Overworked and understaffed

March 8, 2010

Dennis Kosuth, an ER nurse in Chicago and member of the National Nurses Organizing Committee, makes the case for laws mandating nurse-to-patient ratios.

AMONG NURSES who work in the emergency room, there's an understandable fear that when you go to check on one of your patients, they may have stopped breathing. Because many people come in with undiagnosed conditions, it's sometimes impossible to predict the direction they're headed before it is too late.

In a public hospital, this concern is compounded by a waiting room bursting at the seams, where sick patients with nowhere else to turn sometimes sit for 18 hours before being seen by a doctor. While waiting for tests or a bed upstairs, patients are routinely wheeled into the hallway to make room for the next one, so the pressure building out front can be relieved.

Depending on the day, this can result in one nurse having seven or eight patients, and when their covering nurse goes on lunch, the number doubles. All this endangers the patients that nurses are responsible for--not to mention straining nurses to their physical limits.

Every day, in hospitals across the country, this ticking time bomb is wound up, and everyone crosses their fingers, hoping that nothing bad happens to themselves or their loved ones. According to an investigative feature in the San Francisco Chronicle, "[A]ll of the available research indicates that the death toll from preventable medical injuries approaches 200,000 per year in the United States."

Patients endure long waits to be treated in a Los Angeles emergency room
Patients endure long waits to be treated in a Los Angeles emergency room

The profit-driven health care system has no interest in getting to the bottom of these numbers, mainly because it would involve investigating itself. It simply stands to reason that an overworked nurse with too many patients is not an accident waiting to happen, but a guarantee that accidents will happen.


ON A Friday evening in February in Chicago, almost 50 registered nurses gathered at a forum sponsored by the National Nurses Organizing Committee (NNOC) to discuss the need for safe nurse-to-patient ratios in the state of Illinois.

Bills (known as SB0224 and HB5033) have been introduced in each chamber of the Illinois legislature to establish a maximum number of patients per nurse, depending on the level of care. In the ER, for example, the legislation would mandate a maximum of four patients per registered nurse (RN), and this ratio would have to be maintained during breaks as well.

The Illinois bills are modeled after California, the only state to have such regulations. In 1999, Gov. Gray Davis signed the legislation, which mandated compliance by 2004. It was twelve years between the legislation first being introduced to a law going into effect.

Throughout the process, significant resistance was organized by the hospital industry, aided by their friends in state government. Even after the bill was signed into law, Davis' successor, Arnold Schwarzenegger, was particularly obstructive, helping to wage a legal battle against the new law. So the California Nurses Association (CNA) protested him wherever he went, inside the state and out.

The Illinois Hospital Association (IHA) is vehemently opposed to nurse-patient-ratio legislation. One complaint is that in California, the new law raised health care costs by more than $1 million per hospital, "with 23 percent attributable to increase in nurse wages," the IHA claimed in a statement.

But the hospital owners don't say is that having more nurses will actually save medical costs by reducing errors and recovery time--not to mention other insignificant questions like saving some of the 200,000 lives lost to medical error every year. The focus on profits blinds the IHA to measures that would actually improve patient care.

Another excuse for opposing the new legislation is that Illinois already has the "Nurse Staffing by Patient Acuity Act," which took effect in January 2008 and was supported by the IHA, as well as the Illinois Nurses Association (INA), a professional organization that also represents some Illinois nurses through collective bargaining agreements.

But this existing law only requires hospitals to have a written plan for nurse-to-patient ratios, which is designed by a committee made up of at least 50 percent nurses. There is nothing about monitoring, regulation or enforcement of the wishes of bedside nurses. This is a toothless bill that leaves ratios in the hands of management.

There are currently 136,000 RNs in the state of Illinois, making for a definite nursing shortage. This leads to another IHA claim--that mandating nurse-to-patient ratios would further exacerbate the shortage.

The fact is, however, that many nurses don't stay in the field because working conditions are so stressful.

According to one study in 2007, for example, the average voluntary turnover rate for first-year nurses was 27.1 percent. The federal government's quadrennial survey found that only 83 percent of people with a license to work as an RN chose to do so in 2004. With the total number of RNs at 2.9 million, that means there were almost 490,000 nurses nationwide who didn't work in the field.

Ratio laws can actually turn these trends around. In the short time since ratios went into effect in California, the state has seen an increase in the number of nurses being retained, an influx of nurses to California and a greater interest in nursing as a job. Once conditions were improved, nurses went back to work at the bedside, started moving to California from out of state, and more people have enrolled in nursing school.


THE REAL reason the hospital industry opposes the Illinois ratio proposals and similar national legislation is profit, flexibility and speedups. A recent article in Becker's Hospital Review listing "10 Best Practices for Increasing Hospital Profitability" starts with "reducing staffing costs" through flexible scheduling and reducing benefits for full-time employees.

While health care was one industry that created jobs during the recession, this hasn't lessened the corporations appetite to improve their bottom lines. Profits returned at large community hospitals in the first quarter of 2009, partly due to an improved stock market, but also from a decrease in hospital labor costs. Many employers were able to gain significant concessions from workers by playing on their economic fears.

For example, Mount Sinai Medical Center, a large Chicago hospital that serves the poor, has not only gotten away with wage freezes for the past couple years, but has also been on a campaign to get employees to make donations to the hospital. This is the same "not-for-profit" institution that spent significant resources to successfully fight off a unionization drive by nurses three years ago.

On the federal level, Sen. Barbara Boxer of California recently introduced legislation to institute nurse-to-patient ratios nationally. This national bill and other state legislation could produce important improvements in patient care and working conditions.

But this isn't the only path to ratios. Union nurses at Saint Mary's Regional Medical Center in Reno, Nev., recently won contract language that mandates the same nurse-to-patient ratios as exist in California.

The introduction of these bills is a good first step, but it's only the beginning. If the mammoth resistance to even the tepid measures promoted by Barack Obama and the Democrats in their "reform" legislation is any indication, the health care industry will stop at nothing to fight mandating ratios.

As one public health nurse said at the Chicago forum last month, "I've been to Springfield, written letters and called my representatives. We need to start thinking about protest actions that are just on the other side of the law if we're going to get the change we need."

Ratios themselves won't solve the ongoing health care crisis in this country, but organizing around this issue can bring nurses together with patients and others to address one of the more glaring aspects of it--and force the issue of the present nursing shortage higher on the agenda.

E-mail alerts

Further Reading

Today's Stories

From the archives