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Breaking Point: Pennsylvania’s Patient Care CrisisSurvey of 1,000 Pennsylvania Bedside NursesSeptember 20171 Page

A Letter from Nurses of PennsylvaniaNurses are the single biggest group of people in health care. We spend the most time with patients, andwe are the people whom patients and their families most often see and work with in hospitals, nursinghomes and other care facilities.As nurses, we are used to trying to do more with less, but there is only so far any one of us can stretch.Too often in Pennsylvania, giant corporations and multi-billion-dollar hospital systems are calling theshots, and they are making decisions farther and farther away from the beside, focused on profits overpatients. When your health is on the line, it is not the time to cut corners and pinch pennies.We know there are better ways to prioritize patient care and so we’ve come together as Nurses ofPennsylvania.We are a non-profit organization of, by and for nurses. Since our first meeting, held this year duringNurses Week, we have reached out to thousands of nurses and just over 1,000 of us have completed adetailed survey to contribute to this report. Since Nurses Week, more than 12,000 nurses have signaledtheir determination to stand together and to stand for patients – by joining Nurses of PA, by raising theirvoices on social media, by meeting with legislators, by talking to media and by organizing town hallmeetings in their communities. We’re shining a light on what’s happening on the frontlines of care, andwe’re speaking out like never before.Why? Because we always want to be there for our patients in some of the toughest times of their lives,but the situation in our hospitals and other care facilities is making this impossible.When we began our careers, we were under no misconception that nursing was a glamourous job.Nursing school is tough, clinicals are tough. As budding nurses, we saw every bodily fluid you canimagine and often find ourselves front and center managing stressed families, completing rapid fireinstructions and fiercely advocating for our patients. It’s this last role that drew us to this career in thefirst place.Between the three of us, we’ve been in nursing and public health for decades, and while we still lovepatient care for what it is at its core, we see that the system that’s supposed to support us is crumblingunder our feet. While new approvals, processes and paperwork are being piled on us, our staffnumbers—from nurses to aides to secretaries—are being cut. As nurse and ancillary support staffnumbers dwindle, public health emergencies like the opioid crisis are filling emergency departments,leaving nurses with too many patients and jeopardizing patient safety. It’s a perfect storm that’s burningout nurses far too quickly, with many retiring early or leaving the field all together.Every nurse takes an oath to do no harm, and we take this oath seriously. As this report details, we’vereached a breaking point where we cannot continue to watch our patients—your friends and families—be put in jeopardy by a system that refuses to listen to the professionals on the frontlines: nurses.2 Page

Thank you to all who have contributed their insights and experiences to this report. Pennsylvania nursesare coming together for solutions. We’ve been trained to go above and beyond when our patients’ livesare on the line—so that’s what we plan to do.Sincerely,Jake Reese, Jill Kochman and Antoinette KrausNurses of Pennsylvania Board Members3 Page

Executive SummaryPatient care is in crisis in Pennsylvania.Over the last 20 years, hospital profits and CEO pay have grown to record-levels while health caresystems across the state are consolidating and investing more capital in for-profit subsidiaries andinsurance operations. The 1990s especially saw unprecedented restructuring of the health care industry,featuring a staggering rate of mergers, acquisitions and closures of hospitals—between 1987 and 1997,675 acute care hospitals across the county closedi—as well as major shifts in where and how care isdelivered. With competition and pressure to keep the doors open on the rise, major corporations andexecutives began, and continue to this day, to enact policies and practices that put profits over patients,and reduce labor costs. Our health care systems are feeling the effects of these decisions now morethan ever.Nurses and other health care professionals across the state and in every work setting are increasinglyforced to do more with less. This broken system views nursing and frontline care as a line item on aspreadsheet, disregarding nurses’ critical role in providing quality care. Our broken system sees nursesas a cost, not a value.This report compiles results of a survey of 1,000 nurses – who work in hospitals, schools, rehabilitationfacilities, long-term care and more -- from Scranton to Erie to Pittsburgh and Philadelphia. Of surveyrespondents, 25% are 35 years old or younger; 37% are between ages 35 and 54; 3% are between ages55 and 64 and 5% are 65 or older. The majority of respondents -- approximately 64% -- have beennurses for more than 15 years, while about 12% have been nurses for three to eight years.The key findings, detailed in the report, include: 51% of nurses report that their input on how things are done at work has decreased in the last 5years. About 69% of nurses report their time spent bedside per shift has decreased over the past 5years. While Pennsylvania is not experiencing a shortage of available nurses, staffing decisions made byindividual facilities regarding both nurses and support staff and the ability to retain qualifiednurses have fueled a crisis in patient care. 94% of nurses report that their facility does not have enough nursing staff and 87% report thatstaffing levels affecting patient care are getting worse. About 84% of nurses report that a high rate of turnover among nurses is a problem in theirfacility and about 79% report that since they began working at their present job, the rate ofturnover among nurses has increasedNurses across the state are committed to using our experience and training to help create solutions thatguide Pennsylvania back to health care that puts patients first and ends the nursing crisis.Our recommended courses of action include: Safe nurse to patient ratios across the state;4 Page

Transparency for patients about nurse staffing and other support staff levelsImproved clinical training and mentorship opportunities for nurses;Investment in support staff, including wages;Support for nurses at home, including child care and retirement planning; andProcesses that give nurses greater input on care delivery decisions.Nurses of Pennsylvania, united for quality patient care, are talking to each other, speaking out andsharing how this “do more with less” system in Pennsylvania is exacerbating our patient care crisis. Asmany nurses who participated in the survey and other forums have noted, these are not easy issues orcircumstances to talk about. Nurses pride themselves on putting their heads down, being resourcefuland figuring out real-time solutions for their patients. But the realities of Pennsylvania health caredemand that we talk about things that are uncomfortable. To put our state back on a better path,nurses from every corner of Pennsylvania have decided they must expose what’s really going on.5 Page

How did we get here?At the turn of the 20th century, the nursing profession forever changed from a “vocation” in whichnurses provided a support role comforting sick patients to a career for highly-skilled and trained experts.With this shift our education hanged as well. Nurses hold degrees, have licenses and must keep up todate with advances in their fields. As nurses began to assume primary responsibility for individualpatients nursing departments grew until nursing became the biggest department in many hospitals andhospitals dedicated significant resources to maintaining a strong nursing staff.Nursing remains at the frontline of care to this day. Whether in hospitals, nursing homes, clinics, dialysiscenters or other care facilities, nurses today play the central role in patient care. Nurses spend the mosttime bedside, often have the greatest insight into how a patient is experiencing an illness or pain and arethe first line of defense in spotting and acting on changes in condition.However, the priorities of our health care system have shifted in ways that no longer support nurses inthis role. The restructuring of the hospital industry over the last two decades and the evolution ofhospitals – even nonprofits – as essentially big businesses has meant that hospitals are relentlesslypursuing ways to cut costs ever more deeply. Much of this cost cutting has come at the expense of whatnurses need to provide the best bedside care, even while hospitals in Pennsylvania are experiencingincreasing operating margins.According to the Pennsylvania Health Care Cost Containment Council’s 2016 annual report on thefinancial health of state hospitals, statewide operating income grew from 2.3 billion in FY2015 to 2.6billion in FY2016.iiFrom the Pennsylvania Health Care Cost Containment Council:As a result of this shift in focus, nursing has had to adjust, and nurses report that these changes are notalways consistent with patients’ best interests, with the sustainability of the industry, or even withefficient care. A June 2015 study by the Pennsylvania Joint State Government Commission onprofessional bedside nursing found that “nurse staffing in Pennsylvania hospitals is highly variable,” and6 Page

that the time nurses are able to spend with their patients has not kept up with national trends and bestpractices.iii The report confirmed a continuation of trends identified a decade earlier. For example, asurvey of thousands of RNs across the state in 1999 found that understaffing contributed to a number ofimportant nursing tasks left undone at the end of each shift.ivIn practice, nurses say this means that while they try to be responsive to patients’ needs and to makesure that people receive the best and most thorough care, they are too often pulled in too manydirections to do so. Nurses entered the profession because we believe good care demands a hands-onapproach – asking questions and getting to know patients both quickly and intimately is a critical part ofmaking the right decisions.In response to the survey, a Scranton nurse shared: “It’s critical that I have the time I need to give eachpatient. We send thousands and thousands of dollars in medical care down the drain for things likeinfected ulcers that can be avoided if we catch them in time.”Nurses across the state – whether nurses who have been working for 15 or more years or nurses whojoined the profession in the last five years – reported how this environment has changed their jobs: 46% of nurses report their input is unvalued or somewhat unvalued in determining the waypatient care is delivered; 5% report their input is very valued95% of nurses report that the conversation around health care in the US does not adequatelyrecognize the voices of nurses51% of nurses report that their input on how things are done at work has decreased in the last 5yearsDo More with Less System Hinders Patient CareNurses in Pennsylvania are stretched thin. Inadequate staffing in hospitals and other care facilitiesmakes the situation worse, which leads to limited bedside care, paperwork overloads, high turnoverand, most importantly, prevents nurses from doing what we do best: provide hands-on, face-to-facecare with a personal touch. About 69% of nurses report their time spent bedside per shift has decreased over the past 5yearsBedside care, including observational activities like talking with patients and their relatives, sitting nextto patients and bringing them food, can help nurses detect complications and avert errors or find newsolutions early. Restrictions on the amount of bedside care a nurse can provide means that day-to-daycare risks becoming rushed and detached – and that puts patients at risk.7 Page

“The worst is when you have a patient who you know is dying and you can’t be with them to holdtheir hand in the last hours of their life. You’re too swamped, running around to give them thecomfort they deserve. You feel terrible because you couldn’t give the care you wanted to give. Youdon’t feel like a good nurse when you go home.”-Wilkes-Barre RNInadequate StaffingThe United States is experiencing a national crisis in nurse staffing. The Bureau of Labor Statisticsestimates the U.S. will need 1.2 million registered nurses between 2014 and 2022. By 2024, nearly700,000 working nurses are projected to retire or leave the labor force.vInpatient Days Per RNIn Pennsylvania, the WesternAverage Workload for Pennsylvania Registeredand Northeast regions of theNursesstate as well as ruralcommunities have1400.00documented chronic staff1200.00shortages. Statewide, health1000.00care facilities have fewerregistered nurses per patient800.00than the U.S. average.vi600.00The problem here inPennsylvania, however, is not400.00a shortage of available nurses.2002/2003 2004/2005 2006/2007 2008/2009 2010/2011 2012/2013In fact, the number of newSurvey Period for PA DOH Survey of Registered Nursesgraduates entering theTotal RN RespondentsDirect Care RNsHospital RNsworkforce nationally hasmore than doubled since2001. And projections show Pennsylvania will have a surplus of 25,800 RNs by 2025. The problem lies instaffing decisions made by individual hospitals regarding both nurses and support staff like nurses’ aidesand secretaries, and the inability to retain qualified nurses.viiA Pennsylvania nurse explained in the survey: “Recently, I worked a weekend where we didn’t have asecretary for our shift. When we don’t have essential support staff like secretaries, we have to pick up thework of that role. This lab is calling, doctors are calling, worried families are calling, and we can’t notanswer the phone.”This creates a vicious cycle: bedside nurses are leaving acute care settings because of the difficulty andstress of the job. Pennsylvania has 180,000 nurses on its official registry, but this number fails to capturethe realities of nurse staffing across the state.8 Page

94% of nurses report that their facility does not have enough nursing staff87% report that staffing levels affecting patient care are getting worseApproximately 95% of nurses report they have experienced a situation where they felt incapableof providing the best care because of inadequate staffingPaperwork OverloadNurses across Pennsylvania overwhelmingly report they are overloaded with paperwork – often noncare related forms – that detracts from the amount of time they can spend bedside with patients. About 74% of nurses report spending more time on paperwork now than when they first startedtheir job; about 19% report spending the same amount of time on paperworkHundreds of nurses report spending 4 or more hours per shift on paperworkSurvey respondents from every region of the state shared that the hours devoted to paperworkfluctuate significantly. During some shifts, more time may be allowed for direct bedside care. Duringother shifts, as much as 60% to 70% of the time may be consumed with paperwork and other nonnursing tasks. Nurses report that these fluctuations depend considerably on available support staffingand technicians.The responsibilities given to nurses continue to grow. I spend nearly half of my shift —about 5hours—filling out charts that detail the care I’ve provided to each of my patients. Keepingaccurate, real-time records is critical to quality care, but it shouldn’t come at the expense of caringfor a person in their time of need. The question isn’t what’s more important: recording a patient’surine output or helping another to the bathroom. The answer is both.-Lehigh Valley RNHigh Turnover and Low RetentionPerhaps due to the increased demands placed on nurses, turnover in workplaces across the state is atthe highest it has been in decades, imposing a considerable cost to both hospitals and taxpayers.Nurses surveyed cited increased workloads detracting from their ability to safely care for patients as acontributing factor. Newer nurses seriously considering leaving the profession cited stress and burnout. About 84% of nurses report that a high rate of turnover among nurses is a problem in theirfacilityAbout 79% report that since they began working at their present job, the rate of turnover amongnurses has increased9 Page

We are over ratio and I think it is the new norm. Our hospital is hiring, I’ve seen the numbers.That’s not the issue. The issue is retention because people who are hired, they see theseenvironments and they leave, and experienced nurses leave because they get sick and tiredof it. At this point, with barely two years on the job, I’m the most experienced nurse on thefloor. It’s hard to get up and go to work when you know you are going to be over ratio everytime.-Pittsburgh RNNurses across the state testified to significant challenges facing new nurses and the barriers toimproving retention in the profession. Some long-time nurses spoke of intense “reality shock” for newnurses when the policies and practices discussed in nursing school fail to materialize in care facilities.Many cited inadequate training and little time for new nurse orientation as contributing to high turnoverand low retention. Others cited high patient acuity and unsafe staffing levels that make it nearlyimpossible to manage time and patient loads effectively.Public Health CrisesPennsylvania, like many states, is ravaged by our country’s opioid epidemic. The Drug EnforcementAdministration reported that 4,642 people across the state died last year from drug overdoses – upfrom 3,377 the year before. The opioid epidemic has further intensified the state’s patient care crisis andit has more starkly exposed acute vulnerabilities across our health care system. Nurses contributing tothis report noted: The opioid epidemic stretches nurses who are already at the breaking point. As sicker and sickerpatients with more complications seek medical attention, keeping the same number of nurses ona shift is unsafe and unsustainable. Nurses can help fight the opioid epidemic if they are given adequate time to spend with patients,including exploring other types of pain management strategies and observing patients’relationships with pain and medication.I administer the meds because I don’t have time to fight the patient. I don’t have time to convince them towait or try Tylenol or have time to call the doctor for a consultation about pain management. My otherpatients need me too. I don’t have time to question something that’s been deemed “safe” and explore othermethods of pain management. It’s not right. We need the freedom to do better than that for our patients toprevent addiction in the first place.-Northeastern Pennsylvania RN10 P a g e

Recommendations from the Front Lines of CareNurses across the state are committed to using our experience and training to help create solutions thatguide Pennsylvania back to health care that puts patients first and ends the nursing crisis.Our recommended courses of action include: Safe nurse to patient ratios across the state; Transparency for patients about nurse staffing and other support staff levels Improved clinical training and mentorship opportunities for nurses; Investment in support staff, including wages; Support for nurses at home, including child care and retirement planning; and Processes that give nurses greater input on care delivery decisions.The statewide support for improved staffing is not surprising. Numerous studies have shown a directrelationship between higher nursing staffing levels and improved outcomes of care, including lowermortality rates, less antibiotic use, fewer infections, lower hospitalization rates and less weight loss anddehydration among patients. One study of 168 hospitals in Pennsylvania found that risks of patientmortality increased by 7 percent for each additional patient added to a nurse’s workload beyond abaseline of four patients.viiiPennsylvania elected officials and their constituents have also voiced their concerns and calls forimprovement, prompting some emerging action in the state legislature. For instance, in 2015, the JointState Government Commission recommended legislation that provides easily accessible reports onstaffing levels in Pennsylvania hospitals. Since then, a version of the recommended legislation has beenintroduced in the House and Senate. States like California have also implemented legislation that theestablishes safe nurse to patient ratios and a bipartisan group of Pennsylvania legislators has introduceda similar bill.Nurses of Pennsylvania will continue to elevate the stories of nurses in every part of the state and shareinsights from the bedside to help policymakers, health care advocates and health care professionalsimprove the quality of patient care for all residents.11 P a g e

Meet Nurses of PennsylvaniaIn just a few short months, more than 12,000 have come together as Nurses of Pennsylvania – sharingtheir stories and experiences online and offline and calling for sensible staffing and other improvementsthat help put patients first and give nurses the support they need to do what they do best.More than 1,000 nurses were surveyed for this report, many of whom shared personal stories andexperiences from their decades of experience on the front lines of patient care.Here are some of the nurses who have contributed to this report and come together to lead thisstatewide effort:Shannon Reichard, ScrantonShannon Reichard, a registered nurse in a cardiac ward graduated from nursing school just two yearsago. She says she became a nurse because she wanted her life’s work to be “meaningful”— but already,she says that she feels like she “barely survives her shifts” due to understaffing.Shannon is often charged with caring for multiple critical patients, many with dementia who are at riskof bed-jumping and injuring themselves without adequate supervision. Yet, even with a full patient load,she finds that much of her time is spent on paperwork and even janitorial maintenance. At some otherarea hospitals, she’s heard of nurses caring for twelve patients per shift.Sara Kocet, State CollegeSara Kocet works in an oncology unit, where she treats patients with a wide range of chronic diseases,including cancer. Many of her patients have imminently life-threatening conditions, including sepsis,infections, and open wounds. She got into nursing, she says, because she likes helping people and theirstories, especially those of her mostly elderly patients.According to Sara, staffing levels fluctuate widely, and she feels like patient acuity is not taken intoaccount when the number of nurses on call is being determined. For a few months this year, forexample, she said she was frequently “mandated”—required to stay—for numerous sixteen-hour shifts.Merri Beth Allen, Southwestern PAMerri Beth is a registered nurse in an intensive care unit. She has worked in Pennsylvania hospitals inthe region for over thirty years. She believes conditions are getting worse as hospitals have cutadministrative staff. When she and her colleagues are inundated, there is often no help to be had.Keeylynn McGriff, PittsburghKeeylynn is a registered nurse in a telemetry unit. With nearly 2 years on the job, he’s followed in thefootsteps of his mother and grandmother to become the third in a line of nurses. In Keeylynn’sexperience, nurses are sorely understaffed and struggling to hire. With just under two years ofexperience, he is one of the veteran nurses and would like more mentorship opportunities to learn fromexperienced nurses.12 P a g e

Sandra Trimmer, Wilkes-BarreSandra is a registered nurse on the medical surgical floor. In her years as a nurse, she has seen theprofession change to a point where her department is losing nurses faster than they can hire them. Shesays patients are sicker and are coming in in larger numbers. She has repeatedly advocated for saferstaffing levels. She has also seen the devastation of the opioid crisis first-hand and firmly believes thereis more that could be done to prevent opioid addiction in the first place.Alex RendinaAfter an early career working in a factory, Alex chose nursing as his second career because he has alwaysbeen interested in the health care field. He has been a nurse for 12 years and has worked in nearly everyhospital department. Alex has watched nursing evolve over his tenure and sees holes in the efficiencyand effectiveness of patient care. He sees nurses spend half their shifts doing paperwork, and knowsmany feel pulled in too many directions, having to choose between charting or providing physical care.Ahmed Rizik, South Central PAAhmed has been a nurse for nearly eight years on an orthopedic medical-surgical floor. Originally fromZanzibar, he wanted to work in medicine because he saw the lack of medical care in his country. In hisopinion, being a nurse is worrying about other people, so he tries not to let the hardships of the jobbother him. In recent years, he has seen issues like understaffing impact his patients and his fellownurses, and that’s where he draws the line.13 P a g e

About Nurses of PennsylvaniaNurses of Pennsylvania is an organization of, by and for nurses focused on improving the bedside carenurses provide. PA nurses work in cities and small towns, at large hospitals, in nursing homes and more– tied together by their commitment to their patients, their families and their communities. United forquality care, Nurses of Pennsylvania is focused on leading the state to a health care system that putspatients first.For more information, please visit us on Facebook and at www.nursesofpa.org.Our BoardAntoinette Kraus, Executive Director of Public Health Access Network: Antoinette Kraus currently servesas founding Executive Director of the Pennsylvania Health Access Network (PHAN). Since joining PHAN in2008 Kraus has helped grow the Pennsylvania Health Access Network into the state’s largest consumerdriven organization.Jake Reese, RN at Regional Hospital: Jake Reese is a registered nurse at Regional Hospital in Scranton,Pennsylvania. He currently works in the Cardiac Telemetry unit where patients are acutely ill and requirecontinuous cardiac monitoring.Jill Kochman, RN at Allegheny Center for Digestive Health: Jill Kochman has worked in nursing since 2004,starting her career at the Allegheny Valley Hospital and West Penn Hospital, and moving to AlleghenyCenter for Digestive Health. At Allegheny Valley Hospital, Jill served as the Coordinator of Quality Affairs,helping to ensure that the hospital offered the highest standard of patient nts/Vol21997/No1Jan97/HealthCareinChaos.html?css printii http://www.phc4.org/reports/fin/16/default.htmiii 6.30.15.pdfiv Politics/Is More Better.pdfv es.htmvi ealth-Care-WorkforceReports.aspx#.WbG-IbJ96povii ding-surplus/article f1f3b4141ff5-11e5-946d-03425b900317.htmlviii 9543814 P a g e

nurses need to provide the best bedside care, even while hospitals in Pennsylvania are experiencing increasing operating margins. According to the Pennsylvania Health are ost ontainment ouncil's 2016 annual report on the financial health of state hospitals, statewide operating income grew from 2.3 billion in FY2015 to 2.6 .