Issue link: https://nnumagazine.uberflip.com/i/117852
and highly visible mobilization campaigns for the adoption of CNAsponsored enabling legislation known as Assembly Bill No. 394, authored by Assemblywoman Sheila Kuehl, Gov. Gray Davis signed the bill into law on Oct. 10, 1999. The California Nurses Association brought 2,500 RNs and supporters to the steps of the Capitol in Sacramento, presented more than 14,000 letters in support, and commissioned an opinion poll showing 80 percent public support for the bill. It became news all over the world with headlines such as, ���California to Set Level of Staf���ng for Nursing Care. Mandate ���rst in Nation��� (the New York Times) and ���California is the ���rst State to Require Hospital-Wide Nurse-to-Patient Ratios��� (the Wall Street Journal) In the preamble to AB 394, the California Legislature found and declared all of the following: 1) Healthcare services are becoming complex and it is increasingly dif���cult for patients to access integrated services. 2) Quality of patient care is jeopardized because of staf���ng changes implemented in response to managed care. 3) To ensure the adequate protection of patients in acute-care settings, it is essential that quali���ed registered nurses and other licensed nurses are accessible and available to meet the needs of patients. 4) The basic principles of staf���ng in the acute-care setting should be based on the patients��� care needs, the severity of condition, services needed, and the complexity surrounding those services. restructuring of the healthcare industry, namely, the creation and proliferation of a new category of healthcare worker known as unlicensed assistive personnel (UAPs). Hospitals are now prohibited from assigning UAPs to perform nursing in lieu of RNs or from allowing UAPs, under the direct supervision of a registered nurse, to perform functions that require a substantial amount of scienti���c knowledge and technical skills, including: ��� 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 condition ��� Educating patients and their families concerning the patient���s healthcare problems, including post-discharge care ��� Moderate complexity laboratory tests Is the LVN in the Count for the Purpose of the Ratios? The answer is a resounding NO. According to the California LVN practice act, the scope of practice or legal authority to perform speci���c nursing functions of the LVN is very restricted in that it is dependent on the clinical supervision of the RN or MD. The LVN���s scope is limited to performing basic nursing services requiring technical and manual skills and prohibits the performance of many aspects of the nursing process, such as, patient assessments, the formulation of a nursing diagnosis, the design of a care plan, the implementation of complex clinical interventions, the evaluation of the patient���s response to the treatment, and the performance of patient education/teaching. Due to their limited and restricted scope of practice, for the purpose of the ratios LVNs are not in the count. The LVN cannot have a primary patient care assignment. The patients assigned to the LVN are the patients of the supervising RN. For example, when a directcare RN is assigned to provide clinical supervision of a patient ���assigned��� to the LVN, the direct-care RN has the responsibility under the law to carry out the nursing process on all assigned patients, regardless of how the LVN is utilized within the assignment. Therefore if a direct-care RN on a medical/surgical unit is assigned ���ve patients, the maximum allowed under the ratios, and an LVN, under the clinical supervision of the direct-care RN, is also assigned ���ve patients during a shift, the direct-care RN is then legally responsible for all 10 patients. This is knows as the ���doubling factor.��� Such an assignment is in violation of the maximum allowed for a medical/surgical unit. Staf���ng is based on individual patient acuity, of which the mandated direct-care RN-to-patient ratio is the minimum Adoption of Nurse-to-Patient Staf���ng Ratios The legislation mandated that the Department of Health Services (DHS) must adopt regulations that establish minimum, speci���c, and numerical licensed nurse-to-patient ratios by licensed nurse classi���cation and hospital unit for all acute-care facilities. In adopting the nurse-to-patient ratio regulations, DHS was required to take into consideration the regulations dealing with RN scope of practice and existing staf���ng and patient classi���cation system regulations. Minimum Ratios Plus ���exing Up Based on Patient Acuity Once the minimum number of RNs has been allocated, additional staff shall be assigned in accordance with a documented patient classi���cation system (PCS) for determining nursing care requirements. New PCS-Required Patient Care Indicators a. Severity of Illness b. Need for specialized equipment and technology c. Complexity of clinical judgment needed to design, implement, and evaluate the patient care plan d. Ability for self care e. Licensure for personnel required for care Con���ict of Law In case of con���ict between the enabling legislation and any provision or regulation de���ning the scope of nursing practice, the existing scope of practice regulations shall control. Limits Utilization of UAPs: The new law also addresses major concerns about a disturbing trend which surfaced as a result of the 24 N AT I O N A L N U R S E A New Era: Safe, Therapeutic, and Effective Patient Care For decades, the California Nurses Association has described quality as the delivery of safe, therapeutic, and effective patient care and has been a long-standing proponent of protecting and promoting the RN scope of practice and patient advocate role. The new staf���ng standards based on scope of practice, minimum ratios, and patient acuity is the most comprehensive and effective approach to improve patient protection in acute-care facilities, to provide effective therapeutic interventions, and to secure RN scope of practice and patient advocacy role. W W W. N A T I O N A L N U R S E S U N I T E D . O R G NOVEMBER 2012