Looking for That Magic Number of Nurses

When you board an airplane, a law requires a minimum number of flight attendants be on hand based on the number of passengers. When you place your 2-year-old in a day-care facility, another law mandates a certain number of employees per child.

When you are treated in a hospital’s emergency room, however, there are no standards for the minimum number of nurses needed to look after patients.

But landmark legislation signed by Gov. Gray Davis last month will make California the first state in the nation to set minimum nursing levels at hospitals. Recognizing that financial pressures from managed care insurers have led hospitals to reduce their nursing staffs, Davis cited the “erosion in the quality of patient care” at the time of the bill’s signing.

The bill was backed by the California Nurses Assn., a nurses’ union, and a coalition of senior and consumer groups. It was opposed by the health care industry, which foresees a number of barriers to raising nurse staffing levels in California, a state with the nation’s second-lowest number of nurses per patient.

Nurses have become increasingly vocal about their discontent with hospital staffing. Hospital administrators, pressured by insurers and government health programs to discount their fees, stepped up efforts to hire lower-salaried, lesser-trained workers to perform some tasks--from monitoring patients’ vital signs to providing educational information to patients prior to discharge--traditionally done by nurses.

The new “safe hospital staffing law” tackles the staffing issue by preventing unlicensed personnel from performing duties that only nurses should do.

More significantly, the law requires the California Department of Health Services to set the minimum number of licensed nurses per patient that would be needed to guarantee safety in each hospital unit. These minimum ratios are already used in some parts of the hospital, such as the intensive care unit and the operating room, but the law will set standards throughout the hospital.

The law will be phased in beginning in January. In the first phase, hospitals will no longer be allowed to assign certain tasks to unlicensed assistants. For example, unlicensed staff may not be permitted to perform invasive procedures, such as drawing blood or closing wounds, to examine patients, give medications or be involved in patient education.

But patients may not really notice the effects of the law until 2002, when hospitals will have to comply with the still-to-be-determined standard ratio of nurses to patients. This second aspect of the new law continues to be the center of debate between the hospital industry and the nurses’ advocates. The CNA says the low nurse-to-patient ratio stems from two factors: many nurses quitting the profession because of disenchantment and many nurses being laid off. With the new law, the union says, nurses who left would have an opportunity to return to the profession.

But hospital officials contend that nurse job openings go unfilled. Considering the nursing shortage, they question how new nursing positions could be filled.

“Look at the help-wanted ads in papers, and you’ll see that hospitals are in a bidding war for nurses,” said Harry Osborne, a legislative advocate for the California HealthCare Assn., a Sacramento-based trade group.

The nursing shortfall is just one of the tasks facing state health officials as they try to determine how many nurses are necessary to ensure quality medical care.

All parties agree that setting up the ratios will not be an easy task.

First, there is the issue of cost. With hospitals under financial stress, who will pay for the additional nurses, and how much will it cost?

“It’s going to cost more, everyone knows that,” Osborne said.

Another issue is how to get at that “magic” number of nurses per patient. According to some experts, there are few studies that look at which nurse-to-patient ratios work best for ensuring good medical care.

Few “real life” examples are therefore available to lead the way, said John Eisenberg, administrator of the Agency for Health Care Policy and Research, a Rockville, Md., independent research institution.

To Eisenberg, the new law is society’s admission that we were not able to achieve the “magic number” voluntarily. If good research had been available proving that a certain nurse-to-patient ratio was necessary for safety, legislators would not be arguing about the issue today, he said.

In fact, a famous nurse had asked the much-debated question a long time ago, and it’s just now that the conundrum is beginning to be answered, Eisenberg said.

“Florence Nightingale was the first person to question in 1863 why we don’t have better data about quality of care,” he said. “It’s 136 years later, and we’re still asking the same question.”