Debate Intensifies Over Minimum Staffing Levels for Nurses

During a recent night shift at County-USC Medical Center, two nurses were assigned to 23 patients in one unit.

According to a union complaint form filed after the mid-March shift by the nurses, one patient was suicidal. One had fallen out of bed. Another needed a blood transfusion. And two had to be prepared for the operating room.

On the confidential complaint form, obtained by The Times, the nurses indicated they were stretched so thin that they feared for the patients’ safety.

So do nurses and nurse’s unions throughout the state. As the nursing shortage in California has become ever more severe, nurses’ advocates have lobbied for so-called safe staffing ratios in hospitals.

The Legislature passed a requirement for such ratios in 1999, but debate over precisely what the ratios should be continues to polarize California’s health care industry.

As the first state to implement such far-reaching laws governing nurse staffing, the state has no model to follow and no guidelines--not even any clinical data--to help it determine how many nurses is enough.

“It is why this whole discussion is so difficult. There is nothing to turn to--to hang your decisions on,” said Jan Emerson, spokeswoman for the California Healthcare Assn., which represents the hospital industry. “To just legislate a number . . . without any scientific evidence just seems inappropriate to us.”

Hospitals would rather stick to current policy, which allows each institution the flexibility to set staffing levels based on patient needs.

Yet nurses insist that minimum staffing ratios are the only way to ensure that they can do their jobs and that patients get the care they need. They say ratios are the first step to ending the state’s nursing shortage--by improving working conditions and encouraging nurses to return to the field.

In fact, the nursing ratio was a key issue for Los Angeles County hospitals last year when nurses briefly took to the picket lines to demand more help in emergency rooms and clinics. The county agreed to consult the union in determining future ratios.

“We acknowledge that we don’t have enough nurses,” said county health department spokesman John Wallace, who addressed the issue in general but was unable to comment on the March incident at County-USC.

“At the same time,” Wallace added, “we are not in a position where we can close our front door.”

Staffing at Issue in Ventura County Strike

In Ventura County, registered nurses at two hospitals went on strike last December, primarily over staffing ratios. The nurses at St. John’s Regional Medical Center in Oxnard and St. John’s Pleasant Valley in Camarillo struck for two weeks, saying their ranks had been stretched so thin that patient lives were in danger. They also said morale had slumped, making it harder to attract new nurses to the facilities.

Hospital management balked, saying staffing was its prerogative. But after another strike was threatened, the hospital agreed in February to set up a committee of nurses and management personnel to handle staffing issues.

The deal set up two levels of arbitration. If the two sides can’t agree on staffing needs, an arbitrator is called in. If one side remains unhappy with the result, a second arbitrator will step in and make a legally binding decision.

Leaders of the Service Employees International Union, which represents the nurses, hailed the decision as extremely rare in an era of managed care and cost cutting.

Both hospitals are owned by Catholic Healthcare West, which has 47 other hospitals in California, Arizona and Nevada.

When the agreement was reached, Marilyn Morrish, vice president for labor and employee relations at Catholic Healthcare West, said staffing committees will be looked at and possibly copied by the chain’s other hospitals.

In L.A., Bleeding Man Waited Hours

All over the state, many nurses describe the hospital as a moral battlefield where they are forced to decide which patients will receive their attention and which will wait.

Nurses complain of working back-to-back shifts, of patients walking out when nurses don’t respond to their needs and of the overwhelming feeling at the end of each day that they haven’t done the best job they can. One night at Olive View-UCLA Medical Center, a man waited five hours before harried nurses even realized he was in the emergency room, said one nurse, who asked that she not be identified for fear of endangering her job.

No one had logged him in, she said. He lay in bed, bleeding from the mouth and rectum, and had to receive an emergency blood transfusion.

Kathy Carder, who has worked at various hospitals in the region, recalls nights so frantic that “sometimes there would never be a moment in the entire shift when there was no call light on.”

“When you were with one patient, you could hear another call going off and you were . . . running from room to room to figure out whether you needed to save a life or change a bedpan,” she said.

In the 1990s, as managed care took hold, hospitals began seeing more patients with more serious illnesses while nursing staffs were cut back.

By 1996, California had 566 nurses per 100,000 patients, compared with the national average of 798. It was the worst nurse-to-patient ratio in the country. Hospitals said the market for nurses was tapped out.

A June 1999 report on California’s nursing work force said that while 85% of registered nurses were employed, almost one-third were older than 50 and nursing education programs were full.

The California Healthcare Assn. projects the state will have a shortage of 25,000 nurses by 2006.

Davis Signed Measure in 1999

The legislation mandating specific staff ratios was signed in October 1999 by Gov. Gray Davis, who said he was concerned that the quality of care might suffer due to staff cutbacks under managed care.

Nurse-to-patient ratios have been mandated for hospital critical care units for years but in all other units, hospital staff levels have been based on the severity of patient illnesses.

“The patient acuity systems that the hospitals have are all over the map,” said Jill Furillo, a registered nurse and director of government relations for the California Nurses Assn., a nurses advocacy group and union. “They develop their acuity systems solely based on the budget.”

She said ratios will dictate only the minimum number of nurses needed for basic care, and hospitals can add nurses using the systems based on patient severity that are now in place.

The ratio law, sponsored by CNA, is an attempt to require all hospitals to use uniform, higher standards, she said.

Agency to Create Benchmark Ratios

The California Department of Health Services, which is charged with setting the ratios, will publicize preliminary numbers this summer.

It has commissioned researchers at the University of California to create benchmark ratios based on current practices at a sample of hospitals statewide.

Partly because of the difficulty of the task, state officials have pushed back the date of implementing the ratios from January 2001 to January 2002.

Earlier this year, nurses unions, which say that hospitals are using the shortage as an excuse for understaffing, began submitting their own staff ratio recommendations. The hospital association did as well.

To hardly anyone’s surprise, the proposals differed dramatically.

In general medical and surgery units, unions proposed ratios of one nurse to three or four patients. CHA proposed one nurse for every 10 patients, saying that the ratio would be adjusted based on how sick patients are. In behavioral health units, nurses’ advocates would mandate one nurse to four patients. The hospital association would require one nurse for every 12 patients.

Deciding on ratios is “like wetting your finger and putting it up in the air to see which way the wind is blowing,” said Dr. Dennis O’Leary, President of the Joint Commission for Accreditation of Healthcare Organizations, which accredits hospitals nationally.

Although they have submitted proposed ratios, the hospital association is still performing a study to determine whether staffing and skill levels affect patient outcomes. The association says it wants to ensure that staffing is based on factual information.

“There are a lot of factors [besides number of staff] that inhibit nurses from caring for a patient’s needs,” said Holly DeGroot, chief executive of Catalyst Systems LLC, a firm that maintains a national database of nurse staffing data.

DeGroot, who was an advisor to the hospital association, said current data on nurse staffing indicate that how staff are used may actually have a greater impact than the number of nurses.

Nurses’ organizations insisted that their ratios are based on scientific data. CNA said it generated its proposals using millions of patient records that hospitals furnish to the U.S. Health Care Financing Administration.

“If [hospitals] say our numbers are not correct, then we will have to question what they are reporting to the federal government,” Furillo said.