Last May I published my latest book Safety in Numbers: Nurse - to - Patient Ratios and the Future of Health Care. I co-authored the book with workforce researchers John Buchanan and Tanya Bretherton who are at the University of Sydney’s Workforce Research Centre, and it was published by the Culture and Politics of Health Care Work Series of Cornell University Press.
Safety in Numbers is an in-depth look at the struggle for, implementation of, and success of staffing ratios in the state of California in the U.S and the state of Victoria in Australia. These are the only two places on the planet that have government mandated nurse-to-patient ratios. Our book considers why ratios have become the number one solution to containing an out of control and unsafe nursing workload. It looks at the history of nursing ratios in these two states and describes in detail how nurses won these ratios. In the case of California, the ratios of 1:5 nurse-to-patient ratios on medical surgical units – at all times -- (and other ratios on other units) was a result of an almost ten year struggle led by the California Nurses Association, the most powerful nurses’ union in that state. The ratios were legislated in a bill that was passed in 1999 and signed by the state’s governor in the same year. After a three year period, the California Department of Health Services determined the exact numbers of the ratios and the length of their phase-in period. The legislation mandates not only ratios, but maintains that hospitals use patient-acuity systems to determine if patients need more nursing care.
In Australia, the ratio of 5 nurses to 20 patients - which comes down to a 1:4 ratio - is the product of a collective bargaining agreement that was first reached in 2000. It has been revisited every four years when the union contract between the Victorian Branch of the Australian Nursing Federation and the Victorian Government is negotiated. The nurses won this agreement by doing outreach to and mobilizing all nurses in the public health care system in Victoria. The nurses also led a public campaign and gained support from all of those who depend for their health and well-being of the state’s public hospital system.
John Buchanan and Tanya Bretherton, my co-authors, have done extensive work studying the implementation and success of the ratios in Victoria. A 2003 survey they conducted affirmed that nurses overwhelmingly believed that working life would have been worse had ratios not been introduced. Eighty-one percent of nurses who had worked to ratios for three or more years said the quality of patient care would have declined without them. Eighty-four percent reported that nurses’ working conditions would be worse. Over half (53%) said that if the ratios were altered they would reduce the amount of time they worked as nurses: 24 percent would consider leaving nursing altogether; 20 percent would consider cutting their hours; and 9 percent would consider retiring early. The degree to which ratios continue to directly affect decisions on staff flight is illustrated by this 2006 comment from one nurse, who works at an outer suburban Melbourne hospital: "God help us if we hadn't had them. I would have long since gone. It is the only thing that has kept me nursing."
The researchers believe that the ratios have led to a rebuilding of the profession, improved nurses’ status as professionals, and given them more time to engage in the “emotional labor” and empathic work of nursing. Although nurses still contribute far too much voluntary labor and overtime in the system, the ratios, the government says, has brought more than 7000 inactive nurses back into the system.
In California, the ratios have been similarly successful in their intent which is to deal with nurse work overload or work intensification. According to my interviews with California nurses, they say they finally feel they have some control over their workload. In April of 2008, University of California nurse workforce researcher Joanne Spetz published an article that affirms the nature of the success of ratios. [1] She analyzes data collected in surveys done by the California Board of Registered Nursing in 2004 and 2006. She found that “average nurse satisfaction improved with most survey items, including their overall rating of the job.” Nurses were satisfied with adequacy of staff, time for patient education, and clerical support. Nurse turnover was also reduced – which directly impacts patient care.
Researchers Linda Aiken, Sean Clarke and colleagues also surveyed nurses in California, Pennsylvania and New Jersey – states with no ratios. They found patient loads were reduced in California, and nurses there were more satisfied with their job conditions than nurses in either Pennsylvania or New Jersey.
The writing is clearly on the wall. Ratios work – to manage nurse workload. They impact nurse job satisfaction and retention and turn-over. Patients need them and so do nurses.
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