Safety in numbers: Nurses say staff ratios are not acceptable

Laura Dominguez often feels torn at work.

A registered nurse in the intensive care unit of Valley Baptist Medical Center-Brownsville, Dominguez sometimes cares for three critically ill patients at once. She might have two patients on a ventilator and another who needs frequent monitoring. If one patient is in crisis, she can’t spend much time with the others, she said.

It’s a juggling act that Dominguez says could put patients’ lives at risk.

“It happens way too often,” she said of nurse-to-patient ratios that she calls “unsafe.”

“We don’t have time to know the patients or the time to assess them well enough,” she said. “And a lot of nurses have left (the hospital) because of it.”

In Texas and several other states, nurses’ unions and groups are going public with their concerns about staffing shortages and nurse-to-patient ratios in hospitals. They say that as facilities struggle with an ongoing deficit of nurses, and difficulty recruiting and keeping them, staff ratios are becoming dangerous for patients.

“It’s a huge issue for us,” said Kathy McGregor, a registered nurse who works with California-based National Nurses Organizing Committee, a nurses’ union. The union recently has recruited several nurses from Rio Grande Valley hospitals.

The union pushed for state legislation that would have mandated certain nurse-to-patient ratios. The bill, filed by Rep. Garnet Coleman, D-Houston, died in committee during the 2007 legislative session.

That was not the case in California.

In 1999, California became the first state in the country to pass a law requiring particular staffing ratios in hospitals. Under California law, for example, the nurse-to-patient ratio in intensive care has to be 1-to-2, and 1-to-5 in a regular medical unit.

The nurses’ union plans another attempt to bring similar legislation to Texas in 2009, McGregor said.

Local nurses say staffing ratios at many Valley hospitals have been problematic for years, and they believe it’s time for a change.

“All we want is safety for our patients,” said Dominguez, who has joined the nurses’ union.

Ratios and patient safety

The number of nurses on hand in a unit does have a direct impact on patients’ outcomes, research suggests.

According to the federal Agency for Healthcare Research and Quality, hospitals with low staffing levels tend to have higher rates of pneumonia, cardiac arrest, post-operative infections and shock.

A report that appeared in the journal Health Affairs in 2006 suggested that if hospitals increased their staff numbers to match the United States’ top hospitals, more than 6,700 deaths and 60,000 negative outcomes could be avoided.

Other studies have linked high nurse-to-patient ratios to an increased risk of preventable deaths and medication errors.

“The issue now is, how should the state go about ensuring adequate staffing?” said Jim Willmann, general counsel for the Texas Nurses Association.

A touchy topic

Currently Texas hospitals are required to have a written staffing plan that takes into account several factors, including the severity of a patient’s condition, staff members’ experience level, the amount of care patients need and even the hospital’s layout.

The Texas Department of State Health Services can fine a hospital for violating of its own provisions — but only if the violation is reported or if it becomes apparent in an inspection.

Most of the Valley’s hospitals were reluctant to release information about their staffing plans, or answer questions about nurse-to-patient ratios. Several facilities didn’t respond to repeated requests for information or comments on the issue.

A few hospitals submitted brief statements addressing their staffing ratios.

At Valley Baptist’s hospitals in Harlingen and Brownsville, “nurse to patient ratios are based on patient volume and acuity (the number of patients and the severity of their conditions),” hospital officials said in a statement. “We work with our nursing departments to closely monitor care and bring in additional staff when necessary to ensure safe-

staffing levels, as these variables fluctuate daily.”

Knapp Medical Center in Weslaco determines its staffing levels “based on (registered nurse) evaluation of patient needs, unit activity levels and nurse competency requirements,” said spokeswoman Debby Rektorik in a statement. The hospital also has a nurses’ council that gives input on staffing guidelines, she said.

Nurses have input at Valley Regional Medical Center in Brownsville, as well, said Matt Caldwell, chief nursing officer.

“You have to get the front-line nursing staff involved,” Caldwell said. “We’ve tried to have nursing input through a staff advisory committee.”

The Brownsville hospital was the only Valley facility to disclose its typical nurse-to-patient ratios, which Caldwell said range from 1-to-6 on the medical floors to 1-to-2 in intensive care.

Local nurses say they have noticed the ratios seem to vary widely among Valley hospitals. Staff turnover and an increased number of patients at some facilities could be partly to blame, said Lisa Bender, a former nurse supervisor at Valley Baptist-Brownsville who now works at Harlingen Medical Center.

Bender said a crunch of patients and high turnover contributed to high nurse-to-patient ratios at Valley Baptist.

“If we’re going to fill the same number of beds, with fewer nurses, it will increase the ratios,” Bender said. “I don’t think anybody really intended for that to happen, but that’s what happened.”

Bender said the ratios are “better” at Harlingen Medical Center, a smaller facility.

McGregor, of the nurses’ union, said nurses from across the state have told her their hospitals’ ratios are too high.

“It’s the same at every hospital,” she said. “I don’t think there’s a hospital in Texas that isn’t dealing with unsafe staffing ratios.”

Differing on the solution

The National Nurses Organizing Committee is convinced that changing Texas law is the answer. Many nurses have left the profession because of stressful working conditions and concerns over patient safety, and requiring safe ratios will bring those nurses back, McGregor said.

“There’s not a shortage of nurses — there’s a shortage of nurses willing to work under unsafe conditions,” she said.

Several state organizations are ready to oppose the legislation, however.

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The Texas Hospital Association, which spoke out against the 2007 bill, says mandated ratios are too inflexible and don’t take into account multiple variables in the hospital.

“Ratios don’t look at the nurse’s education, the technology available in the unit, or what other caregivers are present, for example,” said Elizabeth Sjoberg, associate general counsel for the association. “The state’s nurse staffing rules provide flexibility.”

The existing law also sets up consequences for hospitals that don’t comply with staffing plans, Sjoberg said.

Some hospitals have been fined thousands of dollars, she said.

In addition, hospitals have nurse staffing committees that are supposed to heed feedback from direct-care nurses on staffing ratios, hospital association officials said. If the hospital doesn’t comply, nurses can report that to the state, they said.

“I think we have too many other avenues that can be used before we go down the path of mandated ratios,” Sjoberg said.

The Texas Nurses Association also opposes mandated ratios, favoring “patient-centered staffing” instead, said Claire Jordan, executive director.

“There are a lot of variables in any situation, and ratios should differ according to patients’ needs as well as the nurses’ skills,” she said. “One ratio doesn’t fit all.”

To address hospital staff shortages, the associations are pushing for the state to increase funding to nursing education programs, eventually bringing in more nurses.

“If we can increase enrollment and produce more nursing graduates, certainly that will go a long way toward addressing our shortage and meeting future demands,” said Ann Ward, a Texas Hospital Association spokeswoman.

Some local nurses, though, think that until hospitals are required to address the ratio issue, nothing will change.

“To have it mandated is just the safest way, because then (the hospitals) have no choice,” said Lynn Rox, a pediatric nurse at Valley Baptist-Harlingen. “I know several nurses who have left because of the ratios, and if that changed, they would run back to the hospital.”

Melissa McEver covers health and environment issues for Valley Freedom Newspapers. She is based in Harlingen and you can reach her at (956) 430-6252.