 1,200 nurses at Saint Barnabas have been without a contract since November, Refiniski said, and the group held a forum earlier this week with state lawmakers to share their concerns. A statement from the hospital said officials have worked with the union to address its concerns and that staffing levels are appropriate; safety is the top priority for “patients and their families and all who work in or visit,” the facility, it said.

While the contract dispute does not specifically involve staffing ratios, Refiniski said most of the staff nurses support the legislative push to ensure specific nurse-to-patient numbers in all departments.

Hospitals are concerned set staffing ratios would limit their flexibility to respond to changing patient loads or disease outbreaks. A statewide mandate for all departments could also create significant cost at a time when providers are under growing pressure to make healthcare sustainable, officials said.

An analysis of the 2015 version of the bill by the New Jersey Hospital Association, which represents the state's 72 acute-care facilities, suggested that measure would require facilities to hire more than 2,000 more nurses at a cost of $159 million.

In addition, federal reports show Garden State facilities have been successful in addressing patient needs and avoiding nursing-related incidents like patient falls and pressure ulcers, noted Aline Holmes, a nurse who is senior vice-president for clinical affairs at NJHA. "Our hospitals are doing really well reducing adverse events," she said.

Holmes stressed that set staffing ratios fail to address differences in a nurse's training or work history; one nurse with many years on the job may be able to handle a workload that would be a challenge for two recent graduates, for example. And with a growing nursing shortage nationwide, hospitals have fewer options to bring in "floaters" or nurses that can be assigned to various units to fill a gap.

"Rigid staffing levels don't really take into account the nurse's experience or patient needs," Holmes said. "It's really just counting widgets."

Schmidt, with NJSNA, said the association's ideal would be to put staffing decisions in the hands of those who best know the challenges: nurse managers who must constantly balance employee resources with patient care. "I think nurses on the units are the ones who should be heavily involved in staffing," she said. "They should have the authority to predict what their staffing should be."

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