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A year after its enactment, a cloud of uncertainty is hanging over the future of the nation’s first minimum nurse-to-patient ratios law.

In what is shaping up as a political firefight, the 58,000-member California Nurses Association that fought 10 years for ratios legislation has stepped into the legal arena to challenge Gov. Arnold Schwarzenegger’s action suspending further implementation of the law until 2008.

On the sidelines, the hospital industry applauds what it calls Schwarzenegger’s “common sense” stance in freezing ratio rules and supporting flexible staffing during a critical statewide nursing shortage. In an emergency edict a day after the Nov. 4 elections, Schwarzenegger ordered the action along with a two-year study by the state Department of Health Services of the mandate’s impact on nurses, hospitals, and patients.

Many hospitals say that the planned January lowering of nurse-to-patient ratios in medical-surgical units from 1:6 to 1:5 would have stretched their creative efforts to comply with tougher staffing standards. The state also gave emergency departments more staffing flexibility by letting ER nurses temporarily exceed a 1:4 ratio limit during surges in patient volume. In addition, the state now allows nurses to sign off to a colleague for short breaks and briefly exceed the ratio limit.

Making it work

“We’re doing everything we can to meet the ratios through recruiting and retention efforts, but it’s a struggle,” says Lorie Shoemaker, RN, MSN, chief nursing officer for Palomar Pomerado Health, which services San Diego County. Staffing has gotten creative with regular 12-hour shifts for all departments augmented by six-hour and four-hour shifts to cover lunches and other breaks, with ED staffing being the toughest task.

Desiree Turner, RN, an emergency room nurse at Palomar Medical Center, a 319-bed Palomar Pomerado Health facility in Escondido, says she’s found that the mandated 1:4 nurse-to-patient ratio for ERs is sometimes inconvenient and not always necessary. However, she says the ratio rule is “comforting” when facing 12-hour daily shifts at a unit that draws 50,000 patients annually. “In the ER, you can get into sticky situations very easily with an influx of patients and the ratios have provided some protection against getting overwhelmed.”

A nurse for 10 years who joined Palomar’s ED in 1990, Turner added that nurses were assigned 4-bed units prior to the ratios law and only occasionally had to handle an extra patient – often someone in the hall needing attention while awaiting an inpatient bed. “In the ER, we’ve always made it work. If a situation arises where a 1:1 ratio is needed with a patient, someone will always jump in to help – usually just for a short amount of time.”

Carol Bradley, RN, MSN, chief nursing officer for Tenet Healthcare’s chain of California hospitals, says she’s concerned that adhering to strict numerical ratios has dealt a serious setback to the nursing profession’s long-sought goals of being more involved in decision making in patient care and workplace situations.

“Staffing ratios themselves have been fine, the numbers are not the issue,” says Bradley. “It’s more about the impact of regulatory language on the work culture of a nursing unit – the application of ratios in an inflexible, rigid manner.” Of less importance is the burden of having to create a significant paper trail to document who is taking care of each patient every hour of every shift in every unit, says Bradley.

When ratios kicked in a year ago, Tenet California had dozens of slots to fill among the approximately 10,000 nurses in its 38 California hospitals, despite a yearlong recruiting drive, but compliance has improved steadily during 2004, says Bradley. “Wedone better (at meeting ratios) every month as we get better at managing the system, based on just pure numbers.”

While the ratios law has earned mixed marks from RNs, the 2004 implementation of the mandate is depicted as the year of living dangerously by the state’s hospital industry. At an approximate cost of $422 million, pressure to recruit and retain hard-to-find nurses is a contributing factor in the closure of several financially distressed hospitals and a leading cause for shutdowns of 11 ERs and psychiatric units, says California Healthcare Association spokeswoman Jan Emerson.

Nurses protest

Starting with a one-day solidarity strike with the Service Employees International Union by 7,000 nurses at hospitals deemed lax on ratio enforcement, the CNA has used a variety of tactics to reboot the stalled law. The CNA has also staged rallies at the state Capitol to oppose Schwarzenegger’s action. In addition, the nurses union spent $100,000 on metro radio ads urging the governor not to play politics with patient safety and filed a lawsuit in Sacramento Superior Court challenging the ratio rollbacks.

Among other things, the lawsuit accuses the governor and DHS of compromising patient protections and unlawfully abusing executive authority to overturn a legislative mandate. The suit, scheduled for a hearing Feb. 15, asks the court to set aside the emergency order, which the administration wants to make permanent following the required public hearings.

CNA President Deborah Burger maintains that safer staffing levels have alleviated the nursing shortage by attracting 30,000 RNs to the state, along with luring burned-out or retired nurses back into the profession because of improved workplace conditions. The hospital industry argues that many of those imported nurses are in traveler roles and not permanent staff. The industry also says mandated ratios jeopardize patient access to health care during a nursing shortage that is acute and getting worse, with state estimates of a shortfall of 43,000 nurses by 2010.