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Gina Henning's official job title with the California Department of Health Services sounds decidedly bureaucratic-health facility evaluator III. But these days, Henning is as far from an anonymous bureaucrat as one can get.

On Jan. 1, California will become the first state to implement mandatory nurse staffing ratios in its roughly 500 hospitals. Henning is charged with determining what the proper nursing ratios should be. DHS Director Diana Bontá is charged with implementing them, although department officials said Gov. Gray Davis has the choice to phase them in over several years.

At the moment, however, the DHS has yet to announce an official timeline for implementing the ratios. The University of California has been commissioned by the DHS to provide a partial portrait of the staffing ratios now in force, which is expected to help the agency decide what the proper ratios should be. Although the work on that project is complete, Henning said her department has yet to analyze the data.

Along with the DHS's own data, Henning said she has a collection of binders stacked 2 feet high sent to her by various nursing and provider interests intent on having their say on the issue. She also receives daily e-mails from nurses voicing their opinions.

"The sooner we do this, the better," said Henning, who worked as a nurse in the Sacramento area during the late '80s and early '90s before joining the DHS. Once the ratios are announced, the state will hold a 45-day public comment period, along with at least one public hearing on the matter.

The law that mandates California's ratios, AB 394, was signed by Davis in October 1999. Although some leeway is given to rural facilities, hospitals within the University of California system and the Los Angeles County Department of Health Services, minimum nurse staffing ratios must be implemented in just about all of the state's acute care, psychiatric and specialty care hospitals.

The ratios were to initially have been implemented at the start of this year, but were pushed back a year at the request of the DHS. (A 1-to-2 nurse ratio in critical care has been in place in California since the mid-'70s. Today, most hospitals staff above this standard.)

Legislation similar to the California law is pending in Massachusetts and is being pursued in Connecticut, New Jersey and Oregon-which recently passed a law that requires hospitals to formulate their own ratios. Legislation requiring hospitals to formulate their own ratios also is pending in New York, Maine, Illinois, Ohio and Pennsylvania.

There is little argument that the nursing profession is in crisis. According to a survey conducted earlier this year by the Health Resources and Services Administration, the number of registered nurses increased by only 5.4 percent between 1996 and 2000, vs. a 14.2 percent increase between 1992 and 1996.

Of the nurses who work, only 59.1 percent do so in a hospital setting. Moreover, the population of working nurses continues to age and disproportionately consists of Caucasians. Only 4.9 percent of nurses are Hispanic, compared to a national total population of 12.2 percent, which means that one of the country's fastest-growing ethnic groups isn't entering the profession.

As a result, more providers find themselves turning to traveling nurses or staffing agencies. Academics say the true crisis still is a decade away, when an estimated 80 million baby boomers will require more hospitalization.

"By then, the nursing profession will be dominated by RNs in their 50s, many in their 60s and a good deal in their 40s," said Peter Buerhaus, Ph.D., RN, a senior associate dean for research at Vanderbilt University in Nashville, Tenn. Although Buerhaus acknowledges that working conditions for nurses have been trying, much of his research through the years traces the decline in the number of nurses to mostly stagnant pay and other career options that began to open up for women in the 1970s.

Buerhaus himself opposes staffing ratios-he believes it's the first step toward a regulatory morass.

"There will be countless debates as to whether ratios are working, and it will lead to more and more regulations," he said. "Hospitals and nursing organizations are in constant turmoil and strife over this issue, while ignoring the meltdown that will occur in the future ... California will show the rest of the country just how bad this is."

Buerhaus isn't alone in his strong opinions. Although the DHS hasn't rendered an opinion on how many nurses should be serving California's hospital patients, just about everyone else has. That most of these parties disagree on the numbers has pitted labor unions, providers and even researchers against one another. It appears that this battle of the wills may be long-term, particularly as other states explore the issue.

There often is, not surprisingly, a huge gap between what unions propose for staffing vs. proposals made by hospital operators. The California Nurses Association, a statewide nursing union that supports among the lowest nurse-to-patient ratios, wants one nurse for every three acute care patients. The Service Employees International Union proposes a 1-to-4 ratio.

The California Healthcare Association, the statewide hospital lobby and an opponent of AB 394, supports a 1-to-10 ratio. Providers and unions agree only on the same 1-to-1 ratios for the labor-intensive environments of intensive care units and operating rooms.

"We took the approach of coming from absolute minimum ratios in order to provide the greatest flexibility," said Jan Emerson, vice president of external affairs for the California Healthcare Association. "It would allow staffing to change from shift to shift in order to accommodate patient needs."

Emerson noted, for example, that most acute care hospitals would require fewer nurses during the early morning hours, when most patients are asleep.

The CHA established its ratio through a working group of about 30 nursing executives, nursing supervisors and floor nurses. Data were supplied by Catalyst Systems in Novato, Calif., which has developed enormous national databases on nursing.

The CHA's point of view is supported by the American Hospital Association, the national hospital lobby.

"How can anyone sitting in a government office building sit and formulate what can happen and what kind of care can be provided?" asked Richard Wade, an AHA senior vice president. "Situations in hospitals change from moment to moment, and we don't feel that government regulation on how you staff units is the way to go."

Catalyst Systems CEO Holly DeGroot, Ph.D., RN, FAAN, believes there still isn't enough unambiguous data available to formulate a mathematically precise ratio system. "There is no truth on the right ratio ... research can only get you closer to the truth,"DeGroot said. "California really jumped the gun on AB 394. It was passed before sound science could catch up."

Along with chafing about mandated ratios, hospital operators say that if they're implemented on the lower end, it would cost too much money. The CHA pointed to a recent study by the Public Policy Institute of California, which concluded that instituting the CNA guidelines would increase the average hospital expenditure by $2.3 million a year.

Were the SEIU's guidelines adopted, it would cost $1.3 million per year for each hospital. The CHA's proposals would cost about $200,000 per hospital per year.

Already faced with unfunded mandates such as seismic upgrades and compliance with the Health Insurance Privacy and Accountability Act of 1996, hospital operators insist mandatory ratios are no way to alleviate staffing woes.

"If ratios are too restrictive, hospitals would have no choice but to either shut down or take beds out of service," Emerson said.

The CNA, by far the most vocal of the labor unions on the staffing issue, staunchly defends its proposals. "Out of all the proposals, ours is the only one based on a scientific study, and that sets us apart from the rest of the world," said Hedy Dumpel, JD, RN, the CNA's chief director of nursing practice and patient advocacy. Dumpel and other CNA officials said that Title 22 of the California Code of Regulations-which strictly governs the competency levels of nursing staffs and calls for hospitals to self-implement appropriate staffing ratios-is too vague and needs to be bolstered with mandated ratios.

The American Nurses Association doesn't support mandated ratios per se, but helped sponsor legislation in five states that would require hospitals to determine their own staffing levels.

"We believe that nurses are dissatisfied with working conditions and that patient care is suffering," said Susan Whittaker, the ANA's associate director of state government relations. "But we support more flexibility to take into account differences in various hospital units, as opposed to across-the-board mandates."

CNA officials said that the ANA's platform on ratios differs because its leadership is too close to hospital officials-a charge that Whittaker denies.

According to CNA literature, its ratios were formulated based on a study conducted by Bay Area-based Institute for Health and Socio-Economic Policy. The organization studied 21.7 million patient discharge records between 1993 and 1998 and assembled a panel of 25 nurses to decide where these patients should have been placed.

The panel concluded, among other things, that as many as 20 percent of patients are inappropriately placed in hospitals units that cannot sufficiently address the acuity of their illness.

However, questions remain as to how close the CNA is linked with the institute. According to corporate records, the institute's mailing address at the time it was incorporated was the San Francisco home of Robert Henderson. He also is listed as an officer on the CNA's articles of incorporation. Susanne Paradis, another of the institute's incorporating officers, was also an incorporating officer for CNA and several of its affiliates. Don DeMoro, the institute's executive director, is the husband of CNA Executive Director Roseanne DeMoro.

CNA officials confirm the linkage, but say the quality of the research by the institute is unaffected by its close relationship.

Researchers such as DeGroot also lambast the CNA research, claiming it improperly applied a number of strictly defined methodologies to reach its conclusions. "They used measures for their own purpose, and as a result came up with faulty conclusions," DeGroot said.

According to the DHS' Henning, little research actually exists that links nursing ratios to patient outcomes. She also acknowledges that ratios will do nothing to resolve the nursing shortage in California.

"There's very little we can do other than work with sister agencies such as the Department of Consumer Affairs and the Department of Education," Henning said. "The whole notion of getting nurses into the pipeline ... is not under the governance of the Department of Health Services."

The CNA claims that implementing staff ratios would solve much of the nursing shortage on its own. CNA officials said mandatory ratios would encourage nurses who left the profession to return to California's nursing workforce, increasing it by as much as 4 percent. That figure could increase to 11 percent if nurses who worked part time were encouraged to seek full-time employment.

The CNA noted that since the Australian state of Victoria implemented ratios last year, more than 2,600 RNs returned to the job, a workforce increase of 13 percent, according to figures provided by the Australian Nursing Federation, the country's primary nurses union.

"If you do away with the issues which create the greatest dissatisfaction and discontent, it's a greater likelihood that nurses would come back," Dumpel said, adding that many nurses who are likely to return are younger than 35.

However, the CNA's position has been criticized by researchers such as Buerhaus, who supports expansion of nursing education programs to increase supply.

The CHA also disagrees with the CNA's assertions, using statistics from the California Board of Registered Nursing that show that 89 percent of the state's nurses already are employed.

"There is no evidence that all these nurses who work part time would go back [to] full time under ratios," Emerson said. "They work part time because they are raising children, have an elderly parent to care for or have the financial means to do so." She added that there are numerous nursing jobs outside of the hospital setting that provide better working conditions, and that few nurses are expected to quit those jobs to return.

Additionally, the CHA said that recent legislative attempts to obtain state funding to graduate 4,000 more nursing students a year in California-an 80 percent increase over today's numbers-have died in committees. Because the CHA is a legislative lobby, it has not drawn up contingency plans for hospitals once the ratios are implemented.

"What hospitals do will come out of what the DHS says," Emerson said.

That lends little comfort to nurse executives such as Jennifer Jacoby, chief nursing officer and vice president of patient services for Sharp Healthcare in San Diego. The five-hospital Sharp system already spends extra money on traveling and staffing agency nurses, who comprise about 100 of Sharp's 3,000-member nursing staff, Jacoby said. Sharp's demand for nurses has grown, she said, because of recent hospital closures in the San Diego region and the growth of the general population.

According to Jacoby, Sharp will address staffing ratios by trying to retain more of its staff and attempting to convert some traveler and staffing hires into regular full-time employees. "The most cost-effective thing that you can do is to retain your staff," Jacoby said, adding that it costs anywhere from $6,000 to $18,000 to recruit each nurse, depending on their skill-sets and market demand.

Sharp also has partnered with local educational institutions such as San Diego State University, Southwest College and Grossmont College to beef up nurse education and refresher courses in the San Diego area, Jacoby said.

Other providers, such as Oakland, Calif.-based Kaiser Permanente, are singly attempting to resolve their staffing dilemmas.

In July, Kaiser announced it had reached an agreement with its SEIU-represented nursing staff for a minimum ratio of one nurse for every four acute care patients at its hospitals. But the agreement, which Kaiser officials said would be phased in during the next several years, drew fire from both the CNA and providers.

The CNA said the agreement is part of an attempt to use more LVNs over more highly skilled RNs, as well as a move by Kaiser to stall implementation of mandatory ratios. According to the CHA, Kaiser has a cushion with its ownership of the state's largest health maintenance organization, allowing any projected cost increases to be covered by higher premiums-an option few other hospital operators have.

But Kaiser spokesman Terry Lightfoot said that Kaiser's proposed ratios follow the guidelines of AB 394, and that Kaiser has no plan to increase the use of LVNs over RNs. "There is no effort by Kaiser to change the nurse mix at this point in time," he said. He also denied the CNA's charge of attempting to delay implementation of ratios. "There is no factual basis for that assertion," he said.

Emerson also noted that LVNs must be supervised by RNs, meaning that patient care is unlikely to be compromised if hospitals choose to meet ratios by using LVNs.