For years, nurses in New Jersey have raised concerns about workforce shortages and staffing levels they believe put patients and employees in danger. The coronavirus pandemic exacerbated this situation and, according to New Jersey nurses unions, the state’s continued suspension of staffing regulations is further adding to the strain.

While COVID-19-related hospitalizations continue in New Jersey at a steady rate, the numbers are just a fraction of what health care providers battled during peak points in the pandemic. But nurses’ unions said their members are still enduring stressful conditions, traumatized by what they have experienced, exhausted by working long hours caring for multiple patients. They are skipping breaks, working weekends and, in some cases, missing out on the time off they enjoyed in past summers, nurses said. Labor leaders point to workforce shortages and a lack of government control as problems.

“Before we went into COVID we had staffing issues,” said Barbara Rosen, first vice-president for HPAE, the state’s largest health care union. When the pandemic struck, nurses and other frontline workers also fell sick, further limiting the pool, she said.  But while the impact of the virus has diminished significantly, “our members are still struggling with staffing issues,” Rosen added. “Even a lot of (bonus) money isn’t enough to bring them in. Nurses are so burnt out.”

Staffing ratios in stone?

HPAE and other nurses unions, including JNESO, which represents some 5,000 health care workers in New Jersey and Pennsylvania, said the problem is complicated by the state’s decision to suspend regulations governing nurse staffing and scheduling at hospitals, to provide greater flexibility under the pandemic. But even when they are active, labor leaders said these regulations are insufficient and they believe it is time for New Jersey to codify in statute specific staffing ratios that govern how many patients each nurse can care for at one time.

The unions, which have pursued this quest for nearly two decades, said fixed staffing ratios have been proven to improve patient outcomes while reducing staff injuries and hospital costs.

“Really the whole point of staff ratios is safety of the patient, safety of the nurses,” said Barbara Jones, a longtime nurse and vice-president of the JNESO board.

But Cathy Bennett, president and CEO of the New Jersey Hospital Association, said the flexibility provided by this state waiver was an essential tool for acute care facilities during the pandemic. “Throughout the pandemic our hospitals have had a singular priority — safety. The safety of our patients and the safety of our staff,” she said. “Empowering our professionals to make real-time decisions afforded a flexibility that would not have been available if those rigid staffing ratios were in place,” she said, noting they are better positioned to make these decisions than public officials.

Going forward, Bennett favors continued flexibility, not a staffing-ratio statute. Hospitals have also raised concerns in the past about the lack of nursing staff available to fill the additional positions such a law would create and the cost of this additional staff.

“The pandemic revealed the weakness of the staffing-ratio policy and approach. Over the past year and a half, we successfully delivered care via a dynamic workflow and the adaptability of teams of nurses, care techs, nursing assistants, therapists and others,” Bennett said. “Now is not the time to double down on rigid staffing ratios.”

Overworked nurses

Labor leaders insist the research proves staffing ratios make clinical, operational and economic sense. According to National Nurses United, which has 170,000 members nationwide, patients are more likely to suffer medical errors, falls or other complications when nurses are short-staffed. Overworked nurses are more likely to experience burnout, injuries and health issues of their own, they note, and by adding nursing staff hospitals can save significantly on overtime and per-diem workers.

In California, the only state with comprehensive nurse-to-patient ratios, the law led to a nearly 32% reduction in occupational injuries among nursing staff, National Nurses United reports. If New Jersey adopted the California standards it would reduce patient deaths by nearly 14%, the group contends.

These standards may not have been sufficient during the pandemic. National Nurses United will hold actions Wednesday at nearly two dozen hospitals in California and several in Texas to highlight the need for greater workplace protections.

Staffing minimums and other safety requirements can be negotiated as part of the contractual bargaining process — something National Nurses United is now engaged in for tens of thousands of members — but labor leaders in New Jersey would prefer a state law to establish uniform standards for all facilities.

The impact of the COVID-19 pandemic on New Jersey’s nursing homes — where more than 8,000 residents and staff have died since March 2020 — prompted state officials to approve a number of reforms, including a measure that sets staffing ratios for those frontline caregivers. The requirement, which took effect in February, led some long-term-care facilities to boost their wages, drawing nurses from hospital jobs, according to labor leaders here.

But the regulations that govern nurse scheduling and staffing at New Jersey’s hospitals have now been suspended for more than 15 months. In March 2020 the state Department of Health lifted the requirements governing overtime, vacation and staffing levels, including regulations that set a ratio of one nurse to three patients for critical care, emergency services, the operating room and a few other units. And while many pandemic-related precautions have since lapsed, these regulations will be reinstated in September under a law Gov. Phil Murphy signed last month to officially end the COVID-19 public health emergency.

“The waivers are in place to support the crisis-level-of-care staffing that may be required during a surge like the one experienced last year, at the height of the first surge,” DOH communications director Donna Leusner said. That flexibility remains important this summer not because of potential vacation schedules, she said, “but rather is related to monitoring surge COVID census past the summer as we saw increased census into the fall last year. This is monitored by the Department every day.”

However, Leusner added, that  hospital “staffing in the summer due to vacations sometimes is less than optimal and the Department responds to those issues on an ongoing basis.”

DOH investigations

Hospitals must file regular staffing reports with the DOH, which can investigate when deficiencies are found; the department declined to say how frequently this has happened under the pandemic.

NJHA’s Bennett said staffing remains a challenge at New Jersey’s hospitals, especially as the workforce ages. The emergence of the more infectious delta variant, which now accounts for at least four in 10 COVID-19 cases here, underscores the need to keep this flexibility in place, she said. “Our hospitals are managing this reality, but we know that this can change at a moment’s notice so we must be able to pivot quickly,” she added.

But Doug Placa, JNESO’s executive director, sees the current situation as far from ideal, with staffing especially challenging in critical-care units. “At some of the facilities that we represent members, they are forced to work through lunch or breaks because of the lack of staff,” he said, noting JNESO will take these concerns to management when needed.

The problem is not limited to critical care wards, nurses note. Rosen, with HPAE, has heard of nurses caring for seven, even 10 patients, at a time in the general medical-surgical wards. Caregivers are exhausted and patients in these beds have higher medical needs, or acuity, than they did in years past, nurses said.

“Summers are always trying times because people do try to take vacation. And you don’t want to deny those vacations,” JNESO’s Johnson said. Hospitals are contracting with nursing agencies for outside help, she said, and offering bonuses for critical shifts.

‘Slim pickings’

“But I have to say, it’s kind of slim pickings out there,” with many hospitals on the hunt for caregivers, Jones continued. “Now on top of the summer vacation in some areas there is an uptick (in COVID-19 cases.) All the hospitals are just trying to pull from everyplace and there just aren’t enough people out there,” she said.

The problem is not limited to nurses, according to Susan Cleary, president of 1199J, which represents a diverse group of caregivers in long-term care and hospital settings. Housekeeping and dietary workers are also in short supply, she said, describing a schedule page shared by a colleague that showed 25 vacant shifts over a two-week period.

“There used to be part-timers who would work on weekends, so full-timers don’t have to,” Cleary said, but those part-time, or per-diem nurses, are now hard to find. “People are working overtime, but people are burned out.”

HPAE, a longtime leader in the fight for staffing ratios in various health care settings, would like to see ratios for all care settings — not just those with the most critical patients — and have these enshrined in law, not just in regulation, Rosen explained. She would also like the law to specify that one nurse can care for two patients, at most, in critical care and no more than five in medical-surgical wards.

While critics have long complained the quest for staffing ratios is merely an attempt to boost union members, Cleary insisted that’s not the case. “It’s not true. We want a better care for our patients and a better life for our members.”

Editor’s Note: This story has been updated to correct Barbara Jones’ name and add the correct title for Doug Placa.

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