California鈥檚 telemetry nurses, who specialize in the electronic monitoring of critically ill patients, normally take care of four patients at once. But ever since the state relaxed California鈥檚 mandatory nurse-to-patient ratios in mid-December, Nerissa Black has had to keep track of six.
And these six patients are really sick: Many of them are being treated simultaneously for a stroke and covid-19, or a heart attack and covid. With more patients than usual needing more complex care, Black said she鈥檚 worried she鈥檒l miss something or make a mistake.
鈥淲e are given 50% more patients and we鈥檙e expected to do 50% more things with the same amount of time,鈥� said Black, who has worked at the聽in Valencia, California, for seven years. 鈥淚 go home and I feel like I could have done more. I don鈥檛 feel like I鈥檓 giving the care to my patients like a human being deserves.鈥�
As covid patients continue to flood California emergency rooms, hospitals are increasingly desperate to find enough staffers to care for them all. The state is asking nurses to tend to more patients simultaneously than they typically would, watering down what many nurses and their unions consider their most sacrosanct job protection: a law existing only in California that puts legal restrictions on the nurse-to-patient ratio.
鈥淲e need to temporarily 鈥� very short-term, temporarily 鈥� look a little bit differently in terms of our staffing needs,鈥� said Gov. Gavin Newsom, after he quietly allowed hospitals to adjust their nurse-to-patient ratios on Dec. 11. Usually, California law requires a hospital to first get approval from the state before tinkering with those ratios; Newsom鈥檚 move gave hospitals presumptive approval to work outside the ratio rules immediately.
Since then, 188 hospitals, mainly in Southern California, have been operating under : They can require ICU nurses to care for three patients instead of two. Emergency room and telemetry nurses may now be asked to care for six patients instead of four. Medical-surgical nurses are looking after seven patients instead of five.
Nurses have taken to the streets in protest, holding physically distanced demonstrations across the state, shouting and carrying posters that read: 鈥淩atios Save Lives.鈥� The union, the聽, says the staffing shortage is a result of聽, of taking a reactive approach to staffing rather than proactive 鈥� laying nurses off over the summer, then not hiring or training enough for winter.
鈥淲hat we鈥檙e seeing in these hospitals is their just-in-time response to a pandemic that they never prepared for 鈥� just-in-time staffing, just-in-time resources, not staffing up, calling nurses in on a shift at the very last minute 鈥� to boost profits,鈥� said聽, government relations director for the California Nurses Association. 鈥淎nd we鈥檙e seeing how nurses are being stretched even thinner.鈥�
But hospitals say this is an unprecedented crisis that has spiraled beyond their control. In the current surge, four times as many Californians are testing positive for the coronavirus compared with the summer鈥檚 peak. As many as 7,000 new patients could soon be coming to California hospitals every day, according to聽, who heads the California Hospital Association.
鈥淭his is catastrophic and we cannot dodge this math,鈥� she said. 鈥淲e are simply out of nurses, out of doctors, out of respiratory therapists.鈥�
The state has asked the federal government for staff, including 200 medical personnel from the Department of Defense, and it鈥檚 tried to reactivate the California Health Corps, an initiative to recruit retired health workers to come back to work. But that has yielded few people with the qualifications needed to care for hospitalized covid patients.
Hiring contract nurses from temporary staffing agencies or other states is all but impossible right now, Coyle said.
鈥淏ecause California surged early during the summer and other parts of the United States then surged afterward,鈥� she said, 鈥渢hose travel nurses are taken.鈥�
The next step for hospitals is to try 鈥渢eam nursing,鈥� Coyle said 鈥� pulling nurses from other departments, like the operating room, for example, and partnering them with experienced critical care nurses to help care for covid patients.
,聽an economics professor who studies health care workforce issues at the University of California-San Francisco, said hospitals should have started training nurses for team care over the summer, in anticipation of a winter surge, but they didn鈥檛, either because of costs 鈥� hospitals lost a lot of revenue from canceled elective surgeries that could have paid for that training 鈥� or because of excessive optimism.
鈥�California was doing so well,鈥� she said. 鈥淚t was easy for all of us to believe that we kind of got it under control, and I think there was a lot of belief that we would be able to maintain that.鈥�
The California Nurses Association has good reason to be defensive regarding the integrity of the patient-ratio law, Spetz said. It took 10 years of lobbying and activism before the bill passed the state legislature in 1999, then several more years to overcome multiple court challenges, including one from then-Gov. Arnold Schwarzenegger.
鈥淚鈥檓 always kicking their butt, that鈥檚 why they don鈥檛 like me,鈥� Schwarzenegger famously said of nurses, drawing broad ire from the nurses union and its allies.
Nurses prevailed in the court of public opinion and in law; rules that put a legal cap on the number of patients per nurse finally took effect in 2004. But the long battle made nurses fiercely protective of their win. They鈥檝e even accused hospitals of using the pandemic to try to roll back ratios for good.
鈥淭his is the exercise of聽聽at its finest, where [hospital administrators] are completely maximizing their opportunity to take advantage of this crisis,鈥� Roberson said.
Hospitals deny they want to change the ratio law permanently, and Spetz said it鈥檚 unlikely they鈥檇 succeed if they tried. The public can see that nurses are overworked and burned out by the pandemic, she said, so there would be little support for cutting back their job protections once it鈥檚 over.
鈥淭o go in and say, 鈥極h, you clearly did so well without ratios when we let you waive them, so let鈥檚 just eliminate them entirely,鈥� I think, would be just adding insult to moral injury,鈥� Spetz said.