Staffing ratio
Staffing ratio mandate rekindles debate over nursing personnel

By Ron Shinkman
November 7, 2002

As California inches toward becoming the first state to mandate nurse staffing ratios, its release of regulations outlining how they will be implemented is reviving the sometimes contentious debate over nursing personnel.

Hospital operators continue to say the regulations will require too much money and personnel to implement, and apparently are stunned by the California Department of Health Services' recent increase in its projected annual costs by more than 20 percent.

Meanwhile, the California Nurses Association-the strongest supporter of staffing ratios-claims the ratios will save hospital operators money in the long run. The Association of California Nurse Leaders is taking the middle ground, supporting the regulations in general, but requesting some specific clarifications before they are implemented in 2004.

"The California Department of Health Services has really done a stellar job in taking input from everyone and rolling a product out," said Patricia McFarland, MS, RN, the ACNL's executive director. McFarland cautioned, however, that state regulators will need to assess the effect of ratios on patient outcomes, and that they are not taking into account an anticipated explosion in the state's nursing shortage by the end of the decade.

"We're all worried that the collision between the nursing shortage and the ratios will create widespread ripples," said Jennifer Jacoby, MSN, RN, vice president for patient care services and chief nursing officer for the five San Diego-area Sharp Memorial Hospitals.

Although Jacoby believes the ratios for the most part have been logically drafted, she is concerned that many hospitals caught between federal and state regulations may have to reduce the number of beds available to accommodate them, even though Sharp Memorial's hospitals have seen an almost 11 percent increase in patient admissions in the past five years.

All sides are expected to air their views on the regulations through written comments and three public hearings scheduled Nov. 15 in Los Angeles, Nov. 19 in San Francisco and Dec. 4 in Fresno.

As it stands, California will require an initial ratio of one nurse for every six patients in medical/surgical units, reduced to a 1-to-5 ratio after one year. Now, about 75 percent of hospitals statewide meet the 1-to-6 ratio. Ratios in other units will range from 1-to-5 in telemetry; 1-to-4 in postpartum; and 1-to-2 in intensive care, surgical recovery and other units requiring close patient monitoring.

Ratios won't be implemented until the beginning of 2004-three years behind the original timetable when the bill was signed into law in October 1999.

The California Department of Health Services' view on how nursing ratios will affect health care delivery statewide is sprinkled throughout the 60-plus pages of regulations released in September. The DHS estimates that costs will peak at $486.5 million per year in fiscal 2004-05, when the basic 1-to-5 ratio is implemented. It also believes that hospitals could choose to close selected units to meet the mandates, and cut non-nursing jobs to accommodate the increase in nurse hiring required to meet the ratios.

California's roughly 500 acute care hospitals appear ready to fight the ratios as they now stand.

"A 1-to-6 and then a 1-to-5 ratio simply won't be possible," said Jan Emerson, spokeswoman for the California Healthcare Association, the state's leading hospital lobby. The association has been a vocal critic of the present ratios, which are essentially a middle ground between the 1-to-3 basic ratio proposed by the CNA and the 1-to-10 ratio proposed by the CHA.

The CHA also is critical of the perceived lack of flexibility in other ratios. For example, Emerson said the mandated 1-to-4 ratio for emergency rooms may be unachievable due to the inability to predict patient flow into the emergency room. The 1-to-6 ratio in psychiatric units would undermine the multidisciplinary approach toward psychiatric care, she added.

McFarland expressed similar concerns regarding ER ratios. Present regulations call for a basic ratio of 1-to-4 in the ER, but 1-to-1 for trauma care patients and 1-to-2 for critical care patients. Moreover, triage and radio nurses would be excluded from the ratios because those positions require "an immediate, focused and often continuous response," according to the draft regulations.

"It's a critical issue," McFarland said, adding that the regulations ultimately could cause hospitals, particularly in rural areas, to pare their emergency services.

McFarland also believes DHS should clarify ratios for labor and delivery and telemetry units. Labor and delivery ratios vary from 1-to-2 to 1-to-6, depending on the status of the patient. The telemetry ratio is 1-to-5, but DHS also recommends that the technician overseeing telemetry monitors watch no more than 10 at any time.

All the nursing ratios will be in force round-the-clock. DHS ruled out averaging over shifts because "it would not provide the needed safeguard for patients," the regulations read.

Providers disagree, insisting that the needs of most patients are reduced at night, when they're asleep. "It doesn't allow for flexibility," Emerson said.

"Most of our nurses required on the night shift would be sitting around while patients are sleeping," said David Langness, spokesman for Tenet Healthcare Corp., which operates 44 hospitals in California. "One of the complaints we receive from patients is that they get woken up unnecessarily, and we find that rational staffing at night is much lower than what would be required during the daytime."

Jacoby also believes the psychiatric unit ratios do not take into account sleeping patients. She also is concerned about meeting the ratios while guaranteeing quality care.

As an example, she is concerned about being able to transfer a deteriorating patient into a critical care unit if there isn't an additional nurse to cover the patient. "In a lot of instances, it's a quantitative issue vs. qualitative," she said.

The CNA counters that when hospitals do not meet the staffing ratios, they have much higher turnover rates, driving up costs accordingly. "Anytime you have a nurse who leaves, you have to recruit another one, and that costs $25,000," said Jill Furillo, RN, the CNA's director of government relations.

She added that the state's provision of $45.1 million to train 3,000 new nurses during the next three years will help provide the 5,000 new nurses required to meet the mandates. McFarland argued that the funding is a "drop in the bucket" for California's future nursing woes.

"We'll need another 109,000 nurses by 2010. Funding for 5,000 isn't nearly enough." She added that Gov. Gray Davis' plan relies on federal funding and does not provide for long-term state funding to increase the number of nursing programs in California.

Furillo countered, using the University of California, Davis Medical Center in Sacramento as an example. According to Furillo, UC Davis regularly meets the mandated ratios and has an annual nurse turnover rate of 1.3 percent.

UC Davis spokesman David Ong confirmed that the hospital meets the ratios, and is even better in some areas, such as in the telemetry and stepdown units. Although it has no plans to hire additional nurses, the hospital's annual turnover rate is actually 7.7 percent.

But Ong does not attribute the relatively low turnover to just having more nurses on hand. "There's a lot of encouragement and opportunity for advancement," he said.

Ong added that Davis, like many other UC hospitals, has a lower nurse-to-patient ratio because it cares for a much sicker population than other acute care hospitals.

By contrast, Tenet has a turnover rate of about 20 percent, according to Langness. However, it was more than 25 percent just a few years ago. Yet statewide, Langness said Tenet will need only 120 nurses to reach compliance with the ratios-fewer than three nurses per hospital.

Is the turnover rate, as CNA claims, linked directly to the number of nurses on hand? Or must hospitals offer something else to ensure that, in the years ahead, the nearly frantic efforts they make to recruit nurses don't become desperate in order to meet ratios?

"Nurses want an atmosphere of professionalism, receptivity and training," Langness said. "We have to make people happy."

Contact Ron Shinkman at rshinkman@earthlink.net