The Ratio Solution NNU’s RN-to-Patient Ratios Save Lives — Better Outcomes and More RNs The National Voice for Direct-Care RNs RN Staffing Ratios are Saving Lives and Bringing RNs Back to the Bedside NNU stands ready to help you bring ratios to your state Dear Colleague, Today in California, RN-to-patient staffing ratios are the law, thanks to the determined, multi-year efforts of members of the California Nurses Association (CNA)/National Nurses United (NNU). Since the law went into effect in all California acute-care hospitals in 2004, there are nearly 130,000 additional actively licensed RNs in California, and staffing and patient outcomes have improved dramatically. CNA was the author, sponsor, and driving force behind the landmark law, which was signed in 1999. The hospital industry and its allies have tried repeatedly to overturn or weaken the law, but CNA/NNU members continue to successfully defend ratios. As elected leaders of NNU, we were extremely proud when a seminal 2010 University of Pennsylvania study showed that the California law saves thousands of patient lives; surgical units in New Jersey hospitals would have 14 percent fewer deaths and Pennsylvania 11 percent fewer deaths if they matched California’s 1:5 ratios. Patients and nurses experience the effects of the sharp deterioration in staffing standards in hospitals across the country. We expect specific standards for clean air and water, limits on classroom sizes, and staffing ratios for airline, day care, and nursing home staff. Hospital patients are also entitled to minimum safety standards and public protection. The first victory came in 2004 when RNs in Arizona, supported by NNU, won their own 1:2 intensive care unit ratios. California’s law is the first time that RN-to-patient ratios are mandated and enforceable throughout acute-care facilities. Nurses have also made gains through union contracts that create staffing protections. RNs across the country have taken inspiration from the California law and are working for mandated state ratios proposed by NNU. States where RNs are working to win ratio laws include Florida, Illinois, Massachusetts, Minnesota, Missouri, Pennsylvania, Texas, and the District of Columbia. This brochure includes facts, statistics, and a research appendix to demonstrate how safe RN ratios enhance patient care while bringing significant cost savings. There is also a state guide to half-measure staffing legislation that currently exists. As registered nurses, we can broaden the victories won by California nurses and patients. Visit our website at www.NationalNursesUnited.org to become a part of our campaign to win mandated RN-to-patient ratios in every state and for every patient. Deborah Burger, RN; Karen Higgins, RN; Jean Ross, RN; co-presidents, NNU 3 RN Ratios 101 California’s Safe Staffing Ratio Law — It’s more than just the numbers California’s historic first-in-the-nation safe staffing ratios, sponsored by the California Nurses Association, took 13 years to win and have been in effect since January 2004 despite continued efforts of the hospital industry to overturn the law. The bill was enacted in 1999 following an extensive grassroots campaign by RNs with broad support from patients and the general public that included thousands of letters, calls, and a massive CNA rally on the steps of the state Capitol in Sacra - mento on the day of the final legislative vote. A concurrent public opinion poll found that by 77 to 13 percent, Californians believed it is “a good idea to have a certain safe number of trained registered nurses per patient to protect the quality of care” and 69 percent they “would expect” the governor to sign the bill. Shortly after, Gov. Gray Davis signed the bill into law. Hospital executives lobbied to defeat the law, tried to persuade state health officials to adopt unsafely high ratios, filed a lawsuit to try to block enforcement of the ratios at all times, encouraged hospital managers to evade the letter and spirit of the law, and recruited compliant allies to propose measures to overturn it. All those efforts have failed. Safe RN ratios have improved quality of care and nurse recruitment and retention in California hospitals. Staffing continued to improve with a 1:3 ratio (from 1:4) in step-down units and 1:4 (from 1:5) in telemetry and specialty units implemented in January 2008. 4 Ratios 101 A.B. 394 — the CNA-sponsored safe staffing law — has multiple provisions designed to remedy unsafe staffing in acute-care facilities. California’s safe staffing standards are based on individual patient acuity, of which the RN ratio is the minimum. Mandates Minimum, Specific Numerical Ratios Establishes minimum, specific numerical RN-to-patient ratios for acute-care, acute psychiatric, and specialty hospitals. Requires a Patient Classification System — Additional RNs Added Based on Patient Acuity and Need Additional RNs must be added to the minimum ratio based upon a documented patient classification system that measures patient needs and nursing care, including severity of illness, complexity of clinical judgment, and the need for specialized technology. Regulates Use of Unlicensed Staff Hospitals may not assign unlicensed assistive personnel to perform nursing functions or perform RN functions under the supervision of an RN including: administration of medication, venipuncture, and invasive procedures. Restricts Unsafe “Floating” of Nursing Staff Requires orientation and validated current competence before assigning a nurse to a clinical area. Tempo - rary personnel must receive the same orientation and competency determination as permanent staff. Applies at All Times The ratios apply “at all times,” including meals and breaks, and excused absenc es. Prohibits Averaging There can be no averaging of the number of patients and the total number of RNs. Bars Cuts in Ancillary Staff as a Result of Ratios In the first year of implementation, CNA successfully fought off challenges from several California hospitals who responded to the ratios by attempting to cut back on LVNs and unlicensed personnel, going against the intent of the law. The state’s safe staffing standards maintain the existing staffing model which utilizes RNs, LVNs, and unlicensed assistive personnel. Prevents Hospitals from Using LVNs in Place of RNs LVNs are not in the ratio count and are assistive to the RN. 5 NNU RNs Sponsor National Ratio Legislation NNU’s Nursing Shortage Reform and Patient Advocacy Act — S. 992/H.R. 2187 Uniform National Professional Standards 1. Patient advocate duty and right 2. Minimum, specific, numerical unit-specific direct-care RN-to-patient staffing ratios for acute-care hospitals n Additional staff required based on individual acuity 3. Whistle-blower protection 4. Prohibition against averaging of ratios 5. Prohibition against mandatory overtime 6. Protection for refusal of unsafe patient assignments 7. Tough monetary fines for violations of ratios and employee and patient rights 8. Registered nurse workforce initiative n Basic educational assistance benefit and living stipend n Preceptorship and mentorship demonstration project 6 Drawing on the lessons from California RNs in states throughout the country are actively working with CNA/NNU to win their own mandated direct-care RN-to-patient staffing ratios. Building upon the success achieved by CNA/NNU in California, RNs in Illinois, Florida, Missouri, Texas, the District of Columbia, and elsewhere are actively organizing in support of Hospital Patient Protection Acts in their states. n There can be no compromise on the need for mandated, minimum RN staffing ratios n RNs must take a highly visible, very public lead in this fight n The alliance that counts is between RNs, patients, and the public n RNs must act collectively in support of ratios The California safe staffing law gives nurses hope “I am a float RN and so I see how RNs in every unit throughout our hospital finally have the time to do proper nursing care, and fully evaluate each patient’s needs. We now have time to check each patient’s chart and make sure there are no treatment delays. And finally there is time to do the patient and family teaching that is essential to avoiding future complications and hospitalizations.” — Kathy Dennis, RN Mercy General Hospital, Sacramento, California Nurses from coast-to-coast campaign for state-based legislation modeled after the success of the California law District of Columbia “P atients in our nation’s capital deserve world-class care. Unfortunately, hospital corporations continue to place an emphasis on the bottom line, and care suffers. As patient advocates, nurses in the District of Colum - bia fight daily battles with hospital management to ensure that there are enough nurses to care for patients. Management consistently opposes our efforts to win better staffing for our patients. It’s time for a legislative solution; it’s time for statutorily enforced RN-to-patient ratios. ” — Lori Marlowe, RN, Washington, D.C. Florida The Florida Hospital Patient Protection Act has been introduced in the Florida legislature every year since 2009. It would mandate RN-to-patient ratios at all times, guarantee the right of patient advocacy, and provide whistle-blower protection. Over 3,000 community supporters have signed pledges to support the legislation and 22 municipalities have passed resolutions calling on their legislative delegations to pass this important life-saving law. “When patients are denied access to a medically-appropriate level of nursing care, their outcomes suffer. It’s that simple, and it is totally preventable. Many hospitals understaff their units, denying access to RNs, and undermining patient safety in the name of hospital profits. The Florida Hospital Patient Protection Act will extend to my patients the level of care they deserve.” — Barbra Rivera, RN, St. Petersburg, Florida Missouri “It is the hope and dream of hospital RNs across Missouri to have safe staffing levels so that when you need one of us, we can be there for you.