When it comes to nurse staffing guidelines, healthcare interest groups in California are not on the same page. They're not even reading the same book.
Last week, the 35,000-member California Nurses Association took the book, poured gas on it and lit in on fire when it submitted its formal recommendations to the state on how to implement a first-of-its-kind law requiring minimum nurse staffing. The CNA proposed a ratio of one nurse to every three patients in medical-surgical units. That's a radically different number than the 1-10 ratio proposed by the California Healthcare Association, which represents the state's hospitals.
As California's Department of Health Services considers the divergent proposals, a growing shortage of nurses could play a big role in determining which ratios are the most realistic. The health department will review all the proposals and issue draft regulations this summer after two rounds of public comment. The final regulations go into effect Jan. 1, 2002.
The CNA argues that its ratio would encourage nurses who are registered but not working to return to a profession they abandoned because of poor working conditions and a responsibility to care for too many patients at once. The CHA, meanwhile, argues there is no evidence indicating that nonworking nurses will come back.
The CNA's proposed ratio "is not going to guarantee the shortage will be solved," said Jan Emerson, a CHA spokeswoman. "We believe their ratio has the potential to seriously exacerbate (the shortage)."
If graduation rates remain steady, California will experience a shortage of more than 25,000 nurses by 2006, according to the California Nursing Work Force Initiative, a coalition of state organizations including the University of California Irvine and the Association of California Nurse Leaders.
California passed its landmark legislation in 1999, when Gov. Gray Davis signed into law a requirement that hospitals adhere to minimum staffing standards. How the state implements the law, and whether it works, may determine if other states follow California's lead.
In the meantime, the healthcare groups in California will duke it out over which ratios make the most sense.
With nurses currently responsible for as many as 12 patients at a time, "there have been a lot of near misses. By the grace of God we've been able to save people's lives," said CNA board member Trande Phillips.
The CNA based its proposals on research conducted during eight months by the not-for-profit Institute for Health and Socioeconomic Policy in Orinda, Calif. For its study the institute used publicly available DRG data supplied by California's Office of Statewide Health Planning and Development. The association used that data to determine the severity of illness among California patients from 1993 to 1998 and to calibrate staffing levels accordingly.
The credibility of the institute's work, however, has quietly been called into question by the state's hospital industry because the institute's executive director, Don DeMoro, is married to the executive director of the CNA, Rose Ann DeMoro.
The CNA also serves as the institute's process agent, a legal relationship under which the association handles legal paperwork on behalf of the institute.
Don DeMoro denied any conflicts of interest, adding that the relationships did not in any way influence the validity of his organization's work.
"Anyone who runs the same analysis will get exactly the same answers," Don DeMoro said. "If you've got a big enough calculator, you can check the data."
Although it commissioned the study, the CNA did not pay the institute for its work, said James Eggleston, an attorney who represents the association. The research, he said, was supported by such groups as the United Steelworkers of America and "other sponsors."
Don DeMoro declined to disclose what the institute was paid but confirmed that the CNA did not contribute any cash to the effort.
In addition to ratios for medical/surgical units, the CNA also disagrees with California healthcare groups on the appropriate ratios for subacute-care units, which house patients who are too sick to leave the hospital but not sick enough to require a stay in a medical-surgical unit.
The CHA recommends a ratio of one nurse to every 16 patients in the subacute area while the CNA recommends a 1-4 ratio.
Justifying its much smaller ratio, the CNA's Phillips said, is that fact that "nobody is in the hospital now unless they're extremely sick." In the subacute units, she said, patients can hemorrhage or experience other problems that require a rapid response, and a lack of nurses can hinder such a response.
Last week the differences among the state's healthcare associations were highlighted when 250 protesters representing the CNA demonstrated outside CHA headquarters. The CHA's Emerson said the protesters shouted "shame on you CHA" before a contingent of 60 or so "stormed the office," some standing on furniture. CNA spokesman Charles Idleson called the protest "entirely peaceful."