Not-So-Nice Ratio

Almost every patient in America has had a frustrating experience in a hospital setting where we feel like we’re on a medical conveyor belt that moves WAY too slowly. We sit for too long in a waiting room; then our nurses or doctors speak with us very briefly; we might feel more like we’re filling out an online survey than we’re being listened to; then we might have more waiting; and then we’re pushed onto the next specialist or appointment too quickly. Of course some patients experience FAR worse disasters in hospitals. As patients, we know that something dysfunctional is going on, and it leads a lot of people to distrust their medical providers, and avoid healthcare altogether. But nurses, doctors, and other medical professionals themselves know that behind the scenes, they are being pushed to the brink by hospital corporations, and not really allowed to treat their patients to the best of their abilities. So today we’re going to focus on one of the most crucial behind-the-scenes hospital policies behind patients’ bad experiences: staff-to-patient ratios. 

Show Notes

Our guest today is Gerard Brogan, RMN, RGN, RN. Director of Nursing Practice at California Nurses Association/National Nurses United. Gerard has over 40 years experience as an RN. He has practiced nursing in the USA since 1984, before joining the California Nurses Association in 1994 as a Nursing Practice Representative.  He is the Director of the Nursing Practice Department for the California Nurses Association/ National Nurses United.

Gerard has extensive experience in nurse-to-patient ratio legislation, having been a part of the successful campaign to establish nurse to patient ratios in California and subsequent experience in seeing the efficacy of the ratio law.  He serves as an educator for the organization, teaching classes to nurses on a variety of  topics relevant to health care in general and  the scope  of nursing  practice  and patient advocacy in particular.

Most of us will be patients at some point, so unsafe staffing practices in hospitals will have an impact on us or our loved ones. Studies show you have a lower risk of death, higher risk of poor outcomes, and a higher chance of re-admission if your hospital has adequate nurse staffing and your care is guided by providers’ professional judgement. Sadly, in a for-profit healthcare system care decisions are made based on more on their budget impact.

You’ll recognize unsafe staffing when you see it: things like long wait times, or feeling like a number instead of a whole person because your nurse doesn’t have enough time with you. The nursing profession takes a holistic approach to care, looking at the entire person and the factors that contribute to their health; that takes time, which the healthcare industry doesn’t want to give nurses.

Improving nurse staffing levels has been the #1 priority of nurses unions (and most unorganized nurses too) across the country for more than a decade. Gerard tells us that nurses are ethically and legally obligated to be a patient advocate and provide optimal care. When that can’t happen due to the business interests of the employer, healthcare workers experience moral distress. (Rather than “burnout” which implies an individual, personal defect, Gerard uses “moral distress” to determine the suffering that happens when nurses are constrained by forced beyond their control from providing the care they should.)

There has been a sea change regarding nurse staffing over the last several decades. When Gerard began his career, staffing was “impeccable,” he had professional autonomy and the institution’s respect of his professionalism. In the 1990s when the Clinton’s healthcare reform attempt failed, “let the market decide” became the dominant narrative in healthcare. Corporate interests descended on healthcare to make a buck and nurse staffing began to decline.

Non-profit hospitals seem like they would be less driven by the profit motive and more concerned about safe patient care than their for-profit counterparts, but Gerard tells us that sadly there is no difference. For-profits generate profits, while non-profits generate what’s known as “excess revenue.” They all play by the same playbook: they see nurses as their largest labor cost, and being a female-dominated profession, they tend to devalue nursing work and see it as a target for cuts.

Over the last few decades we’ve seen the leadership of hospitals change from primarily physicians to primarily people with MBAs. Their priorities have changed from safe care to being more efficient and growing profits. Nursing has suffered under these efficiency schemes, like the Toyota Lean Management model, which treats patients like widgets and nurses like factory workers, with no room for the humanity of either.

Gerard shares that we should have been prepared for the COVID-19 pandemic, with a preparedness and response plan laid out by the WHO years ago, yet the profit-driven healthcare system didn’t value the lives of workers or patients enough to devote resources to preparation. For a lot of healthcare workers, the pandemic was the final straw. Nurses made great personal sacrifices to meet their social responsibility to patients during the pandemic, but the employers failed to meet their responsibility to their workers.

With so many nurses unwilling to work under these conditions and leaving the bedside, the industry is crying about a nursing “shortage.” There are actually 4.4 million licensed nurses in the U.S. but only 3.3 million are working. Instead of creating working conditions that nurses would want to come back to, the employers – who will never let a good crisis go to waste – are proposing cost-cutting measures like “team nursing” and “gig nursing” as solutions to the “shortage” they created.

It costs somewhere between $45,000-80,000 to recruit, orient and retain a new nurse; it’s a terrible business decision to force nurses to work in unsafe, short-staffed hospitals until they eventually leave the bedside. The best way to retain nurses and attract new ones is to improve staffing levels. The best illustration is to compare turnover rates: in Texas, nursing turnover rate in 2017 was 21.7%; in California (with a highly unionized workforce where the legislature approved staffing ratios in 1999) the turnover rate was 3.2%.

Opponents of safe nurse staffing legislation claim that if implemented, patients would suffer and hospitals would be forced to close their doors. According to Gerard, there is no evidence to back up these claims. Hospitals didn’t close, wait times didn’t get longer, patients didn’t suffer more. In fact, California has seen declines in mortality and improvements in patient outcomes since implementing statewide staffing ratios.

Medicare for All would make a huge difference to nursing and the care patients receive. Aside from the fact that nurse-to-patient ratios are part of the federal Medicare for All legislation, the savings from a single payer system would allow the healthcare system to devote more resources to clinical staff, research, and other improvements to patient care.

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