Alternate Analysis of Nurse Staffing: the importance of standpoint

1. Alternate Analysis of Nurse Staffing: the importance of standpoint Patti Hamilton RN, PhD Visiting Scholar, Flinders University Adelaide, South Australia Wilson Professor of Nursing Midwestern State University Wichita Falls, Texas

2. Thanks to All Our Participants (especially hospitals brave enough to let us into their every day working world) Marie Campbell, PhD Gretchen Gemeinhardt, PhD, MBA SondipMathur, PhD Janet Rankin, RN, PhD Valerie Eschiti, RN, PhD Ali Gabriel, MS (indirectly Suzanne Vaughan)

3. Two Contextual Influences Themes of this conference and session Larger study of the working conditions of nurses at night and weekends when hospital mortality increases.

4. A Peculiar Eclipsing: Women’s Exclusion from Man’s Culture Dorothy Smith Being excluded, as women have been from the making of ideology, of knowledge, and of culture means that our experience, our interests, our ways of knowing the world have not been represented in the organization.

5. From the SSSP Website Howard S. Becker presents a view of art as the result of patterned, coordinated, ever-changing social interaction, rather than inherent in or emergent from idiosyncratic genius or talent. SSSP President Wendy Simonds

6. What is …made emblematic in art -and treated as universal…is, in fact, partial, limited, located in a particular position, and permeated by special interests and concerns. Dorothy Smith

7. In keeping with the theme of the conference-The Art of Activism -I will insert images of nurses as expressed in the art of graffiti from around the world. While we as nurses have been excluded from the work of producing the forms of thought and the images and symbols in which thought is expressed and ordered we have not been excluded from the images themselves.

8. Googled “nurse graffiti”

12. I am making no claim of analysis of the content of the nurse graffiti. Instead, I am employing the examples of nurse graffiti merely as an heuristic tool. I leave the relevance of the images to our findings up to you, the audience-participants.

13. I will be talking about the consequences of nurses’ exclusion from a full share in making what is considered essential knowledge in decisions about staffing.

14. Advances in Nursing Science: October/December 2011 - Volume 34 - Issue 4 - p 280–296 Knowledge for Re-forming Nursing’s Future: Standpoint Makes a Difference Patti Hamilton, RN, PhD Marie Campbell, PhD

15. We conducted *** interviews of ICU nurses, nurse administrators, hospital executives and nursing association leaders. ICU nurses came from one urban corporation-owned hospital, one urban public hospital, and one rural hospital that was a joint public/private venture. Textual analysis was conducted on health laws, hospital policies, decision-support tools and other relevant documents.

16. The disjuncture or puzzle I will be discussing this afternoon has to do with the apparent “failure” of recent legislation in Texas mandating nurses’ involvement in staffing. As our title suggests, however, standpoint matters when determining whether the legislation was a success or a failure.

17. We took the standpoint of the bedside nurse. Having analyzed empirical evidence we suggest that Nurses' knowledge is routinely transposed through a procrustean process of “working up” direct care nurses' knowledge into new informational forms without attention to the importance of the full range of what nurses know from their unique standpoint.

19. The American Nurses Association’s Nationwide State Legislative Agenda NURSE STAFFING PLANS AND RATIOS ME* WA MT ND VT NH MN NY OR MA WI CT RI ID SD MI WY PA NJ IA NE OH MD DE NV IN IL wv UT DC VA CO CA MO KS KY NC TN SC OK AR AZ NM GA AL MS AK TX LA FL Enacted legislation/adopted regulations to date: (12 states plus DC) CA, CT, DC*, IL, ME*, NJ, NV, OH, OR, RI, TX,, VT, WA * legislation was either waived or modified from that which was enacted Introduced in 2008-9; (17 states): AZ, CA, CT, FL, IL, MA, MI, MN, MO, NV, NH, NJ, NY, OR, PA, TX, WV HI June 2009

20. TEXAS DEPARTMENT OF STATE HEALTH SERVICES HOSPITAL NURSE STAFFING RULES TEXAS ADMINISTRATIVE CODE, TITLE 25, CHAPTER 133, HOSPITAL LICENSING [Nurse Staffing Advisory Committee] The hospital shall designate an advisory committee established in accordance with Health and Safety Code (HSC) §§161.031-161.033 to be responsible for soliciting and receiving input from nurses on the development, on-going monitoring, and evaluation of the staffing plan. As provided by HSC §161.032, the hospital's records and review relating to evaluation of these outcomes and indicators are confidential and not subject to disclosure under Government Code, Chapter 552 and not subject to disclosure, discovery, subpoena or other means of legal compulsion for their release.

21. Another bill was introduced but received little support.

22. “This legislation builds on the collaboration between TNA and THA in developing nurse staffing rules,” said Elizabeth Sjoberg, RN, J.D., associate general counsel for THA. “Building on this foundation, Senator Nelson and Representative Howard have empowered nurses to use proven strategies in developing staffing plans. The bill also gives nursing professionals more visibility to the hospital governing board, reflecting the high priority that hospitals place on nursing issues, particularly staffing. Supporting our nursing professionals in providing quality patient care is essential to their retention, which is a key component of addressing the state’s nursing shortage.” Source:redOrbit(http://s.tt/16gpg)

24. Textual material prepared by the Texas Nurses’ Association

25. Three Decision-support tools serving as textual vehicles of the ruling relations(Boss Texts)

28. Productivity, we discovered from interviews and the relevant institutional texts, is constituted in the routine work processes of specific staff members working with sophisticated technologies for calculating nurse staffing. Productivity is directly related to profitability of the institution.

30. How did the work to reach targeted productivity levels enter into the everyday staffing decisions?

31. Juanita explains that she “informs her staff” so that they know that “if they ‘staff up’ here, we’ve got to find those hours somewhere. And you would be amazed at them saying, you know, we can go one PCA (auxiliary health worker) here, Juanita, it’s not heavy.... Or we can go home early because we’ve discharged a lot. So once we inform them...they’re onboard”. Here Juanita is informing her staff about the reality of productivity targets in their work lives. There is only so much stretch in the staffing budget and they can use it up now or later.

32. What do the data show to be the dominant standpoint within the legislated nurse staffing committees?

33. One administrator told us “We have done a tremendous amount of education – on what is staffing and how are things determined ...to create our staffing advisory committee [that is now] required by the state of Texas.” For him, the idea is for the advisory committees “not to focus on how different we [nursing management and nursing staff] are, but...on how alike we are, so make sure that everybody has a voice in that process, so that they feel good about ...(the) staffing targets (being recommended).

34. That [they are accepted by nurses as accurate], reflecting the true amount of labor that’s needed on that unit to care for those patients. ...So it’s really a collaborative process that even includes our staffing advisory committee of bedside nurses that help us look at productivity targets, help us understand where the differences are, the variances based on the outcomes we’re trying to achieve.”

35. This constitutes a switch in the use of the advisory committee from what the Texas Nurses’ Association voiced as its purpose. In mandating the nurse staffing advisory committees, direct-care nurses are expected to advise the hospitals.

36. Our data show that while executive interviewees may recognize that direct-care nurses have knowledgeto contribute to those responsible for staffing decisions, the institutional effort is really to educate the nurses to accept that the institutional perspective on staffing is correct.

38. Our analysis suggests this privileging of institutional knowledge not only distorts the notion of empowering nurses but undermines and displaces nurses’ professional judgment about their responsibilities for patient care. While being “educated” about nurse staffing may make them into superior institutional actors, it will detract from their confidence to sum up a nursing situation and “speak up” about unsafe conditions.

39. Our research makes apparent that “empowering” nurses to speak is being enacted in our research hospitals as a practice of ruling. Nurses’ ideas and interests are actively and strategically being coordinated with institutional priorities.

43. Our analysis suggests this privileging of institutional knowledge not only distorts the notion of empowering nurses but undermines and displaces nurses’ professional judgment about their responsibilities for patient care. While being “educated” about nurse staffing may make them into superior institutional actors, it will detratcfrom their confidence to sum up a nursing situation and “speak up” about unsafe conditions. Our research makes apparent that “empowering” nurses to speak is being enacted in our research hospitals as a practice of ruling. Nurses’ ideas and interests are actively and strategically being coordinated with institutional priorities