Who's Looking after the Patients?

According to a recent federally commissioned report published in the journal Image: Journal of Nursing Scholarships, California will face a serious shortage of nurses in the coming decades. A study by researchers at the University of California at San Francisco estimates that by 2010, California will need 43,000 more registered nurses.

March 2002

America is in the grip of a health care crisis arising from an unprecedented shortfall in the number of nurses to care for the nation's ill. A medical journal in fact, has predicted that in less than 20 years, the shortage in nurses would total 20 percent. Already, legislators and caregivers are viewing the situation with alarm, as patients are increasingly being stripped of proper care in hospitals and other facilities due to the problem.

California became the first state to require all patient care units in hospitals to meet fixed minimum nurse-to-patient ratios when Governor Gray Davis signed legislation (AB 394) IN 1999.

"This is a signal that nurses' and health care consumers' concerns over nurse staffing have reached critical mass," says Beverly L. Malone, PhD, RN, FAAN, President of the American Nurses Association (ANA). ANA\California (ANA\C), a constituent member of the ANA federation of state nurses associations, supported the measure.

ANA is the only full-service professional organization representing the nation's 2.6 million registered nurses through its 53 constituent associations. ANA advances the nursing profession by fostering high standards of nursing practice, promoting the economic and general welfare of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying Congress and regulatory agencies on health care issues affecting nurses and the public.

Caregivers' and consumers' concerns have risen dramatically as many institutions have decreased the numbers of registered nurses (RNs) caring for an increasingly acutely ill patient population, cutting corners by substituting unlicensed assistive personnel for RNs.

"Too often, managed care has meant managed cost," says Malone. "If the health care industry continues to dig in its heels and fight for false economies on the backs of patients and RNs, we can expect to see more and more bills on the floors of state legislatures calling for mandated minimum nurse-to-patient ratios."

Malone points out that a number of studies have proven the link between adequate nurse staffing and positive patient outcomes. "Presently, the system works to keep patients out of the hospital as long as possible, and to discharge them as soon as possible. Patients are sicker, and care is more complex. Cutting the numbers of RNs, substituting unlicensed aides for registered nurses, and preventing RNs from speaking out about patient care concerns are exactly the wrong moves," says Malone.

In its 1999 Principles of Nurse Staffing, the ANA calls for staffing decisions to be made on the basis of three sets of principles: those related to patient care, staff-related issues, and institution/organization concerns. Among the Principles are that appropriate staffing levels for a patient care unit should reflect analysis of individual and aggregate patient needs. The document further states, "The specific needs of various patient populations should determine the appropriate clinical competencies required of the nurse practicing in that area."

"What the Principles boil down to," says Malone, "is what should be the obvious Ñ staffing decisions should be based on real patient conditions and real provider competencies, not on a cookie-cutter approach that treats both patients and their nurses as widgets on an assembly line."

Citing concerns related to mandated nurse-to-patient ratios, Malone noted, "While we're glad that passage of the California nurse staffing mandate has once again focused public attention on RN understaffing, we're also concerned that mandated minimum ratios not also become staffing ceilings."

"It gets more complicated than that," says Malone. "If an institution simply states that it has met a mandate because it has 'X' number of RNs per patient in a unit, that fails to completely address other significant concerns. Some of these nurses may be Ôfloaters,' who may be newly graduated nurses who need to become acquainted with the protocols of the unit to which they're assigned." AB 394 does require orientation of nurses "floating" to a unit and of temporary nursing personnel.

"Other nurses, compelled to work mandatory overtime, may be concerned about the quality of care they can deliver after working several days' worth of 12-hour shifts in a row," says Malone. "Understaffing takes a toll not only on patients, but on the health of nurses, who risk injuries ranging from infection by bloodborne pathogens due to needlestick and sharps injuries, to back injuries."

"There is an emerging nursing shortage," says Malone, "and chronic understaffing is not helping to alleviate it. Nurses may elect to leave the acute care setting, and young people are not entering nursing in the numbers needed to meet the growing demand. We must remember that nurses enter their profession in the first place to provide safe, quality, compassionate care. Understaffing impedes their ability to do this. Hospitals also need to care for those who care. No nurse should have to face preventable risks of injury and death in the course of patient care. Also, with a shortage exacerbating patient care issues, it only highlights the importance of matching the appropriate providers to meet the needs of increasingly ill patients."

Malone notes that ANA\C is one of the founding members of the California Nursing Workforce Initiative, a committee that is looking at this critical component of adequate and appropriate staffing.

There are an estimated 183,000 California registered nurses in active practice today.

According to a recent federally commissioned report published in the journal Image: Journal of Nursing Scholarships, California will face a serious shortage of nurses in the coming decades. A study by researchers at the University of California at San Francisco estimates that by 2010, California will need 43,000 more registered nurses.

The same report says current training programs would add only 9,000, and another 13,000 registered nurses are expected to move to California from other states. That still leaves a shortage of 21,000 nurses.

More than eight out of 10 registered nurses in California were trained in either community colleges or the California State University system.

In addition, the current labor force is aging, and large number of nurses will be retiring. According to Janet Coffman, associate director of the UCSF Center for California Health Workforce Studies, and lead author of the report, "Just as Baby Boomers begin to need more care, Baby Boomer nurses are going to start leaving the workforce."

Kay McVay, president of the California Nurses Association, said there is already a shortage of nurses, and puts the blame for it on the legacy of layoffs and mistreatment of the profession by California hospitals.

Mc Vay says, "We need to do something to make nursing extremely attractive. You can't mistreat nurses and expect them to continue on.''

Study co-author Joanne Spetz, a fellow of the Public Policy Institute of California, said wages for nurses in the state have not kept up with inflation. Average hourly earnings in 1997 were $25.46, two dollars less, when adjusted for inflation, than nurses made in 1994.

Coffman's forecast of a nursing shortage is based on projections of a 23 percent increase in the state population by 2010, and assumes that the ratio of registered nurses per state resident will remain constant.

Coffman concedes that the estimates are conservative. A new state law requiring the Department of Health Services to set staffing ratios for nurses in hospitals could increase the demand for nurses.

"The idea that 'a nurse is a nurse is a nurse' -- that one can just count nurse bodies and patient bodies and state the ratio between them -- just doesn't hold," says Malone, "any more than the notion that patients are interchangeable in their specific needs. Clinical knowledge, knowledge of the unit, and getting enough down-time between shifts also influence the quality of care."

According to Malone, "nurses need to be protected from retaliation from their employers when they advocate for their patients -- more so than ever in a health care environment rendered unnecessarily risky both to patients and their caregivers by chronic RN understaffing." Such whistleblower protections are included in the "Bipartisan Consensus Managed Care Improvement Act" (HR 2723) passed by the U.S. House of Representatives October 7.

The "Patient Safety Act" (HR 1288), introduced March 25, 1999 also includes whistleblower protections for nurses, as does the companion Senate bill (S 966) introduced May 5. Both HR 1288 and S 966 would require health care institutions to make public specific information on staffing levels, staffing mix, and patient outcomes. At a minimum, they would have to make public the number of registered nurses providing direct care; numbers of unlicensed personnel utilized to provide direct patient care; average number of patients per registered nurse providing direct patient care; patient mortality rate; incidence of adverse patient care incidents; and methods used for determining and adjusting staffing levels and patient care needs.

"John and Jane Doe can find out more about the quality of a car or a toaster they're thinking about purchasing than about the quality of hospital care they, their parents, or their children might expect to receive," says Malone. "Some things just don't make sense no matter how you look at them, and this inability to find out about the quality of our health care is one of them."

AB 394 went through several major changes before it reached its final form, most notably that the original numeric ratios were removed from the legislation, leaving in place a requirement that the California Department of Health Services promulgate regulations by January 1, 2001. In signing the bill, Governor Davis and bill author Assemblywoman Sheila Kuehl reached an agreement to delay the implementation schedule one year, to January 1, 2002. This compromise was struck to ensure the Governor's signature -- hospitals stated a concern about the time constraints imposed to set the ratios.