California nurses win minimum staffing law, limitations on scope of unlicensed personnel

California’s move to establish minimum nursing staffing ratios last month so rattled the hospital industry and so delighted the nursing profession that neither group called much attention to related, and significant, pieces of the law signed by Gov. Gray Davis.

In addition to setting up the regulatory process for defining minimum nursing ratios in hospitals, AB 394 also wrests from the purview of unlicensed assistive personnel seven specific tasks that nurses say belong only in the realm of licensed nurses.

'Substantial’ skills needed

"That’s a huge change," says Jill Furillo, RN, director of government relations for the California Nurses Association in Oakland. "I don’t see how they’re going to implement it without staffing up unless they make the nurses work like crazy."

Except for the provisions dealing with the ratios, the staffing law goes into effect Jan. 1, 2000.

The tasks taken away from unlicensed personnel, which the legislation says "require a substantial amount of scientific knowledge and technical skills," including the following:

• administration of medication;

• venipuncture or intravenous therapy;

• parenteral or tube feedings;

• invasive procedures including inserting nasogastric tubes, inserting catheters, or tracheal suctioning;

• assessment of patient conditioning;

• educating patients and their families concerning the patients’ health care problems, including postdischarge care;

• moderate complexity laboratory tests.

Legislators also made it tougher for hospital administrators to float nurses from one unit to another, forbidding the practice unless the nurse has "received orientation in that clinical area sufficient to provide competent care to patients in that area, and has demonstrated current competence in providing care in that area."

The provision for establishing the minimum staffing ratios is set now to go into effect Jan. 1, 2001, but is likely to be pushed back to 2002 during next year’s legislative session to allow time for the technical tasks involved in rule promulgation. The new law requires minimum patient-to-nurse ratios for each classification of nurse — registered nurse or licensed practical nurse — and for each hospital unit — critical care, burn, labor and delivery, postanesthesia service, emergency department, operating room, pediatrics, step-down, specialty care, telemetry, general medical care, subacute care, and transitional inpatient care.

The new law also requires when administrators assign personnel above the minimum, they do so using a patient classification system that considers the severity of the illness of the patient; the need for specialized equipment and technology; the complexity of the clinical judgment needed to design, implement, and evaluate the patient care plan and the ability for self-care; and the licensure of the personnel required.

Too much of a good thing?

"Hospitals absolutely do not do it now," says Ms. Furillo. "We went around the country and found out that they look at their census and that’s how they determine the number of nurses. Period."

California’s approach to hospital staffing is misguided, says a consultant who helps health care institutions analyze their personnel requirements. "I don’t understand how they would presume to judge that many levels above the place where the decision is being made whether the ratio is appropriate or not," says Frank Brady, managing partner of Brady & Associates in Kansas City, MO.

"My belief is that this is an extraordinarily bad idea. I think it’s very tough within a single institution to mandate an appropriate, and I underline appropriate, nurse-to-patient staffing ratio because in the end, those judgments I think are best left to professional judgment," he adds.

"If you mandate a fixed staffing ratio, as sure as God made little green apples, you’re going to wind up ratcheting this thing the other way. If it’s bad to have too few staff, it’s bad to have too many staff."

Ms. Furillo notes that California hospitals have worked under selected statutory nursing staffing ratios for more than two decades. Intensive care units are required to have two nurses for each patient, and there must be at least one circulating nurse for every operating room.

Both sides of the staffing question recognize that the nursing profession is feeling enormous changes, driven largely by managed care. Over the last decade and a half, employment growth among hospital RNs flattened much more dramatically in states with high managed care penetration than it did in low managed care states, according to an analysis in the January/February 1999 Health Affairs. At the same time, though, the authors noted that the ratio of registered nurses per hospital bed has grown from .651 in 1983 to 1.115 in 1996.

The ratio of nurses to 1,000 residents in California is about 2.3, or roughly 70.5% of the national average, according to a study completed for the California Nurses Association. The ratio is not adjusted for factors such as the age and sex of a population, which may affect residents’ need for nursing services.

Contact Ms. Furillo at (916) 446-5019, ext. 24 and Mr. Brady at (816) 587-2120. (See: Buerhaus PI, Staiger DO. Trouble in the nurse labor market? Recent trends and future outlook. Health Affairs 1999; 18:214-222.) The California Nurses Association report, "California Health Care: Sicker Patients, Fewer RNs, Fewer Staffed Beds," is available at press/92099.html.