State Implements Last Stages of Ratios Law
John Leighty
Monday January 28, 2008
The final phase of California’s minimum nurse-to-patient ratios law is placing more RNs at the bedside at a cost of millions of dollars, with many hospitals using high-priced traveling nurses to fill their staffing needs.“The fact is, there’s still a nursing shortage, and it’s still expensive to hire a nurse,” says Dorel Harms, RN, MS, FACHE, vice president of quality and professional service for the California Hospital Association.Traveling nurses fill the need
Harms says most hospitals began hiring nurses in mid-2007 to comply with the Jan. 1 requirements that lower nurse-to-patient numbers from 1:4 to 1:3 in step-down units and from 1:5 to 1:4 in telemetry and specialty units. At Providence-owned Little Company of Mary Hospital in Torrance, 14 full-time RNs had to be budgeted at $1.7 million to meet the new ratios, says Kathy Harren, RN, MHA, chief nursing officer and senior VP of patient care.The hospital is using traveling nurses — who are paid one-third more than salaried RNs — to fill the telemetry needs while permanent nurses are recruited for the jobs, Harren says.Unplanned surges
Across the state, hospitals geared up for the new ratios. In Fresno County, Saint Agnes Medical Center hired seven new nurses, Community Medical Center hired 30 RNs, and Kaiser Permanente hired about 18 RNs. Los Robles Hospital & Medical Center in Thousand Oaks held job fairs in September and November to fill more than a dozen new slots.Frank Maas, RN, BSN, manages the Little Company of Mary Hospital’s emergency department in Torrance, where unplanned patient surges can easily upset nursing ratios of 1:4 in admitting and 1:2 for critical-care units.However, Maas has managed to comply with the ratios by improving patient flow through triage redesign, enhancing the patient tracking system, and adding an overflow unit with eight extra beds. He has also involved nurses in decision-making, which has resulted in a reduction in staff vacancy rates, from 38% three years ago to less than 5%. This has made it easier to staff the main 29-bed ED during the busiest times of the day.Uncertainty on patient outcomes
Both Harms and Harren say there’s no empirical evidence to date that shows the ratios law improves patient outcomes. In fact, the American Nurses Association and a report in October 2007 by the Robert Wood Johnson Foundation say strict numerical ratios may have some unintended negative consequences. These include cuts in ancillary staff, a shift of RNs from under-served areas to metro hospitals, and the possibility of a forced closure of beds in hospitals unable to meet the ratios.“Anecdotally, I like to think the ratios would have a positive impact on patient care,” Harren says. “What we do know is that the greater the RN role presence in the patient care area, the better the mortality outcomes.”While several studies show that increasing the number of direct care nurses results in improved patient outcomes, there is a lack of evidence-based results that show whether mandated ratios make a significant impact compared to other factors, says Nancy Donaldson, RN, DNSc, FAAN, co-principal investigator for the California Nursing Outcomes Coalition Database Project (CalNOC).A new expanded CalNOC study affirms the group’s earlier research that showed ratios do change the configuration of how nurses are deployed by hospitals, Donaldson says. However, details of ratios’ direct impact on a number of patient care outcomes are still being analyzed and won’t likely be released until early next year.“The ratios law doesn’t address issues at the unit level that may ultimately show to be more important in patient outcomes,” Donaldson says.Creative strategies
The ratios law that went into effect in 2004 was challenged a year later when Gov. Arnold Schwarzenegger issued emergency orders to halt the lowering of nurse-to-patient ratios in med/surg from 1:6 to 1:5. The hospital industry pressured for the freeze, saying 4,000 nurses needed to be hired to meet the requirements. However, a superior court upheld the ratios standards in November 2005, which effectively ended challenges to the law.Lea Brooks, a spokeswoman with the California Department of Public Health, says state regulators don’t specifically track violations of the ratios law, but investigates complaints under a broad category of “unusual occurrences.” A 2007 law giving the agency the power to fine hospitals $25,000 for staffing violations that can result in serious injury or death to patients hasn’t yet been tested, she adds.Harms says the CHA has abandoned legislative relief efforts over ratios and is helping hospitals with creative staffing, recruiting, and retention strategies. On the bright side, more nurses are also entering the workforce because of a 69% increase in California nursing school graduates from 2004 to 2007, she says.Joanne Spetz, a researcher at UCSF’s Center for California Health Workforce Studies, says the state’s nursing shortage is estimated at about 10,000 RNs, with a predicted shortage of 89,000 nurses by 2030.The state’s nursing schools have more than doubled the number of graduates over the past three years, which has resulted in 10,000 new RNs entering the workforce, according to a Sept. 20, 2007 report authored by Spetz, “Forecasts of the Registered Nurse Workforce in California.”Continuing efforts to fund and increase nursing school capacity, combined with hospital-nursing school partnerships and efforts to retain nurses and bring in foreign-trained or out-of-state nurses, could alleviate and even eliminate California’s RN shortages within 12 years, Spetz says. She adds that a trend to replace licensed vocational nurses with RNs in patient care units makes sense because of the increased complexity of the hospital environment that has sicker patients and shorter stays.Government-mandated ratios
Meanwhile, “under our ratio law, lives are being saved, our ability to be effective advocates for our patients is stronger, and more RNs are entering the work force and staying at the bedside longer, mitigating the nursing shortage,” says Zenei Cortez, RN, a member of the California Nurses Association’s Council of Presidents.The ANA, which opposes rigid government-mandated ratios, has jumped in the fray with a dedicated website (www.safestaffingsaveslives.org) that provides information on nurse staffing research and state and federal legislative updates. The ANA says it supports the establishment of nurse-patient ratios but “feels strongly the ratios must be set in the workplace in direct coordination with nurses themselves, and based on unit-by-unit circumstances and needs.”Spetz says that while research of nurse ratios to patient outcomes studies may be valuable, she agrees with a PricewaterhouseCoopers Health Research Institute report that emphasizes that quality of care is what counts and that RNs are on the front lines of this endeavor.“Nurses deliver quality — it’s a no-brainer,” Spetz says. “Hospitals need to have an adequate nursing staff, regardless of ratios.”
John Leighty is a freelance writer. To comment, e-mail editorCA@nurseweek.com.
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