California's new nurse to patient ratio law becomes effective this January

Nevada RNformation, Nov 2003 by Dumpel, Hedy

California's Staffing Ratio Law, AB 394, was signed by Gov. Gray Davis on October 10, 1999. California State Senator Sheila Kuehl (Democrat-Santa Monica) sponsored the bill on behalf of the California Nurses Association.

* The Department of health services shall adopt regulations that establish minimum, specific and numerical licensed nurse to patient ratios by licensed nurse classification and by hospital unit for acute care settings

* DHS shall adopt the ratios in accordance with the Department of Licensing and Certification's certification regulations as stated in:

* Patient classification definition (CCR 70053.2)

* Planning and implementing patient care (CCR 70215)

* Nursing service staff (CCR 70217)

* Standards of competent performance (CCR 1443.5)

* Once the minimum number of RNs and licensed nurses have been allocated, ADDITIONAL staff shall be assigned in accordance with a documented patient classification system for determining nursing care requirements.

* Patient Classifications systems will be based on the following nursing intensity indicators

* Severity of illness

* Need for specialized equipment and technology

* Complexity of clinical judgment needed to design, implement, and evaluate the patient plan of care

* Ability for self care

* Licensure of personnel required for care

* In the event of a conflict between the health and safety code pertaining to nurse staffing and regulation defining the scope of nursing practice, the scope of practice provisions shall prevail

What the staffing ratio law (Assembly Bill # 394) establishes:

* Requires the California State Department of Health Services to adopt regulations establishing minimum, specific and numerical licensed nurse-to-patient ratios for all hospitals by Jan 1, 2002.

* Ratios must be based on a standard of individualized patient care needs with sufficient RN staffing to ensure that patient care reflects proper assessment, nursing diagnosis, planning, intervention, evaluation and patient advocacy. The law states: "The basic principles of staffing in the acute care setting should be based on the patient's care needs, the severity of condition, services needed, and the complexity surrounding those services."

* Mandates additional nursing staff as needed based on individualized patient needs and severity of illness [acuity]. "Additional staff (above minimum ratios is determined by) the severity of the illness, the need for specialized equipment and technology, the complexity of clinical judgment needed to design, implement, and evaluate the patient care plan and the ability for self-care, and the licensure of personnel required for care."

* Restricts unsafe assignment of nursing staff to hospital area for which they lack proper clinical training or orientation.

* Prohibits hospitals from requiring unlicensed, minimally trained personnel to perform nursing functions such as invasive procedures, patient assessment, patient education, or administration of medication.

The California State Department of Health Services has recently finalized the nurse to patient ratios and they will become effective in January 2004.

The California Nurses Association campaigned for several years to establish mandated ratios in California. The first attempt was in 1993 when AB 1445 was introduced into the Assembly but the bill died in committee. Ratios were also a part of Prop. 216, the health care reform initiative introduced by CNA in 1996. Another version of the ratios bill, AB 695, was passed by the legislature in 1997, but vetoed by former Governor Pete Wilson.

To win enactment of AB 394, The California Nurses Association mobilized nurses and patients throughout California. The governor received more than 10,000 letters, post cards, and phone calls from nurses and patients in support of the bill. More than 2,000 nurses and senior citizens rallied on the Capitol Steps in support of the bill in September, 1999, believed to be the largest rally of nurses ever in the capital. Hundreds of others rallied in Los Angeles and Oakland.

Below is a table of the mandatory minimum nurse to patient ratios that will be effective on January 1, 2004 in California.

Why the Law was needed

The purpose of the law was to address the growing crisis in patient care in California hospitals caused by managed care and market based decisions on hospital care that resulted in California having among the worst RN staffing in the nation and a growing exodus of RNs out of hospitals creating a serious nursing shortage.

CNA campaigned for 10 years to get the law enacted, including the largest gatherings of RNs in California history, major rallies drawing thousands of RNs to the Capitol.

California's law was the first (and still only) ratio law in the nation. It is the single most effective response to protecting patient safety in hospitals and reducing the nursing shortage. The California law is considered a national, even international model, and has generated extensive attention from the national media and RN organizations around the world.