Nurses see shaky future for CA fixed staffing law
Acute care nurses in California, the birthplace of managed care, are cheering over an unprecedented new law that imposes mandatory nurse-to-patient ratios on acute-care hospitals throughout the state.
But critical care nurses in the state who have been working under mandatory staffing levels for several years are questioning whether the law will have any direct benefit to nurses or their patients.
Under the statute, which will be implemented in 2002, acute-care hospitals will be barred from staffing inpatient units at levels below the legal requirement. It requires hospitals to meet set levels of nursing care by limiting the number of patients assigned to each bedside nurse.
"This is a good law because it finally comes close to providing the kind of patient protection that we as nurses have needed for several years," says Jill Furillo, RN, director of government relations with the California Nurses Association (CNA) in Sacramento.
The statute doesn’t specify the nurse-to-patient ratio, but directs the California Department of Health Services to develop standards that will fix the number of nurses to patients in units.
The law originally was scheduled to take effect on Jan. 1, 2001, but backers of the legislation agreed to extend the date by one year to give the state ample time to work on a formula.
Affected will be all general, psychiatric, and specialty hospitals throughout the state.
Supporters of the act, including the 30,000-member CNA, the state’s largest nursing group, asserted that the statute was needed to protect them and ensure patient safety. Drastic hospital cost-cutting and downsizing have sharply reduced nursing departments and, according to nurses, have compromised patient safety and quality medical care.
Hospital industry officials say the cost cuts have been a response to lowered reimbursements and increasing pressure from managed care organizations to restrict inpatient admissions and lengths of stay.
Industry officials say that a severe nursing shortage in many fields is likely to hamper the ability of individual administrators to comply with the law unless provisions are made for training thousands of new nurses over the next five years.
"If these ratios become costly, then the question becomes where are we going to get the money to hire additional new nurses, if they are available at all?’" says Harry Osborne, a legislative advocate for the California Healthcare Association, a hospital industry trade group.
"There is nothing in the law the that requires managed care organizations to pay for any part of this," Osborne says.
For California’s critical care nurses who have been working under mandatory nurse-to-patient ratios for two decades, the statute may be a hollow victory.
"To talk about simply assigning bodies to patients without discussing nurse competence or patient acuity falls short of a real discussion," says Justine L. Medina, RN, MS, CCRN, a clinical practice specialist with the American Association of Critical Care Nurses in Aliso Viejo, CA.
But Furillo countered that state law requires hospitals to use a system of patient classification as the basis for determining optimum staffing levels. The new law for the first time sets ratios at the state level and makes them mandatory, she says.
For critical care nurses, the mandatory level has been 2-to-1, or one nurse for every two patients. ICUs can exceed the coverage to, say 1-to-1, but they can’t exceed the caseload for each nurse beyond the fixed two-patient number.
Hospitals have evaded regulation
But Medina says nurse staffing in most California ICUs has achieved mixed results under the fixed ratios, which were required by provisions of a federal funding regulation that affected California hospitals in the 1970s.
Administrators have in many cases circumvented the mandatory ratios without violating the law by using a loophole in the code. The loophole permits licensed practical nurses (LPNs) and other licensed but nonregistered nursing personnel to care for patients under the same ratio.
Although the RN is ultimately responsible for the patients, under the regulation, an LPN can administer the same level of care as the RN, but at a substantial cost savings to the hospital, Medina says.
So hospitals end up fulfilling the letter, if not the spirit, of the law’s intent, Medina says.
The current statute bars unlicensed caregivers from attending to patients under the fixed ratio, but it doesn’t restrict the use of licensed personnel.
Medina says the current statute is written in such a way that hospitals may try to evade the law.
Meanwhile, the CNA says nursing groups in other states are watching developments in California with an eye toward introducing similar staffing bills in their own legislatures.
"With the current groundswell of support for adequate patient care and coverage, it is likely that we’ll see more states following our lead," says Furillo.
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