Hospital industry seminars advise administrators how to evade RN ratios

PMHNP10 · Dec 11, 2003

For everyone who doubts, everyone who gets discouraged...this is an example of how someone in power has listened to the people and not the money. It can be done. While this issue certainly isn't over, at least the first phase is a success.

sharann, BSN, RN · Dec 11, 2003

This was my letter. Not earth shattering, but it was mine.

Dear Governor Davis,

As a concerned citizen, resident of California, and

actively practicing Registered nurse I am writing to

urge you to leave the law on safe nurse to patient

ratios as is! Please, consider that people, your

family and mine, who are ill and in need of medical

help DO NOT go to a hospital for much else than

NURSING care. Physicians spend minutes (if this much)

a day with their patients, while nurses spend 24 hours

a day (in shifts hopefully, but not always)making sure

that patient leaves the hospital alive...or at least

leaves this life with a compassionate highly skilled

person holding their hand.Putting this law on hold

would be tragic.You will soon see that if ratios are

implemented correctly, the "shortage" of California

nurses will magically disappear. You will see other

states soon following suit so we can stop stealing

nurses from countries with their own nursing

shortages.

Don't let the hospital industry fool you. There is NO

real shortage.They created it with their greed.

Thank You,

xxxxxxxxxxxxxx,RN (I signed my real name)

Southern California, LA County

__________________________

pickledpepperRN · Dec 11, 2003

Originally posted by psychrn03
For everyone who doubts, everyone who gets discouraged...this is an example of how someone in power has listened to the people and not the money. It can be done. While this issue certainly isn't over, at least the first phase is a success.

Thank you for your insite and encouragement. Victoria, Australia was first. California is first in the USA.

Nurses working together can improve healthcare!

Let's try our best!

The Governor has a lot of pressure from the greedy:

http://www.labusinessjournal.com/tofilelabj.htm?user/user.fas/s=614/fp=3/tp=45?T=open_article,575650&P=article

Pressure on Governor to Alter Nurse Ratio Rules

By LAURENCE DARMIENTO

Staff Reporter

Pressure is building on Gov. Arnold Schwarzenegger to delay or amend the state's landmark nurse staffing law, with his administration coming under hospital industry lobbying and even a petition from the Democrat-dominated L.A. County Board of Supervisors.

The law, set to go into effect on Jan. 1, requires hospitals to staff wards with specific nurse-to-patient ratios, but the industry contends that a nursing shortage has made it impossible for many hospitals to hire enough nurses to do so.

Those complaints failed to sway the Davis administration, which established the specific ratios last year following the law's passage in 1999. But with the new governor stressing the importance of making the state more business friendly, there are new efforts to change the law as its implementation date approaches.

"We do not want the regulations to go into effect until they are changed," said Jim Lott, executive vice president of the Healthcare Association of Southern California, a trade group representing the region's hospital industry. "We are not necessarily advocating a delay. You can fix it in 24 hours - or you can delay it and fix it after."

The ratios require at least one nurse for every six patients in a hospital's medical/surgical wards, where most patients are located, but as many as one nurse for every two intensive care patients. The regulations represented a compromise but still the industry was not happy with their final form.

The governor signaled that he might be open to amending the regulations when he issued an executive order after taking office placing on hold all pending Davis administration regulations for up to 90 days while a review was completed on their impact on business.

It is unclear, though, whether the nurse staffing regulations, which already had gone through the administrative law process and were set for implementation, could be subject to such a delay.

A spokeswoman for the governor said the staffing regulations were being studied to determine if they would fall under the order. The governor's office otherwise did not comment.

Beth Cappel, a lobbyist for the Service Employees International Union, which represents nurses in California, disputed that the governor would have the power to arbitrarily delay or change the law.

"It is a regulation that is in place. To revise it would require a change in the law or a change in the regulation. He cannot simply suspend. We have due process. Three branches of government. He is not the king," Cappel said.

California Nurses Association, the registered nurses professional association that sponsored the law, deplored the industry lobbying, said Chuck Idelson, its spokesman.

"Hospitals have had four years to prepare for this law, and because of their failure to prepare and their continuing opposition to a law they don't like they are now trying to sabotage the health and safety of millions," he said.

Specific changes sought

The industry contends that unless certain changes are made, it will be impossible for hospitals to comply with the rules, making them liable for state sanctions.

Specifically, the industry is looking to relax regulations applied to emergency rooms, where hospitals must have one nurse on duty for every four patients. The ratios are even tougher for patients requiring critical care and for trauma victims.

Hospital representatives have argued that unpredictable fluctuations in admissions to emergency rooms make the requirement difficult to comply with. There also are concerns that nurses who operate radios to communicate with paramedics during emergencies cannot be included in the ratios.

"You may staff based on historical data, and all of a sudden you have more ambulances coming to your hospital and more patients than you expected and you are out of compliance," Lott said.

Also at issue are ratios in psychiatric and rehabilitation wards, which hospital groups want relaxed during the evening when patients are sleeping. Moreover, they would like the state to exempt hospitals from sanctions if it can be shown they have done all they can to recruit nurses but are unable to find enough. Current regulations require hospitals to close beds if they do not have enough nurses to staff them.

Representatives of the unions said Davis and the state Department of Health Services had considered these points when the regulations were drafted.

Idelson charged that with the sanctions only amounting to $50 per day per affected patient, what the industry really wants is limiting their economic exposure from lawsuits.

"What they are really afraid of is that the state of California had determined (through these ratios) that the minimum safety standards are for hospitals, and if a patient is harmed by unsafe staffing then you have an enhanced opportunity for litigation," he said.

The hospital industry turned back legislation earlier this year that would have strengthened sanctions, upping them to $5,000 per violation.

The unions' hard line opposition to changes in the law softened last week when the SEIU worked out an agreement with Los Angeles County supervisors who passed a motion asking for limited relief.

Originally the motion, introduced by Supervisor Mike Antonovich, asked for wide-ranging relief for county hospitals. But the union, which represents county hospital and other workers, opposed it. The amended petition asked for the county to be exempted from any sanctions while it continues to vigorously recruit new nurses.

Supervisor Yvonne Brathwaite Burke said she voted for the petition, which passed unanimously, after being convinced that the county will not have enough nurses on hand by Jan. 1 to staff all the available beds in its public hospitals.

"We can't find the nurses. Some of the private hospitals can pay so much more than we can pay," she said. "I support the idea, but I just don't know how we can do it."

L.A. County has been in the process of hiring 640 nurses to meet the ratios, while other private hospitals report similar numbers. Tenet Healthcare Corp., which operates 39 hospitals statewide, has been trying to recruit 1,000 nurses, while Catholic Healthcare West, with 37 hospitals statewide, also is recruiting large numbers of nurses.

However, top facilities like UCLA Medical Center and Cedars-Sinai Medical Center, as well as Kaiser Permanente facilities, say they will have enough nurses and do not anticipate any problems.

NurseStyles · Dec 13, 2003

Spacenurse:

How do you interpret these articles?

To me they seem a bit vague. I would appreciate your input.

From the CNA Q and A webpage:

The minimum, baseline ratio of 1 RN to 4 couplets represents the

The notion of "covering" an LVNs patients is wholly incompatible with the Nursing Practice Act , Title 22 regulations and the Standard of Competent Performance which governs RN practice. Patients are not assigned to LVNs. Patients are assigned to RNs who are required to directly provide ongoing assessment of each assigned patient. The LVN practices under the supervision of the RN and performs delegated functions or nursing activities under the effective supervision of the RN.

The following from the CNA Position statement:

CNA Position

1. The acute care LVN can only function in an assistive role. LVNs may assist direct care RNs and may provide shared nursing care under the clinical direction of the assigned direct care RN.

Example: General Med/Surg RN has five patients; LVN has no independent patient assignment but assists RN (could be more than one RN) with tasks/procedures requiring manual and technical skills.

NOTE: This is to avoid the doubling factor syndrome i.e., RN with 5; LVN with 5; RN has 10.

2. An LVN assigned to an acute care facility unit shall not be included in the calculation of the nurse to patient ratio. In other words, the LVN should not be in the count for purposes of complying with the nurse-to-patient ratio.

pickledpepperRN · Dec 13, 2003

Well, I don't work couplet care so my example will be med/surg.

Say you are the RN assigned to 6 patients.

I am the LVN "assigned to 6 patients.

YOU as the RN are responsible for the entire nursing process for ALL TWELVE patients, thus the doubling factor.

Say it only takes 5 minutes to perform an assessment on each patient and this is a miracle shift with no interruptions that will take an hour (5 minutes times 12 patients)

Say another 5 minutes for the chart check, care plan, and assigning tasks to the LVN.

You are two hours into your shift and ZERO patient care has been given to your 6 patients. The 6 shared with the LVN (me) may have breakfast if it is day shift. Now I want to go on my break. You cannot!

If there are phone calls, doctors, families, infiltrated IV sites, a pre- op, or medical crisis the other patients don't get care.

The LVN needs to be assigned to the RN, NOT to patients because in California an LVN may not function independently in acute care.

I realize there are many LVNs who have learned a lot through experience. The lawer who taught a CE class said, "Competence is no substitute for authority under the law."

If you as the registered nurse allow an LVN to assess the patients without doing it yourself and there is a lawsuit you may lose you license for authorizing the practice of registered nursing without a license (as an RN).

If you assign an LVN to give an IM medication, for example, and the patient develops an abcess resulting in a lawsuit you are not legally responsible because you assigned the task based on the LVN scope of practice.

I learned that in a CNA class recently.

They said there will be more starting in January. There are a couple more scheduled so check the web site for the CNA opinion. I tend to agree because the CNA wrote and lobbied for the law.

The main thing is that the registered nurse is responsible for the patients and must be able to assure safe, competent, therapeutic care.

Since you are new to posting on this BB I will explain that I post LOTS of srticles and links. Here are a couple frome the LVN board:

http://www.bvnpt.ca.gov/

"An LVN must work under the direction of a licensed registered nurse or physician, and a PT must work under a licensed registered nurse, physician, or Director of Services. See Business and Professions Code Sections 2859, 2860.5, and 4502."

http://www.leginfo.ca.gov/cgi-bin/displaycode?section=bpc&group=02001-03000&file=2859-2873.7

Above is from the Vocational Nurse Practice Act

NurseStyles · Dec 14, 2003

I need to clarify my concern. The CNA website q and a page says that it is not legal for an LVN to have 6 patients and the RN to have her 6 plus the LVN's 6 because that would give the RN 12 patients. It also says that the LVN should be assigned to a nurse not to patients as we discussed in the earlier post. Because of reading that, I was led to believe that LVNs are not counted in the ratios.

After reviewing the DHS website, I saw several parts in the addenum (2nd to the last), that said that LVNs do count.

How can this be? We are told that at all times a nurse can only have 6 patients. How can they get around this and give us 12?

I really am confused and do not understand the CNA q and a page. It conflicts with the DHS page. Is the CNA q and a page just what the CNA hopes for, or is it reality?

Do you understand my question?

Say we have 18 patients on the floor. We have two RNs, one LVN, and one charge nurse. EAch RN had 6 patients each and the LVN also has 6 patients. Technically, the charge nurse has 6 (those of the LVN). So when it comes down to relieving for breaks and meals, could the charge nurse cover for us even though she is assuming responsibility for the LVNs patients although assigned to the LVN?

Very Confusing to me.

Also...The CNA q and A website also says that hospitals cannot cut out ancillary personnel, it must remain the same as it is currently. The DHS statement of reasons says that they cannot regulate the ancilarry staff ratios. They keep referring to the PCS, but obviously the PCS does not work or we wouldn't have this ratio law in the first place, right?

Where I work, the CNAs are all worried that they will be responsible for 12-15 patients each now as opposed to the 6 or 7 they currently have. They claim they will not do but the minimum amount of care for the patients under those circumstances. Is there anything illegal about cutting CNAs out altogether? In teh CNA website Q and A, it says that if the ancillary personnel are cut, the hospital MUST hire additional RNs. I did not see that written in law.

I am rambling because I am sooooo darn confused.

Please answere any questions and clarify any of my concerns that are understandable.

Thanks so much.

Jen

Hellllo Nurse · Dec 14, 2003

No matter what does or does not happen with the ratios, I will tell you this- I will NEVER again in my life work in med-surg under the current unsafe working conditions.

I am on a "private" strike against the hospital industry. Unless conditions take a drastic change for the better, my white shoes will never grace the halls of another hospital.

pickledpepperRN · Dec 14, 2003

Originally posted by Hellllo Nurse
No matter what does or does not happen with the ratios, I will tell you this- I will NEVER again in my life work in med-surg under the current unsafe working conditions.

I am on a "private" strike against the hospital industry. Unless conditions take a drastic change for the better, my white shoes will never grace the halls of another hospital.

I understand completely!

My manager has written warning from almost 100% of un critical care nurses who must float to telemetry and step down if needed

that the shift we are assigned an unsafe number of patients will be the last. I will tell the manager or supervisor. If help does not arrive I will fill out an ADO.

While I and the other nurses care for patients the supervisor needs to make calls up the chain of command, all the way to the CEO!

If they do not do the right thing I will resign. Then on the days off from a new jpb I will stand on the sidewalk with the fact that there is one less RN because the hospital did not staff safely. I will give copies of the ratios to the doctors and visitors.

People need to know their care may not be safe.

Would YOU have elective surgery on a day there is not enough staff?

On the question of the DHS allowing for 50% LVN:

Title 22 states the patient classification system determines the staffing and licensure of that staff based on the scope of practice.

I WILL NOT AGREE TO AN ASSIGNMENT OF 10 OR 12 PATIENTS!

I only have one license! Actually my hospital IS staffing telemetry to the minimum ratios. We need to be stronger and insist on more staff when needed/ We do it for making a patient a 1:1 in critical care. I truly believe if all the licensed nurses on a unit insist they will be staffed safely with LVNs working together with one or two RNs. Most units need more than the minimum because patients are so sick.

Any legal questions would probably be better answered on the CNA web site. They have a place to click and send a question by e- mail.

My computer must have a virus (flu?) because cut and paste is very difficult and everything is VVEERRYY SLOOOOOW.