Budget nurses

Wednesday, Oct. 27, 1999 | 11:44 a.m.

One thing seems basic in any hospital -- to have enough nurses to take care of the patients.

But in light of cost-saving measures and a nursing-shortage crisis, many nurses who bear the brunt of the increased workload say that basic principle is being violated.

"Any hospital will tell you they are staffed on acuity level need, but that's not true," registered nurse Theresa Morrow said.

Acuity level is how hospitals measure how much care patients need, taking into account the type of illnesses and how closely their medicine and monitoring equipment must be watched.

In recent years, Morrow said, the number of nurses who work any given shift has more often been determined by budgetary needs rather than acuity needs.

Morrow, as chairwoman of the Healthcare Oversight Committee of the Nevada Service Employees International Union, led a fight in the 1999 Legislature to put guidelines for hospital staffing levels into law. The effort failed, and no new laws are being drafted, but Morrow said this year's effort publicized the issue and laid the groundwork for the future.

"Every hospital has a written acuity staffing rule, but nobody uses it," Morrow said. "It is 'count the number of patients, and this is how many nurses we need.'

"That is unfair to the patient, and it is unfair to the staff."

One area hospital, Morrow said, even gives bonus incentives to middle management nurses who minimize staffing.

"If you're exploiting someone for financial gain by minimizing the amount of care, that is wrong," she said.

Cynthia Bunch, state and federal legislative coordinator for the Nevada Nurses Association, says staffing is not a new issue in this state.

"Nurse-patient staffing has been a primary driving force behind a lot of union organizing that has been taking place throughout the state for the last four years," Bunch said.

She said in the past five to 10 years the trend has been to admit only the most severe medical cases into the hospital and to treat all others either at home or on an outpatient basis.

During that same period, she said, many hospitals have been reducing the number of nurses to cut costs. But the patients in the hospital now require more care than those who were admitted in years past.

The bottom line, she said, is the reduction in nurses has been so drastic that hospitalized patients are not getting adequate care.

Morrow said nurses have less time to do simple things that need to be done, but often get shoved aside because of more important things, such as turning patients to help avoid bedsores.

"Bed sores cost this country $1.5 billion per year, and many of them are preventable," she said.

Bunch said the nurse-patient ratio staffing is not only a state issue.

"It has been identified by the American Nurses Association as the primary crisis facing the profession," she said.

The American Nursing Association has about 2.5 million members throughout the nation. The Nevada Nursing Association has about 14,000 members.

Morrow was one of the leaders in the failed attempt earlier this year to get the Legislature to pass Assembly Bill 586 that would have, among other things, forced hospitals to base the patient-nurse ratio on acuity needs. So fewer, sicker patients could have the same number of nurses assigned to them as a larger group of less sick patients.

"Nursing standards in the intensive care units is two-to-one," or two patients per nurse, Morrow said. "This is pretty standard as being acceptable anywhere you go. That is a minimum. In some critical conditions you need one-to-one and some severe burn patients need two or three nurses."

Bunch said the bill died in the Assembly Ways and Means Committee because of the $1.5 million price tag required to implement it.

If it had become law, it would have been similar to one signed earlier this month by California Gov. Gray Davis.

The California nursing law does not specify minimum nurse-to-patient ratios but requires the state Department of Health Services to set those standards.

While the Nevada law failed, revised regulations of the Nevada State Board of Health, which went into effect Sept. 10, may have the same impact as the law if hospitals follow the new rules, Bunch said.

The new regulation, she said, requires a registered nurse to make the staffing assessment and recommendation, but it is up to the individual hospital to agree to it.

The acuity level of patents will be determined by registered nurses in each hospital, according to the new regulation, and the number of nurses who will be on duty on any given shift will be based on patient needs.

"There will be an ongoing assessment throughout the patient's hospital stay," she said.

Bunch said the "acuity formula is complicated, but there are systems available and systems that can be upgraded to reflect those needs."

Ann Lynch, spokeswoman for Sunrise Hospital and Medical Center, said she has not heard of the new regulation but that her facility has always taken the level of care a patient needs into consideration when making staffing decisions.

"We've done that since we opened our doors," Lynch said.

She said setting nurse-patient ratio standards is very difficult because needs differ from unit to unit. For example, what is needed for neo-natal care differs from well-baby care, which differs from rehabilitation care, which differs from what is needed in the intensive care unit.

"What you do is you figure out with your nursing staff what is your optimum care," Lynch said. "That's the only real way to care for patients adequately.

"Standards are important, but they squeeze people. At times you may have to shut down beds because you can't staff them adequately."

She warned against laws or regulations that might set specific numbers of nurses who must be on hand at any given time, something that could have dire consequences.

"Who will suffer with set numbers is the patients," said Lynch, whose hospital is one of the biggest in the state. "If you say this (number) is what it has to be, you're going to end up with closed beds or breaking the law. You just can't set staffing numbers in concrete."

Lynch says that one point often missed is that there is a severe nursing shortage throughout the country and especially in Las Vegas.

"We hire 85 percent of all the nursing graduates in the state, and we're still short," Lynch said, noting Sunrise has several dozen openings for registered nurses.

She said if nurses aren't available and the law requires a certain number of nurses, "What are you going to do? Throw grandma out in the street?"

Bunch said the new regulations that relate to patient-nurse ratio are very similar to a regulation adopted by California several years ago.

But, she said, there was so much flexibility in the old California staffing formula that hospitals were taking advantage of it to justify reducing staffs. Many California hospitals were ignoring the regulation altogether, she said.

The new California law is the result of bad faith on the part of many hospitals in that state, Bunch said.

"I hope we won't face the same problem here," she said. "We hope facilities will understand the need to address patient care adequately and to work with the nursing community. We see it as an opportunity for hospital administrations to work with bedside nursing staff to achieve acceptable nurse staffing levels."

The patient-nurse staffing ratio is not the only concern of nurses.

Morrow said the nursing bill that failed to make it into law this year would have required hospitals to disclose information such as infection and mortality rates, post-operation complications and other data patients need to make an informed decision about where they want to get their medical care.

"We were hoping to create a report card system for consumers," she said.

Bunch said AB 586 also had a whistleblower clause.

"It would have provided whistleblower protection for nurses who report an unsafe patient care environment to authorities," Bunch said.

She said for now nurses will have to rely on the regulation and a variety of other laws to accomplish what they were trying to do with AB 586.

For example, she said, a new federal patient bill of rights now being considered by Congress would give whistleblower protection.

Even though the Nevada bill failed to make it into law, Morrow sees a victory.

"We influenced some positive changes," she said.

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