What one law would most improve nursing?

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To me it would be more states having the California patient ratio law. Indeed, I was surprised in nursing school (not sure if this has changed" to learn that the ANA didn't explicitly support the California ratio law instead supporting more "flexible" staffing ratio arrangements. However, Medicare has long held via 42 Code of Federal Regulations (42CFR 482.23(b) that hospitals participating in Medicare must have "adequate numbers of licensed registered nurses, licensed practical nurses, and other personnel to provide nursing care to all patients as needed" To me the California nursing ratio law should be the "minimum" to satisfy the requirement. I believe that this is something that most nurses (and even MD's) could get behind.

I would recommend a law where hospitals are reimbursed for nursing time.

The way hospitals are reimbursed currently there is little incentive to adequately staff. Nurses are considered "part of the package" and are rolled into the cost of the bed. Instead, I would have a bed fee and a nursing services fee where nursing time is accounted for and billed. A .1 FTE per bed reimburses at a substantially lower rate than a .3 FTE but there would be caps per DRG to balance things out. The hospital makes more money the more nurses per patient it has.

This way the hospital is financially incentivized to have a low nurse to patient ratio and the burden of adequetely staffing a hospital is not 100% on the hospital. This would allow a degree of flexibility so that even critical access hospitals can be accounted for.

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Specializes in Cardiology.

Staffing ratios, perhaps not treating/viewing the RN as your personal servant and instead viewing them as a medical professional (hard to pass a law on that but it would be nice wouldn't it?).

Unfortunately I don't think we will see a safe staffing law anytime soon. Hospitals and MDs will scare the public. They will also spend ridiculous amounts of money.

If, IF, we want a safe staffing/ratio the only option I see is a federal law being passed and even then I can see states filing lawsuits.

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47 minutes ago, OUxPhys said:

Staffing ratios, perhaps not treating/viewing the RN as your personal servant and instead viewing them as a medical professional (hard to pass a law on that but it would be nice wouldn't it?).

Unfortunately I don't think we will see a safe staffing law anytime soon. Hospitals and MDs will scare the public. They will also spend ridiculous amounts of money.

If, IF, we want a safe staffing/ratio the only option I see is a federal law being passed and even then I can see states filing lawsuits.

There are 14 states with staffing laws.

Regulating nurse staffing at a federal level would be a massive federal effort. Not impossible but significant.

The way you get hospitals to buy in is to incentivize them, not penalize them. You pay them for nursing time instead of rolling it into the cost of the bed and pay them for ideal staffing.

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Specializes in ICU, trauma, neuro.

What separates California is that their ratios are actually followed. I had a friend who traveled to a HCA facility and even they followed the ratio law ( and they actually provided relief nurses for lunch ). This would be like Iran and North Korea actually doing away with their nukes, but California makes it happen. I’ve largely been libertarian to conservative but this one fact alone combined with my positive union experiences might be enough for me to support progressives.

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4 minutes ago, myoglobin said:

What separates California is that their ratios are actually followed. I had a friend who traveled to a HCA facility and even they followed the ratio law ( and they actually provided relief nurses for lunch ). This would be like Iran and North Korea actually doing away with their nukes, but California makes it happen. I’ve largely been libertarian to conservative but this one fact alone combined with my positive union experiences might be enough for me to support progressives.

I love the idea of patient/ nurse ratio laws, but I still think the best way to determine right ratios is by acuity. For example, years ago, before LTC turned into virtual hospital level care on all patients, with an aggressive defensive medicine approach, an assignment of 60 patients on night shift was easy because they had few orders to follow. 30 patients on another shift was appropriate based on volume of tasks. Yet today, there are people being admitted to LTC for S/T rehab who are an entire full time job, by themselves, for 2 staff members. (Extreme example) ...and on most units the mix of patients in LTCs' aggressive care model, an assignment of 5-10 is more appropriate. Find me one LTC facility who staffs this way, anywhere....

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Specializes in ICU, trauma, neuro.

I would argue that the California law "sets a minimum" for acuity by specifying that ICU be "no more" than two to one or that medical telemetry be "no more" than four to one. The problem with less specific requirements is that they won't be followed. For example I worked in a trauma ICU that was normally "two to one", but was supposed to be one to one or even two nurses for one patient during massive blood transfusion protocols, and other intensive procedures. However, this NEVER happened (sure maybe staff would help out for 30 minutes or so during the admission/crisis, but they were leaving their trauma ICU patients unattended to do so). Even if the hospital had wished to operate in good faith (and they didn't it was HCA) it would have required having "extra" staff to stand around or be available to come in for those "higher" acuity situations. Contrast that with California where even HCA complies with the minimum requirements and the lunch breaks. Why? Because every time the ratio slips over the minimum they get financially dinged. Keep in mind that trauma units are required by state regulation to "staff up" for acuity, but that isn't sufficient to make it happen. Only the sort of "heavy hand" of the state backed by vigilant nursing unions (as is the case in California) is enough to make hospitals consistently comply. I would be fascinated to know how compliance to staffing ratios in states with "safe staffing laws" (but no mandatory ratio laws) compares to California where the ratios are set in stone.

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21 minutes ago, myoglobin said:

I would argue that the California law "sets a minimum" for acuity by specifying that ICU be "no more" than two to one or that medical telemetry be "no more" than four to one. The problem with less specific requirements is that they won't be followed. For example I worked in a trauma ICU that was normally "two to one", but was supposed to be one to one or even two nurses for one patient during massive blood transfusion protocols, and other intensive procedures. However, this NEVER happened (sure maybe staff would help out for 30 minutes or so during the admission/crisis, but they were leaving their trauma ICU patients unattended to do so). Even if the hospital had wished to operate in good faith (and they didn't it was HCA) it would have required having "extra" staff to stand around or be available to come in for those "higher" acuity situations. Contrast that with California where even HCA complies with the minimum requirements and the lunch breaks. Why? Because every time the ratio slips over the minimum they get financially dinged. Keep in mind that trauma units are required by state regulation to "staff up" for acuity, but that isn't sufficient to make it happen. Only the sort of "heavy hand" of the state backed by vigilant nursing unions (as is the case in California) is enough to make hospitals consistently comply. I would be fascinated to know how compliance to staffing ratios in states with "safe staffing laws" (but no mandatory ratio laws) compares to California where the ratios are set in stone.

We have a ridiculous system in PA. I think the hospitals do as they please, but in LTC, there is this dopey "2.7" nursing hours in a 24 hour period, per patient. It blocks together total nursing care hours per patient by combining CNAs , LPNs and RNs on staff in a 24 hour period. . So what happens is that there are more CNAs, and nurses get spread paper thin to maximize the bottom line, while meeting the state law. A daily staffing sheet is required to be posted in the lobby, which shows how this minimum 2.7 number is met. If they fall below this number, someone has to file a complaint with the state. The state will visit, and make a canned recommendation, then the DON writes a sentence on a piece of paper promising compliance. That's it, no fine.

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Specializes in New Critical care NP, Critical care, Med-surg, LTC.
On 5/28/2019 at 5:30 PM, Asystole RN said:

I would recommend a law where hospitals are reimbursed for nursing time.

The way hospitals are reimbursed currently there is little incentive to adequately staff. Nurses are considered "part of the package" and are rolled into the cost of the bed. Instead, I would have a bed fee and a nursing services fee where nursing time is accounted for and billed. A .1 FTE per bed reimburses at a substantially lower rate than a .3 FTE but there would be caps per DRG to balance things out. The hospital makes more money the more nurses per patient it has.

This way the hospital is financially incentivized to have a low nurse to patient ratio and the burden of adequetely staffing a hospital is not 100% on the hospital. This would allow a degree of flexibility so that even critical access hospitals can be accounted for.

This sounds like a very sound plan for encouraging facilities to get on board with appropriate staffing levels. Admittedly, I don't know as much about the regulatory side of nursing as I should, I'm willing to be a floor nurse in an overworked system and haven't done much to educate myself on the alternatives. I hope that nurses like you are able to propose viable alternatives that could become the norm for all of us. Someday I'll put more effort into advocating for my fellow nurses, right now I just put my head down and go.

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Specializes in Med/Surg crit care, coronary care, PACU,.

Assault against any medical provider be a felony.

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On 5/28/2019 at 1:20 PM, Asystole RN said:

Staffing ratio laws are great but unintelligent blind staffing ratios that take nothing into account are not. ANA had a pretty good explanation as to why they did not support this law but supported and proposed others.

ANA may have a pretty good explanation(s) (lip service) about their non support of such measures, however their primary motivation has more to do with their being in bed with the AMA, AHA, and other large healthcare conglomerates. ANA; selling out their members for the almighty dollary-follow the money.

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Specializes in ICU, trauma, neuro.

Is there a national nursing organization pushing for an expansion of California ratio laws? If not it would be a good reason to form an ANA alternative. Perhaps a little competition might motivate the ANA to see the light.

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Specializes in OB.
1 hour ago, myoglobin said:

Is there a national nursing organization pushing for an expansion of California ratio laws? If not it would be a good reason to form an ANA alternative. Perhaps a little competition might motivate the ANA to see the light.

I believe National Nurses' United organization is.

https://www.nationalnursesunited.org/about

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