The scene outside the Los Angeles building where the California Department of Health Services (DHS) held a public hearing recently typified a labor dispute. Unionized registered nurses wearing red shirts held picket signs that read, "All-RN ratios save lives" as TV crews searched for sound bites
The mood inside was decidedly different. People -- some of them nurses who had held a daylong strike the previous day in Long Beach -- took turns at the podium, offering their thoughts about landmark California legislation proposing a one-to-five nurse-to-patient ratio on acute-care hospitals' general medical floors.
The ideas and criticisms of those who testified were heard by about 300 people in the auditorium and officially recorded by the state.
For the nurses from Long Beach, the Nov. 15 hearing was the third public forum concerning their profession and the quality of hospital-patient care in three weeks. Like many other nurses in California, they've long complained about long hours, workloads, inadequate pay and inadequate treatment of patients.
California's new law is intended to address the concerns about patient care and nurses' workloads. After additional hearings later this year, the state will decide whether to go with or change the proposed regulations, which are set to take effect by Jan. 1, 2004. The DHS anticipates it will hold another public-comment period regarding further changes, and that this will begin on June 27, 2003.
The nurse-to-patient ratios the reglations would mandate are divisive. Some worry that they will end up reducing access to healthcare because of the serious shortage of nurses. Others believe that the ratios will make nurses' lives livable and improve patient care.
Stephanie Mearns, who heads the Nurse Leadership Council for the Hospital Association of Southern California, contends that the ratios will "cripple" hospitals because they are too rigid. In her testimony, she challenged the lack of differentiation between ratios for day and night shifts, the creation of a pool of nurses to fill in for others on breaks and at lunch, and the requirement that hospitals designated as trauma centers have specialized nurses on continuous call without regard to healthcare activity levels.
One comment Mearns made elicited a rare outburst of laughter. Discussing a proposed requirement that two people need to watch a patient-data screen, she said, "One technician can easily watch 20 patients."
Another woman testified that she had been able to prevent a hospital patient from falling to the floor the previous day precisely because she did not have 10 patients to watch.
Also among the hearing participants was Kathy Malone, a nursing veteran of 15 years. Malone said she favors safe staffing levels but does not support the labor unions that fought for the ratios being discussed.
"Nurses don't need a union to represent them; they're professionals," she said.
Susan Rosenthal, government-relations specialist for the Kaiser Permanente managed care firm, said she strongly supports mandated nurse-to-patient ratios.
The 27 network-members-only hospitals that Kaiser operates in California are beginning to implement a ratio of one nurse to four patients in their medical/surgical units, Rosenthal said. She added that the ratio will eventually be hospital-wide. Previously, the ratios varied from hospital to hospital and unit to unit, but they were not this low, she said.
Kaiser is not worried about reducing the number of beds in its hospitals, Rosenthal said, because it is working to increase the supply of nurses via scholarship programs for initial and continuing education and identifiable career ladders, for starters.
She said that while the one-to-four ratio was right for Kaiser and its 6.3 million members in California, "we're not taking a position on what other hospital systems should do." About 20 percent of California's insured residents have Kaiser policies.
Kaiser's plan to go beyond the requirements of California law coincided with the disclosure last week that it had agreed to pay a $1 million fine stemming from the 1996 death of a Medicare patient. The dead woman had waited for hours to be seen by a Kaiser doctor after she complained of severe abdominal pain. Before the woman could receive treatment in a Kaiser hospital, an aneurysm in her aorta burst.
The fine was the largest in California's history against a full-service health plan.