California's Historic RN-To-Patient Hospital Staffing Ratios Upgraded Again With New Year

Main Category: Nursing / Midwifery
Article Date: 07 Jan 2008 - 4:00 PDT

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California's historic safe hospital staffing law, achieved through years of advocacy by the California Nurses Association/National Nurses Organizing Committee, completes its phase-in period as ratios on several units were lowered on January 1, 2008 to meet state mandates for minimum safe care.

Over the five year course of their phase-in, these ratios have revolutionized hospital care and improved patient safety by mandating that hospitals maintain minimum, specific nurse-to-patient staffing ratios for all hospital units at all times.

Because of their achievements, the ratios have sparked a brush fire around the country by nurses demanding similar laws in other states.

Ratios differ by hospital area, such as a minimum of no less than 1 RN for every 5 patients in general medical or post-surgical care units, 1:4 in pediatrics, and 1:4 in emergency rooms.

The ratios are a floor, not a ceiling, with hospitals also required to increase registered nurse staffing as needed based on individual patient illness or acuity.

As of January 1, new ratios are in effect for three specific units. They are: 1:3 in Step Down (transitional units between intensive care and general medical-surgical floors, reduced from 1:4), 1:4 in Telemetry (where patients are on monitors, improved from 1:5) and 1:4 in Other Specialty Care units such as cancer care (upgraded from 1:5).

"California's ratios are a spectacular success story," said Zenei Cortez, RN, member of the CNA/NNOC Council of Presidents. "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."

Since the law was signed, 80,000 more licensed RNs have come into the state's workforce.

CNA/NNOC has sponsored similar proposed bills in Arizona, Illinois, Maine, Ohio, and Texas, and is working with the Massachusetts Nurses Association on a proposed ratio law in their state. "RNs across the nation have seen the future, and the enormous benefits of this law. They know it works for patients, nurses, and communities," said Cortez.

AB 394, authored by current California State Sen. Sheila Kuehl and sponsored by CNA/NNOC, was signed in 1999 by then Gov. Gray Davis. It directed the state health department to determine the specific ratios, a process that took several years and involved multiple public hearings.

The hospitals, which lobbied extensively to block the law, filed a lawsuit in December 2003 to repeal key portions of the law. The suit failed.

The hospitals then persuaded Gov. Arnold Schwarzenegger to issue an emergency regulation in Nov. 2004 to overturn emergency room ratios and improved medical/surgical ratios. In response, CNA/NNOC launched over 100 protests against Schwarzenegger in addition to a lawsuit. Subsequently a California court overturned Schwarzenegger's regulation as illegal, and a protest movement launched by CNA/NNOC defeated four Schwarzenegger-ballot initiatives in a 2005 special election.

Schwarzenegger has subsequently dropped the fight against the law, and the California Department of Public Health has sent letters to hospitals notifying them of their obligation to meet the standards and improve the ratios on January 1.

The letters also reiterate that hospitals must increase staffing beyond the ratios if needed by patient acuity: "Hospitals must ensure that they are staffed to assure that the needs of the patients are met… Hospitals are reminded that the regulations only reflect the minimum standards for staffing."

"Hospital industry efforts to overturn the law have failed due to their enormous popularity with patients and the public, support from legislators, validation from the courts, and their demonstrated success in improving patient care," Cortez said.

RNs who have experience with the ratio law praise its effects, and nurses in other states cite the importance of winning it elsewhere.

"Finally we have the time to do proper nursing care and fully evaluate each patient's needs." Kathy Dennis, RN, Mercy General Hospital, Sacramento, Ca. "We now have the time to check each patient's chart and make sure there are no treatment delays. And finally there is the time to do the patient and family teaching that is essential to avoiding future complications and hospitalizations."

"Before the ratios were enacted, we had complete turnover of our entire RN staff twice in three years," said Trande Phillips, RN, Kaiser Permanente, Walnut Creek, Ca. "We were always working short staffed and patients suffered. Now the only time nurses leave is if they are moving or going back to school."

"To have it mandated is just the safest way because then (the hospitals) have no choice," said Lynn Rox, RN, Valley Baptist-Harlingen, Brownsville, Tx. "I know of nurses who have left because of the ratios, and if that changed, they would run back to the hospital."

"It is not uncommon for an RN to be responsible for twelve patients on a Med-Surg floor and 1:3 has become the norm for ICU with an occasional 1:4." said Mary Tatum, RN, VA Hospital, Cleveland, Oh. "Minimum staffing levels are essential for quality care."

California Nurses Association