Prognosis Unclear on Nurse Law Compliance

Come New Year’s Day, patients in California hospitals should be getting a little more attention, thanks to a new law requiring that a minimum number of nurses be on hand to care for them.

But it’s far from clear how many of the state’s approximately 500 hospitals will be in compliance. On the eve of the mandate -- which will require hospitals to have at least one registered nurse for every six patients in the main medical ward and one RN for every four patients in the emergency room -- some of the largest hospital chains are making no promises.

Hospital companies, big and small, said they simply hadn’t been able to find and hire enough nurses to meet the demands of the law.

“Ratios or no ratios, we’re not in the business of manufacturing nurses,” said Jill Dryer, a spokeswoman for Catholic Healthcare West, a San Francisco-based nonprofit that operates 37 hospitals in California. She noted that the chain was striving to be in compliance at all of its hospitals but still needed to fill about 500 nursing positions.

Of particular concern to hospitals is the requirement that they maintain minimum staffing ratios “at all times.” Hospital executives contend that this is impossible to manage and leaves them vulnerable to state sanctions and legal action if they are out of compliance for even a few minutes.

On Tuesday, the California Healthcare Assn., which represents hospitals statewide, filed a lawsuit against the state Department of Health Services, claiming that “virtually all hospitals” would be unable to comply with this provision of the law. The complaint seeks to have this part of the law voided.

“What happens if a nurse needs to go to the bathroom?” said Jan Emerson, spokeswoman for the association. “You have to get another nurse to come stand there. Or what about the flu season? It’s impossible for emergency rooms to predict how many patients they will get or how many of their own staff will be out sick.”

Known as the Safe Staffing Law, the measure was signed by former Gov. Gray Davis four years ago, and the staffing ratios were set after lengthy debate. Previously, only the intensive-care unit at hospitals had to meet a nurse-staffing ratio: one RN for every two patients. Nurses have championed the new rules, saying they would improve working conditions for registered nurses -- many of whom had left the profession because of low pay and overwork -- and result in better patient care.

“Every major scientific study has documented that safe RN staffing reduces preventable hospital death rates, infections and accidents,” said Deborah Burger, president of the California Nurses Assn., a labor union for RNs.

Hospital lobbyists have continued to seek more time to comply with the requirements, but it appeared unlikely that Gov. Arnold Schwarzenegger would step in this week to provide relief, despite his pro-business stance.

“The hospitals are asking the administration, six weeks in, to make substantive changes to requirements that have been four years in the making,” said Kimberly Belshe, California’s new secretary for Health and Human Services. “We think it’s prudent and appropriate to make any changes after some experience with how this works. We are prepared to modify the regulations if there are unintended consequences that affect patient care and safety.”

The state Department of Health Services, which has responsibility for monitoring compliance, has estimated that the measure would cost hospitals an additional $422 million in staffing costs next year and more in future years. The hospital industry contends that a statewide nursing shortage makes compliance difficult.

California ranks 49th among states when it comes to the number of nurses per capita, with 544 RNs per 100,000 residents, according to federal data. Only Nevada ranks lower. California has more than 275,000 RNs with active licenses and will need 109,000 more by 2010 to meet requirements of the new law, according to state figures.

Still, the nurses’ union noted that the state had increased the capacity of its nursing programs in recent years and added more than 30,000 licensed nurses to the workforce. And some hospital operators such as Kaiser Permanente said they would be in compliance.

“We’ve been proactively working on this for the past two years. We’re ahead of the game,” said Judy Husted, executive director of patient services for Kaiser in Southern California. Kaiser Permanente operates 30 hospitals in the state, including 11 in the Southland. Husted said Kaiser had hired 750 full-time and part-time nurses in the last year, attracting them with wages, benefits and the increased staffing ratios.

“It gives the nurses more time to spend with the patients,” Husted added. “That’s why they go into nursing in the first place, that one-on-one time with the patients.”

Registered nurse Chriselle Manasan, 28, agreed, saying she has noticed a big difference in care since she began working at Kaiser’s Woodland Hills hospital, with its mandated one nurse for every four patients in the general medical and surgical area. The new law requires only one nurse for every six patients in such a setting.

“When I had to care for seven patients at a time, I went home with such a headache, I didn’t want to go back the next day,” she said. “Now other nurses I know at other hospitals want to come work here. It’s better for patients, better for us.”

At Tenet Healthcare Corp., California’s largest hospital chain, with about 40 medical centers, spokesman Steven Campanini said the firm would use contract nurses and take other steps if necessary to fulfill the requirements of the law.

He said the Santa Barbara-based company expected staffing costs to go up as much as $90 million in 2004 from the planned hiring of 1,000 full-time and part-time nurses.

If those positions cannot be filled, some of the firm’s emergency rooms may have to direct patients to other hospitals, Tenet President Trevor Fetter told Wall Street analysts this year.

“We are taking additional measures to meet the requirement that all hospitals must be in compliance at all times,” Campanini said.

But many other hospitals have far to go, according to nurse and hospital groups monitoring the situation.

In particular, rural hospitals are “very concerned about trying to comply,” said Emerson of the California Healthcare Assn. “They have such a limited pool of people to hire.”

In Crescent City, a small California town on the Oregon border, Sutter Coast Hospital considered curbing some emergency room services because of concerns it would not have enough nurses. The 59-bed hospital serves about 40,000 people.

Although administrators decided against doing that, John Menaugh, chief executive of Sutter Coast, said: “This law is not going to work. I’m not sure what is going to happen across this state in the next few days. It all depends on how it’s enforced.”