Taken from NJ Spotlight News
January 8, 2024
When nurses agreed to settle their nearly five-month strike against Robert Wood Johnson University Hospital in New Brunswick in December, a key component was getting specific nurse-to-patient ratios codified in their contract, along with financial penalties if the hospital is short-staffed regularly.
The fact that RWJUH — a regional trauma center and a major hospital in New Jersey — reached a deal on staffing levels shows it is possible to find balance on an issue that has divided labor unions and hospital officials for years, according to Sen. Joe Vitale (D-Middlesex), the longtime chairman of the Senate Health Committee. Nurses have long argued that more bedside staffing is needed to boost patient safety and workforce sustainability, but hospitals have largely opposed such mandates.
“All the other hospitals were keeping a very close eye” on the strike, Vitale told NJ Spotlight News last week, in which 1,700 nurses represented by the Steelworkers Local 4-200 began picketing in early August. “They know it may come to them — if not through the Legislature, through other bargaining units.”
“I don’t know if it’s one size fits all — I suspect not,” Vitale added, “but there’s a path forward.”
Research has shown that when nurses are caring for fewer patients, those patients are less likely to experience medical errors, hospital-acquired infections, readmission and death. But nurses are leaving bedside care at a growing rate — a trend exacerbated by the COVID-19 pandemic — making it harder for hospitals to hire and retain these staff.
Unsafe staffing levels is the top reason nurses give for leaving the workforce in New Jersey, advocates for reform note, followed by stress and burnout. Similar concerns at nursing homes, which experienced significant deaths and sickness early in the pandemic, led the state to implement a law that specified staff-to-patient ratios for bedside care at long-term care facilities in late 2020, based on a bill also sponsored by Vitale.
They agree this much
Both nurses and hospital leaders agree the lack of bedside caregivers is a problem and that patient safety is critical, but testimony before the Senate Health Committee Thursday made clear that any path to a solution remains rough. The two sides even define the underlying problem differently, with hospital leaders highlighting numbers that show how the nursing workforce is dwindling, while nursing leaders insist their colleagues are instead leaving hospital jobs for other, less taxing roles.
“There is no nursing shortage. There is a staffing crisis,” Judy Danella, a nurse at Robert Wood Johnson University Hospital and leader of Local 4-200, who said there are 1.2 million licensed nurses nationwide who are now not practicing, including 5,600 in New Jersey. Better working conditions, with lower patient loads, would help lure them back to the bedside, she and others said.
Danella told NJ Spotlight News that the contract with RWJUH does include specific nurse-to-patient ratios, which are termed “guidelines.” These include a ratio of 1:4 in oncology, 1:5 in regular hospital units and 1:6 in the emergency department. The hospital, part of the RWJBarnabas Health system, one of the state’s largest, will be required to pay quarterly penalties that start at $500,000 to the nursing staff if they fail to meet these guidelines more than 18% of the time, she said.
“It’s a start, but it’s not where we want to be,” Danella said, noting her members would rather have a ratio codified in state law, as Vitale’s bill proposes. The hospital spent over $100 million to hire replacement nurses to provide care during the strike, which prompted U.S. Sen. Bernie Sanders (I-VT) to hold a hearing on the issue at Rutgers University in October.
Nursing organizations — including the New Jersey State Nurses Association, which had previously opposed mandated staff ratios — said that legislation is needed to force hospitals to hire and deploy more nurses. “Nursing care is simply a line item in a budget that can be cut to its lowest number to maximize profits. Unfortunately, this is what we can always expect hospitals to do,” nurse Debbie White, president of HPAE, the Health Professionals and Allied Employees union, which represents some 13,000 workers in New Jersey and Pennsylvania and has led the fight for staffing ratios, told the committee.
Starting point for legislation
Vitale noted that his bill — which would codify nurse-to-patient staffing at acute care and behavioral health hospitals, facilities that care for people with disabilities and outpatient care centers — is just a starting point for discussion; the committee did not vote on the measure Thursday. “It’s a roughly worded template at this point,” he said, “and frankly it’s stale.”
Whatever form the legislation may take, hospital leaders made clear that from their perspective a state mandate was not the answer. They highlighted the challenges hospitals have faced in trying to recruit and hire additional nursing staff and agreed that staffing levels play an important role in quality care, but said facilities need flexibility to create team-based care that reflects the skills of the individuals on duty and the needs of each patient.
Leslie Hirsh, president and CEO of Saint Peters University Hospital in New Brunswick, said it was the worst health-care workforce shortage he’s seen in 40 years in the business, a problem compounded by rising costs following COVID-19. He urged lawmakers to do more to expand nursing education, as a lack of nurse educators and concern about tuition cost have been seen as barriers to the profession’s growth.
Hirsh said he would eagerly hire more nurses, if they were available. But he said that a larger pool of staff wouldn’t necessarily impact how many bedside caregivers were deployed daily. “We staff to acuity. We staff to patient needs,” he said. “Rigid, inflexible requirements aren’t going to solve the problem.”
Other hospital officials raised concerns that statutory staff mandates would be impossible to meet, forcing facilities to close certain units or programs when they could not find enough nurses for a shift. This could create a cascade of issues, forcing patients to be held longer in the emergency room, or requiring ambulances to divert to another facility farther away, they said.
“We are concerned about the unintended impact of a legislative mandate on patients’ access to health care services,” said Cathy Bennett, president and CEO of the New Jersey Hospital Association, which represents acute care and specialty hospitals and long-term care facilities. “Mandated ratios may lead hospitals to temporarily or permanently [shut] health services in obstetrics, dialysis, cancer or pediatric care. This directly impacts patients and may at times be life threatening.”
“NJHA advocates for a balanced approach that considers evolving care design and the unique needs of patients,” Bennett added.