Labor has a lot of complaints these days about the way hospitals are run, but nothing crystallizes the debate more than the issue of "safe staffing." Unions contend that registered nurses are quitting hospitals because they are being forced to work ever-longer hours, with sicker patients and less assistance. Administrators counter that, if working conditions are tougher, it's because there are simply fewer nurses available to fill the jobs.

The result has been not only an impasse over philosophies, but a state law that requires the Department of Health Services to set nurse-patient staffing ratios. The hospital industry has sought ratios that are far less stringent than those advocated by labor.

With the health department expected to release its proposed ratios this month, we discussed the staffing issue with James Lott, executive vice president of the Healthcare Association of Southern California, the hospital industry trade group; Maura Kealey, health care coordinator of the Service Employees International Union, Western Region; and David Johnson, Southern California director of the California Nurses Association.

Question:

Are poor working conditions contributing to the nursing shortage?

Kealey: Short staffing is the chief cause of the nursing shortage. SEIU nurses are caring for too many patients and doing a terrific job under very, very difficult circumstances. The result is burnout.There is just the fact you can't do it that long. The nurse responsibility and job is to be a patient advocate and there are too many patients to provide for.

Lott: The unions are right about a part of what they are saying. It is hard working in a hospital today, more than it was even 15 years ago. Because managed care lets us only take care of the sickest patients, only when they are the most sick. But as far as the shortage of allied health professionals in general, and nurses in particular, 20 or 30 years ago women were told if you want to be employed be a nurse or school teacher. Women now run Fortune 500 companies. Ninety four or 95 percent (of nurses) are still women. With greater opportunities for women, that is undermining our base. For every three nurses that retire, only one nurse is graduating from nursing school today.

Johnson: It's important to keep in mind that nurses are incredibly committed, caring people. And if they are put in a position where they cannot provide quality patient care, many are not willing to abide that situation. Mandatory overtime is an example of a practice that is driving nurses away from the bedside. When hospitals instead of providing adequate staffing are requiring nurses to stay at the bedside when they are exhausted they are creating an environment that nobody would want to work in.

Question:

Are there other underlying causes of the nurse shortage?

Lott: Managed care organizations pressure hospitals and physicians to discharge patients sooner than our nurses have been trained that patients should be. Their level of frustration and disappointment is high. We acknowledge that is going on, but the ultimate decision is left up to physicians. Patients are not being discharged wholesale. But it's frustrating for nurses not to be able to see the complete cycle. I am not sure the industry can do more about that.

Kealey: What SEIU members have seen over the last decade is that hospitals have engaged in a race to the bottom line in order to cut their costs to turn a profit in the managed care environment. Health care workers and patients have both borne the brunt of that cost cutting. That is wrong. Hospitals should stand up for what is right for patients and stand up for their responsibility for the healing mission. The health care system in this country is unfortunately too geared to the profit motive. Everyone, nurses, other health care workers have a responsibility to fulfill their duties well, to not cut the corners.

Johnson: Many hospitals that are owned by the big corporate chains have made conscious decisions to focus on increasing profits at the expense of patient care.

Question:

Will mandatory nurse-to-patient staffing ratios improve the situation?

Lott: Ratios makes no sense unless you believe that all patients need exactly the same type of care. The other thing is that 20 percent of our budgeted positions money we have to hire nurses is going unspent. We simply don't see how nurse ratios are going to increase that pool of nurses. We are going to need 60,000 more nurses in California over the next decade, and I don't know where they are going to come from.

Kealey: Yes, mandatory ratios will help. Minimum nurse-patient staffing ratios will definitely bring back more nurses to the profession, attract new nurses to it and, most importantly, provide the quality and safety of care to all patients. There is a correlation between nurses leaving the profession with the era of cost cutting, and in fact pay cuts the hospital industry imposed in the 1990s. A recent study has found that between the early 1990s and the late 1990s real wages for registered nurses fell 10 percent in Southern California. They cut wages and they cut staff, and then they wonder why there is a nursing shortage.

Johnson: CNA sponsored the safe staffing bill that called for the nurse-to-patient ratios. We believe strongly that these ratios will have a dramatic impact in drawing nurses back into acute care settings. We certainly have seen that in Australia for example, where nurse to patient ratios were enacted and there was an immediate 13 percent increase in the number of nurses returning to bedside care. We are firm believers the same thing can happen here provided the ratios are strong enough.

Question:

Are there any other solutions to the problem?

Lott: The entire training system for nurses has to be overhauled. The state of California needs to establish nurse training as a priority for all its UC, Cal State and community college programs. The state is supposed to take care of things like that. Right now in California the waiting list to get into a nursing school is six to 18 months, and even if we had enough seats to accommodate them, we would still have a shortage. We also need to improve the retention rate of students who go to school. And the third thing to do is outreach to elementary, middle and high schools to get more of them interested in the profession.

Kealey: One solution is to respect nurses and other hospital workers on the job. Good union contracts which provide not only decent wages and benefits, but also which protect and allow nurses and other hospital workers to act as patient advocates make a huge difference in the recruitment and retention of nurses. You're really just back to the basic issues. This is such a valuable profession and it demands such a high level of skill and is very rewarding when nurses have time to do the job they are licensed to do.

Johnson: Banning mandatory overtime would help solve the problem. I agree that there is inadequate funding for nurse education. The CAN has sponsored legislation to increase funding for nurse education, but the reality is, unless hospitals foster safe patient care, nurses will not stay at the bedside. CNA contracts mandate professional practice committees made up of nurses who act as watchdogs to enforce safe patient care and to curb hospital efforts to cut costs. I think the other thing that would really make a difference is that, increasingly, registered nurses are organizing. Having a strong collective voice makes a difference in addressing those problems.

Question:

Given all these problems, are California hospitals safe for patients?

Lott: We show mortality and morbidity rates being at the lowest levels that they ever were. We admit over 4 million people to California hospitals every year, and 99.5 percent have positive outcomes. We have only seen that figure improve. We would argue they (labor officials) would have to show us where the outcomes have gotten worse. That does not mean they can't find anecdotal situations, but they parade those around as though they are indications of the industry. And they should stop playing bogeyman with the outcomes.

Kealey: The best experts on the safety of conditions in our hospital today are the professional skilled workers who provide the care. It is their testimony that is raising and sounding the alarm on the safety problem. Stroke patients are going home without training on how to take a medication, Coumadin, that kills if you get the wrong dosage. Patients go for more than an hour in severe pain without medications because the nurses are tending to life-threatening emergencies. The bottom line is, it's scary. Nurses and patients need the protection of mandated minimum staffing ratios.

Johnson: Our nurses report daily instances in which decisions are made and appropriate care not provided because of short staffing. I think Jim (Lott) is wrong in saying there is not a problem here. There is a crisis here.

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