Nurses (still) wanted

By Kathy Robertson
Sacramento Business Journal
January 11, 2008

Hospitals are making strides toward complying with the state's strict nurse-to-patient ratio law, but a nurse shortage still looms

Sacramento-area hospitals are still struggling to comply with the state's landmark nurse-to-patient ratio law five years after the initial rules took effect.

They've staffed up despite a statewide and national nursing shortage. Vacancies for registered nurses at local hospitals have plummeted 69 percent since early 2004.

Yet hospitals still fall short of obeying the rules "at all times," particularly when it comes to meal and rest breaks in a 24-hours-a-day business where patient demand doesn't stick to normal workplace schedules. Some hospitals are paying their nursing staff millions in overtime pay as a result.

The final phase of California's strict staffing law took effect Jan. 1. It narrowed ratios in three hospital units -- telemetry, step-down and specialty care -- prompting hundreds of additional hires in a tight market that's shown significant strides but hasn't delivered all the nurses needed, hospital sources say.

The California Nurses Association, a union that campaigned for the staffing law for 10 years before it was signed by former Gov. Gray Davis in 1999, calls the law "a spectacular success story."

"Lives are being saved, our ability to be effective advocates for our patients is stronger, and more RNs are entering the work force and staying at the bedside longer, mitigating the nursing shortage," Zenei Cortez, a member of the California Nurses Association/ National Nurses Organizing Committee, said in a recent press statement.

The hospital industry is not convinced.

"There's no evidence it's saving lives; that's rhetoric without fact," said Jan Emerson, a spokeswoman for the California Hospital Association. "There's no research. We don't know whether the impact is good, bad or indifferent."

Unfounded fears

Some of the hospitals' concerns about possible negative effects of the nurse-staffing law didn't pan out.

Ten or 11 California hospitals closed their doors in 2004, according to Emerson, but staffing ratios were not the only factor in their demise. All had financial problems already and were faced with another looming cost -- making their hospitals earthquake-proof.

A few hospitals have closed every year since then, but none in this area, and none exclusively because of the staffing law.

Fears of vigilante trial lawyers poised to sue the first time a patient died at a hospital that was out of compliance with the new staffing rules were unfounded, too.

"It doesn't appear trial lawyers have gone after this one," Emerson said.

The cost of the new law remains unclear. The state initially estimated it would add $900 million a year to labor costs for California hospitals. No overall figures of actual costs are currently available.

The new ratios that kicked in Jan. 1 prompted Kaiser Permanente to hire at least 20 additional nurses just to staff its telemetry and step-down units at its Sacramento Medical Center on Morse Avenue, said Sandy Sharon, assistant administrator for patient care services at Kaiser's Sacramento and Roseville hospitals.

At an average annual salary of $100,000, these new nurses alone will cost Kaiser $2 million a year.

81,000 more nurses on the job

California's safe-staffing law requires minimum nurse-to-patient ratios for all general acute-care hospitals.

The figures differ by hospital unit and some ratios have narrowed since 2004 (see chart, page 20).

Nurses -- backed by a 2003 report from the Washington, D.C.-based Academy of Sciences' Institute of Medicine -- claimed better working conditions, including adequate staffing and restrictions on forced overtime, are critical to patient safety.

Fix the problem and more nurses will enter the workplace, the California Nurses Association said.

More than 81,000 licensed registered nurses have come to work in the state since the law was signed in 1999, according to statistics from the Board of Registered Nursing.

There were a total of 331,189 registered nurses with active licenses in the state in November 2007. That's up from 250,123 active registered nurses in fiscal year 1999-2000.

"We've seen improvements in terms of RN vacancies going down and shift nurses coming into California," said union spokeswoman Liz Jacobs.

Still not enough

Hospital leaders and a number of independent studies agree the numbers have narrowed, in part because of nurse education funding from the state and hospitals themselves, but say they fall far short of meeting hospital needs.

"The newest staffing ratios will make them seek even more nurses," said Pat McFarland, executive director of the Association of California Nurse Leaders. "We are still in the midst of one of the greatest nursing shortages in our history."

Three studies in 2007 show the shortfall has narrowed but remains a concern. Among them:

• A May 2007 report by legislative analyst Elizabeth Hill concludes the number of registered nurses in the state has not kept up with demand. The mismatch in coming years might not be as big as expected, Hill said, but the state needs to continue efforts to increase the numbers.
• A September 2007 forecast by the Center for Health Workforce Studies at the University of California San Francisco concludes shortages cited in 2005 have shrunk to somewhere between 10,000 and 60,000, but says current programs must be maintained to keep up the progress.

The number of new graduates has increased almost 69 percent in the past five years, the study shows -- to almost 10,000 a year -- but some of the new nurses in California are travelers, who are temporary and expensive to hire. Travel nurses take short-term positions with hospitals across the country that have vacancies to fill.

• Unless the $200 million that has funded this increase is sustained, the gains will collapse and an acute shortage of registered nurses will threaten a health crisis in the state, concludes Deloras Jones, executive director of the Berkeley-based California Institute for Nursing and Health Care, in a Nov. 27 update on the issue.

"Almost all those gains are built on soft money," Jones said this week. She puts California's "actual" RN work force at 236,545, about the same as two years ago, even though the overall number of nurses in the state with active licenses has grown. The disconnect, she states, likely reflects the use of travelers.

Vacancies plummet in Sacramento

Greater Sacramento hospitals appear to be in a better position than some of their counterparts statewide.

"The four health systems all pay relatively well and Sacramento is a less expensive place to live, compared with other parts of the state," said hospital association spokeswoman Emerson at the trade group's Sacramento headquarters.

Kaiser has 73 nurse vacancies, more than any other local health system, but the health system has hired aggressively to remain ahead of the curve.

Sutter Health has 58 nurse vacancies at its local hospitals; Catholic Healthcare West has 34.

"It's not been that difficult (to hire needed nurses)," said Sharon at Kaiser. "We have very competitive salaries and benefits, so we are somewhat at an advantage locally, and Sacramento housing costs less than the Bay Area, so we get a lot of transfers."

The nurse-staffing law "is actually working pretty well," said Carol Robinson, associate director of patient-care services at UC Davis Medical Center, the biggest and busiest hospital in town. "We were already in compliance with the new ratios, although the new rules about specialty care hours are a little vague."

There are 50 vacancies for registered nurses at UC Davis, for a vacancy rate of 6 percent.

"I don't see burnt-out nurses coming back to the workplace," Robinson said. "We're seeing a lot of people who always wanted to be nurses who are finally going back to school to become RNs."

When there's a disconnect between demand and available nurses, local hospitals turn to nurse registries and travelers. The new ratios haven't spurred new business among local nurse staffing agencies -- yet.

"'We haven't noticed an uptick, but this is the first full week of ... the new ratios," said Steve Swan, co-founder of Valley Healthcare Systems Inc., a Gold River company that matches travel nurses with assignments. "There's an ebb and flow to the market. Some hospitals have focused on per diem or full-time employment, but travelers are an attractive alternative."

Patients want more these days, too.

"The public expects they'll be well cared for, be safe, not acquire an infection and we'll do no harm," Robinson said. "That speaks to the fact we need high-quality professionals at the bedside -- and more is better."