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2013 had 392,458 RNs with active licenses, to study each patient's history and plan, "Before we had the compared to 246,068 when the ratios law their diagnoses, their labs, their medicapatient ratios, I felt was passed in 1999. That's a 60 percent tions, and how all of it related and what it like I was working in a increase. meant for that individual. "You were just factory on an assembly Millie Borland is one of those registered like, 'I got to get this done.' But nurses are nurses. Borland, a medical-surgical unit RN not supposed to be task oriented. Nurses line. Remember Lucille at Alta Bates Summit Medical Center in are process oriented. You have to stop and Ball and Ethel in the Oakland, Calif., used to work night shifts in think about all the information you get chocolate factory? Miami, Fla. on an oncology unit where she and what it means for that particular There you go." often had up to eight patients. Sometimes patient. They are not widgets." she also worked charge, but was still given a Now, having four to five patients means six-patient assignment! She would go home after a shift, but be that Dennis has more time to be proactive, and not simply reactive. unable to sleep. She would toss and turn, racking her brain, thinking Having more time to spend on each of her patients affects everything about her patients and wondering, "Did I forget something?" from how many more minutes she can spend getting report from and When Borland's eldest daughter, who was attending college in asking questions of the previous shift's RN, to examining every California, suggested in 2004 that she move out to the West Coast patient's medications, to having a few moments to actually talk with and her hospital offered her an early retirement deal, Borland the patients and their families to glean information that is often critijumped at the chance. She signed on as a traveler and was placed at cal to their care and to teach them how to take care of their conditions Summit. That year was the first one ratios went into effect. after discharge. "It really was a joy," remembered Borland. "I noticed the differ"You're not always saying, 'Can you hang on a minute? Can you ence right away, the time I could spend with a patient and get to hang on a minute?' to patients and their family members," said Denknow them. I knew I was going to be my best, and that I wasn't nis. "If you're just rushing in and out, in and out, patients may not going to be totally exhausted at the end of a shift." talk to you. But if you're passing meds and aren't in a big rush, you When the opportunity came to apply for a permanent position, can have a chat. And then you find out a lot of things about the Borland grabbed it. She also learned how it was the nurses' union, patients that are really important." California Nurses Association, that passed and lobbied for the ratios, With so many patients getting discharged earlier and sent home and how it defended them from Schwarzenegger and the hospital by themselves, Dennis said those conversations are indispensable to industry. "I thought, Wow, I missed that, but I'm not going to miss figuring out if patients can actually be safely released from the hosany more," said Borland, who is now a key RN activist at her facility. pital and preventing readmissions. One patient recently said her "This is what I want to do. This is where I want to be." daughter was picking her up from the hospital, so doctors and nurses thought the daughter would care for her at home. But Dennis learned that the daughter was only providing a ride, not actual care, oday, nurses agree that California's RN-to-patient staffing ratios and the patient would be at home alone. Nobody else caught this are absolutely necessary, but that there are still many improvedetail, not even the discharge planner. "That's kind of a big deal," ments that must be made. For one thing, nurses are constantly said Dennis. "If you don't have the few minutes to sit down and talk fighting to enforce the ratios and making sure that they are observed with the patient, or see what's happening, you could miss it." on all shifts and at all times, especially during meals and breaks so For Debra Amour, now an ICU RN at Seton Medical Center in that nurses are not doubling up on patient assignments. Daly City, Calif., but who was working in an ortho-spine unit when And one recurring theme is the ever-increasing acuity of patients. ratios went into effect, the difference between no ratios and ratios Patients are so sick now that many RNs believe the numerical ratios was like night and day. She remembered standing in her unit one must be lowered still. "The patients that all used to be in ICU are out shift in December 2003, before ratios went into effect, about to cry on the floor now," said Borland. "These are not 'walkie talkie' patients. because she had eight patients, two of which needed blood, and a They have tubes, and lines, and drips. There are a lot of things that slew of antibiotics that were all due to be given at the same time. On you have to be monitoring: fluids, output, drains. If you want to give top of that were dressings to be changed and multiple call bells going them the kind of nursing care that includes the caring, the time, the off. "It was wild. It was so dangerous. I used to be a surfer, and it was teaching, and the monitoring, it's almost impossible." the same feeling as being pushed down by a huge wave," said Amour. And with the Affordable Care Act's focus on shifting care away "You're drowning, and you don't think you're going to make it." from hospital settings to outpatient settings, nurses are worried that Her next shift was in the new year, when ratios were in effect, and hospitals are circumventing safe staffing ratios by sending patients she was amazed. She was assigned six patients and remembered to skilled nursing facilities, rehabilitation facilities, clinics, and even thinking, "Holy cow! I can give a bath!" She felt an immense sense of just home. "This is a largely unregulated industry, and there are vast relief and even went home and talked with her family about how her profits to be made," said Amour, who believes that nurses need to work had changed. "Ratios were like the life preserver," she said. start exploring applying staffing ratios to skilled nursing facilities as well as outpatient settings. "My personal dream is to have ratios all across America," said ince California is the only state so far to have ratios, it has Amour. "Because that little become something like a "Golden Land" for registered nurses. old lady in Florida deserves RNs from all over the country hear about how much better it is Come explore our new, to practice nursing in California and migrate to the state, whether as the same type of care as that redesigned ratios page at a traveler or as a permanent relocation. According to the California little old lady in San Franwww.SafePatientRatios.org Board of Registered Nursing's statistics, the state as of September cisco does." T S 14 N at i o N a l N u R s e 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 o C to b e R 2 01 3