1. Fitzpatrick, Melissa A. RN, MSN, FAAN

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Few health care issues command as much national attention as nurse-to-patient ratios.


Governor Gray Davis (CA-D) proposed nurse-to-patient ratios for California's acute care hospitals. In accordance with a 1999 law that requires hospitals to staff at certain levels or close units that don't comply, these ratios, the first to be released in the United States, call for a 1:6 ratio on medical/surgical floors; 1:4 in emergency departments, pediatrics, and step-down/telemetry units; and 1:2 in critical care, labor and delivery, and post-anesthesia care units. Twelve to 18 months after the law takes effect, the medical/surgical ratios will change to 1:5.


Financial realities

If implemented today, some hospitals would meet or exceed these standards, many wouldn't, and countless beds and units would close. This potential causes great concern when superimposed on the mass shortage of professional nurses, rising patient acuity, and increased hospital financial constraints. In California alone, the total number of new hospital personnel required to fully implement these minimum ratios by July 2003 exceeds 5,000 to a tune of $400 million.


Some oppose the legislation on the grounds that patient needs should drive staffing requirements, and that hospital leaders should determine staffing based on patient condition and staff experience and education. Proponents believe they're designed to improve care delivery and allow them to gain additional staffing that they've had difficulty securing otherwise.


It distresses me when state government must intervene to solve problems that nursing and we as health care leaders haven't resolved ourselves. I worry that patient needs won't remain the focus of our attention. Remember similar examples of patient acuity model implementation? Some colleagues lost all sight of what patients really needed, focusing only on what the numbers said they needed and checking off enough boxes to warrant another nurse. The numbers game didn't work then, and I doubt it will work now.


The good news

Most of the proposed legislation is accompanied by legislation to enhance the recruitment, retention, and education of professional nurses. Governor Davis unveiled a 3-year, $60 million nurse workforce initiative to fund education programs, media campaigns, and workplace reform. Florida's Nursing Shortage Solution Act would provide $6.5 million for recruitment and retention initiatives, loan forgiveness and scholarships, licensing initiatives, and workforce training to increase programs in nursing and teaching. And the New York state legislature approved a $696 million health care workforce proposal for recruitment and retention activities in hospitals and nursing homes.


Such initiatives acknowledge what many of us already know: Nurse-to-patient ratios require fundamental reform to achieve lasting improvement.