Cutting nurses' patient loads boosts care, costs Calif. hospitals struggle to meet new staff ratios

By Julie Appleby
USA TODAY

SAN FRANCISCO -- Nurse Yorsing Chang remembers well the days when she would be responsible for eight or nine patients per shift, was constantly on the move and had little time for any extras. On a recent afternoon, Chang was assigned four patients at Kaiser Permanente's hospital here.

''I now have more time for patient teaching and other care, like emotional support,'' says Chang, who has been with Kaiser for seven years. ''We have more resources.''

That Chang has fewer patients is the result of two things: the nation's first law requiring hospitals to maintain a set number of nurses to patients; and Kaiser's decision to go even further than the law requires.

The California law took effect in January. But not everyone is pleased. Mary Dee Hacker is the chief nursing officer at the 286-bed Children's Hospital Los Angeles.

''On any given day we have physicians who want to admit patients, and I cannot accept them because I don't have enough nurses,'' Hacker says. ''California is in a public health crisis in not having enough nurses. We were dealing with that before the minimum staff ratio, but now it's been exacerbated.''

Even as other states consider similar laws, a deep divide remains between supporters and detractors of the law in California. Passed in response to criticism from nurses that a decade of cost cutting by hospitals was forcing nurses to care for more patients than they could safely handle, the law was opposed by many in the hospital industry.

Similar proposals, backed by nurses unions, are being debated in New Jersey and Massachusetts. Congress may get into the act as well. Two bills have been introduced: One sets specific numerical ratios for hospitals; the other calls for individual hospitals to work with their nurses to develop their own staffing ratios.

Debate over requiring hospitals to have a minimum number of nurses comes as costs rise rapidly, hospitals face a nursing shortage and pressure grows to improve quality. It also comes amid growing evidence that patient care improves when nurses have fewer patients.

''If you don't have an adequate number of nurses, patients suffer and die,'' says Kathleen Ann Long, dean of the University of Florida college of nursing and past president of the American Association of Colleges of Nursing.

But just what an adequate number is -- and how to achieve it -- remains controversial.

One 2002 study by University of Pennsylvania researchers showed that when a nurse is assigned more than four post-surgery patients, the risk of death goes up 7% for each additional patient.

Study co-author Linda Aiken says the study shows that a 1-to-10 ratio, which some in the hospital industry called for when California's law was first being discussed, would be too high. She says many of the proposals now under consideration by hospitals and lawmakers are closer to a 1-to-5 ratio.

It's too early to tell what effect the law will have on patients in California. As with everything else about the law, there are sharp divisions in opinion.

''A patient today will get much more individualized care than they would have (when nurses were overseeing eight or more patients). It's been a wake-up call for the industry,'' says Linda Groah, chief operating officer and nurse executive at the 247-bed Kaiser hospital in San Francisco.

Hacker says the answer is complex.

''To be honest, I do believe some hospitals have done a terrible job of providing an adequate nursing workforce to meet all the needs of the patient. So, at some hospitals, this will improve the care.''

But, she says, many hospitals were already staffing at or near the required ratios before the law went into effect, so there will be little or no change.

Long, at the school of nursing, says there isn't one simple way to improve patient care. She says ratios don't take into account the various experience and education levels of nurses, but simply assign them to patients based on a math formula: ''One-size-fits-all is something that makes us feel good, and it sounds right initially, but it's a simple answer to a remarkably complex problem.''

Labor is major cost

In-patient hospital care accounts for about one-third of the $1.6 trillion the nation spends annually on health care -- and hospital spending has been rising rapidly. Labor is the biggest chunk of a hospital's expenses, so requiring hospitals to use more nurses won't be cheap.

''It's clearly going to drive costs at a time when the country is looking at overall spending in the health care industry,'' says Lauren Arnold, vice president for nursing at Tenet, which runs 37 hospitals in California and has hired 800 nurses to help meet the new ratios.

At the 102-bed community hospital owned by Sutter Health that serves Vallejo, Calif., the new law meant hiring about eight full-time nurses this year. To fill the gaps, the hospital also had to increase the use of ''registry'' nurses, those who are not on staff but are hired from an agency to fill in when needed.

The new hires are expected to cost the hospital $752,000 in salary and $170,000 in benefits for the year, while the registry costs were $1 million in the first quarter this year, compared with $479,000 for the same quarter the year before. The hospital pays the agency $73 per hour, per nurse.

''That's a pretty big impact for us,'' says Sutter Solano Medical Center's chief executive, Beverly Gilmore, who says the hospital's net revenue last year after expenses was $99 million.

The nurses union that backed the law says hospitals may save money over the long term because nurses will stay in their jobs longer, reducing hiring and training expenses. The union also expects the quality of patient care to improve, which could result in fewer hospital-caused medical problems and fewer re-admissions, also saving money.

Around the country -- and in many nations -- hospitals face a shortage of nurses.

In the USA, hospitals average a 13% nurse vacancy rate, or about 126,000 vacancies nationwide, according to the American Nurses Association. About 2.7 million nurses are licensed in the United States, with about 59% working in hospitals, the rest in other areas of nursing. Causes of the shortage are varied: not enough faculty to expand nursing school enrollment, wider opportunities for nurses outside of hospital care and a decade of changes by the hospital industry that nurses blame for increased workloads, driving some to leave the profession.

Hospitals in many metro areas around the country are already in a dog-eat-dog fight to attract and retain their nursing staff. The same is true in California. The state estimated that 5,000 nurses would be needed for the state's hospitals to meet the new law's requirements, but hospitals say the number is higher. Kaiser Permanente alone says it has hired 6,000 nurses statewide in the past two years to help it meet its staffing standards.

To hire and keep nurses, salaries have shot up during the past few years -- a new grad in California can now earn $60,000 or more a year -- and many hospitals are handing out raises even before any union contracts expire. Sign-on bonuses are common, leading some nurses to skip from hospital to hospital to collect.

Nurse vacancy rates are as low as 5% at some Kaiser hospitals after the ratio law. But for many hospitals owned by other companies vacancy rates are higher -- and all are trying to hire from the same pool of available nurses. Vacancy rates jumped from 13% before the ratio law to 18% at San Jose Medical Center, a hospital owned by HCA. The statewide average is 14%.

''The biggest thing against mandatory staffing ratio laws is that most do not take into consideration the reality of the lack of nurses to hire,'' says Leslie Kelsay, spokeswoman for San Jose Medical Center.

Contentious issue

The battle over the law was one of the most contentious in the long history of disagreement between nurses and hospital management.

In the 1990s, facing eroding profit margins, many hospitals nationwide brought in high-priced consulting firms to help trim costs. Some cut back on higher-cost staff, such as nurses, and added lower-paid workers, such as nurses aides. The effect was to increase the number of patients nurses were overseeing.

Unions staunchly objected to the workload changes, arguing that they put patients at risk. Hospitals said the changes were safe and that nurses had the additional assistance of more aides. Nurses in California and elsewhere went on strike over staffing issues.

The California Nurses Association, which promoted the staff-ratio law, likes the initial results.

''Overall, most hospitals are complying, and it is having a significant impact on the quality of care,'' says CNA spokesman Chuck Idelson. ''In the hospitals that are actively complying with the law, (nurse) turnover rates have plummeted.''

During the debate over California's law, hospitals warned of dire effects if the state forced them to hire more nurses: Hospitals would close, the nursing shortage would worsen, surgeries would be canceled and emergency rooms forced to turn away patients.

Seven months in, here are some of the early results:

* One of California's 458 hospitals, Santa Teresita in the Los Angeles suburb of Duarte, closed, blaming the nurse ratios. State officials say the facility was on the edge financially and was expected to close even without the law.

* Data from Los Angeles, Sacramento and Santa Clara counties show an initial jump in the hours hospitals had to ''divert'' ambulances because their emergency rooms were full (either because of an influx of patients, a shortage of nurses or both). But, with the exception of Santa Clara, ambulance diversion hours dropped to or below 2003 levels by April.

* While some hospitals say they have canceled or delayed elective procedures because of the law, state regulators say the industry has provided no data comparing such delays with the year before the law went into effect.

One part of the regulation caught some by surprise: State officials said hospitals must adhere to the ratios at all times.

''When a nurse goes for a 15-minute coffee break, another nurse cannot watch his or her patients unless that nurse has fewer patients than the minimum ratio,'' Hacker says. ''It is extraordinarily challenging for us, for all hospitals, to meet that requirement 24/7.''

The hospital industry challenged the ''at all times'' regulation in court, but a judge in June ruled against the industry and upheld the regulation.

''Before, we could say it doesn't look like the patients need me right now, so it's a good time to go to break,'' says nurse Juni Song. ''Now, it's like a task we have to do: It's 9:30, so if I don't go on break now, someone after me will be delayed. I don't feel that this has helped us.''

But others say that is an important part of the regulation, because nurses could be left with too many patients under the old system.

''Everyone wanted to take off at the same time,'' says Trande Phillips, a nurse at Kaiser's Walnut Creek, Calif., hospital for 21 years. ''No one was in charge. Everyone was down in the cafeteria getting meatloaf. Now that doesn't happen.''