Nursing News

California Law Mandates Nurse-to-Patient Ratios


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By Robert Scally, NurseZone assistant editor

California has released final regulations for its nurse staffing law, which is set to take effect on January 1, 2004.

The law, first of its kind in the nation, sets minimum ratios for the number of nurses to patients in a number of major nursing specialties and for various work shifts in hospitals. The nurse staffing regulations are currently in a final public comment period ending July 17.

Originally signed into law in 1999, the nurse staffing regulations have been hailed by many nursing organizations as a major improvement in patient safety and reviled by the hospital industry for being too costly.

Under the new regulations, nurses will care for no more than eight patients at a time, four mother and baby couplets in postpartum units. In emergency departments only one critical care patient will be assigned to a registered nurse. In most areas of the hospital, including intensive care units, the regulation refers to licensed nurses and does not specify and RN.

Many of the provisions of the nurse staffing regulations will be phased in during the next five years to allow hospitals time to comply with the law, said Gina Henning, a manager specialist with the California Department of Health Services.

In medical-surgical units, for example, the new nurse staffing ratios will require one nurse for every six patients in 2004 and every five patients by 2005. Currently about half of California hospitals meets the proposed ratio for medical-surgical units, Henning said.

"A new era is dawning in which all California families should expect safer standards in California hospitals," Kay McVay, RN, president of the California Nurses Association, said in a statement. "Every patient should be able to demand and count on receiving the registered nursing care they need, when they need it."

The California Healthcare Association, which represents health care providers, contends that the nurse staffing regulations are too costly and unreasonable, especially when the nursing shortage and other state-mandated demands on hospitals, such as earthquake safety requirements, are taken into account.

"Whether we will be able to successfully meet these regulations remains to be determined," said Susan Olsen-Nakada, RN, MSN, chief nursing officer and chief operating officer of the 204-bed Sharp Coronado Hospital in Coronado, California.

California’s severe nurse shortage, which is expected to worsen in the coming years, may make it difficult for many hospitals to hire sufficient numbers of nurses to meet the new requirements, she said.

"The Department of Health Services is projecting that when we get about four years out that this will cost hospitals about a billion dollars a year," said Dorel Harms, RN, MHA, vice president of professional services for the California Healthcare Association. "The other side of the coin is that we don’t have the nurses to do this."

The California Employment Development Department estimates the state will have 97,500 job openings for registered nurses in the state between 2000 and 2010.

The California Department of Health Services estimated that the fiscal impact of the new nurse staffing regulations will cost the state’s hospitals $422 million in 2004, $652 million in 2005 and more than $956 million in 2008 when all of the staffing ratios will be phased in.

The expense of hiring more nurses is also expected to grow substantially in the next few years. Nurse salaries in California have been rising at an annual rate of about 7 percent during the past two years and are expected to continue increasing at about that rate for the next few years, Henning said.

Hospitals are also concerned about two recently introduced bills in the California legislature that would create stiff fines for hospitals that fail to meet the requirements of the nurse staffing law, said Jan Emerson, the California Healthcare Association’s vice president of external affairs.

The new nurse staffing ratios, combined with the threat of fines could create an issue over access to health care.

If California hospitals cannot hire enough nurses to meet the new staffing ratio requirements and are confronted with the threat of severe fines, hospitals would then have no choice but to close units or refuse care to some patients, Harms said.

Not all health care providers are opposed to California’s new nurse staffing regulations.

Kaiser Permanente, the state’s largest health maintenance organization, announced that its 11 hospitals in Southern California already meet the new regulations and that several of its facilities currently exceed the mandated nurse staffing ratios for medical surgical units.

During the past two years Kaiser Permanente has added more than 1,000 nurses in California and is implementing nurse retention programs along with initiatives to improve nurses’ work environments, foster career growth and provide for better balance between nurses professional and personal lives.

Kaiser’s initiatives are part of an "effort to be the best place to work for nurses," the company, which employs 10 percent of the nurses in California, announced in a statement released July 1.

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