New Staffing ratios

cbrnbloompa · Dec 10, 2003

I am so frustrated with the ratios. Yes in an ideal world where we had enough nurses to go around it would be excellent. I work in southern California and I am not at all impressed with some of the nurses I work with and I think alot of that is because people are trying to rush through their nursing education to become an RN. They are not taking the time to learn the concept. There is a college in the area offering a "fast track" to become an RN. We are sacrificing patient safety by not learning the concepts. However having 10-15 patients is also unsafe, so I guess we just can't win..But we really need some GOOD nurses.

PMHNP10 · Dec 10, 2003

Originally posted by cbrnbloompa
I am so frustrated with the ratios. Yes in an ideal world where we had enough nurses to go around it would be excellent. I work in southern California and I am not at all impressed with some of the nurses I work with and I think alot of that is because people are trying to rush through their nursing education to become an RN. They are not taking the time to learn the concept. There is a college in the area offering a "fast track" to become an RN. We are sacrificing patient safety by not learning the concepts. However having 10-15 patients is also unsafe, so I guess we just can't win..But we really need some GOOD nurses.

My apologies for being a bit dense, but what does your frustration with the ratios have to do with the nurses who, in your opinion, are not meeting your standard? So I guess what it comes down to is, would you prefer these unimpressive nurses to be caring for 6 or fewer patients, or 10-15? Now if you wish to expand on the lack of bedside nurses, I could give a lengthy response to such a concern but I can just leave it at...who cares if the hospitals haven't spent the past 4 years trying to become compliant rather than spending that money on lobbying against the ratios. Take care of your 6(or fewer) pts and know that you were able to provide them with the care they deserve. And if that isn't satisfying enough, take comfort in the fact that there is a dramatic decrease in the likelihood of them dying during their hospitalization because of these lower nurse to pt ratios.

cbrnbloompa · Dec 10, 2003

I guess I am trying to say that either way you have it~with or without ratios our patient's safety is at risk!!! Ca is now trying to push LVNs and other students through RN programs at a fast rate. That I believe will decrease patient safety. I understand that fewer patients is safer, but where are the nurses coming from to take care of the fewer patients??? That's right the "fast track" RN programs!!!!! Maybe you understand me and if not that is ok.

PMHNP10 · Dec 10, 2003

Your point of view is a little clearer now, but please understand, these hospitals have had 4 years to (em)brace for these ratios; rather the money used to bring in nurses was squandered on lobbying against the ratios. I do understand what you are saying about the "fast track" programs, but what other nurses are doing should always be a secondary concern to what you are doing; and with 6 pts, and not 10-15 you can do so much more caring, and that really is what is most important. After I posted, I saw where you stated you were a pretty new RN--first off, congrats. Second, whatever you have heard about the nursing shortage in school, or wherever, is incorrect. There are plenty of RNs out there. There are just a lack of ones who wish to torture themselves at the bedside because of the working conditions currently present. If these ratios are given a chance to work as the lawmakers intended, to say nurses won't return to bedside nursing would be ludicrous.

Sheri257 · Dec 10, 2003

Originally posted by cbrnbloompa
I guess I am trying to say that either way you have it~with or without ratios our patient's safety is at risk!!! Ca is now trying to push LVNs and other students through RN programs at a fast rate. That I believe will decrease patient safety. I understand that fewer patients is safer, but where are the nurses coming from to take care of the fewer patients??? That's right the "fast track" RN programs!!!!! Maybe you understand me and if not that is ok.

Actually, I think you have an interesting point, and a good one.

cbrnbloompa · Dec 10, 2003

I see what you are saying and I hope that nurses not working will come back~that would be great and I hope for the patients' sake that is true. Thanks for the congrats~I love what I do and I would not change that for the world.

pickledpepperRN · Dec 11, 2003

http://www.calnurse.org/112103alert/trans12803.html

Debate on the Staffing Ratios between Jill Furillo, RN, CNA's National Outreach Director and Jim Lott from the Hospital Association of Southern California.

From Which Way LA 89.9 FM on December 4, 2003 (Unofficial CNA Transcript).

Warren: On January 1st, California will become the first state in the nation that will require hospitals maintain specific minimum ratios for registered nurses. Nurses say that means better care for more patients. But hospitals claim that they're in trouble because there aren't enough nurses. They are predicting the shutdown of entire units and backups in the emergency rooms. Jim Lott is the executive vice-president of the Hospital Association of Southern California which included both public and private hospitals. Jim Lott welcome to our program.

Jim: Hi Warren.

Warren: Things are really that bad?

Jim: Things are really that bad. Even without the new staffing mandate. Currently, hospitals cannot fill 15% of their budgeted nursing positions. I mean we got money to hire nurses but we simply can't find them. And so adding a new burden on top of that is going to make it worse for the hospitals, but more importantly, hospitals will now be in violation of a law. And that means if you don't want to break the law you're going to have to take measure to come into compliance. And that means if you can't find the nurses, you're going to have to shutdown services in order to reduce the number of patients that the nurses are treating. So that's the dilemma we're facing.

Warren: Why would this necessarily affect the emergency rooms?

Jim: Well, because emergency rooms do not act alone. They're not stand alone units. You can only keep your emergency room open if you have enough ICU, Intensive Care Unit beds available if you have enough medical beds or surgical beds in the rest of the hospital open. So if you have to start closing the rest of the hospital, you have to look at what you're doing in the emergency room and say "we're now going to have to shut the emergency room down to ambulance traffic because we don't have the intensive care or surgery or anything like that to back it up.

Warren: Your association again, represents both private and public hospitals, where do you think the crunch will be felt first?

Jim: Well, I think it depends on the hospital. It depends on the area. I think some of our more acute what we call safety net hospitals. Those hospitals that are on the frontlines providing heavy loads of emergency care like county hospitals and trauma centers. I think they're going to feel it the most first. But every hospital on some shift or on some days of the week is going to be out of compliance. So, we're looking at well over 99% of all hospitals being in violation of the new law at some point in a 24/7 operation.

Warren: Jim Lott, executive vice-president of the Hospital Association of Southern California. Again the law was passed back in 1999. Hospitals have had some time to get ready for it. The Nurses Association contends that there isn't a crisis at all, but this is being manufactured by the hospitals themselves. Jill Furillo is Director of National Affairs Council for the California Nurses Association. She, herself, is a registered nurse and she lobbied for the bill back in 1999. Jill Furillo welcome to you.

Jill: Yes, good afternoon Warren.

Warren: Why would the hospitals manufacture a crisis?

Jill: Well, I think the hospitals have always opposed any effort by either the state or the county or anyone else to weigh in on how they ought to operate with respect to staffing. But I would just say that the deterioration in the working conditions for nurses that has been the primary cause for staff vacancies in any of these hospitals. And that it's necessarily a systemic nursing shortage that has caused that. The nurses have opted not to take nursing jobs in hospitals because they are not attractive positions where they'd be confronted by poor working conditions, mandatory overtime, and short staffing. Actually, this poor staffing existed before the shortage and helped actually to create the nursing shortage and will only be resolved when we begin to move to implement this nurse-to-patient ratios. I would further say that the hospitals have known about this since 1999 when the bill was first passed and signed by the governor. In 2002 the department of health services announced what the ratios will be and the hospitals had two years to come into compliance with this. There should be no reason why they are now all of a sudden saying they can't become compliant when in fact we have 30,000 more nurses this year than we had back in 1999. I think the hospitals that have come in to compliance are those hospital that have realized that they need to implement safe staffing standards in their hospitals as well as pay the kind of wages that make it possible to recruit and retain nurses, and pensions and other things that make the working conditions more tolerable for nurses.

Warren: Jim Lott said you thought that 99% of hospitals would be out of compliance at some time. I take it you're challenging that figure and also the existence nursing shortage you're suggesting that there are nurses out there who aren't necessarily working as nurses who would be available if in fact working conditions were better.

Jill: That's correct. Actually, there are more nurses that have come back to the workforce as a result of this nurse staffing ratios. All the surveys that were done by the California Board of Registered Nursing showed that nurses were leaving hospitals actually in droves as the result of the staffing situation. They found they could no longer provide the quality of care they were trained to provide. And they said that if there was some kind of a mandate like they had in the Intensive Care Units to have a safe number of patients that they would come to the hospital. And that has actually occurred. Jim himself actually said before the LA EMS Commission that 95% of the hospitals currently in LA County look as though they will be meeting these standards.

Warren: Jill Furillo with the California Nurses Association. Jim Lott back to you on that point. Is that what you said?

Jim: No, that is not quite what I said. What I said was that 95% of the hospitals would be able to meet the ratios on many of the shifts, but not any hospitals that I am aware of have reported that they would be able to meet it in all essences on all shifts. At some point every hospital, almost every hospital will be out of compliance. But the nursing shortage, and we can argue about figures and whatnot. But it's well documented that the nursing shortage if not just simply in existence here in Los Angeles it is not only an epidemic, it's a pandemic. It's worldwide. We know that we simply don't have the number of nurses that we're going to need. Reports also suggest that in the next couple of years we'll need 30 thousand more nurses to meet the increase in demands. So, I don't want to debate that issue. The bottom line that regardless of sign-in bonuses and all the other incentives that hospitals have attempted to use to recruit more nurses we simply cannot fill up to 15% percent of our positions. That is a fact. We don't know what's going to change next 27 days to miraculously allow us to do that.

Warren: Back to Jill Furillo. There is a study by the nursing school at the University of California at San Francisco that says that the nursing shortage won't pose much of a problem immediately, but it will catch up very soon by the year 2005. What about Jim Lott's point that this is a much broader problem than just California.?

Jill: Well, again I think you have to go back to what the root cause analysis for that shortage is and that fact is that the nurses have left the profession because of the working conditions and they have said that it's the ratios that will bring them back and if fact that has occurred here in California. To look at 2005 and beyond I think that California is addressing that issue right now. We have 72 schools of nursing where we are graduating 5,000 nurses a year. So the issue isn't that we're graduating enough nurses, the question is, "Are the hospitals retaining the nurses that are there?" And again that goes back to the working conditions. All the studies have shown and there have been several that have been conducted in the last 3, 4 years. One that I would point is the one conducted recently by the Institute of Medicine that shows that it's the nurses who are defending against the medical errors that are out there. There was a study in 2 hospitals that found that nurses intercepted 86% of medication errors before they reached the patients. And so what we find it by having these nurse-to-patient ratios nurses can provide a higher quality of care, you have a better patient outcome, and as a result of that nurses are more inclined to stay working in that hospital environment and they won't leave. And that's what's going to reduce the nursing shortage. At the same time that we are educating nurses and we're attracting more people into the profession.

Warren: Jim Lott back to you. You said that the hospitals are offering special incentives to nurses to try to get them on board that still 15% of the positions aren't filled. What about this question of working conditions, would it cost the hospitals too much money to bring them up to the standards that Ms. Furillo and the nurses association seem to be demanding?

Jim: Working in a hospital today is difficult for all staffs, not just nurses. It's a hard job. And our nursing population is at the older population it used to be. The average age of nurses is 47 working in a hospital. The workload tends to take its toll. And that's not going to change by placing additional requirements on hospitals for that. The patients we're treating are sicker, the circumstances on which nurses work are going to remain that way. So I'm not sure that any of... "building it and they will come" is the approach that Ms. Furillo is talking about, I'm not sure that's going to happen. We can only hope that they are right. But everything we've attempted to do up to now to do what we are currently trying to do with filling these positions isn't working.

Warren: All right. Obviously, the two of you disagree. We're not going to resolve that conflict. Jim Lott and the Board of Supervisors have asked the governor to step in. I think others have as well, what could he do?

Jim: Well, the law is the law. But the law says that the... with a couple of exceptions, the ratios have to be put into place or must be put into place by regulation. The administration controls the regulatory process and they are the ones who actually came up with most of these ratios that we're going to be confronted with. So the administration giveth, they can take it away. They can amend these regulations to make them more workable. They can give hospitals who show through diligence in trying to fill these positions or meet these mandates they can give them relief from sanctions if they so desire. That wasn't specified in the law, not specified in the regulations. The administration can alter those regulations.

Warren: Jill Furillo what do you say to that. Any room for compromise or further delay?

Jill: I guess what I would say to you is that we have had such a long process already where the bill was passed in 1999. The department of health services then promulgated regulations where there were several public hearings that were held. Everybody weighed in. The regulations were mended after that. There were more delays that were put into place by the former administration. I guess what happened since that has occurred several more studies have shown that patient mortality is at risk here. Studies have shown that for every nurse, I'm sorry for every patient that a nurse has beyond four patients, the risk of patients dying increase by 7% for extra patients. So what we're finding is that the liability for hospitals is there regardless of these ratios. I mean the fact of the matter is the department of health services study has shown that patients do better when you have the proper number of nurses. So...

Warren: I will interrupt you in the interest of time. Jim Lott, 'cause we're almost out of time here. Would the hospitals hire more nurses if they were available based on what Ms. Furillo was saying namely that there would be a better patient care?

Jim: No question. The issue isn't whether or not we want to hire more nurses, the issue is simply we can't find them. If we could find them, we hire them.

Warren: And Jill Furillo, you'll be asking the governor not to change the regulations I presume, try to push the issue so that the law does go into effect on January 1st.

Jill: I think the governor has to consider what's in the best interest of patient care at this moment. All the studies are showing that having the proper number of nurses at the bedside is what saves patients' lives. And that's true for California.

Warren: OK. January 1st, the new law will or will not be implemented. Jill Furillo, Director of National Affairs for the California Nurses Association. Jim Lott, executive vice president of the Hospital Association of Southern California. Thank you both for being with us tonight.

Jill: Thank you.

The specific ratios by hospital unit Q & A on the Ratios Full Text of AB394, The Safe Staffing Bill Fact Sheet on RN Staffing Ratio Law Hospital industry seminars adviseadministrators how to evade RN ratios

PMHNP10 · Dec 11, 2003

Originally posted by spacenurse
http://www.calnurse.org/112103alert/trans12803.html
Warren: Your association again, represents both private and public hospitals, where do you think the crunch will be felt first?

I think the real answer to this question is it will affect the hospitals which do not comply.

What comes to my mind about this situation is: Let's say some of these hospitals are truly not able to hire the nurses--of course forgetting about the fact that they have had 4 yrs to prepare. If that is true, I wonder why that is? Obviously some hospitals appear to be, in good faith, complying with the new law, but those who aren't are going to swear they are trying, but can't fill the positions. Could it be because of their reputation? I don't know all of the hospitals that are complying nor those which aren't, but Tenet, for example, nothing indicates they are putting forth much effort. Let's pretend this company truly has been attempting to hire nurses; has their sins of the past and present caught up with them? I can't blame anyone for avoiding a Tenet (or the like) hospital like the plague, but bottom line is that I can see these hospitals crying to anyone who will listen, and when the public (patients) start to catch wind of being refused medical care because they can't (read: refuse to) comply, public sentiment will definitely start to shift back towards the hospital point of view. If it hasn't happened yet, every nurse needs to start educating the public about what they very well might face with their med care in the future.

Another thought: What I see happening is these compliant hospitals will start having a surge in business (since they will not have to shut down units) because these noncompliant hospitals will have to shut down. If my scenario happens, will these Tenet-like hospitals start to comply? I'd like to give the benefit of the doubt, but I'm not quite that delusional. I bet they start spending more money to fight these ratios and do all they can to get them repealed rather than comply. I can't wait until Jan 01; this could be quite the soap opera

cbrnbloompa · Dec 11, 2003

just read your reply and I have a question, you keep saying the hospitals had four years to prepare for the ratios. What do you mean, what are they suposed to do when there is a nationwide shortage and the nurses are just not there? I work for Tenet and I do agree it isn't the greatest, but they truely are trying to comply. Our ICU alone needs 33 full time nurses to be complient with ratio regulations, that is just the ICU!!!!! What do you suggest to get more nurses????

Sheri257 · Dec 11, 2003

Originally posted by spacenurse
http://www.calnurse.org/112103alert/trans12803.html

Spacenurse: I just wanted to say that I'm a big fan of the links you post on a daily basis. Thank you for the great information!

PMHNP10 · Dec 11, 2003

Again, I have to re-stress...the nursing shortage doesn't exist like you were taught since day 1 of nursing school. There is not a shortage of nurses just a shortage of nurses willing to torture themselves at the bedside by woking under staffed, with no auxillary help, etc, etc, etc. Don't you believe that if the shortage were as bad as we have been made to believe that no hospital would have any chance coming close to staffing for the new ratios, yet some hospitals decided not to fight and instead began to embrace these new ratios a year ago or so, and hired accordingly (eg. Ukiah Valley Medical Center). On the other hand you have Tenet hospitals (and the like) which have been spending millions lobbying since 1999 against these ratios rather than accepting the inevitable and working towards compliance. Given this and the long checkered past of Tenet, it is hard to believe they are, in good faith, trying to hire adequate staff. And even if they are, I wonder if they are unsuccessful because of those sins of the past and present.

I don't know how long you have been viewing this board, but perhaps you have noticed that there are quite a few nurses (travel nurses et al) who have expressed interest in going out to CA--myself and my girlfriend (soon to be GN) included. Members of this BB only represent a small percentage of all nurses, so it is safe to assume there are many more like us. And if you can't find enough from that pool, you have the remainder of the planet to work with--foreign nurses would do anything to come to the States to work.

Here is one simple check to see if these hospitals are, in good faith (there is that phrase again), trying to become compliant. Does your hospital use agency nurses? If not, will they change this practice to become compliant? They are going to have to so they can actively demonstrate their intentions to comply, and maybe this will help rebuild the trust lost from the nursing community. If not it appears they plan on cutting off their nose to spite their face. They will close units and cry to the public that they tried but couldn't and when the public starts to suffer because of this, they will have more support in their fight against the ratios.

You happen to use your hospital's ICU as a reference point. This strikes me as funny because I had no idea there were hospitals in the US where the ICU ratios aren't already 1:2 ratios--I thought it was standard nationwide--ahhhh Tenet, how could I be so naive. And how could the nurses who work there tolerate such conditions?

pickledpepperRN · Dec 11, 2003

When I work registry I am the first to be sent home early if patients transfer, are discharged, or die. I then tell the charge nurse i will have my unpaid lunch in the lounge for 1/2 hour.

Most of the time there is a code or admot that would "force" the hospital to violate the ICU ratios that have been in effect since the 1970s. Generally the supervisor is not pleased there is no excuse to say, "We don't have anyone, you have to "absorb" the patient."

When a critical patient is in the ER it takes little logic to assume they will soon need a critical care bed.

I don't completely blame the supervisor. It is the greed of the hospital administration, the pharmaceutical companies, HMOs and insurance companies.

http://www.oaklandtribune.com/Stories/0,1413,82%257E1804%257E1819244,00.html

A caring problem: Training, retention issues complicate nursing shortage By Melissa Schorr, STAFF WRITER

EVERY day on the oncology ward, nurse Jan Rodolfo is forced to make a decision of Solomonic dimensions.

By Melissa SchorrEVERY day on the oncology ward, nurse Jan Rodolfo is forced to make a decision of Solomonic dimensions., STAFF WRITER

Does she respond to the call of the advanced cancer patient in excruciating pain? Or the one suffering post-operative bleeding? Before she can decide, she hears a third, struggling to his feet, at imminent risk of taking a hip-breaking tumble. When the call lights blink on and a nurse is juggling several patients at once, what happens? "You have to prioritize," explains Rodolfo, who works at Summit Hospital in Oakland. "It's not a decision you want to make. It's not fair to any patient to be the one that's not the priority. That's what makes you go home and cry at night. When you don't feel like you've provided good care." Many nurses and their patients may face this scenario more often, health experts warn, amid one of the worst nursing shortages in U.S. history. According to the U.S. Bureau of Labor Statistics, by 2010, the country will be short a million nurses. "This is the ugliest I've ever seen it," said Cheryl L. Johnson, RN and president of the United American Nurses. She was speaking at a recent public health conference in San Francisco. "The shortage will soon reach catastrophic proportions." California is projected to have a shortfall of more than 100,000 registered nurses by 2010. Already, California hospitals average a 15 to 20 percent nurse vacancy rate, and the state has the second lowest ratio of registered nurses per person in the entire country. The problem is not just academic: If you or a loved one ends up ill during this time, you may suffer. Numerous studies have revealed a link between a lack of nurses and hospital stays gone awry, with higher risk of medical errors, hospital-acquired infections and even death. When a nurse is responsible for doing it all -- doling out medications, changing bed pans, filling out paperwork, or simply holding a scared patient's hand -- something's got to give. But the reasons behind the nursing shortage are somewhat surprising. It's not so much that nursing has lost its glam appeal. Rather, the profession is rapidly losing those who are already trained and is simultaneously unable to quickly enough educate those who want to become nurses.

Retention issues

Nurses may be the most dissatisfied

workers in the United States, according to a 2003 report by the United Nurses of America, which found that one-quarter of nurses plan on quitting within a year, and more than half would not recommend a nursing career to anyone else.

Two-thirds of registered nurses are older than 40 and poised to retire -- just as the aging baby boomers need care the most.

"Who's going to fill our shoes?" wonders Lorraine Thiebaud, RN, a longtime nurse at San Francisco General Hospital and an organizer within the Service Employees International Union. "It matters to me whether qualified people will be out there to take care of me."

Trained nurses are out there -- they just aren't employed as nurses. One study found that nearly one out of five licensed nurses nationwide, some 500,000 trained professionals, had quit the profession, disgusted with the low pay, high stress and lack of autonomy.

"We have enough nurses," Johnson notes, "but they're choosing not to do this because of the conditions."

California thinks it has come up with the answer with the Safe Staffing Law. This landmark legislation, passed in 1999, will take effect Jan. 1. The law is the first and only in the nation to set levels of how many patients each nurse can juggle, an issue which nurses say is the key reason they're abandoning their jobs.

"You can't give any personal care," says Theresa Hayes, a nursing student at the College of Marin, describing the struggle between handling eight patients versus four. "You pick and choose your battles; the less sick get ignored because you don't have enough time. If somebody is having some depression, you can't be there for them."

But will the new regulations make a difference?

Hospitals fear the law will make the situation worse, requiring them to fill their rosters with less qualified health care workers. But advocates say the law will improve working conditions and keep nurses in the field.

Trande Phillips, RN, a pediatric nurse at Kaiser Walnut Creek Medical Center, was on the verge of quitting after 32 years but says she changed her mind after her work load was reduced from caring for 13 sick children on a shift to three.

"You can see a real difference," she says. "I'm having a lot more time to spend with my patients, and much better outcomes." Patient satisfaction at the facility has also soared, she adds.

Groups that pushed for passage, like the California Nurses Association (CNA), say that the law has already made a difference, citing 10,000 new nurses registering in California annually, up five times over projections.

Still, many fear that under the new administration in Sacramento, the law may go unenforced -- or even get reversed.

Some shortage may be alleviated in the state because California generally offers higher wages for nurses, compared to other parts of the country. Bay Area salaries average $65,000 a year compared to $45,000 nationwide.

"As a state, California is going to do OK," observes Douglas Segar, dean of the nursing program at Merritt College in Oakland. "But we're doing it at others' expense, taking nurses away from other places that need them."

In fact, half of the new nurses in California annually are coming from out of state or even out of country.

Recruitment

However, keeping nurses happy isn't enough; getting new ones trained is the other half of the equation. Luring young, educated women into nursing seems like it would be a challenge because other career options abound that were not available a generation ago -- and men still shy away from what's seen as a traditionally female-dominated profession.

But this argument breaks down in light of the large number of students on waiting lists for two- and four-year nursing programs. In the last two decades, as a result of the managed care boom, many schools cut back on the size of their programs, anticipating fewer nurses would be needed. Big mistake.

"If you talk to people, they do want to be in this job, but they can't get in," says San Francisco General's Thiebaud. "Every school has 400 people on a waiting list because of budget cuts."

At Merritt, there are 10 applicants for every one of the 53 spots. "The intensity of competition is fierce," says Segar. Similarly, at the College of Marin, 120 people applied for 36 nursing slots last year, Hayes says.

"I know quite a few who sobbed when they got their acceptance letter, and some who were devastated when they didn't get in," Hayes recalls. "We have enough people who want to get in -- they don't have enough professors to teach the classes."

This is partly due to the Board of Registered Nursing's requirement that there be one teacher for every 10 students, a costly expense for a state-funded school. Many don't have the budgets to hire more staff -- or to pay a salary competitive with what that teacher could earn at the bedside.

Overall, the situation has left trained nurses not wanting to work as nurses, and those who do want to work as nurses not able to get trained.

"It's a log jam," Segar laments. "Nursing schools can grow to meet that need, but it can't happen overnight. There's no way to fix this in a short period of time. We're going to be facing a shortage for the next 10 years."

You can e-mail Melissa Schorr at [email protected] or call her at (925) 416-4814.