Hashing out California's staffing ratios

As the California Department of Health Services (CDHS) begins to hash out proposed minimum nurse-patient ratios, ANA\California (ANA\C) will be working hard over the next several months to ensure that their members' concerns are heard on this critical staffing issue.

Gov. Gray Davis signed legislation in 1999 requiring CDHS to establish minimum nurse-to-patient ratios by licensed nurses and by hospital unit. Then, earlier this year, he announced his proposed staffing ratios, which include:

* one nurse to six med-surg patients (to be reduced to 1:5 one year later)
* one nurse to four pediatric patients
* one nurse to four mother-baby couplets
* one nurse to two laboring mothers
* one nurse to one trauma unit patient

"While there has been some criticism about California's ratio bill, I think registered nurses would agree that, acuity aside, there are only so many patients RNs can give quality care to at any given time," said ANA\C Executive Administrator Tricia Hunter, RN. "We're optimistic about the governor's proposal and see it as a positive step toward having a minimum standard."

ANA also praised the governor's plan, calling it a "positive component in a multidimensional quest" to improve patient care and stem a looming shortage of nurses.

"We agree with Gov. Davis' assessment that government intervention is necessary when the marketplace is not protecting patients, and we commend the governor both for putting patient care concerns first and for addressing a nurse staffing crisis that is fast reaching crisis proportions, not just in California, but across the nation," said ANA President Mary E. Foley, MS, RN.

Hunter, however, pointed out that it is difficult for ANA\C to adequately assess the governor's plan until members see the regulations that CDHS proposes around the staffing ratios.

Once those regulations are released, CDHS will take comments from the public this spring, as well as conduct a series of hearings, which likely will begin in June, according to a press release issued through the governor's office.

One of ANA\C's concerns is how CDHS will define specific units in its regulations," Hunter said. For example, members are concerned about the definition of a step-down unit, where a ratio of 1:4 is proposed.

"If the step-down unit definition includes units that take patients just out of open heart surgery, then a ratio of 1 to 4 is a little high," Hunter said. Members also take issue with the number of patients assigned to nurses on oncology units.

"Those patients are the critical of the critical. If they weren't, they would be receiving outpatient treatment," Hunter said. Therefore, she said, ANA\C will be "very involved" in how units are ultimately defined, as well as other critical aspects of the regulations.

ANA\C also is continuing to lobby for several key measures aimed at improving nurses' work environment.

One effort involves increasing funding to CDHS, so it can develop a standard to test the validity of hospitals' acuity systems, and subsequently, ensure that the standard is implemented in California's 400-plus hospitals. Currently, California hospitals are required to staff by acuity, but with its limited staff and financial resources, CDHS has no way of ensuring that the hospitals' acuity systems are valid and appropriate, according to Hunter.

On the nurse recruitment side, ANA\C is lobbying for increased, long-term state funding to nursing programs. Currently, there is a backlog of students who want to get into community college and state programs, yet schools have no incentives to expand their nursing programs, which are more costly to operate than other academic majors, Hunter said.

As part of his plan to boost nurse recruitment, Davis also is proposing a workforce initiative that, among other factors, would funnel $24 million over three years for 2,400 training and preceptorship positions in hospitals, community colleges or the California State University system. Funding for the initiative would come primarily from the Workforce Investment Act, according to the governor's office.

Hunter said much of the funding for this broad initiative relies on federal monies, which are not guaranteed and often come with "strings attached."

The state government reports that there are 264,000 licensed nurses in California, or 544 working nurses per 100,000 population. The national average is 782 per 100,000, which places California next to last among the 50 states.