Phara Souffrant Forrest: Chronic Understaffing Continues to Plague NY Hospitals

The nurse and candidate for central Brooklyn's 57th Assembly District calls for mandated safe staffing ratios that will save lives.

Phara Souffrant Forrest Jul 17, 2020

Because we show up to our jobs every day, healthcare workers are hailed as “heroes.” But as many of us have pointed out, we are not heroes, and our profit-driven healthcare system has made our jobs far more dangerous than they had to be. 

Trust that we would rather have enough nurses on staff than Youtube tributes from our employers. To the people who call us heroes to express their appreciation, I only wish that we were doing more. 

For most COVID patients, we are doing the bare minimum or less. This pandemic shows the way forward: mandate safe-staffing ratios for nurses and pass single-payer healthcare in New York through the New York Health Act.

The so-called “lean staffing method” treats patients like products on an assembly line.

As thousands of COVID patients flooded into New York hospitals, we faced a dire shortage of medical workers. Gov. Andrew Cuomo called for out-of-state and retired nurses to help fill in the ranks. The public grappled for the first time with the idea that the sheer scale of a public health crisis would overwhelm our system. But for nurses, extreme staffing shortages are nothing new. 

Healthcare facilities, whether for-profit or nonprofit, find it useful to staff as few nurses as possible for each shift. In New York, there are no legal limits on how many patients a nurse can be assigned. Extremely high patient-to-nurse ratios are constant features of our jobs. They degrade the basic level of care that we are able to provide and, well before COVID, ensured that hospitals were dangerous environments for patients. It was obvious to anyone who worked in healthcare that a pandemic would be a disaster. Staffing shortages create medical disasters on a daily basis. 

New York has no minimum staffing ratio in nursing homes, whose residents accounted for 20 percent of all deaths from COVID. On any given pre-COVID day, a single nurse could be responsible for an entire floor, dozens of patients, on her own. For each patient, a nurse needs to distribute multiple medications, follow up with doctors about treatment, speak to family members, fill out administrative forms, and monitor chronic conditions. We also need to socialize with the residents, as we are often the only people they speak to on a daily basis. 

It is impossible to accomplish all of this on your own, and nurses are forced to prioritize only the most pressing tasks. The one nurse on shift has to administer fourteen doses of insulin and twenty doses of blood pressure medication, and you think you’re getting a vitamin? At that point, a nurse is just tossing pills in the air, hoping that they land in the right mouth. Many patients feel fortunate if they get more than two showers a week.

The same nursing homes where dozens of patients have died of COVID were targets of  recent lawsuits over their bare-bones staffing. More than 50 people died of COVID at Kings Harbor Multicare Center in the Bronx, a facility which in 2015 was accused of understaffing that routinely resulted in patients left in their own feces for extended periods of time. Seagate Rehabilitation and Nursing Center in Brooklyn, where 28 people are presumed to have died of COVID, was sued by residents in 2018 for its chronic short-staffing. The facility continued to operate despite dozens of health department citations over the past few years. 

Did anyone really believe, when Governor Cuomo ordered nursing homes to accept COVID-positive patients, that these facilities would be able to diligently monitor other residents for signs of infection? 

New York has no required staffing ratio for emergency rooms or Intensive Care Units. One would hope that ICU nurses are able to devote full attention to their patients, but this is not the case. Any hospital system would have been strained by this pandemic, but countless lives could have been saved if our emergency rooms were adequately staffed. 

Infection control was impossible for the nurses in the triage tents at Montefiore Medical Center, where each nurse was assigned nine to 10 patients. The conditions meant that intubated COVID-positive patients were kept in close proximity to patients of unknown status, greatly increasing the risk of infection. Nurses at Staten Island University Hospital were conscripted from other departments to treat multiple intensive care level COVID-patients, despite having no training on ventilators, which require regular monitoring and adjustment. 

At my Administration for Children’s Services facility, as staff became infected and called out of work, remaining nurses were responsible for up to 80 children on their own, many with special needs.

Short staffing in hospitals had already reached a crisis point in the years before COVID. 

Staffing levels consistently rank among the top priorities of nurses in bargaining negotiations with hospitals. Over the last few years, nurses unions across the country have organized strikes to demand safe staffing levels. Members of my own union, the New York State Nurses Association, overwhelmingly voted to go on strike in April 2019 over staffing ratios at three major New York City hospital systems. But so far we have failed to achieve mandated staffing ratios, which would require hospitals to limit the number of patients assigned to each nurse on shift. 

Units that were able to maintain reasonable staffing levels fared far better with COVID patients. 

A refrigerated truck parked outside of Lenox Health (formerly St. Vincent’s Hospital) in Greenwich Village this April. Photo: Sue Brisk.

In one Washington Heights hospital, a pediatric intensive care unit was converted to a general ICU to handle the flood of patients. They achieved remarkable results, saving the life of every COVID patient they treated as of late May. One RN attributed the unit’s success to its staffing ratio, which allowed each nurse to care for at most two ICU patients at a time. Nurses had the time to perform the constant adjustments required by a patient on a ventilator. They could turn ventilated patients to avoid bed sores and massage their chests to discharge lung secretions. The unit was able to remove its patients from ventilators at a rate well above the New York City average. 

They were also able to provide comfort. Every nurse can speak to the medical importance of small comforts. Coaxing an extra bite of food, changing the sheets, holding the phone for the patient to speak to her husband. I am still surprised by what that extra bit can do. The patients light up when we smooth down the sheets. They smell good! They feel good! And they feel like they want to fight today.

The nature of COVID means that most of those who passed from it, passed alone. When no one is there to speak to patients, to instill courage and strength, their sheer hopelessness makes death more likely. I cannot imagine how many people passed away because of a lack of hope. To instill hope is part of the nurse’s job. So when I am called a hero, I only wish I were able to do more. 

The solution is to pass safe staffing legislation at the state level. Right now, there are safe staffing bills (A02954 and S01032) active in the legislature that set minimum nurse-to-patient ratios based on specific units in order to ensure that units requiring more intensive patient care, like ICUs, have the staff they need. The bill also provides a minimum number of care hours per resident in nursing homes. I strongly support these bills and, if I am elected to state Assembly, I will push for their passage in Albany. 

If we had mandated staffing ratios, patient lives would be saved. It is estimated that the odds of patient death increase by 7 percent for each additional patient a nurse is responsible for. Further, as nurses are responsible for more patients, there is an increase in total patient deaths. Patient outcomes are improved when nurses are assigned fewer patients since they have time to give their patients the care they need and deserve. 

The safe staffing bills have faced opposition from Gov. Cuomo and the healthcare industry, which cites false claims that mandated staffing ratios would exacerbate supposed shortages of nurses in the labor market. To understand the governor’s opposition, it should not be ignored that he has deep financial ties to the healthcare and nursing home industries. 

The fundamental cause of chronic understaffing is that healthcare is seen as a business to be drained of every last penny of profit. The so-called “lean staffing method,” adopted by hospital systems, is meant for the optimization of manufacturing processes and cuts any perceived waste or redundancy in the assembly line. 

In the case of nursing, this means lowering the number of nurses who care for the same number of patients. This type of thinking misapprehends the requirements of healthcare, treating patients as identical, fungible parts instead of individual human beings, each of whom require their own unique care. Instead of saving money, studies have shown that lean staffing increases absenteeism rates, workers’ compensation spending, and nurse burnout

Safe staffing policies are incredibly cost-effective. California has adopted safe staffing legislation and later saw billions of dollars more in hospital income and no hospital closures due to staffing issues. Safe staffing also reduces nurse turn-over, a process that can cost up to $88,000 per nurse to be replaced. With staffing the way it is now, new nurses often burn out within a year or two and leave the profession altogether. 

With safe staffing for nurses, we could create a system that gives nurses the time to be nurses. 

Nurses need time and energy to perform the non-billable parts of patient care that are vitally important. We need to be able to spend extra time with a patient who is struggling, give hope to a patient who has lost it, make a patient feel dignified and respected. 

We can’t bill for these tasks, so they are thought of as waste. But they can mean the difference between a patient healing or staying in the hospital longer. There is incredible value in the empathy that goes into nursing and we must create a health system that recognizes that. 

To truly create a healthcare system where patient care is the top priority, we need to pair safe staffing legislation with the implementation of a universal single-payer healthcare system. The New York Health Act would provide healthcare to everyone for free at the point of service. That means no more insurance co-pays, deductibles, premiums or other out of pocket costs. It would be funded by a progressive tax and the vast majority of New Yorkers would pay less in taxes than they currently pay in healthcare costs. 

The New York Health Act would realign the financial priorities of hospital systems by allotting “global budgets.” Hospitals would receive a lump sum of money from the state to provide patient care, and if there is money left over, they have to return it. With a global budget, there is no incentive to cut staff, including nurses, because profits cannot be made from the excess money. 

Safe staffing of nurses in hospitals and nursing homes would increase the quality and safety of patient care. Combined with the New York Health Act, these reforms have the potential to revolutionize our healthcare system, to provide incredible care to every New Yorker in normal times and to be resilient in the face of a public health emergency.

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