Safety in Numbers

Safety in Numbers: Nurse-to-Patient Ratios and the Future of Health Care

Suzanne Gordon
John Buchanan
Tanya Bretherton
Copyright Date: 2008
Edition: 1
Published by: Cornell University Press
Pages: 288
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  • Book Info
    Safety in Numbers
    Book Description:

    Legally mandated nurse-to-patient ratios are one of the most controversial topics in health care today. Ratio advocates believe that minimum staffing levels are essential for quality care, better working conditions, and higher rates of RN recruitment and retention that would alleviate the current global nursing shortage. Opponents claim that ratios will unfairly burden hospital budgets, while reducing management flexibility in addressing patient needs.

    Safety in Numbers is the first book to examine the arguments for and against ratios. Utilizing survey data, interviews, and other original research, Suzanne Gordon, John Buchanan, and Tanya Bretherton weigh the cost, benefits, and effectiveness of ratios in California and the state of Victoria in Australia, the two places where RN staffing levels have been mandated the longest. They show how hospital cost cutting and layoffs in the 1990s created larger workloads and deteriorating conditions for both nurses and their patients-leading nursing organizations to embrace staffing level regulation. The authors provide an in-depth account of the difficult but ultimately successful campaigns waged by nurses and their allies to win mandated ratios. Safety in Numbers then reports on how nurses, hospital administrators, and health care policymakers handled ratio implementation.

    With at least fourteen states in the United States and several other countries now considering staffing level regulation, this balanced assessment of the impact of ratios on patient outcomes and RN job performance and satisfaction could not be timelier. The authors' history and analysis of the nurse-to-patient ratios debate will be welcomed as an invaluable guide for patient advocates, nurses, health care managers, public officials, and anyone else concerned about the quality of patient care in the United States and the world.

    eISBN: 978-0-8014-6493-5
    Subjects: Health Sciences

Table of Contents

  1. Front Matter
    (pp. i-iv)
  2. Table of Contents
    (pp. v-vi)
  3. Acknowledgments
    (pp. vii-xii)
  4. Introduction
    (pp. 1-22)

    In February 2005, three hundred members of the British Columbia Nurses Union gathered in a Vancouver hotel for their Provincial Bargaining Strategy Conference, just days before negotiations were scheduled to begin on a new four-year contract. As the nurses finalized their bargaining agenda, their highest priorities were not just wage and benefit improvements but what they considered intolerable and unsafe patient workloads. Since the mid-1990s, nurses in British Columbia had been asked to care for an increasing number of patients, who, as a group, had more intense nursing needs than the patients they had cared for previously. More hospitals were...

  5. Part I California:: Managed Care, Hospital Restructuring, and the Ratio Response

    • 1 Hospital Restructuring and the Erosion of Nursing Care in California and the United States
      (pp. 25-46)

      As a young recruit new to nursing, Summer Vanslager is both a statistic and a phenomenon. As a modern young woman she has an entire professional world open to her and could have decided to be a doctor, lawyer, or banker. Instead, she chose nursing because she wanted a career in which she could make a difference and be close to patients. Unlike her nursing foremothers, however, she is unwilling to put up with relentless self-sacrifice. During both her nursing school apprenticeship and her first year on the job, Vanslager found that the ratio of satisfaction to sacrifice was less...

    • 2 Not Out of Thin Air
      (pp. 47-57)

      Critics of staffing ratios often claim that there is no scientific evidence suggesting that there is a perfect number of nurses to match a perfect number of patients on any given hospital unit. This is certainly a legitimate concern that we will discuss in chapter ten. After considering many critics’ comments, however, one gets the impression that they believe the numbers the California Department of Health Services—or unions in favor of ratios—proposed were arbitrarily plucked out of thin air. In fact, the Department of Health Services embarked on a long process of investigation and discussion to determine the...

    • 3 The Hospital Industry Response
      (pp. 58-69)

      In the satiric movie about the tobacco industry, Thank You for Smoking, the son of the well-paid tobacco industry lobbyist asks his father what he considers to be the best thing about the American form of government. Without blinking an eye, the morally challenged character Nick Naylor replies, “The endless appeals process.” In response to the ratio bill, the California Hospital Association began to mobilize that relentless process to stall the implementation of ratios in the state.

      In fall 2003, as soon as the Department of Health Services announced its ratios, the California Healthcare Association ran a series of seven...

    • 4 Ratios Redux
      (pp. 70-92)

      In 2005, Nancy Donaldson of the California Nursing Outcomes Coalition (CalNOC) Data Base Project, Linda Burnes Bolton, chief nursing officer of Cedars-Sinai Medical Center in Los Angeles, and four other researchers—three from Cedars-Sinai and one from Kaiser Permanente—published the first analysis of the California staffing ratios in the journal Policy, Politics, and Nursing Practice. The research compared the first six months of 2002 with the first six months of 2004 when the 1:6 ratios went into effect. The researchers reported that most medical/surgical units were already meeting the mandated staffing even before ratios went into effect but added...

  6. Part II Australia:: Nurses and Work Intensification in Public Hospitals in Victoria—Context, Response, and Legacies

    • 5 Working Life for Nurses in the Late 1990s in Australia: A Snapshot
      (pp. 95-102)

      In 2000, Rachael Duncan, a neurosurgical nurse, was working part-time and studying for a master’s degree at the University of Melbourne School of Nursing. At work, she was routinely assigned six very sick patients on an ordinary section of the floor and four in its “high dependency” area. “You left work feeling like a wet rag,” she recalled.

      There was a very poor skill mix on the floor. A lot of casual [temporary] nurses were making up the numbers. Nursing is always hard work, but you never got ahead, you were always chasing everything. It was very demoralizing. You never...

    • 6 How Did It Come to This? The Factors Driving the Intensification of Nursing Work
      (pp. 103-114)

      When they contemplated the nursing shortage in Victoria, health-care policymakers and administrators commonly highlighted the effect of forces from the “demand” and “supply” sides of the issue. They pointed to the new demographics of an aging population, an aging nursing workforce, and the changing lifestyle preferences among young professionals. Many nurses and their unions, however, argued that additional forces were creating the shortage of nurses. The most important was the government’s increasing preoccupation with cost control and the adoption of modern management methods with the aim of injecting greater financial discipline into the organization of hospital services.

      When policymakers discussed...

    • 7 Winning Ratios in Victoria
      (pp. 115-147)

      By August 2002 nurse-staffing arrangements in public hospitals in Victoria had been transformed. Gone were the days when managers could make arbitrary—often purely budget based—decisions on staffing levels. Nurse unit managers could no longer simply tell a nurse who protested about workloads to “cope.” Governments and hospital executives had handled their prerogative over nurse-staffing levels so badly that an Australian Industrial Relations Commission (AIRC) ruling inscribed mandatory staffing requirements in Victoria into Australian labor law.

      This now meant that in a general surgical ward in a large teaching hospital, there had to be a minimum of one nurse...

    • 8 Evaluating the Impact of Ratios: An Imperfect Experiment
      (pp. 148-178)

      Rachael Duncan, the neurological nurse we met in the introduction to this section, has described what it was like to work without ratios. Her story illuminates the way that many nurses have responded to working with ratios. Exhausted and stressed out by work overload, Duncan took a maternity leave, then returned to work in spring 2003. Of course she had heard about ratios and their impact, but she had never experienced working under a full supplement of ratio-scheduled RNs. The difference was remarkable. Her experience is not an isolated one. Countless nurses in Victoria public hospitals have similar stories to...

  7. Part III Arguments and Alternatives

    • 9 What We Know about Nurse Staffing
      (pp. 181-197)

      When Governor Gray Davis received a barrage of letters urging him to veto AB 394, almost all the hospital administrators who wrote him argued that no scientific research had systematically evaluated the appropriate ratio of nurses that should be utilized on hospital wards. In Australia, the Victorian Branch of the Australian Nursing Federation believes the appropriate ratio of nurses to patients on medical/surgical units is 1:4. The California Nurses Association argued that a more appropriate ratio would be 1:3 registered nurses to patients. The California Hospital Association insisted that patients would be perfectly safe with staffing at 1:10 and that...

    • 10 Arguments against and Alternatives to Ratios
      (pp. 198-223)

      In its almost twelve-year journey through the Massachusetts legislature, the minimum nurse-to-patient staffing-ratio bill has attracted numerous opponents, of which the most powerful and prominent is the Massachusetts Hospital Association. In the spring of 2006, the MHA ran several quarter-page ads in the Boston Globe. One was captioned “Bad Rx for Health Care.” It featured two women gazing down at a patient. In front was a trim, short-haired woman in a white coat with a stethoscope around her neck. She was, presumably, a doctor. Standing behind her was a blond, heavyset woman in a dark uniform covered by a peculiar...

  8. Conclusion: Ratios and Beyond
    (pp. 224-238)

    In January 2007 the Massachusetts Coalition for the Prevention of Medical Errors held one of its monthly meetings. In the developed world thousands of groups have formed over the past decade as high-tech health-care systems confront an epidemic of medical errors and injuries, such as hospital acquired infections, ventilator acquired pneumonias, medication errors, and other potentially fatal and often preventable complications. At this particular meeting, representatives of many of the state’s hospitals and health plans gathered with experts in patient safety; officials from medical, nursing, and pharmacy boards; as well as scholars and lawyers. Coalition leaders presented the group with...

  9. APPENDIX: Decision of the Australian Industrial Relations Commission on Nurse-to-Patient Ratios
    (pp. 239-246)
  10. Notes
    (pp. 247-262)
  11. Index
    (pp. 263-270)
  12. Back Matter
    (pp. 271-272)