California Nurses Association Opposes Flawed Staffing Proposal for APHs

The California Nurses Association (CNA), known for establishing the state's pioneering RN-to-patient ratios in hospitals, is voicing strong opposition to the state's newest proposal for staffing ratios in acute psychiatric hospitals (APHs). The CNA is advocating for amendments to ensure patients receive the same care standards as those in general acute-care hospitals. The nurses have been urging the California Department of Public Health (CDPH) to adopt similar staffing protections for APHs. (View CNA's written comments here.)

This proposal aims to satisfy the requirements of A.B. 394 (Kuehl, 1999), a law that CNA nurses championed to ensure safe and quality care for patients. However, the CDPH's proposed regulations for APH staffing contain significant issues and loopholes, rendering the suggested ratios ineffective. Even more concerning, the draft ratios could compromise the integrity of the stringent RN standards already enforced in general acute-care hospitals.

In general acute-care hospitals, only registered nurses qualify for the ratios, with pediatric units requiring at least one nurse per four children. In contrast, the CDPH proposal allows up to half the staffing in APHs to consist of licensed vocational nurses (LVNs) or psychiatric technicians, with only one nurse for every five children. While LVNs and psych techs are valued team members, the CNA argues they cannot replace the expertise and decision-making capabilities of registered nurses.

The legislation set over 25 years ago in California acknowledges that staffing ratios should be based on a registered nurse's comprehensive assessment of patient care needs. State law mandates that only RNs bear legal responsibility for patient assessment and care planning. The draft regulations, by counting non-RNs in APH staffing ratios, misrepresent the actual staffing situation. The proposal could result in an RN overseeing up to 24 patients in a 12-hour shift or 16 in an 8-hour shift, equating to merely 30 minutes per patient, which is insufficient for proper care and assessment.

Patients in all hospital settings deserve uniform standards of care, yet the state suggests a lower staffing benchmark for APHs compared to general acute-care hospitals, which CNA nurses find unacceptable. The inferior standard could become industry-wide, favoring financial over patient safety interests.

An investigative series by the San Francisco Chronicle highlighted how inadequate staffing harms psychiatric patients, even resulting in fatalities, underscoring the need for substantial reforms in APHs. The current draft proposal, however, risks prioritizing hospital profits over patient safety, undermining the established general acute-care hospital ratios.

The draft regulations also omit crucial language that supports RNs' roles in patient care oversight. The existing RN ratios for general hospitals recognize RNs' authority in patient care and staffing determinations. The proposed regulations, through a multidisciplinary staffing committee, might allow non-RNs to influence staffing decisions, creating potential loopholes for employers to bypass safe staffing requirements.

Concerns Raised by CNA:

• RNs could handle up to 24 patients in a 12-hour shift or 16 in an 8-hour shift.
• Non-RNs could comprise half of the staffing ratio count.
• Proposed standards for APHs are inferior compared to those for general acute-care hospitals.
• Absent language ensures ratios are the maximum number of patients per RN.
• RNs may lack adequate time for continuous patient assessments and care.
• No explicit requirement for each patient to be assigned to an RN.
• No ban on averaging patient or nurse numbers per shift to meet ratios.
• Nurse administrators, even with other duties, could count towards ratios.
• A multidisciplinary committee without RNs may decide additional staffing needs.

Research indicates that RN-to-patient ratios save lives in California's general acute-care hospitals, a standard that could extend to APHs if genuine staffing standards are implemented, ensuring ample RN availability for patient care.

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