3. Code Blue 2016 Pennsylvania Nurse 1
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Message from the CEO
by Betsy M. Snook..............................................................2
Testimonials
RNs from Pennsylvania.......................................................3
Nurses Must Act for Passage of Safe Staffing
by Rep. Mauree Gingrich.....................................................4
My Hope
by Rep. William Adolph......................................................6
Building a Culture of Safety
by Cloyd Gatrell & Michael Daniels.....................................7
Critical Demographic and Workplace Factors That
Influence Work Engagement in Nursing Practice in PA
by Danielle Weaver..............................................................8
Healthcare is at a Tipping Point
by Judy Morrison..............................................................10
Nursing Students Advocate for Safe Staffing
by Kristen A. Altdoerffer, Sophie-Charlotte J. Chen,
Toni Dzinic & Alexander C. Fly.........................................12
contents
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www.psna.org
Code Blue Special Issue
71(2)
Cover art designed by Churchill Strategies
Photo credits: Vlad Reshchykovets and PA House Photography
5. Code Blue 2016 Pennsylvania Nurse 3
Pennsylvania patients are suffering the consequences of chronic, unsafe staffing levels.
Because nurses love and respect our patients, a legislative solution can no longer be postponed.
It’s time to act. That’s why we’re contacting lawmakers in Harrisburg.
PSNA Calls a Code Blue
Surgical deaths are more than 60% higher in poorly-staffed hospitals.
The Safe Nurse Staffing Act
Empowers nurses to create patient-safety staffing plans aimed at reducing medical errors, saving lives and
confronting chronic burnout by nursing professionals. Learn more at www.psna.org.
I work in a newborn intensive care, level 3 regional center. When staffing
gets tight and census goes up, we have to take care of five babies and that
it is unbelievable ... parents don’t get the teaching they need, babies are
fed late and things get missed. They are not staffing the unit. One of our
nurses was working in triage and there was unsafe staffing with the new
babies that were coming into the unit. She went to tell somebody and they
essentially fired her ... You know, she threatened to go and they said: Well,
there’s the door. It’s really sad. Our unit’s getting worse.
Our hospital makes us sit in meetings reviewing Press Ganey scores about
complaints that patients have about us seeing them often enough and us not being available for their
care. They then immediately understaff us ... Administrators do not give us the option to refuse patients,
even when we feel it is unsafe staffing. We have had new nurses come out of orientation and immediately
receive maximum patient assignments with little regard of whether or not they are safe to care for these
patients. Managers and administrators get a very large bonus at the end of the year based on budget and
how understaffed we were and how much money they saved.
My unit is very small. We usually have two nurses on the floor and one aide and it is very unsafe for our patients, espe-
cially when we have larger patients that need boosted, or rolled and turned and the entire staff has to be in the room. It
takes 20 to 30 minutes to do some things with all the staff members in one room. But when we are fully staffed, things
run a lot smoother and our patients are well taken care of.
I work at a level I trauma center in a major city in Pennsylvania. I work every day ... short staffed. It’s amaz-
ing that an institution that can do world class medicine can’t figure out how to manage the schedule and
fill in vacancies and call-offs. I work with an incredibly motivated group of nurses in the ER. We all feel a
responsibility to help our co-workers and to show up when the unit is short staffed. We can’t do that if we
aren’t notified in a timely fashion ... it looks like it’s a way to work understaffed and pay less for nursing. It
looks like they work the nurses that they do have at a dangerous, dangerous, dangerous level.
70% of PA nurses surveyed confirm inadequate staffing negatively impacts their ability to serve their patients daily/weekly.
In 2014, a total of 240,778 “Serious Events and Incidents” were reported to the Pennsylvania Patient Safety Reporting System.
6. Code Blue 2016 Pennsylvania Nurse 4
According to the Centers for
Disease Control (CDC), accidents
and unintentional injuries are
the third leading cause of death
in this country, behind heart
disease and cancer, respectively.
In fact, a recent study at Johns
Hopkins University School of
Medicine in Baltimore attributes
many of those unintended deaths
to medical errors in our nation’s
hospitals.
Alarmingly, the study also shows
that each year, roughly 250,000
patients are dying, “not from the
diseases for which they are being
treated, but from the care they
receive.” To remedy this, I am
sponsoring Safe Staffing (House
Bill 476), which takes a collabora-
tive approach to providing safe
staffing levels for nurses in our
hospitals and healthcare facilities.
HB 476 does not create a manda-
tory nurse-patient ratio. It simply
requires hospital administrators
to enlist professional nurses to
Nurses Must Act for Passage of
Safe Staffing Legislation
By Pennsylvania Representative Mauree Gingrich
work with them to establish,
implement and monitor profes-
sional nurse staffing standards
within their facilities. This would
give hospitals the flexibility to
adjust staffing as needed. By
having professional nurses on the
staffing committee, it gives them
an active role in nurse staffing
decisions and the opportunity
to use their expertise in the best
interest of patients, the care team
and hospital.
The Johns Hopkins study found
that some of the more common
causes of unintended deaths stem
from poor communication, diag-
nostic errors, poor judgment and
other systemic breakdowns, as
well as hospital-borne infections
and adverse drug events. I believe
that hospital mortality rates can
be significantly improved with
appropriate staffing. It is widely
known that proper nurse staffing
is crucial to the safety and quality
of patient care. Appropriate nurse
staffing levels contribute to better
patient outcomes, improved job
satisfaction among nurses and a
decrease in healthcare costs.
About six years ago, I sponsored
another successful patient safety
bill requiring Pennsylvania hos-
pitals and healthcare facilities to
have a circulating nurse in the
operating room during procedures
using general anesthesia or deep
sedation. Your advocacy helped
to drive home the need for this
important safety measure and,
ultimately, to get it signed into
law. Likewise, your support is
needed now for my safe staffing
legislation.
Both nurses and physicians agree
that inadequate staffing is a ma-
jor concern. As professional nurs-
es and key beneficiaries of this
legislation, it is essential that you
make your voices heard. We ac-
complished this on April 11, 2016,
during PSNA’s Code Blue rally in
the State’s Capitol Rotunda. Suc-
cess in passing this legislation can
SAFE STAFFING VOICE
HB 476 Prime Sponsor
7. Code Blue 2016 Pennsylvania Nurse 5
also be achieved through private
and/or group conversations with
your State legislators.
HB 476 is currently in the House
Health Committee. With budget
negotiations underway and the
end nearing of our legislative ses-
sion, there is plenty of competi-
tion for the attention of lawmak-
ers. I will do everything possible
to move this bill prior to my
retirement this Fall. In the mean-
time, I encourage you, nurses and
patients, to contact your State
representative and ask him or
her to support HB 476. If they
already support the bill, ask them
to have a conversation with other
state representatives to garner the
votes needed for passage.
It has been a privilege and honor
to work with the members of
PSNA and the professional nurses
in the Commonwealth. I remain
committed to the passage of HB
476, and this can only occur with
you lending your voice to this
vital patient safety legislation.
Rep. Mauree Gingrich was
elected to represent Lebanon
County’s 101st
Legislative Dis-
trict in the Pennsylvania House
of Representatives in November
2002. Citing her strong leader-
ship, experience and interest in
economic and business devel-
opment, Gingrich was selected
by House leadership to serve
as chairman of the Labor and
Industry Committee for the
2015-16 legislative session.
8. Code Blue 2016 Pennsylvania Nurse 6
SAFE STAFFING VOICE
PA House of Representatives
The issue of nurse staffing levels
comes down to one thing: patient
safety. Study after study has
shown that as patient-to-nurse
levels increase, it creates a situa-
tion where things can get missed.
The women and men who serve as
registered nurses are some of the
most dedicated and hardest work-
ing individuals that I have met.
They care about patient outcomes
and providing high-quality care.
That is why safe staffing is so
important.
Every year it seems that nurses
take on more patients per shift.
This means less time with each
patient, which makes it harder for
our nurses to provide their tradi-
tionally outstanding level of care.
A study by the American Nurses
Association (ANA) found that
54% of nurses in hospitals report-
ed insufficient time with patients;
43% reported having to work
longer hours to help cover short
staffing. This is simply unaccept-
able. This is a medical emergency
that needs to be solved. Nurses,
doctors, hospital administrators
and the State should all have a
My Hope
By PA Representative William Adolph (R-165)
vested interest in finding a
solution to this problem.
That is why I co-sponsored
legislation offered by
Representative Mauree
Gingrich of Lebanon
County. HB 476 addresses
the issue of nurse staffing
by establishing professional
nurse staffing commit-
tees through collaborative
efforts of bedside nurses and
hospital administration. I offered
similar legislation in 2011 and
am proud that we have a strong
champion in Rep. Gingrich to
continue that fight. I am hopeful
that working together and con-
tinuing to educate our colleagues
on the patient benefits of this
legislation will allow it to gain the
momentum and legislative atten-
tion necessary to become law.
The men and women who work
as registered nurses have a tough
job. They adapt to an everchang-
ing environment in hospitals
throughout Pennsylvania. It is
incumbent upon State legisla-
tors to advocate for and support
these dedicated professionals. I
have had the privilege for 28 years
to work with many members of
PSNA. It is my hope that this leg-
islation will become law before I
retire at the end of November.
Rep. William F. Adolph, Jr.
was first elected to represent
Delaware County’s 165th
Legislative District in 1988,
and is now serving his 14th
term. Adolph currently serves as
the Majority Chairman of the
House Appropriations Com-
mittee. His legislative agenda
has focused on the environment,
education, economic develop-
ment, and job creation issues.
9. Code Blue 2016 Pennsylvania Nurse 7
SAFE STAFFING VOICE
Physicians
A most fundamental element of
patient safety is having adequate
numbers of qualified, knowledge-
able, skilled and empowered reg-
istered nurses to care for patients.
Physicians committed to safe,
quality care know that we cannot
be successful without adequate
nursing support. The data clearly
show that better nurse staffing
leads to improved outcomes and
fewer complications in hospital-
ized patients.
We recognize that RNs usually
have far more contact with any
given patient than the physician.
We know that no treatment plans
or orders get carried out without
our professional nursing partners.
Nurses’ observations are key;
their input and suggestions often
lead to adjustments and changes
in the physician orders.
In the emergency department,
patients’ underlying conditions
are often unclear and evolving.
With simultaneous patients in
progress, we depend on RNs to
alert us to individual changes and
deterioration that require priority
intervention. On the in-patient
unit, RNs are the constant “eyes
and ears” that keep us informed
of patients’ changing physical
parameters, emotional needs and
family dynamics. When emergen-
cies arise, it is usually the bedside
RN who responds first, initiates
care and activates the team. The
bedside RN also has the biggest
impact on the “personal” aspects
of hospital care. When RNs are
stretched too thin, both the tech-
nical and personal elements of
care suffer.
For the sake of the patients
whom we all care for, it is key
that hospitals recruit, develop
and retain adequate numbers
of RNs, and provide them with
adequate support staff. A culture
of safety is more than words on
paper. Physicians, hospital and
nursing executives, and nurse
administrators must each do their
part to build a supportive envi-
ronment where RNs feel valued
for their skills and contributions.
To promote patient safety, RNs
must feel safe to offer input into
care processes, and into adminis-
trative procedures and manage-
ment practices affecting nursing
care. All members of the health-
care team must be participants
in improving patient safety and
quality of care through reporting
and learning from mistakes and
errors. More importantly, each
must feel empowered to identify,
report and help correct unsafe
practices or situations affecting
patients, including inadequate
nursing staffing.
Adequate nurse staffing in hos-
pitals is not an expense — it’s an
investment. That investment pays
off in shorter stays, fewer compli-
cations, improved patient satis-
faction and better community
relations. Safe staffing improves
both patient safety and the bot-
tom line.
Building a Culture of Safety
By Cloyd Gatrell, MD, FACEP and Michael Daniels, MD, MBA
Dr. Gatrell is a practicing
emergency physician who has
been board certified in emer-
gency medicine for more than
30 years.
Dr. Daniels is a practicing
family physician who has been
board certified in family medi-
cine for 35 years, with addi-
tional certification in geriatric
medicine.
10. Code Blue 2016 Pennsylvania Nurse 8
By Danielle Weaver, BSN, RN | Member, PSNA Young Nurse Professionals
After a more thorough reassessment of her
now flaccid right side, my worst fears seemed
to be confirmed: my patient appeared to be
actively having a stroke. Time seemed to si-
multaneously freeze and speed up as the clock
to save her brain started to tick. As I began
to prepare to take my patient to her CT scan,
I remembered with frustration that we were
— yet again — short staffed. I would not be
finding help for transporting this patient (or
watching my other patients while I was gone)
anytime soon. We were short three nurses. The
charge nurse had a full patient assignment and
was responsible for answering the code pager.
There were no nursing assistants. I reassured
my unconscious patient that it was not her
fault ... this was just another day at the office.
As a nurse fresh out of school, it did not take
long to become aware of the issue of safe
staffing. I did not have to look for it — I was
reminded of it every day I came into work in
a chronically understaffed unit. Part of what
makes nurses so great is their flexibility and
Critical Demographic and
Workplace Factors That
Influence Work Engagement in
Nursing Practice in Pennsylvania
SAFE STAFFING VOICE
New-to-Practice Registered Nurse
Nurses are educators, so let
us work to educate those who
cannot experience what we do.
Nurses are advocates, so let
us fight for those who are
vulnerable and cannot fight for
themselves.
Nurses are healers, so let
us work together to heal this
problem of safe staffing.
11. Code Blue 2016 Pennsylvania Nurse 9
adaptability in times of great stress and limited resources. However,
working in an environment where there are simply not enough nurses
to take care of the patients in any given shift necessitates the kind of
adaptability that quickly can become dangerous, both for nurse and
patient. It is no secret that medical errors increase when nurse fatigue
increases, and yet fatigued and overworked nurses have become the
norm, even the expected.
I have found it difficult to verbalize the issue of safe staffing with
hospital administrators, even those I work with regularly or those who
were bedside nurses themselves. I would hear: “But nursing is a hard,
physically-demanding job. You knew what you were getting into when
you went into nursing.” And the worst: “That is just the way it is.”
Knowingly or unknowingly, these responses silenced the voice — al-
beit my singular, small and relatively inexperienced one — that was
fighting in the trenches for the patients they claimed to serve.
Unsafe staffing is not the way it has to be. Nurses and patients should
not expect chronically fatigued and overworked nurses as the norm.
We have allowed the safety of our patients to be jeopardized far too
long because we have done our best to work with what we have been
given. But it is not enough, and we should not allow our patients and
their families to suffer because of it.
Danielle is a second-degree
nurse. She earned a BA in
English from the University
of Florida, after which she
worked in publishing and for
non-profits before discovering
nursing. She received her BSN
from Duquesne University
and has since worked in criti-
cal care. Danielle is working
to combine her passion for
nursing with her prior degree
and experience to advocate for
nurses and their patients, both
at the local and state level.
12. Code Blue 2016 Pennsylvania Nurse 10
Healthcare is at a Tipping Point:
Healthy Nurse Staffing Sways the Balance
in Favor of the Patient
By Judy Morrison
SAFE STAFFING VOICE
The Patient and The Family
The emergency room was the last
place I expected to find myself at
the close of a summer day. But
here I was, waiting for my broth-
ers to arrive so that we could
find out what had happened to
our dad that afternoon. Looking
back, I know that a miracle oc-
curred during those seven weeks
of intense medical intervention.
This re-telling of those events
cannot include all the details
about the doctors, social work-
ers, healthcare assistants and
other professionals who helped
us through one of the most ter-
rifying experiences of our lives.
However, I will focus on the car-
ing nursing staff and how they
assisted us through the ordeal.
Dad was 86 years old and wid-
owed. He was still very healthy
and as mentally competent as
when he served as a corporate vice
president for a large steel manu-
facturer. On that June day, he was
driving a Ford farm tractor on the
family property. The tires gave
way on a hillside and the three-ton
tractor rolled over and tumbled
down the embankment. At some
point, his head was crushed. Every
facial bone was shattered.
When he arrived at the hospital,
his prognosis was dire and he was
admitted to the hospital’s trauma
unit.
A team of doctors, physician’s
assistants and RNs filled us in on
what to expect. Dad was in an
induced coma; he would not have
surgery to begin repairing the
many fractures to his face until
the swelling subsided. He was
on a ventilator, in a neck brace
and most of his swollen head was
bruised beyond recognition.
When the team left, Brittany, an
RN, informed us that she would
be watching over Dad through
the night. The 3:1 level of nurses
comforted us as we left that first
night. Brittany had a gentle and
knowledgeable demeanor, allow-
ing us to feel confident in his care
during our absence.
Over the next few weeks, we came
to recognize the nursing staff. It
was always a surprise to see who
we would be dealing with on any
given day. The difficulty was in
the continuity of care from one
10-hour nursing shift to the next.
A team of physicians was in
charge and orders were followed
by any one of several nurses
covering Dad’s assigned unit. It
took some time to figure out who
was the direct contact person in
charge of nursing care. We had
developed a relationship with our
first RN, Brittany, and whenever
she was on the floor she would
interpret information for us (even
when not assigned to Dad).
He remained in the trauma unit
and trauma step-down for nearly
a month. As he began to heal,
his brain injury caused him to
be a difficult patient, resisting
13. Code Blue 2016 Pennsylvania Nurse 11
staff assisted us in understanding
the need for this move. Dad no
longer needed intense care in the
step-down trauma unit. However,
nursing care was needed for his
trach and feeding tube. His recov-
ery focused on the swelling in his
brain and determining if it had
caused permanent damage.
The ambulance ride from the
hospital to the brain injury center
was hard on Dad. Immediately
after his admission, a code blue
was issued and he was moved to
intensive care. He received his last
rites for the third time since the
accident.
Dad was released to return to the
brain injury unit the next after-
noon, where he was restrained
and in a tent bed to keep him
from risking a fall. His brain
swelling caused agitation and
irritated behavior. Circumstances
for treatment in this unit were
very different than what we had
experienced. The main focus was
on physical, occupational, speech
and respiratory therapies, along
with the monitoring of cognitive
improvement.
Insurance issues complicated
communication between doctors
at the original hospital and Dad’s
current placement. Without the
willingness of the RNs to listen to
the family, the history of our ex-
perience in the trauma unit would
not have been adequately shared.
Communicating with Dad’s RNs
was vital because they were our
only connection to how Dad’s phys-
ical recovery was progressing. Two
excellent RNs, Elaine and Josie,
interpreted the doctor’s orders and
listened to our medication requests
regarding sleep, pre-accident pros-
tate concerns and oral care due to
the wires in Dad’s mouth. While
orderlies and therapists saw him
most frequently, these issues were
sometimes overlooked. The doctor
in residence consulted and visited
Dad several times per week. How-
ever, he was not accessible at all
times. One afternoon, an RN from
the pool of temps was assigned to
Dad due to short-handed staffing.
Her knowledge of his situation
and needs was limited, and her
level of concern was alarming low.
It was the only time I complained
about his care in the unit.
After two weeks, Dad was re-eval-
uated and approved for release
with 24-hour family care, home
health nursing and therapy. His
cognitive abilities were returning.
His emotional state had leveled
and the restraints and tent had
been removed. Dad’s recovery was
so amazing that he was asked to
be included in a research study
about rapid brain injury recovery
in geriatric patients. Prayers, our
presence, state of the art medical
care, patience and the intense car-
ing of dedicated RNs enabled this
to transpire.
While I always believed in my
heart that Dad would recover, I
was not confident that his recov-
ery would be complete. Nearly
one year after the accident, Dad
is living next door to my brother.
He drives, golfs, cleans and shops.
He even plays bocce one night
a week and recently fished his
favorite stream.
I thank his RNs and recognize the
need for safe staffing levels.
restraints, removing tubes and
feeling unhappy. He was no longer
intubated although still breathing
with a trach tube. His mouth was
wired because he had a broken jaw,
so he was upset that he could not
communicate his needs. Through
all of this, the nursing staff re-
mained informative and kind.
There were now fewer nurses to
monitor him. Our questions were
sometimes mistakenly directed
to a respiratory therapist check-
ing his trach or an aide adjusting
his position. I never realized the
many differences in nursing care
defined by the floor and patient’s
unit. Now that Dad was out of the
trauma unit, it was essential for us
to be present. If the nurses were
short on personnel, it could be
hours until someone could check
on him. Although other staff
stopped in, the RNs were the es-
sential connection between patient
needs and family reassurance.
One RN, Janet, stood out because
of her sense of humor and com-
passion for our family. As Dad
began to heal from the physical
aspects of the accident, his men-
tal condition also changed. With
it came increased confusion and
agitation. Janet was able to cajole
and chastise Dad, while still
getting him to comply. We recog-
nized that it was time for a new
placement. By this time, the nurs-
ing staff knew us very well and it
was difficult to leave the care of
those men and women who had
literally nursed Dad back from
the brink of death.
Insurance coverage was the deter-
mining factor in the decision to
send Dad to a brain trauma cen-
ter. The social worker and nursing
14. Code Blue 2016 Pennsylvania Nurse 12
Nursing Students Advocate for
Safe Staffing
Drexel University, College of Nursing & Health Professions
By Kristen A. Altdoerffer, DNP, CRNP, CPNP-PC, Assistant Clinical Professor
By Sophie-Charlotte J. Chen, BSN Student
By Toni Dzinic, BSN Student
By Alexander C. Fly, BSN Student
SAFE STAFFING VOICE
The Educator and The Students
Nursing attracts students who are compelled to provide high-quality, safe and compassionate care to patients.
Through their nursing clinical rotations, students quickly learn the limitations to patient care related to nurse
staffing. Although many registered nurses welcome students to their clinical setting, the nurses often do not have
the opportunity to teach and further shape the next generation of students. They are engulfed in running from
patient to patient providing care, often with a lack of auxiliary resources. Students learn the reality of bedside
nursing, the need for efficiency and strong time-management skills. They also learn the benefit of a good pair of
running shoes. The students build a healthy fear of medication errors and the continuous pull from direct patient
care toward electronic medical records.
In Pennsylvania, there is an opportunity for improvement with our State’s current safe staffing legislation. House
Bill 476, provides future nurses the prospect of entering a practice with improved patient outcomes, increased job
satisfaction and a decrease in overall healthcare costs.
On April 11, 2016, Drexel University undergraduate nursing students attended PSNA’s Code Blue in the Capitol
to provide exposure to the legislative process in an effort to close the gap between nurses and health policy. In
2010, the United States Census Bureau counted 3.1 million nurses in the U.S. (American Medical Association,
2010). As one of the nation’s largest workforce demographics, RNs have the ability to influence the policy that
shapes the environment in which they practice. Despite the number of RNs, studies of professional nursing
organizations indicate that RNs feel increasingly disengaged from decision-making roles (Cataldo, Spalding, &
Hagiri-Vijeh, 2014). Earlier engagement with health policy will help more RNs become involved in the legislative
process. Hewison (2008) finds that critically analyzing policy as nursing students or new graduates can develop
earlier confidence in health policy and the legislative process.
15. Code Blue 2016 Pennsylvania Nurse 13
Code Blue exposed students to the policymaking process and allowed them the opportunity to be involved before
beginning their career. Students were given the opportunity to advocate for safe nurse staffing, an issue important
to their profession and to Pennsylvania’s patients and families. They interacted with legislators in the House and
the Senate, felt the power of a chorus of RN voices during a rally and networked with colleagues from across the
State. The students came prepared to share their personal experiences with staffing issues; their stories seemed
to leave a lasting impact on the representatives with whom they spoke. Many of the lawmakers’ relatives work
in healthcare, yet they were unaware of the dire staffing situation. It was important for the students to meet
face-to-face with the representatives to provide lawmakers with a connection of faces and stories to HB 476. The
Drexel group left Harrisburg with a new-found impression of the importance of safe staffing and the power of a
nurse’s voice in affecting health policy.
Code Blue was a beneficial introduction to demystifying the student experience of collaborating with policymak-
ers by humanizing the politicians and staffers. It provided students with a clear view into policymaking and lob-
bying, which many students were previously unfamiliar. By understanding the struggle in advocating a bill into
law, the students left with a greater appreciation for the legislative process. Most importantly, they left feeling
that they would return to Harrisburg — and beyond — to continue fighting for better nursing policies in an effort
to improve their profession and patient care.
References
American Medical Association. (2010). Total physicians by race/ethnicity — 2008. Retrieved from http://www.ama-assn.org/ama/pub/about-ama/our-people/
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