Safe Staffing Law

    Article Last Updated: Monday, December 29, 2003 - 5:39:33 AM PST
    By Rebecca Vesely, STAFF WRITER
    PATIENTS WHO find themselves at the hospital on New Year's Day probably won't notice anything different from the day before, except the usual hectic atmosphere of a hospital around the holidays. But for California nurses and hospitals, Jan. 1 marks the start of a statewide experiment -- the first in the nation -- on whether more nurses caring for fewer patients means less staff burnout and better patient outcomes.

    On Thursday, a state law requiring hospitals to meet minimum nurse-to-patient ratios goes into effect.

    Signed in 1999 by former Gov. Gray Davis, AB 394, known as the Safe Staffing Law, sets minimum nurse-to-patient ratios on all hospital units. The ratios range from one nurse per patient (1:1) to one nurse for eight patients (1:8), depending on the unit.

    Some units, such as the intensive care unit, or ICU, have had minimum ratios for years. But in areas of the hospital where most patients are treated -- medical/surgical and the emergency department, for instance -- ratios will be newly enforced.
    Unions representing nurses championed the ratios, citing studies that show a primary reason for the current worldwide nursing shortage is low pay, poor benefits, and, most of all, too many patients to care for on each shift. "Ratios go a long way to improve working conditions and protect patients," said Glenda Canfield, California policy director for SEIU Nurse Alliance, representing 35,000 registered nurses (RNs) and licensed vocational nurses (LVNs) in the state.

    A 1998 survey of more than10,000 nurses nationwide, published in the Journal of the American Medical Association, found that each additional patient per nurse was associated with a7 percent increase in the likelihood of dying within 30 days of admission. Each additional patient was associated in a 23 percent increase in the odds of burnout.

    Hospitals in the state, however, have by and large fought the ratios, arguing the rules are too inflexible and too difficult to meet amid a nursing shortage. California ranks 49th among 50 states in nurses on a per capita basis.
    "We are absolutely entering into uncharted territory in California," said Jan Emerson, vice president of external affairs at the California HealthCare Association, a lobbying group for hospitals. "There is no flexibility, and that is the single most onerous and difficult aspect of the law."

    In the ER, for instance, one nurse must care for a maximum of four patients at each time starting Jan. 1 -- regardless of how many patients are waiting and their acuity. If a nurse goes on a bathroom break, another nurse must be located to care for those four patients or the hospital will be in violation of the law. Hospitals out of compliance could lose their accreditation or MediCal or Medicare reimbursements.
    "We have a dilemma," Emerson said. "Which law are we going to break? Do we turn people away from the ER or do we break the ratio law?"

    Such arguments evoke little sympathy from nurses.

    "My first question is when did the hospitals start working on this?" Canfield said. "Kaiser is a very good example. They had less than a 2 percent nurse vacancy rate a year ago. If Kaiser can do it, anyone can do it."

    The California Nurses Association, which also represents Kaiser Permanente Northern California nurses, cites Kaiser as an example of how the nursing shortage can be overcome by good recruiting methods.
    Over the past two years, Kaiser of Northern California has hired about3,500 nurses in preparation to meet the ratios, and now employs 13,300 nurses in the region.

    "Yes, there is a nursing shortage, but on the other hand, ratios improve work environment and attract more nurses to the profession," said Pamela Johnson, associate director of operations for patient care services for Kaiser Northern California.
    Registered nurses with no experience start at Kaiser at $33.74 an hour, according to their union contract. The average salary for an RN at Kaiser is$82,000, Johnson said. Their shifts can't be canceled, and they get excellent retirement benefits. In 2003, Kaiser spent $3.6 million in nurse education, including partnerships with nursing schools.

    Even with this kind of planning, though, Johnson said meeting the 1:4 ratio in the ER won't be easy.
    "That will be a challenging issue," Johnson said. "The demands of patients change and the number of patients change so frequently."

    A lack of flexibility also will be a challenge for the select hospitals with trauma units, where the ratio will be one nurse to every patient.

    At Eden Medical Center in Castro Valley, which has the only trauma center serving south and east Alameda County, multiple trauma cases can come in at the same time.
    "On a Saturday night, that happens quite a bit," said Rose Corcoran, vice president of patient care services at the hospital.
    In the past, a critical care nurse would "float" -- or be pulled -- from the critical care unit to work on any additional trauma patient. But with mandatory nurse ratios of 1:2 on critical care, Eden would be breaking the ratio on one unit to make it on another. So instead of floating nurses, Eden and other hospitals will likely need more nurses on standby in case trauma cases come in.

    Overall, nurse unions said that Eden is staffed appropriately to meet the ratios.

    Private hospitals in the Bay Area said they will be able to meet the ratios with registry and traveling nurses -- temporary nurses hired day to day or for a tour of up to three months from other states.

    But financially strapped public hospitals could have a harder time of it. The Alameda County Medical Center, including Highland and Fairmont hospitals, has a $71 million deficit. As of November, the medical center had more than 100 nurse vacancies.
    Ellen Waxenberg, the former chief nurse executive for the medical center, quit in November in part out of frustration of an inability to hire new nurses -- or even track recruiting and hiring statistics. Not one nurse was hired in November, she said in a interview, and she feared patient safety would be compromised.

    "These sorts of delays (in hiring) are very unwise and erode our competitive position among hospitals, all of which are desperate for more nursing help," Waxenberg wrote in her resignation letter.

    Susan Spoelma, the medical center's interim director of nursing, said all units are prepared to meet the new ratios, adding that last week the medical center launched a new computer system to track nurse staffing. "I can't say what Ellen's experience was," she said. "We feel we will meet the ratios, even with the law as stringent as it is."

    The main issue isn't the numbers, said Gina Henning, manager specialist at the state Department of Health Services, who worked to develop the ratios, but what level of care the patient should receive.

    "The whole key to this is the requirement that hospitals have an acuity system, that they staff according to a patient's need," Henning said. "If a patient needs one-to-one care, they should get it."

    The California Nurses Association, representing RNs, has been especially critical of Alta Bates Summit in Oakland and Berkeley, and San Leandro Hospital. The union said these hospitals are meeting the ratios by assigning LVNs, who have a lower skill set than RNs, to do the job of RNs. Stanford University and Lucile Packard Hospital also have come under fire from unions for allegedly not creating a good care mix among nurses.

    Alta Bates Summit officials point out that LVNs are allowed to be assigned patients, provided patient needs are within the LVN scope of practice. The state mandates that LVNs can make up a maximum of 50 percent of nursing care at any time. There about 300,000 RNs in the state, and about 70,000 LVNs.
    "There is no evidence that having that (50/50 mix) requirement in place compromises patient care," said Henning from the State Department of Health Services.

    Nurse unions plan to monitor hospitals closely for any violations of the new law, and recommend that patients do so as well.

    "I would really hope the public asks their nurse, 'How many patients do you have besides me?'" Canfield said.

    Contact Rebecca Vesely at <> .
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  3. by   Hellllllo Nurse
    The mandated ratios are a wonderful, wonderful blessing for nurses and pts. I'm not in CA, but I wish I could be just to work under the new conditions!

    Hopefully, the ratios will be a great success and other states will follow suit.

    Kaiser sounds great!

    Congrats to all CA nurses and their pts!
  4. by   pickledpepperRN
    Originally posted by Hellllllo Nurse
    The mandated ratios are a wonderful, wonderful blessing for nurses and pts. I'm not in CA, but I wish I could be just to work under the new conditions!

    Hopefully, the ratios will be a great success and other states will follow suit.

    Kaiser sounds great!

    Congrats to all CA nurses and their pts!
    THANK YOU for your support. We on my unit expect a struggle, but think we are strong enough to prevail. We are critical care so have had ratios for years, but until we acted the regulations were not followed. Now we are working with the telemetry and step down staff to be strong and united.

    Friends at Kaiser have had to work on only having LVNs assigned to an RN with either an assistive role only for most units or with a team nursing approach for the lowest acuity shifts.
    For Immediate Release December 23, 2003

    Contact: Charles Idelson, 510-273-2246, 415-559-8991 (pg), Jill Furillo, RN, 916-417-6203

    Countdown to Safe Staffing - RN Ratios in Effect January 1,
    Hospital Industry Lobby Continues Efforts to Undermine the Law, California Nurses Assn. Warns

    With just over one week to go before final implementation of the nation's first mandated minimum staffing ratios for registered nurses, some hospitals have made genuine progress toward compliance even as the lobbying arm of the hospital industry continues efforts to erode the law, said the California Nurses Association today.

    As of January 1, 2004, all hospitals must be staffed in accordance with the minimum ratios which include at least one RN for every six patients in general medical and post-surgical units, one RN for every four ER patients, and one RN for every four pediatric patients. The law also requires hospitals to increase staffing for patients who need additional care.

    "The RN ratios should permanently alter the healthcare landscape after January 1," said Deborah Burger, RN, president of the CNA which sponsored the law. "Every major scientific study has documented that safe RN staffing reduces preventable hospital death rates, infections and accidents, and improves the therapeutic environment for recovery."

    "Hospitals that fail to comply with the letter and spirit of the law are placing their patients at risk," said Burger. "All patients deserve safe care and should demand no less."

    In recent months some hospitals have hired hundreds of RNs in preparation for January 1. Among the larger systems, according to CNA, the University of California medical centers, Catholic Healthcare West, and Kaiser Permanente (Northern California) are either near compliance or making progress to comport with the law at many of their hospitals.

    But some hospitals remain far from compliance, said CNA, citing Sutter Health and Triad Hospitals, Inc. as examples. Sutter's Alta Bates Summit Medical Center in Berkeley and Oakland, for example, is assigning patients directly to licensed vocational nurses (LVNs), increasing the work load of RNs, and failing to assure the hospital is meeting the ratios during breaks creating periods of inadequate staffing for patients.

    Texas-based Triad's San Leandro Hospital is staffing well below the ratio requirement on medical-post surgical units, and, like Alta Bates-Summit, assigning patients to LVNs.

    CNA said it is especially critical of the role of the California Healthcare Association, the hospital's lobbying group. CHA has held seminars for local officials offering tips on circumventing the law, urged Gov. Schwarzenegger to delay or change the law, and is waging a political campaign claiming the law will lead to closures and delays in care.

    Hospital industry 'questionnaire' continues attack on law

    As part of its campaign, CHA is currently asking hospital members to fill out one-sided questionnaires intended to provide the group with materials for its publicity attacks on the law.

    CHA is asking individual hospitals to provide details on alleged ratio-caused emergency room diversions, waiting times for care, closures of beds, units, or other services, cancelled surgeries, failure to transfer patients in a timely manner, and to list units and shifts on which the ratios were not always met.

    "The obvious purpose of this questionnaire," said CNA Collective Bargaining Director Mike Griffing, "is to link hospital decisions to reduce care to the industry's political agenda - opposition to the ratio law, and the hope it helps them to persuade the governor or legislators to change the law."

    "It's notable that the questionnaires do not once ask the hospitals for examples of how safe staffing protects their patients or improves overall patient care conditions. Apparently they don't want to know," Griffing said.

    "CNA can only conclude that the CHA is more interested in continuing to fight a law they've always disliked than in promoting safer standards in hospitals," Griffing said.

    Studies continue to show the importance of the law to public safety - and how the advent of the law is already helping to tackle the nursing shortage in California.
    o The Institutes of Medicine of the National Academy of Sciences reported in November that "nurse staffing levels affect patient outcomes and safety." Insufficient monitoring of patients, caused by poor working conditions and the assignment of too few RNs, increases the likelihood of patient deaths and injuries at a time when avoidable medical errors kill up to 98,000 people in U.S. hospitals every year. (IOM, November 4, 2003)
    o Inadequate staffing precipitated one-fourth of all sentinel events - unexpected occurrences that led to patient deaths, injuries, or permanent loss of function - reported to JCAHO, the Joint Commission on Accreditation of Hospital Organizations, from 1997 to 2002. (JCAHO, August 7, 2002)
    o Data compiled by the state Board of Registered Nursing, the agency that licenses RNs in California shows that overall California today has over 30,000 more actively licensed RNs than the BRN estimated the state would have at this date - six times the number the state health department estimated would be needed for the ratios.
    More information including the specific ratios can be found on the CNA website,
  5. by   NurseMegA
    Our hospital did not prepare in advance for this. They just decided December 1st that they need to figure out how they were going to meet the staffing ratios. I think that the law is very inflexible though. I work in Labor and Delivery which can me as unpredictable as ER sometimes. We have been trying to maintain these staffing ratios. Breaks are the major issue for us. Our solution has been to have an extra nurse come on during the break times who is only there to break the other nurses on the shift.
  6. by   RNKPCE
    We are doing the break nurse thing too. It has major problems. If you have 7 staff on that break nurse has to relieve 7 hours worth of breaks and meals plus her own break. This has some people taking their first 15 min break 1 hour into the shift, or their last 15 minute break in the last hour of the shift. The logistics are a nightmare. Other than our night shift, the day and evening shift are staffed worse than before. They robbed Peter to pay Paul.

    We were fortunate to have appropriate staffing before the law now we don't. They are cutting our nurses aides and laying some of them off.
  7. by   Hellllllo Nurse
    I think that hospitals could hire "break nurses". These could be nurses with lots experience in different areas. The break nurse would be assigned to a unit for the day. She would go to report and get report on all the pts just like the charge nurse. She could assist staff prn and relieve for breaks. There could be several to a unit, stagger their shifts, if needed.

    Sounds simple, but I think worth a try.

    I just *love* it when I read about hospitals whining: "But we will be violatiing the staffing laws every time we are short!"


    They've had no qualms about trying to violate the laws of physics-

    In that one nurse cannot care for 6,7,8,9 or 10+ pts all at the same time, but hospitals say we can!

    Nurses have had to struggle for years to try and figure out how to provide for their pts.

    Now, it's the hospitals' turn.

    Calif. nurses:

    Please keep us updated and congrats on your victory!
    Last edit by Hellllllo Nurse on Jan 1, '04
  8. by   kc ccurn
    You guys get breaks?

    Good luck CA. A lot of people are watching to see how things work out!
  9. by   pickledpepperRN
    A call for Staffing Ratio success stories

    Please contact the CNA Communications Department if your unit has already implemented the ratios. Let us know of specific examples of the following changes:

    RNs increasing hours

    A return of experienced RNs who left the acute care setting

    Increased retention of senior RNs (nurses who were going to take early retirement decide to stay)

    Travelers taking permanent positions

    Out of state nurses re-locating

    Improved patient outcomes

    Please contact:
    Liz Jacobs, RN, 510 273-2232 < Success Story>
  10. by   TiffyRN
    I just found out I got a message from Long Beach Memorial (step-daughter not real great with passing along messages). My thought is the hospitals over there are desperate enough to start calling nurses in Texas out of the Blue. What do you guys think? I'm curious and will call Monday. I'm not currently interested in relocating but if those ratios work out it would be tantalizing. I might even go back to Telemetry.
  11. by   Hellllllo Nurse
    I would consider short travel assingments to Cali to work med-surg- IF there were a facility willing to give me a proper orientation in pro-nurse environment and strictly adhere to the ratios.
  12. by   tlynsmith
    My sister works at Cedars Sinai in LA, CA. They have already implemented the new law. They had to close one of the units to bring the nurses and patients to another unit to meet this new patient:nurse ratio law...Yippieeeeeeeeeeeeeeeeeeee!

  13. by   it'sallbueno
    The staffing ratio saga continues:

    Today I had six of my own patients, (med-surg) and covered six of the (brand new, and floated in) LVN's, for a grand total of 12 patients. Census was low, just the 12, so the clerk and the NA floated out.

    I think I may have hope, but not necessarily faith! Please continue to send good thoughts until this is all figured out!
  14. by   Sheri257
    Great article Spacenurse. Thank you.

    Is it my imagination, or is Kaiser a really good outfit for work for? Impressive that they seem to be proactive on the ratios.

    I've been impressed with other stuff they've done as well.

    But I'm always too suspicious of big corporations to get my hopes up.