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Nurse Staffing Ratios: California Nears Deadline for Mandate

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By Jennifer Larson, NurseZone feature writer 

In January 2002, California will become the first and only state to have mandated nurse-to-patient staffing ratios in its hospitals.

In theory, anyway.

It’s been two years since California Gov. Gray Davis signed Assembly Bill 394 into law, thus mandating the creation of nurse ratios.

The agency in charge of issuing the proposed ratios-- the California Department of Health Services-- has yet to issue its decision on the ratios, although there is a required 45-day public comment period before the DHS’s proposals can take effect.

“We are working on the regulations,” said Gina Henning, RN, PHN, the DHS project coordinator for implementing the nurse-to-patient ratios. “We are moving forward with them, and it is our intent to have them in place Jan. 1.”

The California Nurses Association and the California Healthcare Association, which represents the hospital industry, have submitted recommendations for ratios. The Service Employees International Union and the United Nurses Associations of California also submitted proposals.

“There’s nothing in the literature to support what an ideal ratio is,” Henning said. “We have no evidence in the scientific literature that increasing the number of (nurses) will increase positive outcomes.”

The Department of Health Services has struggled with the process and contracted with a research team through the University of California’s Office of the President to conduct research and analyze data.

There is no precedent in the United States to which the department can turn for guidance, said Jan Emerson, vice president of external affairs for the California Healthcare Association. CHA also maintains there is no scientific evidence documenting a specific nurse-to-patient ratio as a catalyst for the best clinical outcomes.

Henning called the department’s strategy to have the nursing ratios in place by Jan. 1 “an enormous challenge.”

In fact, Office of Administrative Law could give the regulations an “emergency” designation, she added. Then DHS could implement the ratios on Jan. 1 and hold the 45-day public comment and hearing period after the implementation.

The department is “truly struggling with what to do because you can’t point to another piece of research,” Emerson said. “No other state has attempted this so there isn’t any history.”

The California Nurses Association begs to differ.

CNA points to the adoption of a nurse-to-patient ratio in Victoria, Australia in 2000 as a significant predictor of success of required ratios in another state with a serious nursing shortage.

The nursing ranks in Victoria’s public hospital system swelled by 2,600 RNs, a 13 percent increase after ratios were instituted, according to CNA and the May-June 2001 issue of the nursing magazine Revolution: the Journal for RNs and Patient Advocacy.

DHS has been in contact with the state, but their hospitals are government-owned, so it is difficult to make comparisons, Henning said.

The California Nurses Association also commissioned a study by the Institute for Health and Socio-Economic Policy, which analyzed data from the discharge records nearly 22 million California hospital patients collected by the Office of Statewide Health Planning and Development from 1993-1998.

IHSP developed a scientific formula for defining ratios by hospital unit and acuity level. Sara Nichols of CNA called the study “unimpeachable.”

“In fact, some of our board didn’t like the ratios we came up with,” she said, but the board of directors finally adopted the middle range recommendations for its proposed staffing ratios.

CNA’s recommendations to DHS included one nurse per three patients on medical and surgical units, a 1:3 ratio on emergency units and a 1:3 ratio on step-down or intermediate care units. Existing law already mandates a one nurse-to-two patient ratio in intensive care units.

In contrast, Emerson said such low ratios could put many hospitals out of business. The implementation of a 1:3 ratio for medical and surgical units would eliminate 95 percent of California hospitals from compliance.

Plus, it would cost each hospital an extra $2.3 million in annual workforce costs, she said.

Most hospitals support CHA’s position, but one major hospital system has taken a different stance.

Kaiser Permanente’s California Division prefers a 1:4 ratio for medical and surgical units, per the recommendation of two labor unions, the Service Employees International Union and the United Nurses Associations of California. .

In the past, Kaiser has opposed nurse-patient ratios. Kaiser is California’s largest HMO, but the decision to support increased nurse staffing levels puts it at odds with the rest of the state’s hospital industry.

The hospital industry prefers a 1:10 ratio on medical and surgical units.

Kaiser is increasing its nurse recruiting efforts and plans to implement the ratios “as soon as possible,” said Terry Lightfoot, Kaiser spokesman. “We decided…that the ratio that has been developed by our labor partners is an appropriate ratio.”

The ratios may become minimums if patient needs dictate the need for more nurses, Lightfoot added.

On some level, mandatory nurse staffing ratios represent a philosophical difference of opinion between many of the players.

“We don’t believe it’s in the best interest of the patients for a state bureaucracy to be telling hospitals how to staff,” Emerson said. “We believe the staffing should be based on the needs of a hospital. And those needs change.”

“We support mandatory ratios because we believe the way to restore the quality of healthy care in our hospitals…is to have sufficient nurses,” Nichols said.

According to Nichols, hospitals have hemorrhaged nurses in recent years due to unsatisfactory working conditions, a major cause of the current nursing shortage in hospitals the United States, including California.

“It’s not supply that’s a problem. It’s retention,” Nichols said. “Why do they leave? It’s because they’re having to care for too many patients.”

“ ‘I can’t take it anymore. I’m out of here.’ That is what they’ll tell you,” she added.

CNA and the California Healthcare Association disagree over the potential numbers of nurses available to work in hospitals, when the ratios are implemented.

Emerson cited statistics from a 1997 California Board of Registered Nursing report, saying that 89 percent of California nurses with active licenses are employed in a nursing job, leaving only 11 percent as a potential workforce.

“That is not enough to solve the nursing shortage,” she said.

Nursing ratios may be part of a long term strategy, Emerson said, but they will not be the entire solution.

According to CNA, about 17 percent of California nurses do not work in a nursing job, leaving a wider range of potential nurses for hospital jobs.

Nichols said 175,000 of California’s 200,000 RNs work in hospitals; many left hospitals as the advent of managed care provided job opportunities in clinics, home health agencies, or outpatient surgery centers, which provide better hours and working conditions.

“The entire motivating, driving need behind these ratios is to bring nurses back into the profession,” she said.

The California Board of Registered Nursing noted 60.2 percent of RNs worked in acute hospital settings as of 1997.

To read more, click on Nurse Staffing Ratios: Will Other States Follow California's Lead?.

 October 26, 2001 © 2001. All Rights Reserved.