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New RN Staffing Regulations

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Oakland, CA: The California Department of Public Health (CDPH) has sent letters to hospitals notifying them of their obligation to meet the new Registered Nurse (RN)-To-Patient Hospital Staffing standards. The regulations are designed to improve patient care.

The letters also reiterate that hospitals must increase staffing beyond the ratios if needed by patient acuity: "Hospitals must ensure that they are staffed to assure that the needs of the patients are met. Hospitals are reminded that the regulations only reflect the minimum standards for staffing."

As of January 1st, the new staffing requirements for California Registered Nurse (RN)-To-Patient Hospital Staffing ratios are:
• 1:3 in transitional units between intensive care and general medical-surgical floors.
• 1:4 where patients are on monitors.
• 1:4 in Specialty Care units such as cancer care.

Registered NurseThis is the final phase of the Safe Hospital Staffing Law (AB 394) signed in 1999 by then governor Gray Davis. The California State Health Department first established specific ratios, and then implemented the rules in phases, beginning in 2004.

AB 394, was sponsored by the California Nurses Association/National Nurses Organizing Committee (CNA/NNOC), and authored by California State Senator Sheila Kuehl.

The law has survived a series of efforts to overturn it by hospitals and current Governor Arnold Schwarzenegger. First, a lawsuit filed by the hospitals, in December 2003, failed. Then, an emergency regulation issued by Schwarzenegger in November 2004, was found to be illegal in a California court. Lastly, four Schwarzenegger ballot initiatives were defeated during a 2005 special election.

On October 25, 2007, the first penalties issued by the California Department of Public Health (CDPH) under new authority granted by Health and Safety Code section 1280.1 (Senate Bill 1312, Statutes of 2006, Chapter 895), included administrative penalties against Martin Luther King-Harbor Hospital (Los Angeles, Los Angeles County), for failing to ensure prompt nursing assessments and medical care for a patient who presented to the emergency room. The hospital failed to ensure the availability of competent and appropriate nurse staffing resources so that patients could receive prompt treatment.

The law allows CDPH to impose administrative penalties with a maximum fine of $25,000 per violation. In addition to the penalties, the facility is required to implement a corrective action plan to prevent future incidents.

Staffing to the new law requirements has not been easy for Hospitals, as California faces a shortage of RNs at this time. Yet, California is expected to reach the 25th percentile nationwide of the number of full-time equivalent RNs per 100,000 (756.5) by 2016. According to Forecasts of the Registered Nurse Workforce in California, conducted by Joanne Spetz, PhD, Center for California Health Workforce Studies, University of California, San Francisco, (September 20, 2007), nursing graduations will have increased 68.7 percent between 2003 and 2008, reaching a projected number of over 10,000 new RN graduates per year.

These are welcome news, as out of the 275,658 California licensed RN's, the three largest age groups are 50-54 (17.03%, 46,940), 45-49 (13.91%, 38,333), and 55-59 (13.28%, 36,614). (Source: California Board of Registered Nursing license records)

This expansion is due to significant increases in state funding for expanded educational capacity of nursing programs, increased funding for equipment, use of updated instructional technologies, and other educational resources that have had a favorable impact on addressing the RN shortage in California.

Zenei Cortez, RN, member of the CNA/NNOC Council of Presidents, granted me an interview, in which she answered the following questions:

What do you think AB394 has done for patient's quality of care?
AB 394 has done a lot of good for our patients. They are being cared for safely, by RNs who do not have to rush to see their next 6-7 patients. The patients' needs are met in a timelier manner. There is more quality time for interaction with the patient and their families.

What do you think AB 394 has done for the California RN's quality of work life?
The RNs in California are happy with the ratios. They do not have to go home thinking about things they might have missed while rushing through their shift. RNs are able to do what they need to do, like discharge teaching. They can spend more time with their patients. They can be true patient advocate.

Do you think there is a shortage of RN's in California?
I do not think that there is a shortage of nurses. The RNs left the profession in the late 90's because the working condition was so bad and dangerous for both the RN and the patients. RNs were caring for up to 12 patients with no one to relieve them for coffee or lunch break. They were forced to stay another shift if there was no one to relieve them at the end of their shift. Since the working conditions and nurse/patient ratio is much better, RNs are coming back.

Has AB 394 impacted retention levels?
There has been no formal studies done to look at trends, but if you look at the BRN (board of registered nursing) statistics, there has been an increase in number of licenses issued. Since the working condition is much better, I do believe RNs will stay in practice much longer.

Do you feel enough is being done to encourage more young people to enroll in a California nursing programs?
I think there have been some improvements, but there still is work to do. Young people are discouraged to enroll in the nsg. program due to long waiting lists. More slots need to open in our community colleges and universities. There should be scholarships offered for the program.

What additional actions would you recommend in order to improve both RN's quality of work life and patient care?
CDPH should have stiff penalties for those hospitals that do not comply with the ratios. Given that it is the law, there are still a few that will not comply periodically. If only every hospital will be in compliance, at all times, the RNs and patients will be assured that safe/quality care will and can be delivered all the time.

The hospital should learn and listen to the Staff RNs. They know what is best for their patients and families since they are there for them at the bedside, 24/7.
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