Even as nurses and hospitals in California continue to debate the effects of the state's new landmark nurse-staffing law, momentum is building behind similar legislation in several other states.
California is the first and so far only state to enact a law requiring hospitals to meet minimum nurse-to-patient ratios designed to reduce nurses' workloads and improve patient safety. Under regulations that took effect Jan. 1, each nurse is now limited to six patients in general medical-surgical units, four patients in emergency departments, two in intensive-care and labor units and one in operating rooms.
Labor unions and consumer groups across the country are pushing for similar mandates on the state and federal levels. Groups in at least 12 states are seeking bills that would require hospitals to adopt stricter staffing standards, while several others are seeking related laws such as those that would eliminate mandatory overtime.
In a recent poll by the Governance Institute, 52% of hospital executives said they expect their state legislatures to consider mandating ratios within two years. Of that number, 25% predicted the measure would pass. Those respondents spanned Florida, Kentucky, Michigan, New Jersey, New York, Oregon, Pennsylvania and Texas.
Separately, a survey released last month by the National Consumers League found that 78% of respondents who had been hospitalized support national legislative action to set minimum nurse staffing standards.
"States are very concerned about workplace issues, and there's a lot of movement in several states to address these issues from a regulatory perspective," says Tim Henderson, a program director at the National Conference of State Legislatures.
Meanwhile, California's healthcare industry has been working to adjust to the state's new ratio law, though nurses and hospitals remain at odds over the extent of the progress that's been made. Hospitals say they are working hard to meet the ratios but have been thwarted by a severe nursing shortage and the high cost of recruiting staff. The state Department of Health Services estimates that the ratio law will cost hospitals $422 million this year and more than $956 million per year by 2008.
Compounding hospitals' staffing troubles is wording in the law that stipulates the ratios must be maintained every minute of every shift, says Jan Emerson, spokeswoman for the California Healthcare Association.
The CHA sued the state in December to have the provision amended, arguing that it would be impossible for hospitals to satisfy the ratios during lunch and coffee breaks or when nurses are transferring patients between units. But the suit was dismissed last month by Sacramento County Superior Court Judge Gail Ohanesian, who ruled the ratios would be meaningless if not applied "at all times." The CHA is considering an appeal. "There just aren't enough nurses in the state of California to make that aspect of the law work," Emerson says.
According to a CHA survey of 300 hospitals, 85% to 86% said they had failed to meet the ratios at some point between January and April. Thirty-four percent said they had to close beds or units and 41% said they had to divert ambulances elsewhere because they didn't have enough nurses to maintain the required ratios. Thirty-eight percent of hospitals blamed the ratio law for increased patient wait times in their ERs.
"There are real problems (in California) right now," Emerson says. "The whole notion behind the ratio law was to improve patient care, but it's doing just the opposite: It's jeopardizing patients' access to timely care."
The California Nurses Association, however, says the hospital industry is greatly exaggerating the situation. According to CNA President Deborah Burger, there is no shortage of trained nurses, only a shortage of nurses willing to work in substandard conditions-a situation the ratios are quickly ameliorating.
"Since January, there has been a definite change," Burger says. "Nurses now have time to spend on family support and patient education, things that were traditionally their duties but had to go by the wayside because they were too busy. They're claiming those things back again, and it's having a positive effect on patients."
The CNA's own survey of 111 hospitals showed that 60% of them had complied with the new law by late January and that conditions had improved at 68%.
The debate in California hasn't stopped nurses and legislators from pursuing similar mandates elsewhere. On the federal level, Rep. Jan Schakowsky (D-Ill.) introduced a bill last month that would require all hospitals to meet specific nurse-to-patient ratios-including a stricter 1-to-4 ratio in general wards-by 2007.
The House is also considering a bill, introduced in December by Rep. Lois Capps (D-Calif.), that would require all hospitals treating Medicare patients to develop staffing plans with direct comment from bedside nurses. Rather than setting specific ratios, the bill would require hospitals to maintain an "appropriate" number of nurses for each department and shift based on patient volume, the severity of patients' conditions and the use of support technology. Hospitals that violate the law would be fined up to $10,000 and have their names publicly disclosed.
Issues relating to overtime are also being addressed on the federal level-yet not to the satisfaction of many nurses. Companion bills designed to prohibit employers from requiring nurses to work beyond their scheduled shifts have languished in House and Senate committees since they were introduced by Sen. Edward Kennedy (D-Mass.) and Rep. Pete Stark (D-Calif.) in February 2003. Meanwhile, confusion abounds regarding how nurses will be affected by recent changes to the Fair Labor Standards Act, passed in April and set to take effect Aug. 23.
Proponents say thousands of nurses could benefit from the new regulations, which extend overtime pay to workers earning less than $23,660 per year, up from a prior ceiling of just $8,060. But opponents argue that other changes-namely one that allows certain hourly workers to be considered "salaried professionals"-could strip several higher-paid nurses of their current overtime eligibility. A registered nurse who earns $25 an hour and typically works 50 hours a week, for example, would lose $6,500 a year as a result of the regulations, according to the union-backed Coalition to Preserve Overtime Rights for Registered Nurses.
"This new exemption means that hospitals may try to claim that their RNs are salaried, and therefore exempt from overtime, even though they are being paid according to the number of hours or shifts that they work," says Cheryl Johnson, president of United American Nurses, one of nine unions in the coalition.
In May, the Senate passed an amendment that would block any portion of the regulations that strips workers of their current overtime eligibility. The House has yet to act on the measure.
Many states, however, aren't waiting around for national solutions.
Last month, Connecticut became the 10th state to ban mandatory overtime for nurses. Under the measure, signed into law May 19, hospitals are prohibited from penalizing nurses who refuse to work beyond their scheduled shifts. Some 15 other states, including Florida, Illinois, Iowa, Michigan, Ohio, Pennsylvania and Wisconsin, have similar bills pending, according to the CNA.
Meanwhile, labor unions continue to fight for fixed nurse-to-patient ratios in Massachusetts and at least six other states, even as such measures were recently quashed in Nevada and Washington state.
Six states-Florida, Kentucky, Nevada, Oregon, Texas and Virginia-already have laws on their books that require hospitals to develop and maintain individualized staffing plans.