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A law with teeth

Sacramento (Calif.) Superior Court Judge Gail Ohanesian’s ruling May 27 upheld the interpretation of the law as issued by the California Department of Health Services. The judge stated that “the hospital must reassign the nurse’s patients to another nurse and the reassigned patients must not cause the relieving nurse’s patients to exceed the applicable ratios set forth in the regulation.” She added that removal of the “at all times” provision would make the statute “meaningless.”

Clayton agreed that the “at all times” provision was the most challenging part of the ratios law. “We can’t always find enough qualified people to relieve nurses during lunches or breaks.”

As a result, two full-time nurses do nothing but relief work for their entire shifts, Clayton said, adding that the court ruling takes away the option for nurses to relieve each other in some units. She says nurse managers now will be pulled into patient care more than in the past, when they usually helped only in emergency situations.

Markowitz said the nursing ratios have been met consistently in her unit. If a situation arises where there’s a jump in patient volume, unit nurses will pull together to adjust their breaks or work beyond their regular shifts to keep the ratios intact.

Although some nurses have applauded the ratios, others suggest that the law prevents nurses from having the freedoms they need to do their jobs. Nancy Blake, RN, MN, CCRN, CNAA, director of critical care services at Childrens Hospital Los Angeles, said the pediatric facility has traditionally staffed to meet the needs of its patients and that numeric ratios take away the flexibility nurses need to prioritize care based on acuity and other factors.

“I understand the intent of the ratios. My concern is that rolling out the ‘at all times’ requirement is extremely problematic,” Blake said. “In a hospital setting, there’s an ebb and flow of work, and emergencies can occur, such as a patient having to go to radiology for tests or to the operating room. So, at the beginning of a shift, we could have the staff to meet the ratios, but if something unexpected occurs, we would be out of compliance.”

In the emergency department, critical care units, and the Level 1 trauma unit, where patient-to-nurse ratios are 4-to-1, 2-to-1, and 1-to-1, respectively, it’s difficult to anticipate patient flow and a sudden influx of a few injured or ill patients could result in noncompliance, Blake said.

Nicole Sheppard, RN, an ED charge nurse at Childrens Hospital, said while she supports the mandated ratios for general patient care, the view from the emergency department is different. A pediatric trauma patient, for example, could require four nurses initially — one for bedside care, one to document the trauma, one to start an IV, and another for medication.

At other times, a nurse assigned to four patients who don’t need much care often could take on another child, but the ratios law won’t allow this.

“The ratios are out of whack based on numbers,” said Sheppard, who joined the ED as a clinical nurse 11 years ago. “For critical trauma, we would never leave one nurse alone with the patient. It’s not safe.”

On the other hand, children could be turned away on a crowded day because there’s no flexibility once the maximum ratios are reached even if a nurse wants to help another patient, she said.

Filling the bill

Deborah Burger, RN, president of the California Nurses Association, which sponsored the ratios law, said a survey done by the association showed that in the first three months of implementation, 70% of hospitals were in compliance, including covering nurses during breaks and meals. She said float nurses or charge nurses often were used, and that the “at all times” provision was an integral part of the law.

DHS spokeswoman Lea Brooks said that as of June 22, 77 hospitals have voluntarily reported being out of compliance since the law went into effect. Of that total, nine staffing deficiencies were found, three showed no violation, and the remaining reports are being investigated.

Another 66 mostly smaller, rural hospitals have applied for flexibility waivers because of difficulties in meeting ratios. Of these, 21 were approved, 26 were denied, and the others had partial approval or denial, Brooks said.