Changes to California Nurse-Staffing Ratios?
By Christina Orlovsky, senior staff writer
In a move that has angered nursing unions, the California Department of Health Services (CDHS) has proposed a relaxation of the state's nurse-staffing law, which went into effect early this year.
The regulations, which are the first of their kind in the nation, require hospitals to enforce nurse-to-patient ratios in all medical and surgical units. Sponsored by the California Nurses Association (CNA), the 1999 law requires separate ratios for different units. Currently, for surgical departments, it's one nurse for every six patients; for emergency departments, it's one for every four.
Last week, California Governor Arnold Schwarzenegger's administration announced a proposal to ease the requirements during busy times in emergency departments.
The proposed changes include:
- Maintaining until January 2008 the current limit of no more than six patients assigned to any one nurse for medical/surgical and mixed units. This ratio was set to decrease to five in January 2005.
- Providing hospital emergency departments with temporary staffing flexibility to respond to an unforeseeable influx of patients with immediate needs.
- Clarifying the requirement that the regulations be met "at all times" to include whenever the nurse is on the unit and available for patient care. The language of the current regulation indicates that all patient assignments must be given to another nurse during restroom breaks or phone calls.
According to Brenda Klutz, CDHS deputy director, the decision was based partially on the effects of the staffing regulations on California hospitals, 68 of which have petitioned CDHS for more flexibility in the enforcement of the ratios. This year, 11 hospitals said that the ratios contributed to their decisions to close or reduce services.
"We have an obligation to preserve the core ratios that went into effect Jan. 1, but we also have a responsibility to understand the effects they have had on our hospitals," Klutz said.
To that end, the state intends to accelerate its research on hospital dynamics, looking closely at nurse retention and salaries.
According to Klutz, it was the response not only from hospitals but also from other segments of the health care industry that raised a red flag.
"Because of the fierce competition from the hospitals, many home health agencies and nursing homes are finding it nearly impossible to fill nursing positions," she said.
"Additionally, a lot of the assisted staff positions aren't being filled in order for facilities to budget for more nurses," she added. "It was never anyone's intention to resolve an issue in one segment and cause problems in another."
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What these proposed changes have done instead is cause outrage in the nursing community.
"We have been in a 10-year struggle to establish ways to provide care for patients in a safe and rational manner," said Deborah Burger, RN, CNA president. "We used CDHS data to establish the law, which has had a four-year delay period. California hospitals have had plenty of time to get ready for this."
During that four-year duration, Burger said the CNA worked with nursing schools to increase enrollment in preparation for the staffing increase. Additionally, within the past year, the union has helped facilities comply with the ratios and develop ranks among nurses, from charge nurse to triage nurse, so they are able to deal with a rush of patients during times of emergency. For these reasons, the new regulations seem unwarranted.
"The state is citing the need to have flexibility for an unforeseen influx of high-need patients to the emergency room. That's the very definition of an emergency room," she said.
"They are also citing hospital closures, but these hospitals were having problems years before the ratios went into effect," she added. "The only conclusion you can come to is that the hospital industry and the governor are putting business first."
Addressing the mission statements of hospitals throughout the state, which aim to provide the best patient care, Burger pointed out that in supporting a relaxation of nurse-staffing laws, hospitals do not have the patients' best interests at heart.
"Research has shown that there is a 7 percent increase in risk of death within 30 days of hospitalization with each person that is added to an RN's workload," she said. "When nurses are assigned in the appropriate risk-based on the ratios we established-the likelihood of death or hospital injury decreases. It just doesn't make sense to relax the ratios."
The CNA is in the midst of an appeal to the Office of Administrative Law, which has 10 days to put through a proposal. The changes, proposed on Nov. 4, can be approved or vetoed on Nov. 14.
"If we fail to win our appeal, the changes will go into effect for 120 days, allowing for public comment on the future of the law," Burger said. "That's the time for us to try to change the governor's mind."
Despite the CNA's efforts, the CDHS is standing firm on the reasoning behind their decision.
"The whole reason for ratios was patient safety and improving both quality of care for patients and quality of work environment for nurses," Klutz said. "Nothing that we've done changes that at all."
For more information about the proposed changes, visit the CDHS Web site or the CNA Web site.
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