High above the busy streets of Los Angeles, billboards depict a smartly dressed woman behind the wheel of a plush car, her hand clutching the gearshift confidently. Its slogan reads, "Our nurses really enjoy their shifts."
The ads are designed to promote Queen of Angels-Hollywood (Calif.) Presbyterian Medical Center and its new program offering free two-year auto leases to newly hired nurses.
Four hundred miles north, Mercy Healthcare Sacramento is paying an extra $200 per month to six employees who have agreed to drive around town in cars shrink-wrapped with nurse hiring slogans, such as "Drive your career in the right direction."
Just as a national nursing shortage has grown worse, California hospitals are facing an impending state law mandating higher nurse to patient ratios, a law that may threaten their very survival. That law has many facilities and systems taking drastic measures to compete for the dwindling pool of available registered nurses. Salaries and signing bonuses have shot up and education loan-repayment programs and employer-subsidized day care are now typical benefits offered by many hospitals. Recruitment efforts have intensified and expanded in the international nursing market. Advertising budgets have ballooned.
"Hospitals are doing everything they can to recruit nurses, but there just aren't enough to go around," says Jan Emerson, spokeswoman for the California Healthcare Association, which represents 500 hospitals. "Everyone is scrambling."
In 1999, California became the first, and so far only, state to pass a law requiring hospitals to maintain specific nurse-staffing levels to improve patient safety. Under guidelines proposed by Gov. Gray Davis in October 2002, hospitals would be required to staff one nurse for every six patients in general medical-surgical units, with that ratio rising to 1-to-5 within the next 18 months (Oct. 7, 2002, p. 17). Ratios would be 1-to-4 in pediatric units and 1-to-2 in intensive-care units.
The state Department of Health Services has been reviewing testimony presented during several public hearings last fall and plans to release any revisions to the proposed regulations this month, followed by another public comment period. The law goes into effect in January 2004.
Meanwhile, the California Nurses Association is already pushing for tougher enforcement of the law. The 40,000-member union is sponsoring a bill that would levy steep penalties, including fines of up to $5,000 per day, on hospitals that fall short of the mandated ratios and would extend state health officials' ability to conduct unannounced inspections.
The mandate comes amid a growing body of evidence showing a strong link between nurse-staffing levels and patient outcomes. Mandating ratios, proponents add, also will go a long way toward reducing hospital turnover and attracting more students to the field by improving working conditions for nurses.
An October 2002 article published in the Journal of the American Medical Association, for instance, found that each additional patient assigned to a nurse who already has four patients represented a 7% increase in risk of death within 30 days of admission (Oct. 28, 2002, p. 14).
"Ratios save lives-it's been proved. Yet hospitals have failed to police themselves adequately," says Jill Furillo, an RN and the CNA's director of national affairs.
Hospitals, however, fear it will be nearly impossible to meet the mandated ratios in time because of the state's severe nursing shortage, and they worry that the cost of hiring more nurses could wreak financial havoc on budget-constrained facilities. The Department of Health Services estimates that California hospitals will have to hire 10,000 more nurses to meet the ratios at an extra cost of $500 million per year, with individual hospitals shouldering from $200,000 to $2.3 million annually at a time when most already are struggling to meet rigorous state seismic-safety standards and cope with cuts in government funding.
Hospital officials also argue more flexibility is needed. The law doesn't count charge nurses-trained nurses who supervise the work of other nurses-in determining a ratio. That means they could not help with nursing duties while another nurse was on a break, Emerson says. The regulations also say hospitals must comply with the ratios at all times, something that's especially hard to do in ERs, where patient volume and acuity is constantly changing.
"That's a big challenge," says Bill Littlejohn, chief executive officer of Sharp HealthCare Foundation, a unit of San Diego-based Sharp HealthCare, which recently expanded the intensive-care unit at its Sharp Chula Vista (Calif.) Medical Center to 28 beds from 15 as part of a $420 million, systemwide capital improvement project. "We've been expanding to meet the area's growing capacity crunch. But we can't operate the new units if we can't find enough nurses to staff them."
Job satisfaction stressed
To prepare for the law's enactment, hospitals have redoubled their recruitment and retention efforts, throwing generous-and often creative-benefit programs into place to attract new nurses.
Kaiser Permanente, Oakland, began stepping up its efforts more than two years ago, when it launched a program emphasizing nurse job satisfaction. Besides offering nurses salary increases, improved benefits and new career-advancement opportunities, the health system also has adopted a stricter 1-to-4 staffing ratio and a no-cancellation policy in certain areas, bucking the industry practice of canceling shifts or sending nurses home when patient admissions are low. In addition, employees who refer nurses to the company receive bonuses of $3,000 to $5,000 per new hire.
"It's not just about getting more nurses. We're really trying to develop an environment that's supportive of what they do," says Marilyn Chow, an RN and Kaiser's vice president for patient care. These efforts have helped Kaiser hire more than 1,000 new nurses since 2001 while reducing its turnover rate to 9.7% from 14%, she says.
Alta Bates Summit Medical Center, Berkeley, has been sending recruiters to local colleges and offering to pay the student loans of newly graduated nurses in lieu of signing bonuses. The Sutter Health-owned hospital also is luring out-of-state nurses by paying their relocation costs and finding them affordable housing, and has hired a recruitment firm to hire nurses from Australia, Canada and Europe. The 468-bed hospital offers referral bonuses of up to $2,000 and scholarships for employees who want to attend nursing school.
Although several states have adopted laws that address nurse staffing or working conditions, none have followed California's lead in dictating specific ratios, according to the National Conference of State Legislatures, Washington. For example, five states have laws requiring hospitals to develop their own "valid and reliable" staffing plans that reflect various factors, including patient acuity, the experience of the nursing staff, technology and available support services.
"Most of the country is watching us to see what shakes out (in California)," the CHA's Emerson says.