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The Beginning of a Nationwide Nurses Movement establishing safe rn staffing ratios is part of a nationwide movement to protect patients. California was the first state to mandate staffing ratios, but a number of other states have made similar attempts. From 1996 to 2001, Massachusetts, New Jersey, New York, and Pennsylvania introduced legislation targeting some form of mandated staffing ratios. Since the healthcare industry���s selfimposed and market-led restructuring efforts began in earnest, spurred by the failed Clinton health plan, more than 20 states have proposed bills/regulations to protect patients. There is little doubt that the legislative push to ensure patient safety will continue. California has been one of the most negatively impacted states by the healthcare industry���s restructuring programs and the widely acknowledged problems of the nation���s managed care experiment. Other states are also feeling these effects and NNU nurses are collectively pursuing ratio legislation, based on the successful law passed in California. Among the basic principles for staffing California���s AB 394 sets out are patient care needs and the severity of the patient���s condition or illness. AB 394 directed the DHS to ���adopt regulations that establish minimum, specific, and numerical��� nurseto-patient ratios for patients in acute-care hospital units. In addition, the legislation mandates that the nurse-to-patient ratios shall ���constitute the minimum number��� of nurses allocated; and, ���additional staff shall be assigned in accordance with a documented patient classification system (PCS) for determining nursing care requirements.��� The PCS must include ���the severity of the illness, the need for specialized equipment and technology, the complexity of clinical judgment needed to design, implement, and evaluate the patient care plan and the ability for self-care, and the licensure of the personnel required for care.��� Patient Classification Systems: Time to Re-Tool the Acuity Tools most patient classi���cation systems (PCS) were developed in the 1960s for the purpose of forecasting staffing needs on patient care units. They were also used as administrative tools to project or monitor unit workload. It became very clear from the outset that ���maximum flexibility��� and ���efficient use of staff��� became the cornerstone of hospital cost-containment schemes. DHS required clinical alignment (PCS based on individual patient acuity/severity of illness), but that was soon manipulated into fiscal alignment, or staffing based on budget and patient census. There was no room for differentiating patient acuity and individual nursing care needs. Most problematic was the PCS override of the RN���s individual professional clinical judgment. The majority of commercially available patient classification systems utilize a ���closed��� proprietary method for converting patient acuity/care hours calculated by the direct-care RNs into staffing and skill mix. The PCS was intended to assure that the number of nursing staff was aligned with the healthcare needs of the patients, while allowing the hospital administration ���maximum flexibility��� for ���efficient��� use of staff. Since 1977, RNs engaged in direct, patient-care services have been critical of the various ���home grown��� and/or commercial systems and how they were used by their hospital employers. Commercial systems that measure patient acuity or workload use a variety of definitions for and measures of staffing and workload. Most focus on patient contributors, not work-environment contributors. Thus, research results using their data may be inconsistent and inconclusive. When initiatives are undertaken or imposed in an effort to improve patient safety or care quality also increase workload, the 28 N AT I O N A L N U R S E results can be other than intended. Winters (2006) and colleagues have argued, for example, that the widespread use of rapid response teams, for which the evidence is equivocal, might be exposing facilities to ���financial and reputational risks.��� They asserted that if other options already well-supported by the evidence, such as increased nurse staffing���were pursued first, the complications suffered by the patients that these teams treat might be prevented! Been There, Done That! Direct-care RN Criticisms of Existing PCS the pcs does not adequately measure the domain of nursing practice as defined in the California Nursing Practice Act and the Standards of Competent Performance. The latter mandates that the nursing process is the required standard/model for delivery of nursing care by a competent RN. There are numerous reliability and validity issues. There was, and still is, a significant disagreement among direct-care RN staff in classifying individual patients while utilizing an existing PCS tool, resulting in the inability to validate the staffing requirements. In addition, the PCS instrument/tool did not capture what it was intended to measure, which is individual patient acuity. In most instances, the individual patient acuity does not exist or is ignored, and staffing is driven by budget and census. The focus of the PCS tool was on the amount or volume of nursing care (nursing care hours) required and not on the complexity of nursing care needed by an individual patient. PCS tools are designed to control RNs��� decision-making and professional judgment. This rigid computerized system fails to permit the direct-care RN to override the system when, based on his or her professional judgment, an individual patient requires more care than that allowed by the PCS/acuity tool. It reduces the profession of nursing to lists of tasks, procedures, and patient characteristics. California���s safe staffing law, AB 394, put a halt to the DHSgranted supreme flexibility by converting the average needs of a group of patients on a specific unit to meeting the individual needs of each patient. It also codified some of the concepts identified in the Patient Intensity for Nursing Index (PINI), which is a valid measure of the volume or amount of care and the complexity of nursing care delivered to patients (Prescott). According to Prescott, ���Severity of illness refers to the patient���s medical condition and how ill the patient is in terms of the abnormality and instability of his physiological parameters.��� In addition, ���Clinicians recognize that all patients with the same diagnosis are not equivalent and that more severely ill patients require more care than less severely ill patients.��� In summary, one of the key Patient Classification System provisions is that it must meet the nursing care needs of individual patients that reflect the assessment made by the direct-care registered nurse assigned to the patient. Moreover, one of the most important factors the RN must consider is the type of licensure mandated to provide the required care. It is outside the LVN scope of practice to have an individual patient care assignment. LVNs must be assigned to an RN and are only allowed to provide basic nursing care functions and those interventions with routine and predictable outcomes that are within their scope of practice and level of competence for patients who are stable and not medically fragile. When a direct-care RN is assigned to provide clinical supervision of patients assigned to the LVN/LPN, the direct-care RN has the responsibility under the law to carry out the nursing process on all of 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 SEPTEMBER 2012