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Volume 5/Issue 10 November 30, 2007

Breaking the Cycle: Mandatory Overtime and Unsafe Staffing

750 registered nurses at Appalachian Regional Healthcare (ARH), a large hospital system with nine facilities in eastern Kentucky and West Virginia, have been on strike for several weeks. Reportedly the pay range for ARH nurses is $47,000 to $65,000 - far above the $39,000 median household income in Kentucky. In Appalachia, more than a quarter of the population lives below the federal poverty level. But the striking nurses say the dispute isn't about salaries. They say staffing levels are spread too thin and mandatory overtime has become the norm. Striking is not an option for many nurses. Therefore, some have requested the assistance of elected officials at the state and federal levels to protect patients through legislation or regulations requiring adequate nurse staffing. As ANA works with Congress to enact federal legislation to address issues of safe staffing and prohibition of mandatory overtime, many states have led the charge.

Research has demonstrated that with fatigue, one's decision making skills decline, reaction times lengthen, and problem solving is impaired. Legislators have recognized the impact that fatigue has in the air and on the highway by regulating hours for pilots and truck drivers, so why not recognize that impact in the clinical setting as well! Inadequate staffing and a lack of choice in working extra hours concern RNs, because these conditions not only threaten patients' safety, but also their own health and safety. Additionally, the licensee's legal and ethical commitment to patients is placed in jeopardy.

Legislative and regulatory attempts to address staffing are varied, but generally one of three approaches has been taken. One is to mandate specific staffing ratios with set numbers of nurses-to-patients through either legislation or regulation. Another option that is receiving increased attention is to require hospitals to create staffing committees charged with creating staffing plans specific to each patient care unit. Plans are comprised of minimum nurse-to-- patient ratios with provisions for adjustment based upon patient acuity, staff and skill mix and experience, and the availability of human and technological resources. Staffing committees would be composed in large part by direct-care nurses. This approach is consistent with ANA's principles for safe staffing.

The third approach is that of disclosure of staffing levels to either a regulatory agency and/or the public. Recently several states, recognizing the relationship between inadequate staffing and mandatory overtime, have combined attempts to address mandatory overtime and safe staffing in the same legislative initiative. So far in 2007 a dozen states introduced legislation prohibiting the use of mandatory overtime for nurses. Three new states enacted legislation prohibiting the use of mandatory overtime for nurses, bringing the total to fourteen states: Connecticut, Illinois, Maine, Maryland, Minnesota, New Jersey, New Hampshire, Oregon, Rhode Island, Washington, and West Virginia through statute; California, Missouri, and Texas in regulations.

Nine states (California, Florida, Illinois, Maine, New Jersey, Oregon, Rhode Island, Texas, and Vermont) and the District of Columbia have enacted legislation or adopted regulations which address nurse staffing, and more than a dozen additional states introduced legislation during the 2007 session.

While a few states have regulations specifying nurse-to-patient ratios in specialty units such as intensive care and labor and delivery, only California passed legislation (1999) calling for regulations to be adopted that would define the same unit-specific nurse to patient ratios be utilized in all patient-care units in all California hospitals. The mandated ratios represent minimum requirements that may be adjusted based upon patient acuity. California hospitals have been required to utilize a patient classification system, described in regulations by the California Department of Health Services, since 1986. The system is intended to set nurse staffing levels that identify the nursing care requirements of individual patients, and indicate to the hospital the amount of nursing staff needed to provide the identified care by patient, by unit and by shift.

To date, four states (Illinois, Oregon, Rhode Island, and Texas) require each hospital to have a staffing committee to develop, recommend and review a written hospital-wide plan. The latest to enact such legislation is Illinois, with regulations still to be crafted. Oregon's law (2005) requires the hospital's staffing plan to include the number, qualifications and categories of nursing staff needed for all units, and specifies that the plan must be developed by a committee composed of an equal number of hospital managers and direct-care registered nurses. Staffing plans must also be consistent with nationally recognized evidence-based specialty standards and guidelines. Civil penalties exist for hospitals which violate the law.

Rhode Island's law (2005) requires every licensed hospital to submit a core-staffing plan to the state department of health in January of each year. The plan must specify, for each patient-care unit and each shift, the number of registered nurses, licensed practical nurses, and/or certified nursing assistants assigned to provide direct patient care and the average number of patients upon which such staffing levels are based.

Texas adopted regulations (2002) requiring hospitals, under the administrative authority of a chief nursing officer and in accordance with an advisory committee comprised of nurse members, to adopt, implement and enforce a written staffing plan. This plan must be consistent with standards established by the Texas nurse licensing boards and based upon the nursing profession's code of ethics. Patient outcomes related to nursing care are to be evaluated to determine the adequacy of the staffing plan.

Almost as soon as legislation passed in Maine that would establish staffing systems with required minimum nurse-to-patient ratios, new legislation was enacted directing the Maine Quality Forum Advisory Council to review the ratio approach and make recommendations. The Forum's December 3, 2004 report concluded that mandated ratios would not be the best approach without more scientific evidence demonstrating that they gurantee the quality and safety of inpatient care. The Forum instead recommended the collection of 15 nurse-sensitive indicators in hospital settings.

Disclosure is the approach taken by Vermont, and New Jersey. Illinois also enacted disclosure legislation prior to this year's staffing plan law. Vermont's law (2006) adds a provision to the Bill of Rights for Hospital Patients requiring public access to information related to nurse staffing ratios. New Jersey (2005) requires a general hospital or nursing facility to complete and post daily staffing information for each unit and each shift. The information is provided to the Commissioner of Health and Senior Services monthly and the Commissioner in turn makes it available to the public on a quarterly basis. Illinois (2003) instituted a Hospital Report Card, which in addition to reporting patient outcomes would report on nurse staffing plans, orientation & training.

It's evident that one size does not fit all. This holds particularly true when examining fixed mandated ratios. Without flexibility to accommodate for the range of patient complexities, staff experience and skill mix, and available resources, patient and nurse safety continue to be at risk. Isn't it possible that with improved staffing, mandatory overtime and nurse fatigue will be kept to a minimum and nurse retention will increase? Could addressing staffing and mandatory overtime break the cycle and prevent future nursing shortages?

Janet Haebler MSN, RN
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