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California Tightening Nurse-to-Patient Ratios in 2008

In 2004, California became the first state to establish mandatory nurse-to-patient ratios across various specialties. On January 1, 2008, California will make history again when it tightens these ratios further in three areas that could make a significant impact on patient care delivery.

The staffing changes will impact hospital step-down units (changing from 1:4 to 1:3), telemetry units (changing from 1:5 to 1:4) and specialty care units (also changing from 1:5 to 1:4). The ratio changes mean that step-down units will need to increase their RNs by 33 percent while telemetry and specialty-care units will require a 25 percent increase. The new 2008 requirements are spelled out in the California Code of Regulations.

Mandated nurse ratios has been the subject of debate for several years in California. When the original law went into effect, Governor Arnold Schwarzenegger issued an emergency order to lift the mandated requirements, arguing that the severity of the nursing shortage made it impossible to meet the staffing ratios. The California Nurses Association (CNA) sued Schwarzenegger and won; the courts ruled that the governor did not have the authority to suspend the law.

California remains the only state with mandated nurse-to-patient ratios, but Massachusetts, Texas, Maine and other states have movements underway to enact similar measures.

Jan Emerson, vice president of external affairs for the California Hospital Association, said that there doesn’t appear to be a large amount of concern among hospitals that they can meet the new requirements in the three unit types. “The ongoing concern is more about the ‘at all times requirements.’ As it stands, if a nurse goes to the bathroom, you are supposed to cover for them with another staff member, but that just isn’t feasible.”

Emerson feels that the ratio changes haven’t solved the nursing shortage or “created more nurses,” but that hospitals have relied more on travel nurses to fill staffing gaps. She notes that the impact of the existing ratios is still unknown. “There have not been any studies done to this point to determine whether the existing mandatory ratios have actually improved patient care.”

Malinda Markowitz, president of the California Nurses Association and a registered nurse at Good Samaritan Hospital in San Jose, California, feels that the original ratios have improved patient care while further impacting the nursing shortage.

“In California, even though we still need nurses, we have more RNs working than we did before. More nurses are coming to California and many have told us it is because of the ratios,” she said. “They feel that having fewer patients allows them the chance to provide the level of patient care they have been trained to give." She believes that many of the nurses who previously chose not to work in the hospitals have been coming back into the hospital workforce, adding more hours or moving from private practice.

The new ratios coming in 2008 will help some very important areas for patient care, explains Markowitz. “Where the ratios will be improved are critical areas, such as step-down units. Here you are dealing with patients who were just released from intensive care, but they still require a higher level of care and need to be closely monitored.”

“In the specialty care units, the ratios are now 1:5. Here you have units such as oncology, where the ratio will be changed to 1:4. Patients in these areas obviously need more care from their nurses,” explained Markowitz. “Telemetry units are also important. We have more elderly patients than in the past, in part thanks to modern technology that helps them live longer. But because of cardiac problems, pulmonary issues, etc., it is important for them to have nurses who can monitor them closely and provide additional support.”

According to Markowitz, the main advantage of the new ratios is that nurses can give acutely ill patients better care and better education.

“Nurses can get their patients up and mobilize them to help avoid complications, and to maintain their strength. Nurses can also give patients the emotional support they need. Ultimately, patient outcomes are also improved.”

Markowitz points out that when patients are more satisfied and outcomes are improved, hospitals also benefit.

“When patients feel that they get individualized care, they leave the hospital with a more positive view of their experience. It makes a huge difference,” she said. "If patients are satisfied that the nurses are there when they need them, they will want to come back to that facility and they will tell friends and family. The liability issues are also minimized and hospitals save money.”

“Having fewer patients per nurse also helps cut down on job stress and nurse turnover,” added Markowitz. “When you have satisfied nurses, they will stay and work.”

“The new nurse-to-patient ratios allow us to give the care we are trained to do and are expected to do. It also gives us more time to be a patient advocate. If you’re so busy that you are just going from one patient to the next making assessments and dispensing medicine, you are not able to do your job adequately.”

From personal observations at her own hospital and from her experience with the nurses association, Markowitz feels that hospitals have been able to maintain the ratios that were enacted in 2004 and will be able to do so again. She also feels that their ability to do so is vital.

“We’re dealing with patient’s lives and they have the right to have safe patient care. These ratios were made because they weren’t getting the care they needed.”

For more information on the new nurse-to-patient ratios, visit the California Code of Regulations, Title 22, Section 70217.

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