Today, I wanted to explain why I recently canceled my membership to the American Nurses Association.

If I were to tell you that this action has nothing to do with the midterm election, I’d be lying.

It’s taken me a little over a month since the election to publish something, initially because it didn’t affect me directly and I thought I might just let it go. However, after thinking more about it, I feel it’s something I need to get out there in the open.

I’m just going to come out and say it: I was unimpressed by the response that the ANA produced with the defeat of Massachusetts’ Ballot Question #1.

For those of you not familiar, the ballot question dealt with staffing ratios for nurses. Had the question received enough support, staffing ratios would be mandated by government and a timeline would be set for these actions to take place.

The ballot question was proposed by a different, much smaller, Massachusetts-based nursing association; and, after reading the proposed implications of the measure, I think it might have been a bit ambitious, especially in terms of the timeline and individual ratios at some levels of care. However, is it really appropriate to be “pleased” in our colleagues’ failures?

To highlight,

  • One patient per nurse if caring for a patient under anesthesia; in critical care or intensive care units (two patients in stable condition); caring for active labor patients; patients with intermittent auscultation for fetal assessment, and patients with medical or obstetrical complications; caring for a patient during birth and up to two hours after birth; caring for a baby during birth and up to two hours after birth.
  • Two patients per nurse if caring for post-anesthesia patients; caring for urgent non-stable patients; caring for babies in intermediate care or continuing care units.
  • Three patients per nurse if in step-down or intermediate care units; caring for urgent stable patients.
  • Four patients per nurse if caring for pediatric patients; in medical, surgical, and telemetry units; in observational and outpatient units; in units not otherwise listed above.
  • Five patients per nurse if caring for non-urgent stable patients; caring for psychiatric patients; in rehabilitation units.
  • Six patients per nurse if caring for uncomplicated mothers or babies postpartum;
    caring for well-baby patients.
  • Penalties for noncompliance include per day and per violation fines.
  • Law would go into effect January 1, 2019.

In its proposed state, maybe the measure shouldn’t have passed based on barriers in implementation, including the quick turnaround period, and some tweaking needed in the ratio specifications. However, I agree with what it aims to accomplish at its core. Overall, this measure attempted to guarantee a degree of certainty when deeming what’s appropriate for safe nurse staffing. This seems to be the opposite stance that ANA is taking.

According to the ANA, they have been a “strong advocate for appropriate nurse staffing in all health care settings,” but they do not support nurse-patient ratios. In turn, they have outlined what they believe the recipe for success is when it comes to staffing in their publication, Principles of Nurse Staffing.

To summarize,

“ANA’s Principles underscores that:

  • nurse staffing is more than numbers
  • one size does not fit all
  • nurses’ experience, as well as other components of the staffing mix, along with patient acuity, workflow such as volume of admissions, transfers, and discharges, and available resources in the delivery of care, all impact the determination of what is appropriate staffing at any given time
  • patient care needs are fluid – and vary between hospitals, among units in a hospital and across shifts
  • nurses work as a team; flexibility and teamwork are essential to effectively meet the ever-changing needs of patients.”

This all seems great. It’s something that you might learn about in your Nursing Theory class, right alongside Maslow and Nightingale, but let’s take a realistic approach and actually read between the lines.

Nurse Staffing is More Than Numbers

Technically, this isn’t wrong. Nurse staffing is much more than numbers. It involves a lot of prayers, hopes, and disappointment too. Prayers that you have enough nurses on the schedule today so they don’t pull someone to another unit and load up your assignment from the start of your shift, essentially making their problem yours. Hopes that the house supervisor won’t change your unit “guidelines” and give you an additional admission or transfer and chastise you for speaking up, claiming you’re not a team player. And, disappointment knowing that you, your colleagues, and your patients don’t have nearly the amount of support you all deserve or require.

One Size Does Not Fit All

The nurse-patient ratio should act as a minimum requirement for support. They do not need to be rigid in the sense that you can’t have more nurses available on the unit. You just can’t have any less than is required. Some might just say, “Fine. We’ll just make the ratios big and let the hospitals decide anyway.” But then what’s the point? They have to serve a purpose and be impactful in order to protect the well-being of nurses and the livelihood of the medically vulnerable they care for.

Nurses’ Experience…Acuity…Workflow…and Available Resources…All Impact the Determination of What is Appropriate Staffing…

This one has a lot bundled into one. It’s like the swiss-army knife of bullet points. I should probably address each portion separately.

I would agree that a nurse’s experience has a positive correlation to the quality of care a patient receives in many cases. However, I don’t think it’s necessarily appropriate to say that because a particular nurse has seen some stuff in their day that they should have any sort of impact on the number of nurses required. Although, I can understand grouping them with more inexperienced nurses to serve as a resource or mentor to balance the experience on the floor. What good is having an experienced nurse as that resource figure if they’re too busy to help you because they’re drowning in their patient load themselves?

Acuity might be the most straightforward of all these points. Sicker patients need nurses who have fewer patients. This leads to more patient care hours for them. Ratios are typically structured in this fashion with the level of care as the grouping factor. In a more macro approach, generally, ICU patients are sicker than step-down patients who are sicker than telemetry patients and so on. Of course, when using a magnifying glass and zooming in on the different levels of care and patient groups, there will also be variations in acuity, but to a smaller extent. I feel as though the levels of care are an appropriate benchmark for assigning degrees of acuity.

The workflow of a unit (admissions, discharges, and transfers) has to a lot to deal with access to hospitals, the unit’s level of care, the patient population, etc. As a nurse, you may have found yourself working on a floor where you felt pushed to your limits and then well beyond them. It seemed that at the very moment someone was discharged, there was another patient there to take their place. If you’ve never worked on a unit like this, you’ve been blessed by the nursing gods. Yes, there are times where extra support and resources would alleviate the pressure from a busy unit where many people are coming and going. However, I can’t think of a moment where a unit that wasn’t as busy in terms of turnover of patients would require less nursing staff to do their normal nursing tasks (outside of those ADT functions). In times where the patient census isn’t high, I can understand the need to allow people to leave early to save costs and avoid being overstaffed, but not at the expense of patient care.

Patient Care Needs Are Fluid…

Okay…so a father with a heart attack in a rural community needs less patient care hours or attention than that same father if he were to have lived in the suburbs or city? Patients have needs and must be to be cared for – period. If I have seven telemetry patients and work a 12-hour shift, each of my patients can only possibly get 1.7 hours of face time and care from me (if I’m spreading the love equally). That amount of time jumps to 2.4 hours if I have 5 patients, and all the way up to 3 hours if I have 4 patients. Yes, at night, patients sleep (or you hope so at least), but medical emergencies don’t care what time it is. If that father’s heart decides to give up at 2 AM, we tend to it. We compress his chest until that life-saving attempt is done. We don’t have the liberty to say, “Sorry, we’re understaffed tonight. We’ll get to it when we can.”

Nurses Work As A Team…

To a nurse, when “teamwork” and “flexibility” are used in the same sentence, they’re onto you. They know that means, against all odds and lack of resources and breaks and staff, find a way to make it work. Yes, teamwork is necessary when working alongside your fellow nurses at the bedside in terms of safety and to provide excellent care. It is also important when coordinating with other disciplines (e.g. physicians, pharmacists, therapists, social workers) to improve patient outcomes and formulating safe plans for care and discharge. But, don’t take my willingness and ability to adapt and hold me hostage with it.

Now that I’ve actually taken the time to think and respond to these points, I think I get it. I think I understand where their stance stems from. Nurses have fought a long battle to gain respect as a profession. A battle that has been complicated by the treatment of women in this country in a profession that is historically female-dominated. There’s a reluctance to forfeit some of the autonomy in the decision-making process for how we, educated professional nurses, go about performing our jobs and the amount of work we are capable of handling.

There’s a statement of independence but, I also see dollar signs. It also comes down to money.

A teacher of mine once said, “Whenever a decision is made, always look to the pocketbook.”

I believe that many of the principles noted above appear to be sugarcoating the truth as well in an attempt to fabricate a facade of empowerment. Maybe I’m just being cynical here, but then again, maybe not.

Many of those individuals who are forming the official opinions and at the helm of the association are very far removed from the bedside. It makes sense that their viewpoints would more likely align with the administration and the hospitals they operate. I believe there needs to be an understanding that the daily reality of those nurses forming policies and systems are very different from those at the bedside – the frontline of nursing.

I understand that nurses are a large expense for hospitals in their operations, and essentially with a ratio, this expense would increase by nearly double in some levels of care. It comes down to the fact that if ratios were to be implemented, hospitals would be required to employ more nurses which will take away from the hospital’s profits. Facilities don’t want to pay for more nurses. Hell, they don’t even want to pay the ones they have on staff now it seems at times.

Looking back to November of this year and the mid-term election, the major supporter in shooting down the measure and the proposed ratios, with over $25 million in contributions (over double that of those who supported the measure), was the Massachusetts Health and Hospital Association, which contains many of the hospitals in the state – no surprise here.

If it were left up to the ANA, hospitals would be able to determine what they feel is appropriate staffing with input from nurses, many of which I’m sure will be long-removed from the bedside.

Regrettably, nurses do need the support of government and its citizens because their facilities and health systems are failing them. It would be wonderful if hospitals could be left to self-govern and make decisions that would do more than benefit their bottom line. However, that’s just not the case. As things stand now, the conditions imposed on nurses are forcing burnout, mental breakdowns, and ultimately causing great nurses to leave the bedside. Meanwhile, the ANA stands to the side, promoting a utopian healthcare system of hopes and dreams rather than something that is objective, quantifiable, and enforceable.

Nurses should have the desire to further their education as a personal calling or advance their career. Unfortunately, instead of a personal calling away from the bedside to something different, it’s more of a sprint away from the lack of support, unrealistic patient assignments, and constant fear of making mistakes from being spread too thin.

Ask just about any nurse in a graduate program for their motivations in enrolling. Yes, many will cite something along the lines of “better pay” or “more autonomy” or “this was always my plan from the beginning of nursing school”. However, I will guarantee that the overwhelming majority will state “I needed to get away from bedside” as their primary motivation, or at the very least, a very strong contributing factor.

Please don’t twist my words here. I am not shaming those who advance their careers and the profession by pursuing higher education and climbing the professional ladder. However, I would rather this not be the only way that many find themselves with the possibility of retaining any sense of sanity and remaining in the field of nursing.

Things need to change if nursing has any chance of being a healthy profession.

It’s fairly evident that this change will not come without the help of the laws protecting nurses and their patients. Having worked in states with and without mandated ratios, I believe that these ratios are useful tools in promoting the safety of patients and the wellbeing of nurses: physically, emotionally, and professionally.

For this to work, it’s pretty obvious that change will need to be somewhat significant. Health systems and hospitals will need to become leaner in their operations along with some tweaks in their business models. However, this isn’t a discussion about that. I don’t pretend to know all of the answers. Nevertheless, I think at least one of them is a mandated nurse to patient ratio, which will help keep our nurses willing to work at the bedside, enhance the safety of patients and nurses, and will allow nurses to give all of our patients the time, attention, dignity, and care they deserve.

After its celebration of defeat for the measure in Massachusetts and the subjective staffing principles it promotes, it becomes apparent that the ANA and I do not see eye to eye, nor do I feel that they have the best interests of the majority of nurses it represents at heart. And, like a Shark on ABC’s “Shark Tank,” “For this reason, I’m out.”

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