For Christina Schofield, RN, the last straw in a long battle over nurse staffing and workload at Desert Springs Hospital Medical Center in Las Vegas, Nevada, came the day she was assigned primary responsibility for a newly admitted patient while being the sole RN on duty in the hospital's gastrointestinal lab.
"I refused for the sake of the patient," Schofield says. "I would have been in a completely different room helping with a procedure and the patient would have been by himself."
Schofield says she was fired for refusing the patient assignment. A hospital spokeswoman declined to comment, citing a policy of confidentiality regarding personnel matters. But the issue Schofield raised-patient safety and its relationship to a nurse's workload-isn't going away. Indeed, it's become a staple of contract negotiations between hospitals and unions across the country.
State legislatures also are weighing in. Ten states have passed laws to address nurse staffing in the context of patient safety, and more than a dozen others considered similar bills in 2006. The clamor for action has intensified, nurse leaders say, as hospitals cut ancillary staff and services to save money.
"As hospitals become more pressed financially, they are pushing nurses to do more with less," says Cheryl L. Johnson, RN, president of United American Nurses, which represents 115,000 nurses in 24 states. "They are removing support staff-transporters, techs, and dietary aides-and also supplies and equipment, such as patient lifts."
The result is extra work for nurses, Johnson says. Cuts to pharmacy staff, for example, can burden nurses with additional medication preparation duties such as crushing pills for tube-fed patients. The loss of a supply clerk can translate into protracted searches for clinical tools-time nurses should be spending with patients, says Diane Sosne, RN, president of the Nurse Alliance of the Service Employees International Union (SEIU), which represents 85,000 nurses in 23 states.
Research into nurses' workload and performance is growing as part of a larger trend to identify components of health care quality. Several studies have examined the role of nurses in preventing medical errors and how their workload affects their ability to do so. In 2003 the Institute of Medicine published Keeping Patients Safe: Transforming the Work Environment of Nurses, which concluded, "Nursing surveillance was one of three organizational process variables consistently related to lower mortality." Among other findings were that hospitals and nursing homes frequently had too few nurses for the number of patients, and that some allowed or required nurses to work more than 12 hours consecutively, leading to fatigue and the risk of medical error.
Clinical outcome studies have documented lower rates of both urinary tract infections and pneumonia and shorter hospital stays when RN staffing is adequate for the number and acuity of patients. A 2002 study published in the New England Journal of Medicine by Needleman and colleagues found improved outcomes in hospitalized patients when a higher proportion of their care was provided by RNs. A 2007 study published in Critical Care Medicine by Hugonnet and colleagues analyzed nurse-to-patient ratios and infection rates in critical care patients and concluded that 26.7% of all infections could be avoided if the nurse-to-patient ratio (total number of nurses working per 24-hour period, divided by patient census for that period) was greater than 2.2.
Such studies have helped to establish the elements that contribute to or detract from the quality of care. But the optimal mix of these elements is more complicated, nurse leaders say, than simply setting a numerical formula.
"A nurse is not a nurse is not a nurse," says Linda Everett, PhD, RN, president of the American Organization of Nurse Executives. "You can't plug a floor nurse into a critical care environment. They have to have a minimum skill set."
Debate over how to use nurses for optimal patient care goes well beyond union-management disputes. Some nurse leaders favor legal mandates that would require hospitals to have one nurse for every five medical-surgical patients. Others favor more flexible and individualized solutions, such as hospital internal nursing pools from which nurses are assigned to the units with the greatest need.
"The type of work that hospital nurses have to do is taxing," says Everett. "They're on their feet, lifting and so on. Many of them are reaching the age where they can retire and, believe me, people are retiring in droves."
The challenge is to liberate RNs from work more appropriately assigned to others while using their skills more efficiently. Although researchers, such as Aiken and colleagues in the Journal of the American Medical Association in 2002, have found a correlation between staffing ratios and nurse burnout, simply increasing the number of nurses won't address subtler elements of nurses' dissatisfaction, such as the exploding volume of paperwork that takes time away from more stimulating and professionally rewarding interactions at the bedside.
Marilyn P. Chow, RN, vice president for patient care services at Kaiser Permanente in San Francisco, says nurses must think beyond minimum staffing and shift length to improve their working conditions. She cites information technology (IT) as one way to free nurses from tedious and time-consuming clerical tasks. But to benefit from its potential, nurses must demand a voice in hospital IT decisions. Chow says nurses often end up as "the human interface for technology that doesn't work" by having to manually input data that could be transmitted electronically had the IT system been better designed.
Ideally, hospital management would welcome such collaboration with clinical staff. But the cost-cutting ethos in health care has been discouraging, pushing nurses to seek relief in collective bargaining and legislation. Carol Robinson, RN, the chief nursing officer for the University of California Davis Health System, says her state's minimum staffing law has substantial drawbacks from a management standpoint, but at least she has enough nurses to meet patients' needs.
"I hate to say this because I don't like things done by regulation, but the hospitals, strictly for financial reasons, would not have given us sufficient staff without the law," Robinson says. "The problem is the law doesn't address patients' needs and is too prescriptive in terms of where you assign nurses. If a patient is improving and doesn't need that much attention, you still have to staff according to the law. It affects nurses in that they can't take breaks or go to lunch if it would violate the minimum ratio law."
At Desert Springs Hospital Medical Center, the facility from which Schofield was fired, a test of collaboration without legal mandate is under way. The hospital and SEIU Nevada recently settled a nine-month contract dispute over nurse workload and pay. The agreement, which also covers Valley Hospital Medical Center in Las Vegas, includes beefed-up hospital patient care committees at the two hospitals to address nurse-to-patient ratios and other workload issues.
Schofield will be monitoring the situation at Desert Springs as part of her new job with the union and says she doesn't regret the action that led to her firing. "As patient advocates, we have a duty to stand up for ourselves and our patients," she says. "If we don't, who will?"
Irene Wielawski