Registered nurses of California Nurses Association strongly object to and call for corrections to major flaws in state’s proposal to set staffing ratios for acute psychiatric[...]

The registered nurses of California Nurses Association (CNA), the union that spearheaded our state's historic, first-in-the-nation safe RN-to-patient ratios standard for hospitals, strongly object to major flaws in the state's latest proposal to set similar ratios in acute psychiatric hospitals (APHs) and are calling for corrections to the proposal to establish real, meaningful ratios that all patients deserve. CNA nurses have been advocating for the California Department of Public Health (CDPH) to protect nurses and patients in APHs with the same safe RN-to-patient ratios protections as general acute-care hospitals. (CNA written comment submissions here.)

Through this proposal, the state is attempting to fulfill the original requirements of A.B. 394 (Kuehl, 1999), the law that CNA nurses fought for more than a decade to win so that patients could get safe, quality care and nurses could provide safe, quality care.

But CDPH's proposed APH staffing regulations are riddled with major problems and loopholes that make the recommended ratios essentially worthless. Even worse, the draft APH ratios as written threaten and undermine the legitimacy of the stronger RN ratios standards already in place for general acute-care hospitals.

Currently, in general acute-care hospitals, only registered nurses count toward the ratios, and pediatric units must be staffed at or better than one nurse for every four children. Instead of using the same safe staffing standard that patients receive in general acute-care hospitals, CDPH is proposing that in APH facilities, up to half the personnel used to count staffing can be licensed vocational nurses (LVNs) or psych techs, and that only one nurse is needed for every FIVE children. While nurses wholeheartedly agree that LVNs and psych techs are important members of the care team, they cannot substitute for the education, judgment, and skills of registered nurses.

As recognized in California's safe patient staffing ratios legislation over 25 years ago, nurse staffing ratios must be based on a registered nurse's ongoing and comprehensive assessment of a patient's care needs. Under state law, only RNs can assume legal responsibility for the comprehensive assessment and care plan of patients. But CDPH's draft proposal undermines the registered nurses' role in caring for acute psychiatric patients. By allowing non-RNs to be counted toward APH ratios, the proposed staffing numbers are deceptive and misleading. In reality, under the draft proposal, an RN could be responsible for up to 24 patients in a 12-hour shift or 16 patients in an 8-hour shift, which translates into 30 minutes per patient for the entire shift. That time is insufficient to provide initial and ongoing observation and assessment of patients, as well as nursing care, and makes the proposed APH staffing ratios meaningless.

Hospitalized patients deserve the same standard of care no matter what kind of facility they are in, but the state is proposing an inferior staffing standard for acute psychiatric hospitals compared to general acute-care hospitals, and that's unacceptable to CNA nurses. Hospital employers will want to apply the proposed inferior standard across the industry.

As the San Francisco Chronicle investigative series showed, insufficient staffing is severely hurting and even leading to the death of psychiatric patients. Meaningful staffing reforms are desperately needed in APHs to prevent further harm. But under this current draft proposal, the state is caving in to the hospital industry and money-driven psych hospitals that want to keep their profit margins higher by keeping staffing costs low - at the expense of patient safety. The proposal as written does not set safe standards, but makes the situation even worse by undermining existing general acute-care hospital ratios.

In addition to proposing a lesser standard, the state has also omitted important language in these draft regulations that further undermines the role of RNs in overseeing patient care. Key language in existing RN ratios for general acute-care hospitals affirms the role of RNs in providing ongoing care to patients and determining safe staffing levels. But the draft APH regulations' proposed use of multidisciplinary staffing committees to determine additional staffing for an APH patient could mean that non-RNs are overriding RN assessments of needed staffing levels. There's no reason for this besides creating loopholes for employers to evade safe staffing.

CNA is concerned that in CDPH's proposal:

• RNs dangerously can be responsible for up to 24 patients per 12-hour shift or 16 patients per 8-hour shift.
• Half of the staffing ratio count can be filled by non-RNs.
• The proposed rule sets an inferior standard for acute psychiatric hospitals and does not match existing ratios for general acute-care hospitals.
• The proposed rule omits important language assuring that the ratios represent the maximum number of patients a registered nurse can be assigned at one time.
• RNs will have insufficient time to provide ongoing assessments and direct care for patients.
• There is no clear language stating that each patient must be assigned to an RN.
• There is no prohibition on averaging the number of patients or nurses on a unit in a shift to meet the ratios.
• Nurse administrators and managers dangerously can be counted towards the ratios even if they have other administrative duties.
• A multidisciplinary staffing committee without RNs can determine - or deny - additional staffing needs.

Research has unequivocally concluded that RN-to-patient ratios in California general acute-care hospitals save lives, and they will in acute psychiatric hospitals as well if we establish real standards that ensure there are enough RNs to provide the safe and quality care all patients deserve.

California Nurses Association/National Nurses United is the largest and fastest-growing union and professional association of registered nurses in the nation with more than 100,000 members in more than 200 facilities throughout California and more than 225,000 RNs nationwide.