RN to RN: A Conversation of Global Concern

RN to RN: A Conversation of Global Concern

Eileen (RN – San Francisco, USA)
I’m struck by our similar concerns, even though we care for different kinds of patients in three different countries with different health-care systems. We all face budget cuts that are making it more difficult to care for our patients.

Aisha (RN – Ontario, Canada)
Hospitals across the province of Ontario are chronically under-funded, and they are cutting nursing positions to balance their budgets. Every RN position lost is equivalent to 1,950 fewer hours of nursing care per year.

We are very concerned about this, because a higher proportion of RNs in a hospital has been shown to reduce patient deaths. For every ten percent rise in the proportion of RNs, patient deaths drop by five percent. Every patient added to the workload of an average RN causes the rate of complications and deaths to increase by seven percent.

Patricia (RN – Belfast, Northern Ireland)
I want to express my admiration for the work of the California Nurses Association (CNA) for winning legislation to ensure a minimum ratio of nurses per patient. That’s got to make it easier to practice safely and provide quality care for patients.

Our National Health Service (NHS) prefers to blame frontline workers than provide them with more resources. I’m eager to learn how the CNA achieved this benefit.


Australian nurses won the first RN to Patient Ratios in 2001. After a 12-year battle involving numerous rallies at the Capitol in Sacramento and meeting with legislators while facing fierce opposition from the hospital industry, the California Nurses Association (CNA) won the first RN to Patient ratios in the United States in 2004.

We won ratios of 1 nurse for every 4 patients in the ER – 1 to 2 for ICU patients and 1 to 1 for trauma patients. The ratios apply at all times, including meals and breaks. We also won restrictions on the use of unlicensed staff, restrictions on unsafe “floating” of nursing staff and no cuts to ancillary staff as a result of ratios. You can find out more by visiting the CNA website.


We have a long way to go. In our ER, RNs have worked 24-hour shifts and been responsible for 15 patients at a time! Nurses are being forced to care for patients in hallways, and they are burning out.

Our local newspaper carried a front-page story about the deterioration in patient care at the hospital where I work. The hospital recently closed 16 beds and laid off 30 staff. The loss of beds and nurses means that patients are waiting much too long for care, and there aren’t enough nurses to provide the care that’s needed.

Too much work and too much stress are driving people out of nursing. More than one in four of the RNs currently working in Ontario are over age 55. Who will replace them?

In California hospitals, safe RN ratios have improved the quality of care as well as nurse recruitment and retention.

Unfortunately, the California Department of Health Services, the government agency that regulates healthcare facilities and should be enforcing the law, is understaffed and beholden to the Schwarzenegger administration. As hospital administrators constantly seek ways to cut budgets in order to increase profits, we nurses must be diligent and insist on enforcing the law in our workplaces.

Also, California law states that the ratios must be reviewed after five years – in 2009. The hospital industry recently released two studies questioning whether the ratios really work, so we know that another is battle brewing to undermine the ratios again.

I work as a Community Psychiatric Nurse, and CPNs are very concerned about the number of patients under our care. Can you tell me about community nursing in California? Does the nurse-to-patient ratio legislation protect nurses and patients in the community?

I’m sorry to say that the law mandating nurse-to-patient ratios in California applies only to RNs in acute-care hospitals.

When patients with complex medical issues are sent home or to post-acute or skilled nursing facilities, the number of RNs is much lower. However, in the non-acute-care setting, we have gained improvements in nurse-to-patient ratios using our union-mandated staff nurse committees. Home health or visiting nurses who are unionized can also negotiate decreased case loads.

We don’t have a strong union leadership here in Northern Ireland, and this is reflected in the way our health service is being run down. I’ve been involved in forming a new union for health workers, because the existing unions are more interested in developing a relationship with management than in protecting the rights of patients and health workers.


While you mentioned the cuts to the NHS, the idea that all patients can access health care is something that Americans want, but don’t have. As more people lose their jobs and their health insurance benefits, we’re going to see many more people with no access to healthcare.

How has the NHS changed since its original inception, and would the residents of the U.K and Canada ever give up the idea of national healthcare?

After winning national medicare in the 1970s, Canadians never imagined that we would see such a severe and escalating deterioration in our health-care system. We have been fighting back, but we have to fight much harder.


NHS has changed significantly since its inception. Privatisation has taken a stronger hold since the Thatcher years, and New Labour continued Thatcher’s policies, dismantling a health service that was once the envy of the world.

The idea that all patients would not have access to health care would be beyond comprehension for us. However, while all NHS patients have health care in principle, the waiting lists for essential procedures and life-saving operations are increasing. As a result, many people are forced to go private.

Mental health services in Northern Ireland are grossly underfunded. For example, young people requiring specialist treatment for eating disorders and personality disorders must go to England for treatment. They are effectively exiled from their own country, far away from their families and friends. So health care is not really available for all.

I cautioned US health-care campaigners at a recent Labor Notes conference. I told them if you are going to fight for health care, fight for quality health care. A half-baked health-care system isn’t good enough.

In Canada, the reintroduction of for-profit competitive bidding is putting a downward pressure on wages, making it even more difficult to keep people in nursing.

I think we are headed for a public health disaster if we don’t get the profit factor out of healthcare.

The demand for a single-payer healthcare system is growing in the United States. For-profit insurance companies shouldn’t be involved in our healthcare decisions, and any healthcare reform that keeps them in the mix will surely fail.

We need to build stronger unions so we can improve our working conditions and make sure that our patients get the quality care they deserve.

All these cuts on the backs of patients have to stop. Only in solidarity can we win this tough battle.


Patricia Campbell is an RN and Community Psychiatric Nurse in Belfast, Northern Ireland. She is also a founder of the UNIVERSI health workers’ union.

Aisha Jahangir is an RN in the Family Birthing Unit at the Guelph General Hospital in Ontario, Canada. She is also a local coordinator for the Ontario Nurses Association.

Eileen Prendiville is an RN at an acute-care hospital in San Francisco, USA. She is also on the bargaining team of the California Nurses Association.

This conversation was originally published in PEOPLE FIRST!

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