California RN-staffing ratio law is threatened. See letter to legislators.

Published

Urgent Letter to California State Legislature

June 14, 2012

Dear California State Legislature,

The proposed budget language to suspend the nurse-to-patient ratios for every patient on every unit in the acute care hospitals for the entire period that nurses are away from their patient assignment for meal and rest breaks undermines patient safety in every hospital setting. Intensive care units, neonatal intensive care units, pediatric units and all other medical-surgical and oncology units where patients receive critical acute care nursing services would find that their RN' s patient care assignment would be doubled during a significant portion of each shift.

The proposed budget language means that on a medical-surgical unit where two RNs each have an assignment with the maximum number of patients per RN (5 patients), for two hours out of every eight hour shift, an RN would be required to provide care for 10 patients each. In effect, during one quarter of the shift an RN would be required to provide care for 10 acutely ill hospitalized patients. That is double the number of patients that the DHS found was consistent with safe patient care. Patients will see delays in care impacting pain management and severely reducing RNs ability to provide protective surveillance of patients in the acute care setting increasing the likelihood that there will be increased "failure to rescue" patients, a significant contribution to inpatient deaths.1

The requirement that minimum ratio standards be in place at all times including meals and breaks has been in place for nearly 40 years in the ICUs, Neonatal Intensive Care Units and the Operating Room. Just before implementation of the nurse-to-patient ratios in the remainder of hospital units in 2004, the California Hospital Association filed a lawsuit claiming that the Department of Health Services (DHS) "at all times" interpretation was inconsistent with the language of the regulation and was not clearly stated as a requirement during the lengthy rulemaking process. Superior Court Judge Gail Ohanesian ruled that the California Hospital Association's (CHA) was aware of the requirement with respect to maintaining the minimum nurse-to-patient ratios at all times, including meal and rest breaks and that it was the only reasonable interpretation of the nurse-to-patient regulation. Judge Ohanesian stated that "[a]ny other interpretation would make the nurse-to-patient ratios meaningless."2 [Emphasis added] She went further in characterizing CHA's arguments against meal and break replacement as " ... an attack on the ratios themselves. "3

During the years that followed implementation of the ratios a seminal study of the first in the nation California ratios compared patient outcomes and staffing levels of California hospitals to those of two other states, New Jersey and Pennsylvania. The study determined that there would have been 13.9% fewer death of surgical patients in New Jersey and 10.6 % fewer deaths in Pennsylvania if these state's had staffed according to the ratio standards in California.4

In 2007 a 539 page technical review of 96 studies related to nurse to patient ratios staffing between 2000 and 20065 also noted:

"Higher registered nurse staffing was associated with less hospital-related mortality, failure to rescue, cardiac arrest, hospital acquired pneumonia, and other adverse events. The effect of increased registered nurse staffing on patients safety was strong and consistent in intensive care units and in surgical patients. Greater registered nurse hours spent on direct patient care were associated with decreased risk of hospital-related death and shorter lengths of stay." (emphasis added)

This proposed language would be a major set back in the progress made in California as a result of the first in the nation nurse-to-patient ratios and, as Judge Ohanesian so wisely observed, would be an attack of the ratios themselves.

Sincerely,

Bonnie Castillo

Director, Government Relations

California Nurses Association

Cc: Governor Jerry Brown

1 : Clarke SP and Aiken LH Failure To Rescue: Needless Deaths Are Prime Examples of the Need for More Nurses at the Bedside, American Journal of Nursing, 1 03(1 ), Jan 2003 pp.42-47

2 : CHA v DHS, Superior Court of Sacramento, No. 03CS01814, May 24, 2004, p. 5

3 : Ibid, p.8

4 : Linda H. Aiken, et. allmplications of the California Nurse Staffing Mandate for Other States, 2010., p.l

5 : Robert L. Kane, MD et. al., Nurse Staffing and Quality of Patient Care, AHRQ Publication No. 07-EOOS, 2007 {539 pages).

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this article title (and the letter) is misleading.

the letter is addressing only the time that nurses are taking a break.

"the proposed budget language to suspend the nurse-to-patient ratios for every patient on every unit in the acute care hospitals for the entire period that nurses are away from their patient assignment for meal and rest breaks undermines patient safety in every hospital setting."

so what is the letter writer hoping hospitals do as an alternative?

does she expect that the hospital hire dozens of floating nurses to cover just lunchtime?

good luck finding nurses who will come in for 1.5 hours a day to work.

the way it has always happened in my experience is:

when nurse jane is scheduled to go to lunch, in a perfect world, she should be sure that:

1. all of her patients are stable (as stable as can be expected)

2. no meds or treatments on her pts should be due while she goes to lunch.

3. her pts should have been assessed for pain and medicated before she leaves the floor.

4. she gives report to the nurse covering her assignment.

icu/ccu/etc areas....i don't know what they do. my exp was mostly ed.

my point is that if the nurse going on break properly prepares her pt load, then the covering nurse wont actually have to do anything but look in on the additional pts. so therefore it should not (hopefully) result in any emergencys.

the way this letter is written, she prefaces by saying this is during lunch/break times, and then gives statistics relating to the entire shift and hospital stay, not just break times. i personally find this slanted and misleading.

unless i'm misunderstanding the entire letter, her second paragraph is invalid:

"patients will see delays in care impacting pain management and severely reducing rns ability to provide protective surveillance of patients in the acute care setting increasing the likelihood that there will be increased "failure to rescue" patients, a significant contribution to inpatient deaths.1"

of course if a nurse does not properly prepare her pts before leaving for break, that's another story, but not one that needs legislation.

she also does not propose any solutions in this letter.

ca nurses are some of the highest paid, with the best ratios, and the biggest whiners.

but they do get better standards set.....whining can pay off.

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Specializes in Cardiac.

Please, I work in PA and I have 9 patients on night all by myself, it basically sucks and it's unsafe and I'm sick and tired of this. I need to go to congress. I have to do a study, I'm thinking of doing this kind of study for my doctorate!

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so, a nurse is not entitled to lunch if any of her/his patients are not not perfectly "spit polished"? are you an academic? with little, no recent experience at the bed side?

this article title (and the letter) is misleading.

the letter is addressing only the time that nurses are taking a break.

"the proposed budget language to suspend the nurse-to-patient ratios for every patient on every unit in the acute care hospitals for the entire period that nurses are away from their patient assignment for meal and rest breaks undermines patient safety in every hospital setting."

so what is the letter writer hoping hospitals do as an alternative?

does she expect that the hospital hire dozens of floating nurses to cover just lunchtime?

good luck finding nurses who will come in for 1.5 hours a day to work.

the way it has always happened in my experience is:

when nurse jane is scheduled to go to lunch, in a perfect world, she should be sure that:

1. all of her patients are stable (as stable as can be expected)

2. no meds or treatments on her pts should be due while she goes to lunch.

3. her pts should have been assessed for pain and medicated before she leaves the floor.

4. she gives report to the nurse covering her assignment.

icu/ccu/etc areas....i don't know what they do. my exp was mostly ed.

my point is that if the nurse going on break properly prepares her pt load, then the covering nurse wont actually have to do anything but look in on the additional pts. so therefore it should not (hopefully) result in any emergencys.

the way this letter is written, she prefaces by saying this is during lunch/break times, and then gives statistics relating to the entire shift and hospital stay, not just break times. i personally find this slanted and misleading.

unless i'm misunderstanding the entire letter, her second paragraph is invalid:

"patients will see delays in care impacting pain management and severely reducing rns ability to provide protective surveillance of patients in the acute care setting increasing the likelihood that there will be increased "failure to rescue" patients, a significant contribution to inpatient deaths.1"

of course if a nurse does not properly prepare her pts before leaving for break, that's another story, but not one that needs legislation.

she also does not propose any solutions in this letter.

ca nurses are some of the highest paid, with the best ratios, and the biggest whiners.

but they do get better standards set.....whining can pay off.

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Specializes in Interested in public health, psych, EMS.

I work nights in the ED here in Southern California. No one is coming in for 2 hours to do lunches. On a night that we are fully staffed (?!) we have a triage nurse and two nurses that work with the triage nurse in the "Fast Track" section. One of the fast track nurses will cover us all for lunch. With one EMT (preferably two) we all get lunches, our work environment is sane, our patients get better care, and if someone gets a critical we can all pitch in to help them/the patient out without our own pts care suffering.

The article is a political piece therefore the title is appropriately alarming. A weakening of our staffing ratios could begin with a sly maneuver like starting with just lunches, then whittling away bit by bit. Instead of complaining that CA nurses have it so good, others around the country should organize and fight for their own safe/sane staffing ratios. I say sane because even if our patient's outcomes were not improved by ratios, MY stress level is manageable with four patients. There is no reason to "get off" on the fact that you take care of 10 pts with no tech/aide, no secretary, blah blah. I'm taking care of myself as well.

Fight on CardiacRocks!

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So, a nurse is not entitled to lunch if any of her/his patients are not not perfectly "spit polished"? Are you an academic? with little, no recent experience at the bed side?

I never said they aren't entitled to lunch.....Do you not try to stabilize your load before passing it over to someone to cover you?

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Specializes in Hospice / Ambulatory Clinic.

Does she expect that the hospital hire dozens of floating nurses to cover just lunchtime?

Good luck finding nurses who will come in for 1.5 hours a day to work.

Actually I think at this time the luck would be quite good and besides nurses take more than lunch breaks and there are times they may need to leave the floor. I can imagine right now some nurses would be willing to come in for say 4 hours a day just to cover breaks. That wouldn't be a bad part time job for moms and such.

It's not like there's a shortage of nurses out there.

Though I wonder if a new grad had a preceptor if the preceptor could cover breaks. There's a workable solution here. I see this change for what it is a slow attempt to chip away at ratios. If we are willing to bend eventually we will snap.

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Specializes in ICU + Infection Prevention.

One hour lunches? California here I come!

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Specializes in Hospice / Ambulatory Clinic.
One hour lunches? California here I come!
No not hour lunches. 30min lunch and 2 15min breaks (though legally they only have to give you 10mins most give 15min)
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Where I work we get 1 hour for lunch and to be honest, I would rather take 15-30 min and go home earlier. I asked if I could do that and was told no. :(

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Specializes in med/surg/ortho/tele.

Yes California has staffing law but there are ways to work around laws by the hospitals. Sometimes one can be assigned to teams with LVN who can help you but documenting on all 10 pts is your responsibility plus hanging chemo or TPN. Sometimes there is only 2 CNA 's for 45 pts and RN's have to do total care like ICU for all 5 patients because there is a new system in fashion known as team steppes.

Sometimes when Joint commission would make rounds you'll get 5 patients otherwise you get 6 pts in California. So, there are ways. Nurses do get exploited anywhere whether its PA or CA.

Appealing to Legislature will not help. When everyday new budget comes, new rules apply for medicare or medicaid reimbursement to hospitals and docs all the reactions goes to poor nurses. There'll be no raises because of budget problems but patient load under poor staffing keeps increasing. A nurse cannot even talk to families for some time as she gets pulled over to do million things. The direct patient care and connection gets lost. Hospitals are now businesses not place for treatment of sick and underprivileged.

I am still proud to be a nurse but working conditions in big picture should be improved for all nurses.When patient's own family members leave them for days and months under our care, we are those helping hands and gentle eyes to which patient relates to everyday.

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To cover break and meals many California hospitals have a "float" or "cover" nurse that is qualified to cover the patients and they work a full 12 hrs shift. In addition, many of the Charge RN's cover for break and meals too. California while having controlled staffing ratios is not without problems. I would have to look up the study but when California was compared to other non-union, non-ratio (nursing to patient) mandated states, their (California) did not have better patient safety outcomes. I have worked outside of california without the ratio laws and in California with the ratio laws and the only improvement I could see was that, as a nurse I could only be given so many patients in California. Sadly at times acuities are not taken into consideration, and wait times in the ED's are ever increasing.

As far as making your patients "break ready" that is a great idea on paper. In real life that does not work. You can try but you are attempting to control something that you can at best hope to safely manage. In addition, what about the nurse covering your "break ready" patients? What is their patients are fresh post-ops, or being discharged, or taking a turn for the worse?

The best thing for patient safety is communication, and understanding that a blanket law or ruling is not a fix for every hospital or situation that nurses will find themselves in. We have to be flexible and recognize that what may work at one time or in one situation or in one particular unit, may not work outside of that particular situation or place. Being creative and open to changes and trying new ideas is what will work.

~Kris :)

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