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Nurses challenge staffing

Hospital says state requirements are met; RNs say team-nursing approach overburdens their workload

Posted: March 17, 2011 1:55 a.m.
Updated: March 17, 2011 1:55 a.m.

Team nursing — a pilot program in place at Henry Mayo Newhall Memorial Hospital for more than a year — stretches registered nurses too thin and poses a danger to patients, registered nurses say.

But hospital officials say “team nursing” is perfectly safe and meets all state requirements for nurse-to-patient ratios. Patient care is not compromised by the practice, they say.

“Henry Mayo (Newhall Memorial Hospital) meets all state, professional and licensing requirements for nursing ratios,” said Larry Kidd, a registered nurse who serves in a management capacity as chief nursing officer and vice president for patient care services.

“And while we have had some challenges as it relates to nursing work flow, as we move toward a full implementation of an electronic medical record, this is not uncommon for hospitals around the country as we work to adopt this technology that will provide better care, safety and service to patients.”

A committee representing registered nurses sent a letter to Kidd on Monday requesting that the hospital cease its team nursing practice.

“The team-nursing program is unsafe for our patients,” reads the letter, signed by eight registered nurses. “It significantly increases the workload of each RN while reducing the amount of time each RN can spend providing direct primary care for his or her assigned patients.”

The committee has a mandate to investigate, analyze and recommend hospital improvements of patient care, nursing practice, nurse safety and nurse staffing, according to Article 27 of its labor agreement with the hospital.

“I am currently working closely with staff nurses and management to make adjustments, where necessary, and have convened a nurse task force to assist in developing recommendations for improvement,” Kidd told The Signal on Tuesday.

“In the meantime, Henry Mayo will continue to ensure we are in compliance with all state and federal requirements to meet and exceed patient safety and quality of care.”

Registered nurses say it’s only a matter of time before “something bad happens” and a patient is hurt.

“If anything happens to that patient, that family is going to come after you. They’re going to come after the doctor and the hospital,” said one Newhall Memorial nurse. “Guess what the hospital’s going to say? ‘Oh, it’s the RN’s fault.’ Guess what the doctor is going to say? It all falls on the RN.”

Patient-to-nurse ratio
California is the only state in the country that mandates a ratio of patients to licensed nurses. The ratio varies according to the level of care required.

For example, no more than two patients can be assigned to a registered nurse working in a hospital’s intensive care unit.

By comparison, patients in less critical units such as those in a “well baby nursery” can number six to each registered nurse.

Under team nursing, a registered nurse is teamed up with a licensed vocational nurse. Together, the team handles more patients than an RN would handle by himself or herself.

Hospital officials explained their math in arriving at team nursing.

“Henry Mayo has a maximum of eight to 10 patients per team in the general medical units, which includes two licensed nurses — one registered nurse and one licensed vocational nurse — and one nonlicensed certified nursing assistant, who provides general patient care and support, including comfort measures and collecting patient information,” said hospital spokeswoman Andie Bogdan.

Newhall Memorial initiated team nursing in March 2010 as a pilot program. It is employed only on general medical-surgical units and those requiring less critical care.

The practice originated after World War II as a response to a shortage of nurses. Some nurses remember Newhall Memorial embracing a version of team nursing in the 1970s, Bogdan said.

RNs and LVNs
Registered nurses have a college degree in registered nursing. They obtain their credentials by completing an associate degree in nursing, a bachelor of science degree in nursing or a diploma. A two-year internship follows.

LVNs undergo a one-year study of three semesters, which demands three days a week working an eight-hour hospital shift, along with two days of classroom instruction.

A high school education is not required, but most LVNs have high school diplomas, according to Kathy Carder, a veteran registered nurse who speaks regularly on nursing at colleges throughout Southern California.

A registered nurse with 25 years of experience is paid $50.74 an hour, according to the California Nurses Association. An LVN is paid $14 to $24 an hour.

The responsibilities  of LVNs and the type of care they can provide varies. LVNs cannot assess patients, and thus cannot propose solutions to patient problems.

Nurse complaints
Earlier this month, a group of Newhall Memorial registered nurses came to The Signal to discuss what they saw as the dangers of team nursing. They spoke on condition of anonymity, with their California Nurses Association representative present to vouch for their credentials.

One, whom we will call “Kelly,” had an LVN to help her with eight patients during one shift. Under the law, LVNs can help only so much, she said.

Kelly said she was administering medication when one patient started choking.

“So I threw them (the medications) in the cart real quick and went in there. She (the LVN) is kind of like holding the patient up. And then, maybe 30 minutes later, or maybe an hour at the most, another, different patient is choking.”

After attending to that patient, Kelly said, “I went down the hall ... found my other patient confused, on the floor at the end of the bed.

Then you have to write up paperwork for that now because the LVN cannot asses the patient that’s on the floor and cannot do the paperwork that goes with it.”

Bogdan said the hospital has a 24/7 Rapid Response Team to aid nurses in such a situation.

“When necessary, a nurse can call a rapid response code, which signals expertise from across the hospital to support the nurse and provide whatever is necessary in care until (the) patient is stable or moved,” she said.

Kelly said the job has become much more stressful since team nursing was initiated.

“Jan” was a “floating nurse” assigned, last minute, to hospital units in need of nurses. Now, she said, she will work only in units with RNs exclusively.

“They would call me from the nursing office and ask if I can work on a floor, and I used to say ‘yes,’ but not anymore since they have this team nursing,” she said. “It’s hard for me.”

Paper records
“Helen” has been a registered nurse at Newhall Memorial for more than a decade. She was just off shift before talking to The Signal.

“I don’t know any of the meds my patient got today,” she said, “because all the thousands of medications that we give to patients each day — an LVN is giving them.”

Bogdan says whether the RN or LVN administers medication, it is all documented. “Henry Mayo’s policy is consistent with state laws that require the licensed nurse who administers the meds is the same one to make the documentation,” she said.

“It’s in the chart,” Helen acknowledged. “But I don’t see the chart. ... A doctor says to me, ‘Did that patient get their so-and-so?’ ‘Honey, I got eight patients today. Let me flip through this pile of paper here,’” she said, holding her hands about six inches apart. “It’s this thick because I got twice as many patients.”

Bogdan said the hospital will be documenting medications electronically in the near future.

‘Visual picture’
Helen said things ran much more smoothly before team nursing was implemented.

 “The other day, I had the three (patients), and here comes the doctor again. He says: “What about that patient over there?’ And I go ‘Well, blah-blah-blah-blah.’

“He finally had to tell me to shut up. ... That’s a good response from your doctor when he can walk up to you and ask you how a patient is doing, and you can give him a visual picture from head to toe — from all the medications they’ve gotten today to what their blood pressures have been, their skin, their IVs their pain meds, their reactions, their swallowing, have they had chest and evaluations done?

All the results, all the labs and you can spit them out like a little choo-choo train, and it’s delightful.

“They love that,” she said. “And that’s the way it should be.”

Studies on ratio
California law defines its registered nurse-to-patient ratio based on the critical intensity of the hospital unit.

Health studies show fewer patients die when a registered nurse is assigned fewer patients.

In a 2006 study completed by Health Services Research, researchers found: “California hospital nurses cared for one less patient on average than nurses in the other states and two fewer patients on medical and surgical units.

“Lower ratios are associated with significantly lower mortality. When nurses’ workloads were in line with California-mandated ratios in all three states, nurses’ burnout and job dissatisfaction were lower, and nurses reported consistently better quality of care.”

The study concluded: “Hospital nurse staffing ratios mandated in California are associated with lower mortality.”


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