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Shoemaker and other nurse leaders statewide find the biggest staffing challenge to be the “at all times” mandate for adhering to ratios during lunches, breaks, or unanticipated absences. She says the Pomerado district’s two acute care hospitals were in compliance when the ratio law took effect one year ago, but some tweaking had to be done.

“I had to hire 43 more full-time equivalent RNs just to meet the ‘at all times’ standard and in the face of the worst nursing shortage in state history, this was a very hard thing to do,” says Shoemaker. “It’s been frustrating from an administrative point of view because it’s never been proven that there’s any value-added in the ‘at all times’ clause. Otherwise, we’d absolutely do it without question.”

Bradley says Tenet, which sold 19 of its 37 California hospitals over the past year to save $1.6 billion in seismic upgrading costs, geared up for the ratios mandate by analyzing staffing patterns in every acute care nursing unit to determine compliance. The surveys revealed the greatest need for additional nurses was to fill night shifts.

“We previously staffed higher on days than nights, so the largest impact was on the night shift,” says Bradley. “Of course, we added FTEs (full-time equivalents) to deal with the ‘at all times’ requirement, which falls above and beyond the ratios themselves. Like every other hospital system, we continue to struggle to fill these positions, but there are simply not enough nurses out there to meet the needs.”

Prior to mandated ratios, a strong emphasis was placed on creating an environment where nurses were in charge of their own patients, making decisions about quality care and planning the workday to meet the needs of themselves and patients, says Bradley. This included having lunch with coworkers, attending staff meetings, and building a positive infrastructure of support.

“All it is now is a numbers game. One nurse told me, ‘I’m insulted that I can’t make a decision when to go to lunch.’ In some units, we’ve hired nurses who do nothing but cover lunches and breaks, moving to a different patient every 30 minutes or hour, which is a very boring job.”

Looking for solutions

Marty Hay, RN, pediatric nurse at Children’s Hospital in San Diego, says while nursing ratios provide some relief from patient overload, the rule doesn’t take a lot of things into account, particularly the intense “hands-on” care that occurs in acute pediatric nursing. Hay would prefer the adoption of an acuity-based staffing tool developed by the Chicago-based Emergency Nurses Association and supported by the California chapter of the ENA.

“In the ER, you can get inundated, and the tool has been well thought out to analyze needs based on a number of factors, including time of year, time of day, and seasonal events, such as flu season.” Hay adds that the California chapter of the ENA would like to see the ratios law be amended to allow emergency departments to use the alternative acuity-based model.

The tool was developed for determining the optimal nurse “safe and effective” staffing levels of an ED based on six factors: patient census, patient acuity, length of stay, nursing interventions, skill mix, and non-patient care time. The tool works by putting data into an Excel worksheet, which calculates hourly, weekly, and monthly staffing needs based on the various factors.

“The motivation for the guidelines came from emergency nurses across the country who had been asking the ENA to help determine what is appropriate staffing for an ED,” says Carl Ray, RN, BSN, BC, an information technology specialist at DePaul Medical Center, Norfolk, Va., who helped develop the program. “It’s a big issue. There are many EDs and they’re all different, so one of the challenges we faced was trying to come up with something amiable to any ED.”

Diana Bonta, RN, PhD, former director of the California Department of Health Services who helped develop the ratios law, recalls launching an intense process to look at staffing issues that was aided by her background as a nurse in med/surg, pediatrics, and clinical instruction.

“I wanted to gather information directly from observation,” says Bonta, who held public hearings and visited 30 hospitals before drafting the three-year rollout of ratio levels. She and others envisioned the levels as easing nursing workloads, enhancing nurse recruitment, and increasing patient safety.

Bonta, recently appointed vice president of public affairs for Kaiser Permanente’s Southern California region, says she isn’t privy to hospital industry complaints or other criteria the state has used to freeze the ratios, but noted Kaiser has been in the forefront of compliance. The large provider network established minimum nurse-to-patient ratios ahead of the law and has a 1:5 ratio or better in med/surg departments statewide, she says.

Bonta says she supports ratios and knows the pressures of being a busy staff nurse. Running a $32-billion state health department with 6,000 employees might be tiring, says Bonta, “but it doesn’t even come close to one day on the floor as a nurse.”

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