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| Struggling
safety nets |
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California’s
24 public hospitals are in a bind when
it comes to recruiting nurses to meet the
new ratio requirements. Public hospitals
are dependent on government reimbursement
at a time the state is in a budget crisis.
Although
public hospitals provide 55% of the cost
of medical care to the poor and
uninsured, the safety net system faces
a shortfall of nearly $3 billion in the
next five years, according to a report
by the California Association of Public
Hospitals and Health Systems.
The struggle
with funding can make it difficult to recruit
nurses, association spokeswoman
Rachael Kagan said. “Public hospitals
don’t have the resources other hospitals
have to compete for a small talent pool.”
On
the positive side, once nurses join public
hospitals, they tend to stay, Kagan
said. “We’re very fortunate
to attract a group of nurses who are very
committed to the vision of public hospitals
and the challenges of serving their patients.”
With
the exception of one or two public hospitals,
most are cutting their budgets,
reducing services or laying off staff,
making administration cuts, and renegotiating
contracts, Kagan said.
These hospitals are “basically
in a cost-cutting mode,” driven by
county budget shortfalls because most are
county-owned
and operated, she said.
“
There are some public hospitals and health
departments that are in a bind because
they have received less funding or no increases
due to the state budget crisis, yet they
are expected to hire more nurses to meet
the ratio requirements,” Kagan said. “With
the ratios law in effect, it makes it much
more difficult to compete when the nursing
shortage is already a big problem.”
One
of the exceptions is the 373-bed Arrowhead
Medical Center in San Bernardino, Calif.,
where creative staffing methods, incentives,
and a dedication to the public hospital’s “safety
net” mission has helped attract and
retain about 1,000 nurses, said Victoria
Selby, RN, BSN, MHA, associate administrator
of patient services. This has been enough
to satisfy ratios requirements in all units,
she said.
Selby, who earned her nursing
degree from Mount St. Mary’s College
in Brentwood, Calif., worked the majority
of her 20-year
career in Los Angeles County hospitals
where she often cared for 10 or 12 patients
during her shifts in med/surg. “When
I first started, there would be 20 patients
under the care of the nursing team — one
RN, one LVN, and if we were lucky, a nursing
assistant. I’ve seen a lot of changes
and believe the nurse staffing ratios are
good. It’s all about providing quality
patient care.”
When Selby took the
Arrowhead job three years ago, the first
thing she did was
hire a nurse recruiter who has proved effective
in filling needed slots and improving nurse-to-patient
ratios. Among incentives offered nurses
is a benefits package that includes 14
paid holidays and a $700 annual stipend
for educational purposes.
“
Essentially, we’ve been close to
meeting nurse ratios for some time and
in the med/surg unit we were already there,” Selby
said. “So, when the ratios came into
play, we were ready.”
John Leighty
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Brooks also said most of the deficiencies found
were technical violations in which nurses were
temporarily assigned more patients than the law
allowed. However, there were no cases in which
patient safety was found to be at risk, she said.
The state agency does acknowledge the high annual
costs to hospitals to meet the unfunded mandate — $422
million in 2004, $652 million in 2005, and $956
million by 2008.
The department also forecasts a shortage of
30,000 nurses in 2006 and 97,000 by 2010.
Although the hospital industry agrees with the
state on the nursing shortage crisis numbers,
the CNA’s Burger maintains that recalculated
figures paint a much brighter picture. She said
nursing schools have increased enrollments and
have waiting lists, which will help ease the
crunch during the next couple years. The number
of actively registered nurses went from 255,145
in January 2001, to 288,491 as of April 30 — a
gain of more than 33,000, she said.
Nevertheless, hospitals are scrambling to attract
and keep nurses. Good Samaritan still has 90
openings for nurses, although traveling nurses
fill some slots temporarily.
The hospital’s parent company, Nashville,
Tenn.-based Hospital Corporation of America,
has contributed $10 million to nursing scholarships
during the past two years, paying full tuition
for qualified students who agree to start their
career in an HCA hospital.
“The challenge is to find nurses,” Clayton
said. “I’ll hire them if we can find
them. Some people have a misconception that the
hospital is not hiring, but the fact is the nurses
are just not there.”
Mills-Peninsula Health Services in San Mateo,
Calif., hired 34 new nurses to meet the ratios
requirement and is looking for 15 to 18 more
nurses because of staff losses. The hospital
recently put an additional $2 million toward
plans to meet the ratios, said Christine Delucas,
RN, MSN, vice president of acute care services.
Delucas said Mills-Peninsula has 633 nurses
and is one of the top recruiters in the Sutter
Health system, developing partnerships with nursing
schools across the country and hiring foreign
nurses. Although the turnover rate is low, about
7%, it’s difficult to recruit in a state
that ranks 49th in the nation in the ratio of
nurses to the population — 585 nurses for
every 100,000 residents, Delucas explained.
Children’s Hospital and Research Center
in Oakland, Calif., is planning to hire additional
nurses to its RN staff of 650 because of the
recent court ruling regarding the “at all
times” staffing issue, said Nancy Shibata,
RN, MSN, vice president of nursing. “In
the meantime, we’re doing the best we can
to provide coverage within the ratios.”
Before the ruling, the hospital’s policy
allowed a nurse to fill in for a colleague if
the task to be performed was specific and time-limited,
Shibata said. “So if a nurse had a stable
patient whose meds and so forth were OK and she
wanted a 30-minute break, she could take it and
another duty nurse could assist the patient during
the break. This was an area we considered very
flexible and had hoped it could continue.”
Success story
In critical care, there’s
always been a required ratio of one nurse for
two patients,
but it hasn’t always been easy to maintain “at
all times” because of past nursing shortages,
said Carol Wocholz, RN, who has been a critical
care nurse at Arrowhead Regional Medical Center
in San Bernardino, Calif., for 10 years.
“The key is making sure we always have
a charge nurse, which wasn’t always the
case before the ratios took effect,” she
said.
Remy Bartolome, RN, who has worked in telemetry
and renal transplant at Arrowhead for five years,
said the 1-to-4 nurse-to-patient ratio for her
unit ensures that enough nurses are available
on each shift to give the best possible care.
For a group of 24 patients, there are six RNs,
five LVNs, and one charge nurse, who watches
the monitors and coordinates nursing activities.
“It’s much better with the ratios
law because I know I can meet my patients’ needs,” said
Bartolome, who received much of her training
in the Philippines and won a Nurse of the Year
award for mentoring at the teaching hospital. “When
a patient calls, I can respond right away.”
One area that needed extra staffing attention
was the hospital’s Level 2 trauma unit,
which requires a 1-to-1 nurse-to-patient ratio,
said Victoria Selby, RN, BSN, MHA, associate
administrator of patient services.
If there’s an influx of patients from
a major accident, or a full-blown disaster such
as the devastating wildfires in October, nurse
managers and assistant managers are called to
help with patient care.
“If I was called to come in, I’d
come in and help as well,” Selby said. “At
times, meeting this ratio can be challenging,
so we’ve increased staffing to have more
nurses on at all times.”
Selby said funding for 48 additional RNs was
approved in the 2005 budget, and that will give
the hospital a free charge nurse for each unit.
This nurse, along with nurses in a float pool,
will help maintain ratios during every shift.
Also being implemented are so-called SWAT teams
consisting of an RN and nursing assistant who
will float throughout the hospital to give additional
support where needed, such as in transferring
patients.
“We have flexible scheduling as well,” Selby
said. “There are four, six, eight, and
12-hour shifts, which serves a double advantage.
It accommodates the needs of nurses as well as
providing a way of covering for breaks and lunches.”
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