Landmark Nursing Ratios Law
Faces Uncertain Future
By John Leighty
January 31, 2005
A year after its enactment, a cloud of uncertainty is hanging over the future of the nation’s first minimum nurse-to-patient ratios law.
In what is shaping up as a political firefight, the 58,000-member California Nurses Association that fought 10 years for ratios legislation has stepped into the legal arena to challenge Gov. Arnold Schwarzenegger’s action suspending further implementation of the law until 2008.
On the sidelines, the hospital industry applauds what it calls Schwarzenegger’s “common sense” stance in freezing ratio rules and supporting flexible staffing during a critical statewide nursing shortage. In an emergency edict a day after the Nov. 4 elections, Schwarzenegger ordered the action along with a two-year study by the state Department of Health Services of the mandate’s impact on nurses, hospitals, and patients.
Many hospitals say that the planned January lowering of nurse-to-patient ratios in medical-surgical units from 1:6 to 1:5 would have stretched their creative efforts to comply with tougher staffing standards. The state also gave emergency departments more staffing flexibility by letting ER nurses temporarily exceed a 1:4 ratio limit during surges in patient volume. In addition, the state now allows nurses to sign off to a colleague for short breaks and briefly exceed the ratio limit.
Making it work
“We’re doing everything we can to meet the ratios through recruiting and retention efforts, but it’s a struggle,” says Lorie Shoemaker, RN, MSN, chief nursing officer for Palomar Pomerado Health, which services San Diego County. Staffing has gotten creative with regular 12-hour shifts for all departments augmented by six-hour and four-hour shifts to cover lunches and other breaks, with ED staffing being the toughest task.
Desiree Turner, RN, an emergency room nurse at Palomar Medical Center, a 319-bed Palomar Pomerado Health facility in Escondido, says she’s found that the mandated 1:4 nurse-to-patient ratio for ERs is sometimes inconvenient and not always necessary. However, she says the ratio rule is “comforting” when facing 12-hour daily shifts at a unit that draws 50,000 patients annually. “In the ER, you can get into sticky situations very easily with an influx of patients and the ratios have provided some protection against getting overwhelmed.”
A nurse for 10 years who joined Palomar’s ED in 1990, Turner added that nurses were assigned 4-bed units prior to the ratios law and only occasionally had to handle an extra patient – often someone in the hall needing attention while awaiting an inpatient bed. “In the ER, we’ve always made it work. If a situation arises where a 1:1 ratio is needed with a patient, someone will always jump in to help – usually just for a short amount of time.”
Carol Bradley, RN, MSN, chief nursing officer for Tenet Healthcare’s chain of California hospitals, says she’s concerned that adhering to strict numerical ratios has dealt a serious setback to the nursing profession’s long-sought goals of being more involved in decision making in patient care and workplace situations.
“Staffing ratios themselves have been fine, the numbers are not the issue,” says Bradley. “It’s more about the impact of regulatory language on the work culture of a nursing unit – the application of ratios in an inflexible, rigid manner.” Of less importance is the burden of having to create a significant paper trail to document who is taking care of each patient every hour of every shift in every unit, says Bradley.
When ratios kicked in a year ago, Tenet California had dozens of slots to fill among the approximately 10,000 nurses in its 38 California hospitals, despite a yearlong recruiting drive, but compliance has improved steadily during 2004, says Bradley. “Wedone better (at meeting ratios) every month as we get better at managing the system, based on just pure numbers.”
While the ratios law has earned mixed marks from RNs, the 2004 implementation of the mandate is depicted as the year of living dangerously by the state’s hospital industry. At an approximate cost of $422 million, pressure to recruit and retain hard-to-find nurses is a contributing factor in the closure of several financially distressed hospitals and a leading cause for shutdowns of 11 ERs and psychiatric units, says California Healthcare Association spokeswoman Jan Emerson.
Nurses protest
Starting with a one-day solidarity strike with the Service Employees International Union by 7,000 nurses at hospitals deemed lax on ratio enforcement, the CNA has used a variety of tactics to reboot the stalled law. The CNA has also staged rallies at the state Capitol to oppose Schwarzenegger’s action. In addition, the nurses union spent $100,000 on metro radio ads urging the governor not to play politics with patient safety and filed a lawsuit in Sacramento Superior Court challenging the ratio rollbacks.
Among other things, the lawsuit accuses the governor and DHS of compromising patient protections and unlawfully abusing executive authority to overturn a legislative mandate. The suit, scheduled for a hearing Feb. 15, asks the court to set aside the emergency order, which the administration wants to make permanent following the required public hearings.
CNA President Deborah Burger maintains that safer staffing levels have alleviated the nursing shortage by attracting 30,000 RNs to the state, along with luring burned-out or retired nurses back into the profession because of improved workplace conditions. The hospital industry argues that many of those imported nurses are in traveler roles and not permanent staff. The industry also says mandated ratios jeopardize patient access to health care during a nursing shortage that is acute and getting worse, with state estimates of a shortfall of 43,000 nurses by 2010.
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.”