"ratios"? and pay in California?

UKRNinUSA, RN · Nov 19, 2006

All I know is that before the ratios went into effect I had no real control over patient assignments. I remember working registry at an LA hospital med/surg floor in the late 90's and having 11 patients and half a CNA to help out (the CNA had an assignment of 25 patients). It was all I could do just to pass the meds, hang the IV's, turn/change the most vulnerable patients (every 4 hours) and make sure everyone was still breathing. And these were sick patients!

Now we have mandated ratios and I get to give the care I was educated to provide. I worked at one facility recently where there was a dedicated break nurse assigned just to fulfill the ratio requirements and so for the first time in my nursing career I actually got ALL my breaks- even the 10 minute ones. Sure emergencies would crop up from time to time, but most of the time, most of us got most of our breaks. It's not perfect, it's not foolproof, but it is a heck of a lot better than it was. I no longer daydream about the day when I finally get out of nursing or get up in the morning to dread going to work.

Since I came over in the early nineties, my pay has more than doubled and I am finally recognized for my years of experience (the pay scale rewards years of experience rather than years of service).

Thanks, California Nurses Association!

Sheri257 · Nov 20, 2006

Every hospital that I have talked to still has nurses aides.

Every hospital I've been in still has aides also. I've heard of a few cutting aides but, I haven't actually seen it.

:typing

Sheri257 · Nov 20, 2006

Now we have mandated ratios and I get to give the care I was educated to provide. I worked at one facility recently where there was a dedicated break nurse assigned just to fulfill the ratio requirements and so for the first time in my nursing career I actually got ALL my breaks- even the 10 minute ones. Sure emergencies would crop up from time to time, but most of the time, most of us got most of our breaks. It's not perfect, it's not foolproof, but it is a heck of a lot better than it was. I no longer daydream about the day when I finally get out of nursing or get up in the morning to dread going to work.

Every veteran nurse I've talked to says the same thing you do. If people have any doubts about the ratio law, they should talk to nurses who worked before the law was enacted. IMHO ... they're really the experts on whether the law is working or not.

:typing

okikuma · Nov 26, 2006

There's a common misnomer that the ratio law in California only applies to RNs (the California Nursing Association an RN union, perpetuates this disinformation) ... wrong! The law applies to Licensed Nurses (i.e. LVN and RN).

Currently, the ratio is 5:1 per "licensed nurse" on a Med/Surg floor. Also, the nursing assignment can not exceed 50% of LVN. So out of 6 nurses, 3 must be RN and 3 muse be LVN. There's nothing within the law to disqualify and RN & LVN working as a team. This means that an RN/LVN team can legally have up to 10 patients together and many hospitals do just that. It's legal because of the definition of Licensed Nurse.

What I have seen and heard, because of the Ratio Law, many hospitals have removed their LVNs and replaced with CNAs. CNAs are not licensed so the ratio law need not apply. One CNA can be split between any number of RNs. If any or all CNS on the floor call in sick or a no-show, well sorry Mr. or Ms. RN, you will just have to have your 5 patients alone today (and the hospital saves money because one or more less person to pay for the day).

pickledpepperRN · Nov 26, 2006

If a hospital does not use sufficient licensed and inlicensed staff as determined by the assessment of the direct care registered nurse they are violating both the spirit and the language of the ratio law.

WE fill out an incident report and assignment despite objection form each time patient care is sub optimal. How dare a hospital claim the be "The best" and skimp on nursing care?

The Title 22 Section 70217 regulation includes, " Hospitals shall provide staffing by licensed 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."[/I]

and

"In addition to the requirements of subsection (a), the hospital shall implement a patient classification system as defined in Section 70053.2 above for determining nursing care needs of individual patients that reflects the assessment, made by a registered nurse as specified at subsection 70215(a)(1), of patient requirements and provides for shift-by-shift staffing based on those requirements. The ratios specified in subsection (a) shall constitute the minimum number of registered nurses, licensed vocational nurses, and in the case of psychiatric units, licensed psychiatric technicians, who shall be assigned to direct patient care. Additional staff in excess of these prescribed ratios, including non-licensed staff, shall be assigned in accordance with the hospital's documented patient classification system for determining nursing care requirements, considering factors that include 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, the ability for self-care, and the licensure of the personnel required for care. The system developed by the hospital shall include, but not be limited to, the following elements:"

Here is a link: California Code of Regulations

Click Title 22

Then: DIVISION 5. LICENSING AND CERTIFICATION OF HEALTH FACILITIES, HOME HEALTH AGENCIES

Then: CHAPTER 1.GENERAL ACUTE CARE HOSPITALS

Then: ARTICLE 3. BASIC SERVICES

Then the second choice under 70217. Nursing Service Staff

NewJA · Nov 26, 2006

In other words the law is very clear, and not open to deliberate abuse.

Good, all the more reason for me to try to live in California... Although that looks highly improbably based on all of my recent research lately which has shown me the extreme unaffordability of any place in that state worth living in.

Sheri257 · Nov 27, 2006

There's a common misnomer that the ratio law in California only applies to RNs (the California Nursing Association an RN union, perpetuates this disinformation) ... wrong! The law applies to Licensed Nurses (i.e. LVN and RN).
Currently, the ratio is 5:1 per "licensed nurse" on a Med/Surg floor. Also, the nursing assignment can not exceed 50% of LVN. So out of 6 nurses, 3 must be RN and 3 muse be LVN. There's nothing within the law to disqualify and RN & LVN working as a team. This means that an RN/LVN team can legally have up to 10 patients together and many hospitals do just that. It's legal because of the definition of Licensed Nurse.
What I have seen and heard, because of the Ratio Law, many hospitals have removed their LVNs and replaced with CNAs. CNAs are not licensed so the ratio law need not apply. One CNA can be split between any number of RNs. If any or all CNS on the floor call in sick or a no-show, well sorry Mr. or Ms. RN, you will just have to have your 5 patients alone today (and the hospital saves money because one or more less person to pay for the day).

Funny ... I've been in a dozen hospitals and, I've only seen one that uses the RN and LVN team nursing system with ten patients. But they still had one CNA for every 10 patients on top of that. You can't actually replace an LVN with a CNA but, you can do without CNA's at all if you want to yet ... they chose not to do that. Probably because it would be really hard for them to keep the RN's if they did.

Now there was a problem with CNA's calling out, quitting or whatever but, most of the time, this hospital would also bring in registery CNA's at $15 an hour if that happened.

I don't know why people are so concerned about these CNA cutbacks to make up for ratios. If a hospital is doing that, there are so many other places to work that still have aides, at least in my area, because they've got to keep the RN's happy. If the RN's quit because there aren't any aides, and many of them will, then the hospital is back to square one.

:typing

RNinSoCal · Nov 27, 2006

I have been working in med/surg in California since before the ratios and I remember having 8-10 pts per nurse.

Where I work now we do get 6 pts once in a while (it has happened to me 3 times in 1 year) due to sick calls or a busy ER. We fill out an ADO form that goes to the union for review. If we know we are going to be short a nurse ahead of time many of our nurses will stay double shift (we are on 8s here) and get the lovely double pay. If we miss our meal break we get 2 hours penalty pay.

We still have CNAs on days and pms but none on nights.

The non-union hospital I used to work for in LA county used LVNs with RNs to "cover". I usually had 5 pts of my own and "covered" for 3 LVN pts. I used to have to co-sign their charting/asessments. I really did not like this but it was required by management. I found out that this is not an approved BON practice because LVNs have their own licenses and should not need to be "covered" by an RN.

Where I work now LVNs have RN co-workers or the charge nurse help with IV meds but do all other nursing tasks independantly. We do not "cover" for any pts but our own.

In my opinion the ratios are working in California and I never want to go back to having 8-10 pts on med/surg.

bjlyst · Nov 28, 2006

it seems to me that you are all rn's talking about acute care hospitals. can anyone tell me what the ratios are for skilled or long term care facilities. because i'm an lvn who works in long term care, as a charge nurse/supervisor on the night shift. i have 74 patients that i am responsible for, plus the security and well being of the patients and building on the other floor at night.

NurseguyFL · Dec 29, 2006

I know I am coming in on the back end of this discussion, but I want to add my 2 cents to a comment Lizz made about ratios in California. Yes, the law is a good thing but what others have said about the rules being broken in some hospitals is also true. No I am not talking about emergency situations, but cases where the hospital deliberately and repeatedly violates the law. I came to California as a traveler, and until recently I was working at an HCA facility that does this on a fairly regular basis. They do not like to spend money on registry nurses, although in many instances they have been forced to because they often don't have enough staff nurses (and after being there for only a short while I could understand why!)

When a nurse goes on his/her breaks this hospital hospital expected that those of us who are on the floor should cover the patients, even if we already have the maximum of five patients. If you refused they would try to find ways to penalize you. What they often do when they are short staffed is tell nurses not to clock out when they take their breaks, but to just go and come back within the allowed time. Then they ask us to fill out a 'missed break' form which states that we did not actually take a break because of the need to stay in ratio. There is no doubt in my mind that this is both fraudulent and illegal because we were signing a document which states that we missed our breaks when we, in fact, took them and were off the floor, and our five patients were, during our break time, divvied up among other nurses, all of whom already had five patients. Since there were usually at least two nurses off the floor on these 'unofficial breaks' at a time, the nurses who were on the floor ended up carrying 6 or 7 patients (sometimes eight, depending on the census) each during the break periods.

So far they have been getting away with it because there is no punch clock evidence to prove that nurses actually leave the floor for two 15 minute breaks and a 30 minute lunch break. If one were to add up all these minutes for every nurse, it would amount to quite a few hours of being out of ratio every week and this is routine, not an emergency. This may seem like no big deal to some people, but it could very easily escalate into a huge deal if something seriously bad happens to a patient that we are supposed to be responsible for during those 15 or 30 minutes while we are gone. If the worst happens, I can easily see the hospital pointing fingers at the nurses for being off the floor on unauthorized breaks, and there would be no official record of anything to prove otherwise.

It is not a secret that HCA doesn't have the best reputation when it comes to ethics, but from what I've heard they are not the only ones that are doing this. The entire time I was working there I was always very nervous that at some point state regulators would bust the place and that I could possibly lose my license for wilfully committing fraud and patient endangerment. It was shocking to me that so many of the staff nurses who were working at this particular hospital didn't seem to think anything of it, I guess because the practice has become an acceptable part of the culture.

This is also one of the hospitals that had removed most of the nursing assistants from the floors, so most of the time we had no help with moving or turning heavy patients, had to bathe all our patients and change bed linens, pass meal trays, etc. Often there is no secretary, and sometimes no charge nurse either so we were pretty much on our own there, too. I hear that no traveler ever renews his/her contract at this hospital and they are always trying to hire because the nursing turnover is so high. The effects of the neverending drive to cut costs were also unbelievably bad and the deteriorated state of the facility itself was nothing to be desired. I understand that these for-profit hospitals need to make money for their shareholders but some of what I have seen is just ridiculous, unsafe, and unsanitary. Workorders to fix broken beds and faulty bathroom fixtures are always being put in, but no one shows up to do the repairs until several days later. In the mean time, patients are going into other patients rooms to use the toilet because the toilet in their own room doesn't work and has unflushed excrement sitting in it for days.

And did I mention the faulty equipment? Nurses fight for a functional med cart at the beginning of each shift because some of them do not work. The batteries in the med cart computers are so old that they don't hold a charge for long so they keep cutting off and you have to keep moving furniture to plug them in as you push the cart from room to room. Then there is the huge problem of clutter in all the hallways on the floor becuse this is where all the med carts and blood pressure machines are plugged in, and also where wheelchairs, repiratory equipment, and just about every other device is 'parked'. I don't know how the fire marshall allows them to get away with this because it is a HUGE fire hazzard. In case of a fire, I don't see how they expect to quickly move the patients out with all that stuff cluttering up the halls. I've never seen such a thing in any other hospital where I'ved worked, and when I raised it as a safety issue people looked at me as if I'm crazy. Another issue I had with these med carts is that they are never sanitized by housekeeping, and we were not given any cleaning materials to do it ourselves even though we had to push these carts into isolation rooms to scan the patients.

And most annoying of all was the discharge planning nurse, who would always show up at the busiest time of the morning demanding that we all drop everything that we are doing to give her report on all our patients. I never understood that one because all the information she is asking us for she could just as easily have gotten from the patients' charts herself. Its supposed to be her job to talk to the patients, their families, the physicians, and coordinate the discharge plan with whatever facility or home health care they are going to, but she would always find some way to put all of that responsibility on the nurses and then disappear until long after the patients are gone, then she would come back asking for another report!

I would never work at an HCA facility again, not in California or anywhere else. It was a good learning experience though because at least now I know exactly what questions to ask before accepting another travel gig.

Sheri257 · Dec 29, 2006

Thankfully, I've never been in an HCA facility but I've heard nothing but horrible things about them so, I guess it's not surprizing that they're breaking ratios on the sly.

And their CNA cuts did result in a patient suicide, due to the lack of available sitters ... that made the paper. The family is suing them.

:typing

bjlyst · Dec 30, 2006

in reply to the ratios law. yes, it can work but, the nurses have to refuse to take more than what the law allows. no facility or hospital in calif. is going to stick to the law if they know that one or more nurses will take on more than the law allows. it isn't their license that goes on the line. and every nurse out there is replaceable, and your chances of winning if you are personnally sued aren't good because you have your word against the hospital. and they have been covering their numbers for a long time. so, just remember, the next time you get stuck with more than the law allows. report it. write it down, and turn them in, the law only works if we all work the law.