Nurse-staffing ratios set for January debut

Published

Nurse-staffing ratios set for January debut

The first such regulations in the nation leave issues of enforcement uncertain.

By Lisa Rapaport -- Bee Staff Writer - (Published September 30, 2003)

Gov. Gray Davis announced regulations Monday that will determine how many patients each nurse in a California hospital can treat, paving the way for the nation's first nurse-to-patient staffing ratio law to take effect Jan. 1.

The rules unveiled by the governor increased the number of nurses required on some critical care units but left untouched the staffing levels that state health officials proposed earlier this year for most hospital wards.

Davis administration officials described the minor changes to the staffing law as a "natural progression of protecting more and more patients" in the state's hospitals.

"We have been working since 1999 on creating a fair and responsible working environment for the thousands of men and women who care for the sick and elderly at our state's hospitals," Davis said in a prepared statement.

"This nurse-to-patient ratio is groundbreaking, and in the end, everyone in California wins."

As at every juncture in the path to enacting the landmark law, health workers' unions continued Monday to raise concerns about how it would be enforced. The hospital industry repeated fears that it could be impossible to find staff to comply with ratios during a nationwide nursing shortage.

For every hospital unit, the law spells out the maximum number of patients nurses can care for at one time. On the general medical wards where most patients recover from illness and injury, for example, nurses can treat no more than six patients. On intensive care units, nurses can have only two patients.

The law passed and reached Davis in 1999 amid concerns that patient safety was being compromised by inadequate staffing and fears that poor working conditions were driving nurses from the profession.

Proponents of the law, including the California Nurses Association and the Service Employees International Union, said strict state staffing rules would improve working conditions in hospitals and alleviate a grave nursing shortage by encouraging more people to enter the profession.

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Our Nursing assistants are all up in arms, wondering if they will be let go once the hospital staffs according to ratio. Rumor is, nurses (in our facility) will have patients according to unit specific ratios, but secretaries and aides will become history. Of course the hospital is still "taking the issue under consideration".... It may be better, may be worse. Who knows? Although 6 total cares may be better than 15 with a secratary and one aide for a floor of 30?

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They should be kept, you need them. We have saved staffing assignment sheets, minus patient names, to record the numbers of secretaries, CNAs, transporters,and monitor techs so we can insist the staffing does not decrease. Below is from the DHS site

http://www.applications.dhs.ca.gov/regulations/search.asp?REGID=R-37-01&advanced=yes&c2=@filewrite&o2=%3E&q1=&EMERGENCY=&submit1=Begin+Search

SUPPLEMENTAL STATEMENT OF REASONS:

In order to clarify that a hospital cannot reduce overall staffing by assigning licensed nurses to duties customarily and appropriately performed by unlicensed staff, it is stated that staffing for care not requiring a licensed nurse is not included within these ratios and shall be determined pursuant to the patient classification system. At 22 CCR 70053.2 and 70217(b), the PCS is defined as a system that is established to determine the amount of nursing care needed by each unit, on each shift, and for each level of licensed and unlicensed staff. Setting a minimum level of staffing for licensed nurses is not intended to alter the current requirement of the PCS to determine needed staffing levels for licensed and unlicensed staff.

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To become effective 1/1/2004:

1) Amend Section 70217 to read:

Section 70217. Nursing Service Staff.

(a) Hospitals shall provide staffing by licensed nurses, which includes registered nurses, licensed vocational nurses, within the scope of their licensure in accordance with the following nurse-to-patient ratios. Licensed nurse means a registered nurse, licensed vocational nurse and, in psychiatric units only, a licensed psychiatric technician.

Staffing for care not requiring a licensed nurse is not included within these ratios and shall be determined pursuant to the patient classification system.

No hospital shall assign a licensed nurse to a nursing unit or clinical area unless that hospital determines that the licensed nurse has demonstrated current competence in providing care in that area, and has also received orientation to that hospital's clinical area sufficient to provide competent care to patients in that area. The policies and procedures of the hospital shall contain the hospital's criteria for making this determination.

Licensed nurse Nurse-to-patient ratios represent the maximum number of patients that shall be assigned to one licensed nurse during one shift at any one time. "Assigned" means the licensed nurse has responsibility for the provision of care to a particular patient within his/her scope of practice. There shall be no averaging of the number of patients and the total number of licensed nurses on the unit during any one shift nor over any period of time. Only licensed nurses providing direct patient care shall be included in the ratios.

Nurse Administrators, Nurse Supervisors, Nurse Managers, and Charge Nurses, and other licensed nurses not having a specific patient care assignment, shall not be included in the calculation of the licensed nurse-to-patient ratio only when those licensed nurses are engaged in providing direct patient care. When a Nurse Administrator, Nurse Supervisor, Nurse Manager, Charge Nurse or other licensed nurse is engaged in activities other than direct patient care, that nurse shall not be included in the ratio. Nurse Administrators, Nurse Supervisors, Nurse Managers, and Charge Nurses who have demonstrated current competence to the hospital in providing care on a particular unit may relieve licensed nurses during breaks, meals, and other routine, expected absences from the unit.

Licensed vocational nurses may constitute up to 50 percent of the licensed nurses assigned to patient care on any unit, except where registered nurses are required pursuant to the patient classification system or this section. Only registered nurses shall be assigned to for Intensive Care Newborn Nursery Service Units, which specifically requires one registered nurse to two or fewer intensive care infants,. or where registered nurses are required pursuant to the patient classification system. In the Emergency Department, only registered nurses shall be assigned to triage patients and only registered nurses shall be assigned to critical trauma patients.

Nothing in this section shall prohibits a licensed nurse from assisting with specific tasks providing care within the scope of his or her practice to for a patient assigned to another nurse. "Assist" means that licensed nurses may provide patient care beyond their patient assignments if the tasks performed are specific and time-limited.

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Spacenurse, I really appreciate your information on the ratios, thank you!

One thing that is still not clear to me is the mix of LVNs and RNs and how that effects the RNs patient care load. I frequently work a Med/Surg unit that uses a lot of LVNs on night shift, with RNs "

covering" the patients for MD calls, IV meds, assessment co-signatures, end of shift documentation/assessment, etc. The LVNs do the vital signs and chart the assessments, and give PO meds.

So, if an LVN has six such patients that is within the new law, ok. But what about the RNs who are covering the patients? Are the patients they are covering, and legally responsible for, to be counted in their minimum ratios -- like, primary nurse for 4 patients and covering 2 LVN patients means a total of 6?

The other issue I have is with the patient classification system, and every RN I know takes issue with it! It is supposed to reflect the compexity or time-demands of nursing duties, but it completely misses some very demanding situations like hourly or bi-hourly Accuchecks, patients on epidural pain relief, patients with pain control issues, etc. In some cases, a patient that requires a sitter but is perfectly ok as long as a sitter is with him and doesn't need any real extra nursing care is given a high acuity, and someone that requires a nurse in the room every hour or 30 minutes for some reason is a very low acuity.

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Boy is that the struggle!

The hospitals are trying every trick they can think of not only to save money but it seems they want to punnish nurses.

I truly think it is because they have a very mixed opinion of us.

They trust us to provide safe care under whatever situation they force us into.

They do not trust us when we say safe care is not possible. I have to sleep today but am off tomorrow so can try to give more help. At my hospital staffing is good most of the time on units and shifts where the staff is united in insisting on safe adequate staffine. Other times nurses work short too often.

This is the full text of the original law. Please note the purpose. That tells a lot!

AB 394 Health facilities: nursing staff.

BILL NUMBER: AB 394 CHAPTERED 10/10/99

BILL TEXT

CHAPTER 945

FILED WITH SECRETARY OF STATE OCTOBER 10, 1999

APPROVED BY GOVERNOR OCTOBER 10, 1999

PASSED THE ASSEMBLY SEPTEMBER 9, 1999

PASSED THE SENATE SEPTEMBER 8, 1999

AMENDED IN SENATE SEPTEMBER 3, 1999

AMENDED IN SENATE AUGUST 16, 1999

AMENDED IN SENATE JULY 6, 1999

AMENDED IN SENATE JUNE 23, 1999

AMENDED IN ASSEMBLY JUNE 1, 1999

INTRODUCED BY Assembly Member Kuehl

(Coauthors: Assembly Members Calderon, Dutra, Gallegos, and Villaraigosa)

(Coauthors: Senators Burton, Escutia, and Perata)

FEBRUARY 11, 1999

An act to add Section 2725.3 to the Business and Professions Code, and to add Section 1276.4 to the Health and Safety Code, relating to health care.

LEGISLATIVE COUNSEL'S DIGEST

AB 394, Kuehl. Health facilities: nursing staff.

Existing law provides for the licensing, registration, and regulation of nurses, and sets forth the scope of practice.

This bill would prohibit a general acute care hospital, an acute psychiatric hospital, and a special hospital, as defined, from assigning an unlicensed person to perform nursing functions in lieu of a registered nurse, or from allowing unlicensed personnel under the direct clinical supervision of a registered nurse to perform certain functions.

Existing law prohibits operation of a health facility, as defined, without a license issued by the State Department of Health Services and provides for the issuance of licenses and for the regulation of health facilities and sets forth the services to be provided therein. Willful or repeated violation of these provisions is a crime.

This bill would require the department, with regard to general acute care hospitals, acute psychiatric hospitals, and special hospitals, to adopt regulations that establish certain minimum nurse-to-patient ratios, and would require these health facilities to adopt written policies and procedures for training and orientation of nursing staff. This bill would authorize the department to take into consideration the unique nature of the University of California teaching hospitals as educational institutions when establishing the ratios, in accordance with certain requirements. This bill would also require a county hospital in Los Angeles County to be subject to a phase-in process developed in conjunction with the department.

By changing the definition of an existing crime this bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

SECTION 1. The Legislature finds and declares all of the following:

(a) Health care services are becoming complex and it is increasingly difficult for patients to access integrated services.

(b) Quality of patient care is jeopardized because of staffing changes implemented in response to managed care.

© To ensure the adequate protection of patients in acute care settings, it is essential that qualified registered nurses and other licensed nurses be accessible and available to meet the needs of patients.

(d) The basic principles of staffing in the acute care setting should be based on the patient's care needs, the severity of condition, services needed, and the complexity surrounding those services.

SEC. 2. Section 2725.3 is added to the Business and Professions Code, to read:

2725.3. (a) A health facility licensed pursuant to subdivision (a), (b), or (f), of Section 1250 of the Health and Safety Code shall not assign unlicensed personnel to perform nursing functions in lieu of a registered nurse and may not allow unlicensed personnel to perform functions under the direct clinical supervision of a registered nurse that require a substantial amount of scientific knowledge and technical skills, including, but not limited to, any of the following:

(1) Administration of medication.

(2) Venipuncture or intravenous therapy.

(3) Parenteral or tube feedings.

(4) Invasive procedures including inserting nasogastric tubes, inserting catheters, or tracheal suctioning.

(5) Assessment of patient condition.

(6) Educating patients and their families concerning the patient's health care problems, including postdischarge care.

(7) Moderate complexity laboratory tests.

(b) This section shall not preclude any person from performing any act or function that he or she is authorized to perform pursuant to Division 2 (commencing with Section 500) or pursuant to existing statute or regulation as of July 1, 1999.

SEC. 3. Section 1276.4 is added to the Health and Safety Code, to read:

1276.4. (a) By January 1, 2001, the State Department of Health Services shall adopt regulations that establish minimum, specific, and numerical licensed nurse-to-patient ratios by licensed nurse classification and by hospital unit for all health facilities licensed pursuant to subdivision (a), (b), or (f) of Section 1250.

The department shall adopt these regulations in accordance with the department's licensing and certification regulations as stated in Sections 70053.2, 70215, and 70217 of Title 22 of the California Code of Regulations, and the professional and vocational regulations in Section 1443.5 of Title 16 of the California Code of Regulations.

The department shall review these regulations five years after adoption and shall report to the Legislature regarding any proposed changes.

Flexibility shall be considered by the department for rural general acute care hospitals in response to their special needs. As used in this subdivision, "hospital unit" means a critical care unit, burn unit, labor and delivery room, postanesthesia service area, emergency department, operating room, pediatric unit, step-down/intermediate care unit, specialty care unit, telemetry unit, general medical care unit, subacute care unit, and transitional inpatient care unit.

The regulation addressing the emergency department shall distinguish between regularly scheduled core staff licensed nurses and additional licensed nurses required to care for critical care patients in the emergency department.

(b) These ratios shall constitute the minimum number of registered and licensed nurses that shall be allocated. Additional staff shall be assigned in accordance with a documented patient classification system for determining nursing care requirements, including the severity of the illness, the need for specialized equipment and technology, the complexity of clinical judgment needed to design, implement, and evaluate the patient care plan and the ability for self-care, and the licensure of the personnel required for care.

© "Critical care unit" as used in this section means a unit that is established to safeguard and protect patients whose severity of medical conditions requires continuous monitoring, and complex intervention by licensed nurses.

(d) All health facilities licensed under subdivision (a), (b), or (f) of Section 1250 shall adopt written policies and procedures for training and orientation of nursing staff.

(e) No registered nurse shall be assigned to a nursing unit or clinical area unless that nurse has first received orientation in that clinical area sufficient to provide competent care to patients in that area, and has demonstrated current competence in providing care in that area.

(f) The written policies and procedures for orientation of nursing staff shall require that all temporary personnel shall receive orientation and be subject to competency validation consistent with Sections 70016.1 and 70214 of Title 22 of the California Code of Regulations.

(g) Requests for waivers to this section that do not jeopardize the health, safety, and well-being of patients affected and that are needed for increased operational efficiency may be granted by the state department to rural general acute care hospitals meeting the criteria set forth in Section 70059.1 of Title 22 of the California Code of Regulations.

(h) In case of conflict between this section and any provision or regulation defining the scope of nursing practice, the scope of practice provisions shall control.

(i) The regulations adopted by the department shall augment and not replace existing nurse-to-patient ratios that exist in regulation or law for the intensive care units, the neonatal intensive care units, or the operating room.

(j) The regulations adopted by the department shall not replace existing licensed staff-to-patient ratios for hospitals operated by the State Department of Mental Health.

(k) The regulations adopted by the department for health facilities licensed under subdivision (b) of Section 1250 that are not operated by the State Department of Mental Health shall take into account the special needs of the patients served in the psychiatric units.

(l) The department may take into consideration the unique nature of the University of California teaching hospitals as educational institutions when establishing licensed nurse-to-patient ratios. The department shall coordinate with the Board of Registered Nursing to ensure that staffing ratios are consistent with the Board of Registered Nursing approved nursing education requirements. This includes nursing clinical experience incidental to a work-study program rendered in a University of California clinical facility approved by the Board of Registered Nursing provided there will be sufficient direct care registered nurse preceptors available to ensure safe patient care.

(m) A county hospital in a county of the first class, as defined in Section 28022 of the Government Code, shall be subject to a phase-in process developed in conjunction with the department. This phase-in process shall be completed within one year of the adoption of the regulations that implement this section.

SEC. 4. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution.

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