Issue link: https://nnumagazine.uberflip.com/i/159216
CE_Nov REV 6/30/11 12:45 PM Page 17 these concerns, Congress in 1993 requested an Institute of Medicine (IOM) study of the adequacy of nurse staffing in hospitals and nursing homes. The IOM noted there was insufficient empirical evidence to determine adequacy. Since then, the evidence supporting an association between nurse staffing and better patient outcomes has grown. In October 1999, the California State Legislature passed AB394 (Kuehl), adding section 1276.4 to the Health and Safety Code (HSC). This landmark safe-staffing legislation required the California Department of Health Services (CDHS) to develop a staffing ratio threshold based on scope of practice which includes minimum, specific, numerical licensed nurse–to-patient ratios for specified units of all general acute-care hospitals in California. The Legislature examined the evidence and decided that the quality of patient care was related to the number of RNs at the bedside, and pushed to ensure a minimum, adequate number. In addition the regulations require that hospitals have a valid patient classification system (PCS) in place, requiring hospitals to flex-up their staffing, above the minimum required, to assure that the number of nursing staff was aligned to the healthcare needs of individual patients. The California Department of Health Services undertook a multiyear process to determine the minimum ratios to be mandated based upon research and other factors. Aiken et al. (2002) reported that each patient added to nurses' workloads was associated with a 7 percent increase in mortality following common surgeries. Replications in Canada, England, and Belgium produced similar findings as did other studies in the United States. The Department of Health Services further defined hospital units and appropriate patient population for the purposes of licensing and certification of healthcare facilities and for monitoring compliance with existing public health and safety regulations. Because the literature describes the most common factor underlying failure to rescue as "triage error" or admission to a unit other than one that provides the optimal level of care required by the patient, it's instructive to include a review of unit/patient population definitions upon which the California nurse-to-patient ratio law and staffing standards are predicated. The California nurse-to-patient ratio in a step-down unit shall be 1:3 or fewer at all times. A "step down unit" is defined as a unit which is organized, operated, and maintained to provide for the monitoring and care of patients with moderate or potentially severe physiologic instability requiring technical support but not necessarily artificial life support. Step-down patients are those patients who require less care than intensive care, but more than that which is available from medical/surgical care. "Artificial life support" is defined as a system that uses medical technology to aid, support, or replace a vital function of the body that has been seriously damaged. "Technical support" is defined as specialized equipment and/or personnel providing for invasive monitoring, telemetry, or mechanical ventilation, for the immediate amelioration or remediation of severe pathology. The California nurse-to-patient ratio in a telemetry unit shall be 1:4 or fewer at all times. "Telemetry unit" is defined as a unit organized, operated, and maintained to provide care for and continuous cardiac monitoring of patients in a stable condition, having or suspected of having a cardiac condition or a disease requiring the electronic monitoring, recording, retrieval, and display of cardiac electrical signals. JUNE 2011 The California nurse-to-patient ratio in medical/surgical care units shall be 1:5 or fewer at all times. A medical/surgical unit is a unit with beds classified as medical/surgical in which patients, who require less care than that which is available in intensive care units, step-down units, or specialty care units, receive 24-hour inpatient general medical services, post-surgical services, or both general medical and post-surgical services. These units may include mixed patient populations of diverse diagnoses and diverse age groups who require care appropriate to a medical/surgical unit. The California nurse-to-patient ratio in a specialty care unit shall be 1:4 or fewer at all times. A specialty care unit is defined as a unit which is organized, operated, and maintained to provide care for a specific medical condition or a specific patient population. Services provided in these units are more specialized to meet the needs of patients with the specific condition or disease process than that which is required on medical/surgical units, and is not otherwise covered by the described units. Identifying a unit by a name or term other than those described does not affect the requirement to staff at the ratios identified for the level or type of care described in the California regulations. The California mandates can be viewed as a benchmark against which to compare hospitals within California and between California and other states, according to Aiken, et al. In 2010 Aiken published the results of their study which examined how nurse and patient outcomes, including patient mortality and failure-to-rescue, are affected by the differences in nurse workloads. (The study is suggested reading and included in the references. It can be found online by typing "Aiken HSR" into the search field at www.nationalnursesunited.org.) The study published in Health Services Research (2010) titled: "Implications of the California Nurse Staffing Mandate for Other States," (Aiken, L.H., Sloane, D.M., Cimiotti, J.P., Clarke, S.P., Flynn, L., Seago, J.A., Spetz, J., & Smith, H.L.), reveals that improving nurse-to-patient ratios has demonstrated significant positive outcomes: New Jersey hospitals would have 14 percent fewer patient deaths and Pennsylvania 11 percent fewer deaths if they matched California's 1:5 ratios in surgical units. Fewer California RNs miss changes in patient conditions because of their workload than New Jersey or Pennsylvania RNs. In California hospitals with better compliance with the ratios, RNs cite fewer complaints from patients and families and the nurses have more confidence that patients can manage their own care after discharge. California RNs are far more likely to stay at the bedside, and less likely to report burnout than nurses in New Jersey or Pennsylvania. Duty and Standard of Care let's review relevant laws regulating RN practice. The primary duty performed by registered nurses in acute-care hospitals is ongoing patient assessment, sometimes referred to as ongoing patient surveillance or monitoring. In general, such assessment requires direct observation of signs and symptoms of illness, reaction to treatment, general behavior, or general physical condition, and a determination of whether the signs, symptoms, reactions, behavior, or general appearance exhibit abnormal characteristics (Nursing Practice Act). Furthermore, RNs must formulate/design and implement a care plan based on observed abnormalities and then evaluate the patient's response. W W W. N AT I O N A L N U R S E S U N I T E D . O R G N AT I O N A L N U R S E 17