by Susan Trossman, RN
There's a classic scene in the 1976 movie "Network" in which a TV news anchorman -- at the end of his rope -- calls on viewers to open their windows and shout with him at the world: "I'm mad as hell, and I'm not going to take it anymore."
Registered nurses have a war cry of their own.
They've had it with staffing conditions that compromise patient care and their own health and practice. But unlike the fictional newsman, they have been fighting back in concrete ways. Some have gone on strike to gain strong contract language that addresses their concerns. Others have lobbied for state legislation or other regulatory measures. Still others are documenting and publicizing the connection between adequate RN staffing and quality patient care.
The last defense
It was Mother's Day, and registered nurse Alquietta Brown was ready to go home to her family after working a routinely hectic day shift on her 42-bed, med-surg-telemetry unit at Howard University Hospital. Instead, she was mandated to stay because the entire evening shift called in sick.
Joining her was one other experienced med-surg nurse and a combination of agency nurses and RNs who had been floated from non-med-surg units. After working more than 15 hours, Brown's experienced colleague was allowed go home at 10 p.m. Brown remained.
"When you're working short-staffed," said the District of Columbia Nurses Association (DCNA) member, "the patient is the one who is compromised, because you can't do everything. Also, you can't provide personalized care, which is very important."
Brown, a Howard staff nurse since 1987, was not the only nurse worried about patient safety. Prior to contract talks last year, a DCNA survey at Howard revealed staffing -- and its impact on the quality of nurses' working lives and patient care -- as the No. 1 issue among the roughly 350 RNs in the bargaining unit. In October, management's heavy reliance on forced overtime as a routine way to staff units led to a successful one-day strike.
"Nurses were being forced to work overtime two, three times a week," said Gwen Johnson, MA, RN, a negotiating committee member and Howard staff nurse. "They were very tired and concerned about the many 'near misses' occurring in their practice."
Johnson attributed the victory to members' strong advocacy efforts. Bedside nurses testified before management negotiators about their growing inability to serve as patients' last line of defense against potentially life-threatening errors. RNs also personalized their stories to the media, which resulted in press coverage that linked inadequate staffing and forced overtime to potentially unsafe patient care.
Howard's management agreed to language that severely restricts its use of forced overtime and incorporates ANA's Principles for Nurse Staffing into the contract. Also recently, the Hawaii Nurses Association successfully negotiated ANA's principles into five major hospital contracts (see "In Brief," page 10). The principles, not only take into account the number of patients, but also look at other important staffing considerations, such as the experience level of nurses on the unit, staff mix and patient acuity.
"Now we have better contract language and a better working relationship with managers so they are getting us more staff and implementing more (inservice) classes to bring up new nurses' skills," Brown said.
They just said 'no!'
It started as a routine change-of-shift on the medical ward of the Veterans Affairs Medical Center in Durham, NC, with the day nurses ready to report off to the oncoming crew. What happened next, however, was anything but routine.
"The evening nurses refused to accept their assignments at shift change, because the staffing was unsafe," said Mike Boucher, MSN, RN, a North Carolina Nurses Association member and local bargaining unit chairman.
Eight nurses had been kept busy caring for medically complex patients during the day shift, but only four were scheduled to work the evening shift. Further, one of the four had recently been counseled for performing a new skill unsupervised, Boucher explained.
After trying unsuccessfully to resolve the issue, the on-coming nurses continued to stand their ground. The evening charge nurse called the nursing supervisor, who quickly assessed the situation and determined that the staff nurses' concerns had merit. The nursing supervisor then called all the floors and found a couple of RNs willing to work overtime.
"I believe this is the first time that an entire shift came together as a group to say 'this is unsafe,'" said Boucher, a MICU staff nurse. "They knew that if they accepted an unsafe patientload, they would be putting the lives of their patients and their licenses in jeopardy."
A few years ago, nurses at the VA facility tended to "go with the flow" when it came to short staffing, he said. However, the staff turnover rate also was high.
"Now, nurses know their right and responsibility to ask for appropriate staffing, and to expect that management will find a solution," Boucher said. "They feel like they have more control of their destiny."
Putting it in writing
The issue of staffing made headlines nationally in October 1999, when the California governor signed into law a measure that would require hospitals to meet fixed minimum nurse-to-patient ratios on all patient care units.
Nurses have mixed opinions on whether putting nurse-patient ratios into law is the answer to ensuring safe, quality staffing.
"It is a real Catch 22," said Cynthia Bunch, RN, a Nevada Nurses Association (NNA) member and strong advocate for nurses' and patients' rights. (see profile, page 27) "My preference would be to empower nurse managers to truly make appropriate staffing decisions rather than have them mandated by law. On the other hand, if you don't try to go for minimum staffing ratios, you run the risk that the issue will never be addressed by hospital management."
At Howard University Hospital, Brown welcomed the idea of incorporating ANA's staffing principles -- which go beyond ratios -- into her bargaining unit contract.
"There was a tendency for management to just look at the numbers of patients and nurses, as opposed to what was really happening on the floor," she said. For example, 17 different services funnel patients on to her unit. Admissions come at a rapid pace Ð often 10 in a single shift, and there is only a handful of experienced nurses to precept a relatively large number of new nurses.
To address these situations in yet another way, ANA is developing legislative language around its staffing principles that state nurses associations can take to their lawmakers. Meanwhile other states, such as Nevada and California, are moving ahead with their staffing measures.
During Nevada's '99 legislative session, NNA lobbied unsuccessfully for a measure that would address the issue of inadequate nurse staffing. The law fell short, but nurses' efforts paid off in September when the State Board of Health approved regulations that would require hospitals to provide nurse staffing levels based on patients' needs as determined through RN assessments.
Although Bunch supported the measure, she still questions how the board of health will enforce the new regulations -- a question that should be answered by state regulators who are scheduled to attend NNA's staffing forum this spring.
She also wants to ensure that staff nurses participate in the development of their hospitals' new staffing models. Since the regulations were approved, Bunch knows of only two hospitals that have set up staffing task forces that include bedside nurses.
Back in California, nurses are working to have their voices heard as state officials begin to determine specific staffing regulations, with an eye toward implementing them by Jan. 1, 2002.
A serious look
After many months of prodding by ANA, SNAs and individual nurses, short staffing, and its impact on patient care, has become a hot national topic of late. The ABC television show "20/20" recently covered it (see "Media Briefs," page 11), as did the national newspaper USA Today.
Three factors are fueling the issue, according to Carol Diemert, MSN, RN, who recently completed a study for the Minnesota Nurses Association (MNA) funded by a grant from ANA -- which also received a lot of press attention -- on RN concerns in acute care settings.
One is the looming national nursing shortage caused, in part, by an aging nurse population coupled with declining enrollments in nursing programs. Another is the impact managed care has had on management decisions regarding staffing, such as replacing experienced nurses with lesser skilled staff.
"And the third factor, I heard loud and clear from nurses," said Diemert. "Nurses are finally saying, 'We can't do this anymore.'
"Double shifts, cross-training and mandatory overtime are causing immeasurable stress. Nurses are constantly worrying about their practice, and several told me that the joy of nursing is gone for them."
The MNA study revealed that 70 percent of study participants were unable to perform fundamental nursing responsibilities, such as patient assessment and monitoring, when working short-staffed. Also, RNs couldn't meet patients' basic needs -- hygiene, feeding and toileting Ð 52 percent of the time. And they weren't able to give meds on time or at all 22 percent of the time.
In the MNA report, Diemert offers strategies to tackle short-staffing, and one of them involves a key collaboration. (See other recommendations, this page).
"Nurses need to inform consumers that short-staffing is a community issue, not something that nurses are just moaning and groaning about," she said. "And we need to build a strong partnership with consumers."
Said Diemert, "I'm hoping for a revolution."
ANA's Principles for Nurse Staffing are at www..nursingworld.org/MainMenuCategories/HealthcareandPolicyIssues/ANAPositionStatements/ANAPrinciples/NurseStaffing.aspx or call (800) 274-4ANA and ask for PNS-1.
Susan Trossman, RN, is the senior reporter for The American Nurse.
Tackling short staffing
In the Minnesota Nurses Association report, "Concern for Care: Identifying trends in registered nurses' concerns about practice in acute care settings," author Carol Diemert, MSN, RN, recommends ways for nurses to tackle short-staffing and also boost their morale.
* developing a single tool for collecting and analyzing data on staffing and its impact on patient outcomes
* working with management to create comprehensive staffing guidelines, such as those outlined in ANA's principles
* addressing the concerns of nurses who feel little or no support in their current working environment
* collaborating with educational institutions on strategies to ensure an adequate supply of nurses.
Diemert added that nurses must continue talking with legislators and other policy-makers about the relationship between nurse staffing and patient care.