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Setting Nurse-Patient 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 the borough.

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 floating assignments.

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" levels.

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.

"Sometimes, it’s 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 ratios.

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" says Patterson.

"We function 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 problem.

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 very frustrating."

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 our patients."

NEXT STEP: BEYOND RATIOS

Establishing 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.

"We had 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.

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