Uncharted Waters
Nursing communities nationwide watch closely as California hospitals struggle to implement staffing ratio law

By John Leighty
February 27, 2004

The enactment of California’s nurse-to-patient ratio law—the first of its kind in the nation—is undergoing some political birthing pains. Key questions are whether hospitals can find enough nurses or come up with creative solutions to meet staffing ratios “at all times,” including breaks and lunches, and whether they can afford the cost of hiring additional staff in times of financial uncertainty.

At least 28 other states are considering similar ratios with the backing of some nursing organizations, according to the National Conference of State Legislatures. Although none of the pending proposals has been put to a vote, ratios are most likely to be enacted in Massachusetts, New York, Florida, Michigan and Oregon.

Karen Higgens, RN, president of the Massachusetts Nursing Association, which has 22,000 members, said the group was backing a state legislative bill, HB 182, that would ensure quality care and safe RN staffing through improved RN-to-patient ratios similar to California.

The proposal calls for one nurse for every four patients in medical/surgical units, where most patient care takes place, whereas California requires a 1-to-6 nurse-to-patient ratio this year, and a 1-to-5 ratio in 2005.

In emergency departments, the Massachusetts bill asks for a 1-to-1 up to a 1-to-3 ratio depending on the severity of the patient’s conditions. Ratios would be 1-to-1 in labor and 1-to-2 for intensive care units.

Charles Stefanini, director of legal and government affairs for the Massachusetts association, said the bill is supported by a majority of the state’s legislators and more than 200 advocacy groups. “Things look promising and the law could be passed here before the legislative session ends in July,” he said.

Although many large hospital systems in California were prepared to meet the minimum nurse staffing ratios when the mandate took effect Jan. 1, other acute care facilities have scrambled to comply in the face of a statewide nursing shortage. Some otherssmaller hospitals with budget deficits—have sought waivers because of their difficulty in meeting ratios, which get tougher next year.

Kaiser Permanente, for example, met or exceeded the nursing ratios in 2003 in its 27 California hospitals, voluntarily adopting a 1-to-4 nurse-to-patient ratio in all medical and surgical units by investing nearly $200 million to recruit and hire 1,300 new nurses. Another model of compliance is the University of California, Davis Health System, where most nursing units are fully staffed and even have waiting lists of RNs seeking jobs.

Although some large facilities have fared well, the implementation of ratios has been “pretty rough” for most hospitals in California, said Barbara Patton, a senior vice president of The Camden Group, which specializes in hospital operations, management and nursing services.

“Most of the hospitals we’ve worked with have had to tighten their belts and look at ways to effectively provide care under the new guidelines,” Patton said. “This sometimes entails cutbacks in services. Because of the severe nursing shortage, even if they want to hire nurses, there are very few available.”

Strict interpretation

Strict interpretation of the law requiring ratios to be maintained “at all times” is almost impossible to meet, Patton said. Some hospitals are trying to comply by hiring extra nurses through agencies at premium prices. The cost of hiring eight to 10 nurses to fill in for breaks and absences could cost as much as $1 million a year, Patton said.

Patton also said many ER departments are strained and adding more diversion hours, when ambulances are turned away because of hospitals’ inability to maintain the required 1-to-4 nurse to patient ratio at all times.

Kathleen Dracup, DNSc, FNP, RN, dean of the University of California, San Francisco School of Nursing, said the ratio law was passed because many hospitals in California used too few nurses in some busy units, jeopardizing patient safety.

“We have anecdotal reports of 10 patients for one nurse on surgical/medical floors. Years ago that might have been safe because patients weren’t as sick and stayed for longer times. Now, the patient population is older, sicker, more vulnerable and needs to be assured that enough nurses are available.”

Dracup said UCSF met the nurse staffing requirements, but like many other hospitals, was blindsided somewhat by a strict ruling late last year from the California Department of Health Services that ratios had to be maintained at all times.

“This means that a nurse who has five patients on a med/surg floor, for example, must have a nurse substitute when they’re away from the bedside on a break, during lunch or in an educational meeting. In the past, nurses have substituted for each other, giving them a lot of flexibility.”

UCSF, she said, has hired a rotating staff to fill in for nurses when they leave the bedside for short periods. “Most hospitals were caught off guard by this rule and it’s going to take awhile for them to figure out how to do it,” Dracup said.

Another barrier to meeting ratios is the continuing nursing shortage, Dracup said. Although UCSF has a good retention rate among its 1,700 nurses because of the attractive work environment and opportunities, other hospitals aren’t so fortunate.

“Unfortunately, the shortage continues unabated and projections outstrip supply because of the aging population,” said Dracup, adding that even a 17 percent increase in nursing school enrollments nationally won’t stop an estimated shortage of nearly 500,000 to 1 million nurses by 2020.

The DHS has estimated that 5,000 additional nurses would be needed to meet the mandate at an annual cost of $900 million for all hospitals in the state. The department also estimates the state will have a shortfall of about 30,000 nurses by 2006.

In the first three weeks of the mandate, the DHS received 67 requests for flexibility and waivers from hospitals. Nine were denied, two were found to be in compliance and one waiver was approved. The other cases are pending.

“Hospitals can request waivers, but they have to be rural and meet certain conditions,” said DHS spokeswoman Lea Brooks.

Brooks said 54 complaints also were filed over noncompliance, mostly anonymously, and these were reviewed to determine if patient lives were at risk. The department ended up investigating just one case. “We found the hospital was clearly not meeting the ratios; however, we did not find patients at risk.” In such cases, Brooks said, hospitals must prepare a plan of correction.

Hospitals that are out of compliance also can self-report and, as of Jan. 21, 86 reports were received from hospitals that weren’t complying with the ratios in some patient care units. One report involved a dispute over the interpretation of the roles of RNs and LVNs and the DHS decided the hospital was in compliance, Brooks said.

“Anytime a new law takes effect, there’s a transition period when clarification is needed,” Brooks said. “For nearly 28 years, we’ve had nurse-to-patient ratios in intensive care units. What’s different is that ratios are now specified in the law for other hospital units.”

Jean Ann Seago, Ph.D., RN, a researcher on nursing issues and associate professor in the UCSF department of community health systems, said many hospitals are looking for creative ways to comply with the nurse staffing mandate. “One director of nursing created units of 12 patients attended by two RNs and an LVN to take care of covering for lunches and breaks. It’s a solution that makes sense, meets the ratio and assures continuity of care.”

The California Healthcare Association, a hospital trade group, has filed a lawsuit, which is pending, challenging the section of the law that requires nurses to be relieved by “competent” and qualified caretakers during breaks, lunch and short absences.

“My own feeling is that ratios are not going to solve all the patient care problems, but it’s certainly a step in the right direction,” Seago said.

Nursing organizations themselves are split on the ratio issue, and the American Nurses Association, while working for adequate staffing levels for patient safety, opposes ratios because of the inflexibility nurses have once legislation takes effect.

Michelle Campbell, MSN, RN, president of the Pennsylvania State Nurses Association, an ANA affiliate, said once mandates are set, they’re difficult to change and could result in loss of access to care in some regions.

“Unfortunately, the nurses aren’t available to meet these ratios,” Campbell said. “I think a lot of providers would hire more nurses if they could.”

The California Nurses Association, which sponsored the ratio law in California, split with the ANA several years ago over the issue and is a founding member of the American Association of Registered Nurses, which advocates for ratio laws. The AARN has 80,000 members in California, Massachusetts, Maine, Pennsylvania, St. Louis and southern Arizona.

Regardless of their differences, nursing organizations are united behind research from the University of Pennsylvania and elsewhere that shows that higher levels of nurse staffing result in improved patient outcomes, including mortality.

Linda Aiken, Ph.D., RN, a leading researcher on the nursing shortage at Penn, found that patients scheduled for routine surgery were 31 percent more likely to die in a hospital with a patient-to-nurse ratio of 8-to-1 than in a hospital with a ratio of 4-to-1. The study was published last year in The Journal of the American Medical Association.

Also, a Joint Commission on the Accreditation of Healthcare Organizations report said low numbers for nursing staffs were a factor in 19 percent of medical errors resulting in deaths or serious injuries in hospitals. Nurses’ inadequate orientation and training were cited as factors in 58 percent of serious errors.

“The rationale for ratios is an important thing for people to know,” UCSF’s Dracup said. “Clearly, research shows outcomes related to patient safety, morbidity and mortality are related to the number of nurses per patient and the education of the nurses.”

Contact John Leighty at johnsan@aol.com.