National Nurses United

Ratios:4 3/18/09 4:09 PM Page 13 "As long as we are the only state with ratios, ratios will always be under attack." —James Darby, RN very aware of ratios and asserting their "consumer" rights to be cared for by an RN who does not have an excessive patient load. "Nurses feel a little safer," said Sichley of the current situation. She now works as a psychiatric RN assessing patients in the ER at Antelope Valley Hospital in Lancaster, Calif., and says her colleagues make sure they stick to their 1:6 ratio. "We still have work to do. But it's much improved." CNA/NNOC sponsored the ratio law, called AB 394, and got it passed and signed in 1999 after more than a decade of lobbying and organizing registered nurses and patients. Numerous studies have shown that increasing staffing improves patient outcomes, and anecdotal evidence of California's ratios point to fewer sentinel events, increased patient education and teaching, and greater nurse satisfaction which leads to lower turnover. Despite the all-around success of ratios, the hospital industry is constantly looking for ways to undermine, roll back, and even rescind the standards. At the end of 2004, after ratios had not even been in effect for one year, the hospital industry persuaded newly elected Gov. Arnold Schwarzenegger to block scheduled ratio improvements and remove standards for emergency departments in an emergency regulation that many viewed as the first step toward a total repeal of ratios. CNA/NNOC called on registered nurses to defend ratios, and thousands responded. Nurses held more than 100 public protests against the governor, inspiring other California workers to do the same, and also won against the Schwarzenegger administration in court. Since that time, many CNA/NNOC RNs have also successfully bargained enforceable, minimum staffing ratios into their contracts. RNs need to stay alert, however, because during the current economic crisis, it's likely that the hospital industry will be on the lookout for additional strategies to erode the law. California RNs and CNA/NNOC understand that they will be continually defending ratios if California remains the only state with enforceable, numerical staffing standards. The large hospital chains that employ CNA/NNOC members often own facilities in multiple states and prefer to operate under the lowest common set of standards. That's why CNA/NNOC is now sponsoring ratio legislation— often packaged with language ensuring RNs' of their right to act as patient advocates— starting in Arizona, Texas, Ohio, Illinois, Nevada, Pennsylvania, and eventually in Congress, to ensure that patients across the country receive safe patient care (see sidebar for details on state bills). CNA/NNOC is also supporting the Massachusetts Nurses Association's efforts, as part of the new United American Nurses-NNOC formation, to win ratios in that state. In response to CNA/NNOC ratio bills, the hospital industry, often through state chapters of the American Hospital Association and the Service Employees International Union, floats competing legislation that merely requires hospitals to develop staffing plans or other weaker alternatives. The plans are not enforceable and hospitals suffer no consequences if they don't stick with them, but the legislation provides political cover for legislators who are afraid to stand up for mandatory staffing ratios and for the hospital industry to look like they are addressing staffing problems without incurring any real responsibility. Though it will be an uphill fight to expand ratios across the country, CNA/NNOC registered nurses in California often say they have an ethical interest and professional duty in improving nursing condiMARCH 2009 tions and patient care in other states. "All my family is back in Pennsylvania and Ohio, and it scares me what's going on in other states. I wouldn't leave a family member alone in the hospital," said James Darby, an RN working in neuro ICU at University of California San Francisco Medical Center. "As long as we are the only state with ratios, ratios will always be under attack." Back in the 1990s and early 2000s, Darby was working as an RN in Pittsburgh, Penn. but closely tracking CNA/ NNOC's monumental struggle to win passage of legislation mandating staffing ratios for acute-care hospitals in California. CNA/NNOC had to try three times over nearly a decade, through a variety of methods and under different governors, before the law was passed and signed in 1999. "I was watching from afar," remembered Darby. "I never thought it could happen, but when it did happen, it was so exciting." It took several more years for the California Department of Health Services to hold the hearings and take the testimony needed to formulate the exact numerical ratios. CNA/NNOC was a constant presence at those meetings, making the case for lower staffing while, in the other corner, the California Hospital Association was lobbying heavily for the highest ratios it could get away with. The industry wrongly predicted doom and gloom, arguing that the nursing shortage made it impossible for them to meet ratios and that ratios would cause hospitals to shut down. Finally, mandatory minimum numbers were reached, with additional staffing required depending on the acuity levels of patients, and the ratios started Jan. 1, 2004, with improvements for certain units scheduled on Jan. 1, 2005. California's 2004 ratios dictated that RNs in step-down units could be assigned no more than four patients, but Darby back in Pittsburgh was reaching his breaking point as the night charge nurse in a neuro RATIO REVIEW California's ratio bill, AB 394, addressed a number of issues affecting patient safety in hospitals. The first phase of AB 394 was implemented in January 2000. These provisions prohibited hospitals from assigning unlicensed assistive personnel to perform registered nursing procedures. Hospitals that had replaced RNs with unlicensed staff immediately hired back thousands of registered nurses to comply with the law. The second phase of AB 394 implemented staffing ratios on Jan. 1, 2004, just over five years ago, and also states that "the department shall review these regulations five years after adoption and shall report to the Legislature regarding any proposed changes." The benefits of improved staffing are evident, but maintaining the improvements will require ongoing organization, advocacy, and militancy on the part of California nurses in order to protect patients and nursing practice. CNA/NNOC RNs will have to be especially vigilant for any backdoor attempts to erode staffing gains through avenues such as expansion of scope and weakening of regulations related to RN practice. W W W. C A L N U R S E S . O R G REGISTERED NURSE 13

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