Memo From The Editor

Toward safer patient care

Marianne Dekker Mattera

On January 22, California's Department of Health Services finally announced the list of proposed nurse-patient staffing ratios mandated by law in 1999. It's a sure bet that other states considering such legislation—Massachusetts, Ohio, Rhode Island, and Florida, among them—will look long and hard at the numbers California is proposing. And so should you; it's your patients who'll be affected.

Here are the numbers:

• ORs and trauma EDs would have one nurse for every patient.

• ICU/CCU, neonatal ICU, labor & delivery, post-anesthesia care units, and critical care EDs—1:2.

• EDs, step-down/telemetry, and burn units, and pediatrics and the intermediate care nursery—1:4.

• Oncology, telemetry—1:5.

• Med/surg, and mixed units—1:6, to be phased down to 1:5.

• Well-baby nursery, postpartum—1:8.

Are these numbers enough to assure that there are enough nurses to properly care for patients' needs? No one knows for sure. As I mentioned to you in this space in May, the California Nurses Association suggested the best ratio on med/surg floors would be 1:3. They didn't get that, but 1:6, moving eventually to 1:5, comes a lot closer to what the nurses wanted than to the 1:10 ratio suggested by the state hospital association.

I find it reassuring that the bureaucrats seem to have paid more attention to the people who are actually delivering the hands-on care than to the administrators. But there are still very real concerns to be dealt with, and by and large they must be dealt with by the administrators.

For instance, what if hospitals can't find nurses to fill the jobs they are now mandated to provide? Or what if it becomes too expensive to fill them? Then units—or entire facilities—will be closed and what impact will that have on patient care?

A hospital association spokesperson admits that closures are a very real possibility. Particularly if the plans the governor announced to boost enrollment in nursing schools fail to produce the estimated 5,000 additional nurses it would take to meet the requirements.

I don't think it will take 5,000 new nurses, though. Only about six nurses in 10 work in hospitals now. Hundreds—if not thousands—have left hospital nursing over the last decade because they were being asked to do too much with too little. They were wearing themselves out physically and emotionally. Leaving work frustrated and guilty at not being able to provide the kind of care they felt their patients needed. You know how that feels!

Assured that there will be enough trained, capable, and caring hands to care for the patients, I suspect many nurses can be lured back to the bedside—where the real action in nursing is.

At the earliest, though, the new staffing ratios won't go into effect until July of 2003 and there will be a period of public comment this spring before the proposals turn into final regulations. So much can still change.

Doctors in California need to talk to the nurses at the facilities where they admit patients to see how the proposed numbers are sitting. Will they do the job? If not, what would work better? You also need to talk to the administrators at those same facilities to see how they feel about it. Then you need to weigh in on the ratios: Let the Department of Health Services know if they're on target or where they need to make changes.

Doctors who don't practice in California need to pay attention to the California experience. The numbers the Department of Health Services came up with may well serve as the numbers other states propose automatically—without going through the years of fact-finding that California did. You need to ask the same questions of the nurses and administrators at the hospitals where you admit patients and be ready to act if necessary.

The goal of all this activism is the same whether you're in California or Connecticut, Alaska or Alabama—safer patient care, better patient care.

 

Marianne Mattera. Memo from the Editor: Toward safer patient care. Medical Economics 2002;4:4.