MANAGED CARE Minimum staffing of nurses sparks debate By Brian C. Jones

A bill requiring hospitals to ensure there are enough nurses to care for all patients has this going for it — those for and against the measure agree on the basic issues.

• The more nurses hospitals have for their patients, the better off patients will be.

• Hospitals in Rhode Island generally provide the sort of nurse-to-patient levels that the bill proposes.

For example, many intensive care units provide one nurse for every two patients as the bill proposes; medical-surgical wards may have one nurse for every five or six patients.

What’s being debated is whether a minimum staffing law is needed. Opponents, hospitals, and the state Department of Health argue that ratios would hurt their ability to reassign nurses as patient needs ebb and flow. Elizabeth Haker, chief nursing officer at Landmark Medical Center in Woonsocket, cites this example:

A patient requires care by one nurse, who can be freed up by assigning her patients to other nurses. Haker says the bill, if it became law, would stop her from doing this. Similarly, a hospital might be forced to divert rescue squads to other hospitals on a given night if it didn’t have enough nurses to handle incoming patients.

But backers, including nurses’ unions and some legislators, worry that nursing staffs are potential targets as economic pressures grow.

Katherine M. Lukas, a cardiac ICU nurse at Rhode Island Hospital, says nurses in her unit have been caring for up to three patients at a time this year, instead of two. She recalls a shift during which she cared for a pregnant woman with a life-threatening heart condition, a man in constant pain, and a man awaiting surgery. The first two required most of her attention. But at the end of her 12-hour shift, the less-demanding patient had developed an infection.

"I don’t think I neglected him," Lukas says. "I just sort of neglected his arm over the course of the day, and he didn’t mention it to me. But you walk out of there feeling that as though you failed that patient."

Cathy E. Boni, a senior vice president at the Hospital Association of Rhode Island, and a veteran of 15 years as an ICU nurse, says, "We won’t dispute the fact that there is a relationship between the number of nurses and patient outcomes." But, she adds, "We don’t know what the magic numbers are."

Says Rick Brooks, director of Lukas’s union, the United Nurses and Allied Professionals, "When nurses are assigned too many patients, there’s a whole slew of medical problems that ensue — everything from medical errors, to increased rates of pneumonia, urinary tract infections, patient falls, bedsores."

One circumstance working against the bill is that there has been no nursing disaster comparable to the Station fire, where the death of 100 nightclub patrons has prompting an urgent review of Rhode Island fire codes.

Brooks warns a crisis could be in the wings. "Nurses intervene and assess and prevent crisis," he says. "We are trying to alert the public, alert the legislature that there is a crisis pending . . . before things get any worse and before we begin to see those tragedies."