Staffing Ratios: a Long Journey Nears Its End.
Source: 1199 RN News, 1199 League of Registered Nurses
SEIU/AFL-CIO, Winter 2000
Boardroom B at New
York Community Hospital is located only a few steps
from the main entrance to this 112-bed institution in
the Midwood-Gravesend section of Brooklyn. On the walls
hang water-color paintings: a glowing sunrise; a sunset;
a flock of sea gulls rising to the sky. A peek through
the window shades of the room shows King’s Highway,
a wide avenue that cuts across this southern tip of
On a sunny morning,
October 7, 1999, a group of nurses were gathered around
an oval table to determine whether their hospital had
an adequate number of registered nurses to serve that
community. For several more days, this room became the
workplace of a unique effort: staff nurses sitting across
their nurse managers to qualify and quantify nurse-patient
ratios. Their task stemmed from a provision in the 1998-2001
contract between 1199 RNs and the League of Hospitals
and Nursing Homes. Under the heading of "Quality
of Care" the contract defined a comprehensive set
of staffing practices to guarantee sufficient numbers
of staff nurses to care for a changing number of patients.
Along with ratios, the language mandated limits on mandatory
overtime, restrictions on the use of agency nurses and
The core of the language
lies in reaching agreement on nurse-patient ratios,
a long-sought but rarely achieved goal. Current Ianguage
on many RN contracts calls for ratios but seldom cites
numbers; those that do lack an enforcement mechanism.
California’s widely heralded nurse-patient ratio
legislation of last October is a state mandate, not
a contractual agreement between hospitals and their
nurses. Moreover it gives the State’s Department
of Health Services, not hospital personnel, the task
of establishing "minimum" ratios. It was also
noted that the State has until 2002 to implement the
ratios. And to some nurses, "minimum" staffing
levels are not as desirable as "sufficient"
1199’s RN Division
approach took a completely different method-ology. Realizing
that for any ratios to be enforceable without resorting
to arbitration (a threat that the language carries),
staff nurses and their managers must mutually agree
on the numbers. This meant learning a new way of negotiating
that contrasts sharply with traditional, adversarial
bargaining That process is called "Interest-Based
Problem Solving", a 3-day workshop undergone by
nurses and managers chosen to hammer out the ratio guidelines.
In training sessions
that began July 12, 1999, more than 150 managers and
staff nurses learned the ground rules of IBPS. Among
them were information sharing to satisfying the others’
interests as well as their own by using jointly agreed
upon criteria, being open to new approaches, using consensus
to make decisions.
It was an "information-sharing,
creative exploration, while working towards beneficial
solutions," said John Stepp, a labor consultant
with Washington DC-based Restructuring Associates Inc.,
the company that conducted the training.
On that October day
at New York Community Hospital, 1199 nurses Colin Patterson
from the emergency room and Ketly St.Pre, a medical-surgical
nurse, together with their chief nursing officer and
senior clinical instructor held their first ratios session.
Acting as facilitator was Robert Johnson of Restructuring
Associates. It was his job to steer discussions along
IBPS ground rules as the nurses argued their positions.
The first target was
the Progressive Care Unit, a 12-bed stepdown unit on
the ground floor. Who is the typical PCU patient? What
is the average daily census? What is the patient acuity?
What skills and experience are required of the nurses
in the unit? What is the present coverage on the day,
evening and night shifts?
With these basic data
estab-lished, the bargaining began. It was said the
hospital has a formula that measures the level of care
given a patient by averaging the number of hours of
care given to a patient at each of the nursing units.
The number however does not account for acuity. Everyone
agreed that what was needed was a reliable system for
obtaining useful data to determine acuity.
They also agreed that
"unsched-uled no-shows" created staffing problems.
For ratios to work, every-one comes on duty as scheduled
so that there is no hustle to fill vacancies Difficulties
are compound-ed when replacements created their problems
such as float nurses who do not want to do PCU work,
orienting agency nurses, and so forth.
not the numbers, it’s all this other stuff that
impact on the numbers," observed Johnson. "Are
these issues related to staffing or are they systems
issues?" The remainder of the discussions was consumed
by addressing "this other stuff" before tackling
The second session
on October 21 reached agreement on some numbers: at
all times, one RN at a minimum for each PCU room, and
one nurses’ aide at night. Bargaining moved on
to the Emergency Room where weekend staffing "gets
to be difficult." On the busiest evening shift
period, "things go crazy, which is why there is
always a triage nurse and a clerk to answer phones,
to take blood specimens to the lab, and other jobs"
very well at night with two RNs but we need a third
nurse when census goes up and we begin holding them,"
he said. For the next session, Patterson was asked to
prepare a list of variables that makes ER staffing a
He returned with a
laundry list – patient acuity, rising census,
bed availability, skill mix, number of support staff,
waiting times, number of doctors – and on it went.
How to factor all these variables into the ratios took
a good part of the discussion.
At the next session
on November 4, the group focused on the medical-surgical
units, the largest unit occupying three floors and about
100 beds. Once more, the variables that impact patient
care and staffing kept intruding into the discussions.
A second floor med-surg nurse, Jeri Cohen, was called
to the Boardroom to describe conditions on her unit.
She complained of
high stress levels, acuity conditions of elderly patients
who require constant dressings and frequent ventilator
suctionings. There are combative patients, and the need
for inter-preters for the increasing number of Russian
patients. "We don’t think staffing numbers
consider acuity, we’re too busy, we have no time
for breaks," she said.
St. Pre concurs: "Last
night, we had six admissions, almost one every two minutes.
We were chasing after the doctors, we handle clearances
and consents; there’s no time to explain to anxious
patients procedures they will undergo, it’s very
The chief nursing
officer remark-ed that these conditions prevail on all
floors. Patterson followed up, "So how can we handle
all these with the current staffing?"
For the rest of the
morning and into the afternoon, a flip chart began to
fill up with rows and columns of numbers as the group
juggled staffing patterns for different shifts and for
varying census. One area of contention was to decide
at what points the census will automatically trigger
the need for additional nurses. Two methods of mapping
out the caseloads produced different results. The day
adjourned with some tentative ratios.
At 13 other 1199 hospitals
covered by the nurse-patient ratio language, bargaining
sessions similar to those at New York Community went
through the autumn. In most of them, the ratios were
agreed upon. In others, such as in Community, only one
med-surg unit is left for bargaining. By the end of
January 2000, the ratios agreed upon, specific to each
hospital’s conditions, will be incorporated in
each hospital’s 1199 RN contract.
"Our goal is
to make all the different institutions, which have their
own cultures and ways of doing things, go in one direction,
to identify common interests," said Norma Amsterdam,
executive vice president of the RN Division. "The
process is a new experiment, and involved some risks.
But I believe we have succeeded, and the winners are
STEP: BEYOND RATIOS
mutually agreed and contractually mandated nurse-patient
ratios is only one part of our contract’s
language on Quality Performance Improvement Program,
known as QPIP.
a vision during our contract negotiations of pioneering
a standard for ratios, not just for our hospital,
but for all 1199 hospitals," said Miriam
Kho of Beth Israel North hospital. "We cannot
go back to our corners and ignore the rest of
the quality indicators.
To that end,
QPIP will switch to part two. Next month, a training
program for 1199 nurses will give them the skills
to measure nursing standards of practice and care.
The 12-module, 35-hr. course will be open to all
members. A trainer has been chosen. Details will
be available by the middle of February.