Thursday, March 12, 2009

Legislating nurse to patient ratios in Texas

There are bills in the Texas House & Senate now to establish mandatory nurse staffing committees to help set policy on nurse to patient ratios in hospitals. It's well established in the literature that smaller ratios equal better patient outcomes. Less patients per nurse means more time spent with the patients. The current bills were introduced by Senator Jane Nelson and Representative Donna Howard. Howard is often cited as former nurse, but 1) I doubt she's let her license lapse and 2) even if you're not providing direct patient care, once you've put in a few years you're always a nurse.

The bills are supported both by the Texas Nurses Association (I'm a member) and the Texas Hospital Association in a good example of positive collaboration between organizations that are sometimes at odds. Essentially the bills require at least 50% of the nurse staffing committee members to be bedside nurses chosen by their peers, use patient-sensitive measures to evaluate their staffing, and it also extends whistle-blower protections to government-run hospitals and clinics (this doesn't already exist?! I need to look into that one further).

At the same time, there are competing bills supported by the National Nurses Organizing Committee—really an arm of the California Nurses Association that's aggressively pro-union and organizes in other states—that mandate specific, low nurse-patient ratios. While this sounds good, in reality the inflexibility of the ratio is a major stumbling block. Our ratios in ICUs are one nurse to two patients or 1:1, or even two nurses to one patient if acuity requires it. On the non-ICU patient floors, the nurse to patient ratio varies widely from hospital to hospital. Around 1:5 is decent, getting around to 1:8 is unacceptable in my opinion. Setting a specific ratio is nice, but ignores the reality. What if two of your patients need a lot of care? In that case a mandatory 1:5 doesn't really cover it. If your patients are doing well, 1:5 could be a light assignment.

As well, those mandatory ratios mean that staff nurses can't just give a quick report to a co-worker who will watch her patients during lunch. The hospital would have to hire extra nurses to cover meal breaks. Just really unnecessary. I'm for letting staff nurses make the best staffing plan at their hospital. Sure, step up investigation of hospitals with poor patient outcomes, but don't lay out a one-size-fits-all requirement as a panacea.

I didn't think the National Nurses Organizing Committee (and I am a fan of nurse unions, just not the way NNOC is going about it) had a chance of garnering much support for their bills, but I just read that Rep. Senfronia Thompson and Sen. Mario Gallegos filed them. Thompson did so after her granddaughter waited four hours at a hospital ER with a high fever. I'm going to have to call her office, because this bill has nothing to do with wait times in ERs. Patients seen in an ER are not in-patients until they're admitted upstairs and therefore nurse-patient ratios don't apply. The long wait times in ERs has more to do with many people not having coverage or access to a primary care physician and therefore the ER serving as their doctor or clinic.

OK, more on this later as I tease out the intricacies.


  1. Did you see this recent development?

  2. That link is to a press release with no details. What amendments is the NNOC offering? I'll have to look into it further when I have time in a couple weeks.

  3. Your comments about mandatory ratios are pretty unsubstantiated. Did you know that with each additional patient that is added to a nurse's workload, the risk of a patient dying increases by 7%-- this is from published research in JAMA by Linda Aiken.

    And why would ratios interfere with lunch breaks? Please elaborate.

    Why would ratios be inflexible? No ratio laws would ever prevent nursing managers to assign more RN's to care for patients. Indeed, the ratio would simply be a MINIMUM requirement, not the maximum.

    Of course the NNOC would be aggressively be pro-union-- they are one! If you think nurses are going to get ahead without organizing themselves and yes, oh my god, yes, paying strong, educated people to advocate with us, then you are a fool. Do you know how much institutional power and money the bedside nurse is up against?

    Did you know that in Victoria, Australia, mandatory minimum nurse to patient ratios brought over 4,000 nurses back to the bedside?

    It sounds like you have been listening to a lot of rhetoric rather than doing the research, my fellow nurse.

  4. Calling someone a fool isn't the best way to convince them, but we'll leave aside the flinty rhetoric for now. As you'll note if you pay attention to what I wrote, I'm all for better ratios - I just have reservations about mandatory ones that consider only numbers.

    As for lunch breaks, I'll use a real example. I'm an ICU nurse so I usually have two patients. Right now, if my patients are stable I can tell that to another nurse in my section that's not too busy and they can watch my patients for me while I eat. With mandatory ratios, another nurse without any patients would have to sit with my mine while I eat. Unnecessary.

    I criticize NNOC not because their pro-union (I'm pro-union too), but because I frequently find their methods arrogant and paternalistic. Rather than come into a community and work from the ground up to establish trust and a conversation with the area nurses, I've seen NNOC come in with a we-know-better attitude that ends of hurting their cause and bolstering the arguments of anti-union folks.

  5. St. Murse,

    The ratio law in California does have an acuity component. As does, the NNOC legislation in Texas. Your assertion that NNOC's proposed ratios are just "about numbers" isn't factual. You should really read the bill before making those kind of statements! The bill was drafted by RNs. BOTH acuity AND numbers are taken into account. The NNOC bill contains the strongest protections of any ratio bill out there. Texas patients deserve no less!

  6. I moved to Texas this year after living in California for 7 years and have been a bedside nurse for 34 years. The jury is still out on the texas senate bill 476. We will see if it really has any teeth. On the surface it sounds like it was drafted by the AHA. I was on the nurse committee that set up the recc staffing ratios on my unit at the TX Med Center. But compliance has already been poor. Leaderships says the will TRY to keep to agreed upon staffing. The ratios as outlined in California's bill had teeth and was based on MINIMUM ratios. Pt acuity could increase the #s needed. As for lunch relief. How many nurses out there have regular lunch/break relief? Nonmedical people have no idea what nurses go through. When my husband (who sets at a desk all day) says he had such a hard day with his multiple meetings. My response: "did you eat today, did you pee today"? If the answer is yes, then I reply "Then you have had a good day". Walk a mile in a bedside nurse's shoes and you will see why if you always need to find a peer who is "not busy" to "watch" your patients, then you will not be having lunch on a regular basis. Ex: I have 2 active labor pts. I can not and should not "watch" 2 additional labor patients. And should not for that matter- if I am providing safe care. Since coming to Tx, I can safely say, I get lunch before 2-3pm only 1/2 of the time. That is not acceptable. And when I turned over my pts while on lunch in CA- the other nurse "assumed" care, not just "watched" them. Big difference. Time will tell, but Texas just lost an opportunity to rally behind their nurses and really provide safer care, not just go through the steps. I am not impressed.

  7. Ca nurse,
    If you don't like it here in Texas feel free to go back home. I am all for lower nurse:patient ratios, but isn't California in a crisis right now because of it? It's also not fair to pick out someone's words and pick them apart. I am sure they meant "assume care" when they said a nurse would "watch" the patients. It's ridiculous to think someone should hire nurses just to cover 30 minute lunch breaks. On the med/surg floor I work on we have 5-6 patients most of the time. Sometimes we have fewer, and rarely we have 7. Most of the nurses I work with handle this load just fine.

  8. First, what is ridiculous about having an extra nurse available to relieve nurses for breaks? This allows the nurse time for herself (himself) to relax and eat, while their patients are safely and effectively watched over by another nurse. We don't get paid for our lunch breaks, so shouldn't we enjoy them? If one nurse in the ICU has 4 patients to watch and something arises with one of them, that attention to the other 3 patients has seriously dwindled. A "floor" not a "ceiling" is beneficial to patient care in terms of nurse-patient ratios. The idea behind this type of legislation is to establish minimum nurse-patient ratios, not mandate that one nurse must always have 2 patients, in terms of critical care. This is safe for safe patient care!! Who cares if the hospital has to foot the bill for an extra nurse? Maybe they ought to rethink salaries of administrators! Or, rethink a lawsuit that results from inadequate attention by nurses forced too take to many patients.

  9. writing a report on the nurse union movement and in my research of SB 476 here in TX i couldn't find anywhere in the bill that said what would happen to the hospital or administration if the rules weren't followed.... would they get fined? would they get a "talking to" would they get their hand slapped or put on "time out" or would the nurses revolt and demand mandatory staffing ratios that were backed by strict fines? hhmmmmm interesting.

  10. I am a bedside nurse in Texas and the nurse to patient ratio's are completely unsafe. 1 to 6 on a med/surg floor regardless of the patient needs is unsafe. Texas needs to set safe ratio rules. I am currently considering changing professions because I do not want to feel "at risk" every single day I work. I became a nurse because I want to help people. I am considering a profession change for the same reason "I want to help people". With the ratio of 1 to 6 that I experience everyday on M/S, I am not helping anyone...I am flying through the day just trying to keep up. I feel sorry for people in Texas when they are so ill they require hospitalization. They are really risking their lives with the way things are now. I am not alone in my thinking. Many nurses fear for their patients every shift they work. The nurses that do not fear for their patients, do not care about their patients. Those are the nurses that barely say hello to their patients. Is there a way I can join a group in Texas whose goal is to change the way Texas views "nursing"? A group dedicated to getting the rules changed in this state so that patients are given the care they deserve?