Too few nurses for California to meet new hospital staffing law

  1. [color=#6f6f6f]san francisco chronicle, ca - mar 23, 2004

    california's hospitals are on the front lines, delivering care 24 hours a day to every person who needs our help, whether or not they can afford to pay.


    new state regulations, however, are seriously testing the ability of hospitals across california to provide this care. although the requirement for hospitals to base their staffing on specific nurse-to-patient ratios was signed into law in 1999, the california department of health services (dhs) didn't finalize the numeric ratios or the regulations needed to implement them until september 2003. these new regulations, which took effect this past january, are now forcing hospitals throughout the state to close beds, deny patient transfers, increase ambulance diversions and require longer waits in the emergency room. the major reason for hospitals' inability to meet the nurse-to-patient ratio regulations: a dire shortage of nurses and dhs' interpretation that the ratios must be met "at all times." the california nurses association would have the public believe that there is no nursing shortage. the cna, a labor union for nurses, even goes on to claim that california has 30,000 more nurses than we had just three years ago, yet this is not supported by the facts. california ranks 49th among states in the number of nurses per capita, according to 2001 data by u.s. bureau of labor statistics. only nevada has fewer. the state economic development department says california will be short more than 30,000 rns by 2006. by 2010, the department adds, the shortage will more than triple -- to more than 109,000 rns...

    read more: http://www.sfgate.com/cgi-bin/articl...dgb95ogri1.dtl
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  2. 29 Comments

  3. by   yupyup5
    I understand California's mandated ratios, but what isn't clear is whether the RN's have help from nursing assistants?
  4. by   nursemaa
    My guess is that the staff mix will change- more RN's but fewer numbers of support staff.
  5. by   pickledpepperRN
    My experience as one who works registry in addition to a regular job is that most hospitals have improved. Most also have some units or some shifts with staffing problems that are not complying with the regulations.
    http://www.calnurse.org/finalrat/ratio7103.html

    Some have decreased the number of nursing assistants while adding RNs and/or LVNs. Others don't provide break relief.
    At my hospital we do not take a break without a competent RN who takes report and assumes responsibility for our patients. A couple times we got many admits and di not take our break. We get double time for missed breaks. The employer, I think, also has a fine for not providing breaks so they are better off finantially to have a charge nurse without patients and another unassigned RN to provide break relief. After all breaks have been taken that nurse can transport or admit patients.

    The requirement to staff by acuity is also a big problem. This has been in the regulations for 8 years. Still managers try to change the acuity. We tell her, "If you assess the patient and assume responsibility for the nursing care fine.
    They allow the safe staffing. Often they want to send a nurse home, even at 3:00 am! then later there is an admit. That only happened ONCE! Now we call the ER to find there are possible admits so the nurse to go home goes for a 15 minute break. Amazingly after the supervisor (always the same one, others do NOT try this) sees that nurse is not in the unit we are told about the admission.
    Like Cinderella with the slipper we still have our nurse!

    So how can they say there are no nurses when they send licensed nurses home?
  6. by   pickledpepperRN
    http://www.calnurse.org/cna/press/2404a.html
    February 4, 2004
    Staffing Improved at Nearly 70% of California Hospitals
    Safe RN Staffing Law 'Off to a Good Start,' Says CNA

    Just one month after its effective date, California patients are already benefiting from the state's landmark law requiring safe registered nurse staffing ratios in California hospitals, the California Nurses Association said today.

    Staffing conditions are improved at 68% of the hospitals surveyed by CNA, and 59% were generally in compliance with the requirements of the law. The CNA survey covered 111 hospitals, nearly 30% of the general acute care hospitals in California from mid to late January. The results were based on interviews with RNs in the hospitals.

    "Our survey demonstrates that the Safe Staffing Law is off to a good start," said CNA President Deborah Burger, RN. "A sizeable majority of hospitals we looked at are making a good faith effort to abide by the law, and most have already seen results with improved conditions. That should be welcome news to all Californians and their families who are in need of hospital care."

    "If we continue this trend," said Burger, "the law will undoubtedly save the lives and promote the safety and therapeutic healing of thousands of Californians."

    Remarkable progress as industry attempts to undermine law continue

    "While some significant problems remain, the progress made to date is very encouraging, and a hopeful sign of the intended promise of the law," Burger said, the results of the survey are especially remarkable given the ferocious industry opposition to the law - and active efforts to undermine it - by the lobbying arm of the hospital industry.

    Hospital industry opponents have challenged the law in court, are seeking to persuade state officials to roll back patient protections established by the law, and have encouraged hospitals to find ways to evade the full intent of the law.

    Two continuing issues, the CNA survey found, are the inappropriate use of Licensed Vocational Nurses and the efforts of some hospitals to reduce support staff which increases the work load of RNs and decreases the time they have to spend with patients.

    Some hospitals have assigned patients directly to LVNs (which increases the patient care responsibilities of RN who are legally responsible for LVNs' patients), and even permitted LVNs to assess patients, which violates California law. "LVNs have an important role to play in the delivery of care, but not as a substitute for RNs," said Burger. Among the most consistent violations with LVN use is in Maternal Child/Postpartum care.

    Specific, numeric RN-to-patient ratios, established by state health officials, became effective on January 1, 2004, some four years after the CNA-sponsored law was enacted. Some large hospital systems, including the University of California Medical Centers, and Kaiser Permanente have made good use of the intervening time in both hiring additional RNs and meeting the ratios in most clinical areas, the survey found.

    CNA providing a more effective voice in ratio compliance

    Hospitals represented by CNA had better record with 76% showing improved staffing and 63% in general compliance. "At these hospitals, RNs have a more effective voice, with the support of CNA, to take collective actions to advocate for enhanced patient safety," Burger said.

    The CNA survey also found some hospitals that continue to lag far behind.

    Antelope Valley Hospital in Lancaster, for example, is substantially out of compliance in its general Medical and Post-Surgical units and Telemetry (where patients are on monitors). San Leandro Hospital has not been meeting the ratios in its telemetry units and support staff has been cut. Several Sutter Health hospitals have also had problems with compliance in inappropriate roles for LVNs and other staff cuts.

    For hospitals out of compliance, CNA RNs have met with hospital officials to press for changes, disseminated forms for RNs to report problems, and, in a few instances, held public protests. CNA will continue to monitor ratio compliance and pursue improvements, and seek to work with hospitals to assure safe staffing.

    While state sanctions for violations are relatively weak, CNA noted that hospitals that willfully and egregiously endanger patients by failing to meet the safety standards established by state health officials are now more vulnerable for civil suits.

    The survey results announced today are the first in what will be regular updates on the progress of the law, said CNA.
  7. by   pickledpepperRN
    http://sfgate.com/cgi-bin/article.cg...DGB95M71K1.DTL
    Regulating Health Care
    Patient-ratio law ends 'nursing shortage'

    Rose Ann DeMoro
    Imagine a hospital without registered nurses. Picture yourself in a hospital bed, in pain, recovering from a stroke or a serious accident, seeing an RN only once in eight or 12 hours, sharing her with 12 or 18 or 20 other patients. Envision your husband, mother or infant deprived of the proper care from an RN who does not have time to carefully observe the subtle changes in condition that can lead to instant death or permanent loss of function.
    Sound far-fetched? Not long ago that was the common order in many hospitals, especially with the rise of corporate medicine and managed care that put profits, market share and severe restrictions on services ahead of therapeutic healing and recovery, and that pushed thousands of nurses away from the bedside. That's the world some in the multibillion-dollar hospital industry want back.
    In 1999, California took a step back from the precipice of deteriorating conditions, enacting a long-overdue commonsense law that mandates a minimum level of on-duty nurses for safe care and requires staffing beyond that minimum if patients need more intensive care.
    Hospitals had four years to implement the law, and many did. But executives in the California Healthcare Association, the hospital industry's lobbying arm, are continuing their campaign to reverse the new patient protections. These are the same industry lobbyists who fought virtually every bill to improve the quality of care from crackdowns on HMO abuses to nursing- home reforms, and they have opposed efforts to expand health-care access. Their efforts come despite convincing evidence that decreasing nursing staffs can endanger patients' lives. The Journal of the American Medical Association, for example, has reported that each additional patient assigned to an RN increases the likelihood of a related death within 30 days by 7 percent.
    These hospital officials are bombarding Gov. Arnold Schwarzenegger, the Legislature, the media and the courts with lawsuits, new bills and a misleading PR drive in an attack on the staffing law. In this cynical, deceptive campaign, hospital administrators appeal to the public to accept a substandard level of hospital care -- thus producing bigger profit margins and higher executive compensation.
    What the officials don't mention is a decade-long industry push to consolidate hospitals, close emergency rooms, place less-skilled caregivers at the bedside and lay off thousands of RNs -- creating a self-inflicted nursing shortage. Ironically, they now claim this manufactured "nursing shortage" has prevented hospitals from hiring RNs.
    But the law has sparked a stunning reversal. Since it was signed, the state's RN workforce has grown by more than 10,000 a year. Today, California has 30,000 more RNs than was anticipated -- six times more than the number of additional RNs the state health department said were needed to accommodate the safe staffing law.
    RNs are the guardians of patient safety. Many in our hospitals today are the valiant caregivers who stayed at the bedside through all the cutbacks and the shredding of the patient safety net, who often jeopardized their own health and their licensure to protect their patients in unsafe conditions created by an uncaring industry. Many fought for years to achieve passage of the safe-staffing law and remained in the profession with the hope and anticipation of what the law would bring.
    The law has already made a difference. Since implementation in January, staffing has improved at nearly 70 percent of California hospitals surveyed by the California Nurses Association. That's the progress the hospital executives want to curtail, threatening to create a new exodus of RNs and endangering the lives of thousands.
    While the hospital industry tries to manipulate the public, it has seriously underestimated the resolve of the RNs and the patients to protect the gains this law has already produced. On both the national and international stage, RNs are mobilizing to enact similar safe-staffing legislation, bringing hope back to their profession and health to their patients.
    In the process, nurses hope to recalibrate the hospital's moral compass, which has allowed them to drift so far from their historic self-avowed mission: a single standard of care for all.
    Rose Ann DeMoro is executive director of the 56,000-member California Nurses Association, which sponsored the safe-staffing law.
  8. by   pickledpepperRN
    This letter was published in the Orange County Register on March 9, 2004
    Safe staffing at hospitals

    I was shocked to learn that the California Healthcare Association persuaded the Orange County Board of Supervisors to ask the governor to waive sanctions against hospitals that violate the safe-staffing law. As a patient advocate, I must protest this dangerous agenda on behalf of our most vulnerable citizens, those who are sick and in the hospital.

    This is a transparent attempt by the hospital trade association to punch a giant loophole in the only consumer law that will reduce medication errors, decrease hospital malpractice liability and reduce patient mortality. Protecting the public is government business.

    DeAnn McEwen, R.N.

    Cypress
  9. by   pickledpepperRN
    http://www.thepresstribune.com/main....ArticleID=3912
    Friday, January 09, 2004

    Roseville's two hospitals fully staffed

    By Sarah Langford


    Due to careful planning and foresight, Roseville's two hospitals entered the New Year in full compliance with a challenging new law that lowers the nurse-to-patient ratio in hospitals across California.

    Both Sutter Health and Kaiser Permanente were fully prepared when the law requiring there be one nurse to every six patients in the general medical-surgical unit of hospitals became effective Jan. 1.

    AB 394 is the first law in the nation to require specific nurse-to-patient ratios for every unit of a hospital, and was signed by former governor Gray Davis in 1999.

    Barbara Nelson, chief of nursing at Sutter Roseville, said the hospital has been working hard for the last several years on retaining and recruiting new nurses.

    "While most things are running quite smoothly, I would say the most challenging part of the new law is the 'at all times' requirement," Nelson said. "The ratios must be in place around the clock, and as a result there has been less flexibility in breaks and lunches."

    According to Sandy Sharon, nursing executive at the Roseville hospital, the law taking effect in the midst of the flu season has added to the challenge of meeting it.

    "A number of our own staff has been out with the flu," Sharon said. "We've had managers providing lunch and break relief when we are short-staffed."

    Kaiser currently employs 445 registered nurses and licensed vocational nurses at its Roseville hospital. There are 550 at Sutter.

    Cinde Breedlove, a spokesperson for Kaiser in greater Sacramento, said there is no current plan to admit fewer patients to comply with the law. In fact, Kaiser recently added 50 beds to the Roseville hospital and is planning a 179-bed, state-of-the-art Women and Children's Center to open in 2007.

    The law, sponsored by the California Nurses Association, corresponds with a several-year nursing shortage in California. The state ranks 49th nationally in number of RNs per capita, according to the California Healthcare Association.

    Nelson said increased career opportunities for women in the workforce has contributed to the shortage in nurses.

    Sharon believes factors such as an aging population, technology that increases the life-span of patients and a generation of nurses moving into retirement are additional factors.

    "We are calling 2004 the 'Year of the Nurses,' " Sharon said. "Nurses are central to patient safety. They are the person at the patient's bedside 24-7 administering medications and providing continual care. Nurses will get a lot of attention this year and for a good reason."

    Though the effect of the new law won't be clear for several years, Nelson anticipates positive results.

    "Increased patient care and more jobs for nurses? Of course those are always good things," Nelson said.

    Sarah Langford can be reached at sarahl@goldcountrymedia.com
  10. by   pickledpepperRN
    January 5, 2004
    For more information: Alan Brill 510-910-0998 / Liz Jacobs, RN, 510-435-7674
    Day 5-Staffing ratio law update
    Sutter Solano RNs Demand Safe Staffing According to New Law

    Sutter Solano Medical Center (SSMC) Registered Nurses, represented by the California Nurses Association (CNA) said today they plan to provide patient care in strict adherence to the safe patient loads guaranteed by the new ratio law starting with the morning shift Monday.

    The RNs said they will be protesting inadequate staffing of RNs for patient care needs and the improper assignment of nursing tasks to Licensed Vocation Nurses (LVNs).
    PRESS CONFERENCE
    When: Monday, January 5, 2004,
    12:00 Noon
    Where: Sutter Solano Medical Center
    300 Hospital Drive, Vallejo

    The RNs who work in the SSMC medical surgical units maintain that the unacceptable staffing situation has been present for many years at Sutter Solano.

    "Sutter Solano Medical Center has been assigning too many patients for nurses to care for safely for many years, sometimes as many as 12 for one Registered Nurse on our medical surgical units," said Jeffrey Dover, RN, Professional Practice Committee co-chair. "All of the nurses in our hospital are grateful that the RN to patient ratios have gone into effect and we intend to ensure proper compliance. SSMC reported a $14.8 million profit last year and has no reason to staff in a manner that jeopardizes patient care."

    Off-duty RNs will make themselves available on their off days to work beginning on Monday to ensure adequate staffing to meet the requirements of the new law

    Discussions are currently underway between CNA representatives and the hospital in an effort to resolve the issue. "This is not a matter that cannot be resolved easily and amicably," said Nancy Cook, RN, co-chair of the facility Professional Performance Committee. "We are working with the Sutter Solano administrators and I have great hope that we will be able to work through this."

    Over recent weeks, spokespersons for the Sutter Hospital System have claimed that it will be impossible to meet the new state guidelines for staffing due to a shortage of available RNs. "There are additional RNs ready and willing to work in hospitals," said CNA President Deborah Burger, RN. "All too often, this talk about a nursing shortage is merely a subterfuge to cover unwillingness to staff in accordance with the new law."

    The California Nurses Association (CNA) is the largest and fastest growing all-RN professional organization in the country representing 55,000 Registered Nurses in 150 facilities throughout the state. CNA sponsored the Safe Staffing Bill that was signed into law in October, 1999.
  11. by   pickledpepperRN
    Later that day:
    January 5, 2004
    For more information: Alan Brill 510-910-0998 / Liz Jacobs, RN, 510-435-7674

    UPDATE Monday PM - Day 5-staffing ratio law update
    Sutter Solano RNs Improve Nurse Staffing As New Law Goes into Effect

    Sutter Solano Medical Center (SSMC) Registered Nurses, represented by the California Nurses Association (CNA) reported this after noon that the hospital had made significant progress toward meeting the standard set by California's new nurse-to-patient staffing law.

    The improvement in the hospital's staffing ratio came after the RNs said they were willing to provide patient care in strict adherence to the new mandated ratio regulations which went into effect January 1.
    The nurses began their action on the law starting with the morning shift Monday insisting on adequate staffing and against any improper assignment of nursing tasks to Licensed Vocation Nurses (LVNs).

    As the day began, off-duty RNs made themselves available to work in the SSMC medical surgical units beginning this morning to ensure adequate staffing to meet the requirements of the new law.

    For the morning shift an agreement was reached for a ratio of one RN to six patients which conforms with the state regulations. There were 25 patients and only three RNs on the medical surgical units when the evening shift began, which would have required each RN to have eight patients-a clear violation of the 1:6 rule. The Hospital again called in additional nurses resulting in a 1:5 ratio with the additional help of one LVN.

    "As was demonstrated at Sutter today, there are RNs ready and willing to work in hospitals to meet the requirements of the new regulations," said CNA President Deborah Burger, RN. "Administrators from other hospitals in the state would be wise to learn from this example."

    The one outstanding issue is preserving the assistance of the LVNs historically assigned to each floor. After calling in additional RNs, the hospital sent LVNs assigned to the medical surgical floor home today.

    "The intent of the law is to staff with the prescribed RN ratios for that unit and at the same time to maintain the ancillary caregivers that have always assisted the RNs," said Burger.

    "For many weeks the Sutter Solano hospital management has been adamant that they could never meet the staffing ratios as required by the new law," said Myrna Aquino, RN, a 14 year veteran at the facility and member of the nurse Professional Performance Committee. "We are thrilled that the nurses remained united until Sutter had no choice but to staff according to the ratios."

    The California Nurses Association (CNA) is the largest and fastest growing all-RN professional organization in the country representing 55,000 Registered Nurses in 150 facilities throughout the state. CNA sponsored the Safe Staffing Bill that was signed into law in October, 1999.
  12. by   bukko
    My hospital in San Francisco started the year trying to have proper compliance with the ratios. Charge nurses had no patients, and were not counted in the staffing mix. This was great, because we had someone to help with problems, cover what the LVNs can't do and watch our lights during dinner breaks (I work 3-11).
    But lately, management has been chipping away at the ratio rule. Now they say charge nurses SHOULD take patients. Either they can start the shift with some of their own patients, or they must take any patients admitted late in the shift when we're maxed out. One night, ER dumped four patients on our unit between 9 and 10 p.m. The supervisor expected our charge nurse to assess each of them, take off all the admission orders and fill out the masses of paperwork -- four hours worth of work in 60 minutes!
    Currently we're disputing this with the help of our CNA rep. It's not because we're lazy. We need the charge nurse to back us up when we're running from room to room dealing with all the things that happen. I work on a tele unit where people get unstable in a hurry.
    I'm curious about how other hospitals are trying to erode the staffing ratio law.
  13. by   Jaaaman
    Quote from bukko
    My hospital in San Francisco started the year trying to have proper compliance with the ratios. Charge nurses had no patients, and were not counted in the staffing mix. This was great, because we had someone to help with problems, cover what the LVNs can't do and watch our lights during dinner breaks (I work 3-11).
    But lately, management has been chipping away at the ratio rule. Now they say charge nurses SHOULD take patients. Either they can start the shift with some of their own patients, or they must take any patients admitted late in the shift when we're maxed out. One night, ER dumped four patients on our unit between 9 and 10 p.m. The supervisor expected our charge nurse to assess each of them, take off all the admission orders and fill out the masses of paperwork -- four hours worth of work in 60 minutes!
    That sounds horrible!
  14. by   Hellllllo Nurse
    Great articles, spacenurse. Thanks for posting them!
    There really is a light at the end of the tunnel.

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