BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Elaine K. Alquist, Chair
BILL NO: SB 360
S
AUTHOR: Yee
B
AMENDED: April 2, 2009
HEARING DATE: April 15, 2009
3
CONSULTANT:
6
Hansel/sh
0
SUBJECT
Health facilities: direct care nurses
SUMMARY
Clarifies that current requirements, under which hospitals
must ensure that direct care registered nurses receive
orientation to the hospital and to the patient care unit or
clinical care area in which they will be working, apply to
new hires, casual, per diem, registry, and traveler staff.
Specifies procedures through which the competency of direct
care registered nurses may be demonstrated and validated.
Provides that patient care staff who are undergoing
orientation, and who have not had their competency
demonstrated and validated, shall not count as staff for
the purposes of meeting minimum nurse-to-patient ratios.
Deletes provisions of existing law that allow the
Department of Public Health (DPH) to take into
consideration the unique nature of the University of
California teaching hospitals when establishing licensed
nurse-to-patient ratios.
CHANGES TO EXISTING LAW
Existing law:
Existing law provides for the licensing and regulation of
Continued---
STAFF ANALYSIS OF SENATE BILL SB 360 (Yee) Page 2
health facilities, including general acute care hospitals,
acute psychiatric hospitals, and special hospitals by the
Department of Public Health (DPH).
Existing law requires DPH to adopt regulations that
establish minimum, specific, and numerical licensed
nurse-to-patient ratios, by licensed nurse classification
and by hospital unit, for hospitals, and provides that
these ratios shall constitute the minimum number of
registered and licensed nurses that must be allocated.
Existing law also requires additional staff to be assigned
in accordance with a documented patient classification
system for determining nursing care requirements that
includes the severity of the illness, the need for
specialized equipment and technology, the complexity of
clinical judgment needed to design, implement, and evaluate
the patient care plan, the ability for self-care, and the
licensure of the personnel required for care.
Existing law and regulations require general acute care,
acute psychiatric, and special hospitals to adopt written
policies and procedures for the training and orientation of
nursing staff, and further provides that a registered nurse
shall not be assigned to a nursing unit or clinical area
until they have received orientation in that clinical area,
and have demonstrated current competence in providing care
in that area. Existing law provides that these
requirements also apply to temporary personnel. Existing
regulations further require patient care personnel to
receive an annual written performance evaluation which
includes an assessment of competency.
Existing regulations limit the duties and responsibilities
of all patient care personnel, prior to their completion of
competency standards for a patient care unit, to specific
duties and responsibilities for which competency has been
validated, as well as other limitations, as specified.
Existing law defines the practice of nursing to include the
administration of medications and therapeutic agents
ordered by a physician or other professional who is
licensed to prescribe such agents, administration of skin
tests and immunizations, withdrawal of blood, observation
of signs and symptoms of illness or general physical
condition, implementation of appropriate reporting and
referral procedures or changes in treatment regimen in
STAFF ANALYSIS OF SENATE BILL SB 360 (Yee) Page 3
accordance with standardized procedures, and the initiation
of emergency procedures.
Existing law allows DPH to take into consideration the
unique nature of the University of California teaching
hospitals when establishing licensed nurse-to-patient
ratios, including for nursing services provided as part of
a work-study program in which there will be
sufficient direct care registered nurse preceptors
available to ensure safe patient care.
This bill:
The bill would provide that the competency of direct care
registered nurses to care for patients in specific units or
clinical may only be demonstrated and validated by the
direct observation of the orientee by another direct care
registered nurse who has previously demonstrated current
competency with the relevant patient population, and may
not be based on self-assessment.
The bill would require the observing direct care registered
nurse to directly observe and assess the orientee within
the relevant clinical area, and with the relevant patient
population, for a minimum of five standard nursing shifts,
in order to determine whether the orientee displays the
required knowledge and skills of patient assessment,
patient care planning, intervention, evaluation, and
patient advocacy, to satisfactorily fulfill the duties
required under the Nursing Practice Act, and to meet nurse
competency requirements established by the Board of
Registered Nursing.
The bill would exempt state mental hospitals, state
developmental centers, and state veterans' homes, as
defined, from these new requirements.
This bill would additionally clarify that current
requirements, under which general acute care, acute
psychiatric, and special hospitals must ensure that all
direct care registered nurses receive and complete
orientation to the hospital and patient care unit or
clinical care area in which they will be working before
they are assigned to that unit or area, apply to new hires,
casual, per diem, registry, and traveler staff. The bill
would exempt state mental hospitals, state developmental
centers, and state veterans' homes, as defined, from these
STAFF ANALYSIS OF SENATE BILL SB 360 (Yee) Page 4
existing requirements.
The bill would provide that an orientee shall not count as
staff for the purposes of meeting minimum nurse-to-patient
ratios that otherwise apply.
The bill would additionally delete provisions of existing
law that allow DPH to take into consideration the unique
nature of the University of California teaching hospitals
when establishing licensed nurse-to-patient ratios.
FISCAL IMPACT
According to the Assembly Appropriations Committee analysis
of SB 1721 (Yee) of last session, which is substantially
similar to SB 360:
(1) Annual increased General Fund (GF) training costs to
the California Department of Corrections and Rehabilitation
(CDCR) of $200,000 for nurse observation required by this
bill. There are three CDCR hospitals and 300 nurses
working in these hospitals.
(2) Annual increased GF cost pressures to the University of
California (UC) medical centers of $3 million for nurse
observation required by this bill. There are five UC
medical centers and 10,000 nurses working for UC.
(3) Additional costs to the remaining 400 acute care and
psychiatric hospitals statewide.
BACKGROUND AND DISCUSSION
According to the author, current practices for validating
competencies of hospital nursing staff, including temporary
staff, are inconsistent due to the lack of uniform
standards for validating competency, with the result that
patients have been harmed. The author states that
hospitals are relying on inadequate competency validations
performed by temporary agencies, contrary to statutory
requirements that each hospital perform its own competency
validation, which is specific to each clinical area of the
hospital. According to the author, SB 360 will increase
patient safety by ensuring that all direct patient care
STAFF ANALYSIS OF SENATE BILL SB 360 (Yee) Page 5
staff, including per diem and temporary staff and new
hires, receive an objective competency assessment, specific
to the care unit in which they will be working, before
assuming patient care responsibilities.
Prior legislation
SB 1721 (Yee) 2007-2008 contained provisions that are
similar to the provisions of SB 360. Held in Assembly
Appropriations Committee.
SB 1760 (Kuehl), Chapter 148, Statutes of 2000, provides a
one-year extension for the adoption of regulations
establishing specified nurse-to-patient staff ratios in
health facilities.
AB 394 (Kuehl), Chapter 945, Statutes of 1999 requires DPH
to adopt regulations specifying nurse-to-patient ratios for
general acute care hospitals, acute psychiatric hospitals
and special hospitals. Requires hospitals to adopt written
policies and procedures for nursing staff training.
Prohibits hospitals from assigning unlicensed personnel to
perform nursing functions in lieu of a registered nurse.
Allows waivers of nurse-to-patient ratios for rural
hospitals, as long as the health, safety, and well-being of
patients affected is not jeopardized.
Arguments in support
The California Nurses Association (CNA), the sponsor of SB
360, states that, due to the lack of uniform standards for
validating registered nurse competency, RNs have been
accepted into clinical areas where they are not competent,
and that this has resulted in patient harm. CNA further
states that hospitals and temporary agencies are heavily
relying on subjective self-assessments of competency,
rather than objective assessments by qualified registered
nurses, and, based on these inadequate assessments, are
allowing nurses to assume responsibility for patient care.
CNA also expresses concern that registered nurses who have
not had their competency validated are being counted as RNs
for the purposes of calculating the hospital's adherence to
mandated nurse-to-patient ratios.
Arguments in opposition
The California Hospital Association (CHA) and the
California Children's Hospital Association (CCHA) argue
STAFF ANALYSIS OF SENATE BILL SB 360 (Yee) Page 6
that current statutes, regulations, and accreditation
standards adequately ensure nurse orientation and
competency. Specifically, these organizations state that
current law requires hospitals to adopt written policies
and procedures for training and orientation of nursing
staff, including temporary staff, and to ensure that nurses
have demonstrated competency in providing care in a
specific unit. The organizations state that hospital
accreditation standards contain similar requirements for
competency verification, and that those standards apply to
hospitals, including when they use temporary nurses. They
further state that if a staff nurse has concerns that a
newly assigned nurse does not possess requisite
competencies, he or she can file a complaint without fear
of retaliation.
CHA and CCHA argue the bill will exacerbate the current
nurse shortage and increase hospital costs by requiring
staff nurses to take reduced patient loads and by requiring
experienced nurses undergoing orientation to spend more
time to demonstrate competency before they can be assigned
to patient care.
A number of hospital organizations and individual hospitals
also argue that the bill's requirement that competency may
only be validated through direct observation over five
working shifts is arbitrary, eliminates the ability of
hospitals to plan orientation based on the level of
experience of the particular nurse, and to use temporary
agency staff to address gaps when a staff nurse is sick, or
when there is a labor dispute.
COMMENTS
1. Should the bill allow for documentation of prior
comparable training and observation? It may be possible
for a hospital to determine whether a nurse, including a
temporary agency nurse, has worked in the same unit of one
hospital as the unit they will be working in another
hospital, and has undergone direct observation of their
nursing skills for some number of shifts. In some areas,
it might be possible for hospitals to utilize a common
STAFF ANALYSIS OF SENATE BILL SB 360 (Yee) Page 7
registry in which they would document the training and
observation of nurses who rotate among hospitals. In these
cases, would it make sense for the hospital to be able to
credit some of the previous training and observation to the
five working shift requirement?
2. Exemption of state mental hospitals, developmental
centers, and veterans homes from orientation and competency
validation requirements. As drafted, the bill would exempt
these hospitals not only from the bill's requirements that
nurse competency be validated through direct observation
over five working shifts, but also from existing
requirements that nurses in these hospitals receive
orientation to the unit in which they will be working and
have their competency validated before they are assigned to
patient care. This could create a different standard for
state-administered hospitals versus other hospitals.
3. Bill eliminates special nurse staffing provisions for
UC teaching hospitals. As part of the nurse staffing ratio
statute enacted by the Legislature in 1999, DPH was given
authority to take into account the unique nature of UC
teaching hospitals in setting nurse ratios, but was
required to ensure that the ratios are consistent with
nursing requirements set by the Board of Registered Nursing
for UC clinical training programs. SB 360 would delete
these provisions of the nurse staffing ratio statute.
According to the Board of Registered Nursing, because it
doesn't set staffing ratios as part of its approval of
clinical training programs, these provisions have never
been implemented.
POSITIONS
Support: California Nurses Association (sponsor)
American Federation of State, County and Municipal
Employees
Consumer Federation of California
United Nurses Association of California/Union of
Health Care
Professionals
Oppose: California Hospital Association
California Children's Hospital Association
STAFF ANALYSIS OF SENATE BILL SB 360 (Yee) Page 8
California State Council (unless amended)
Catholic Healthcare West
Centinela Hospital Medical Center
Children's Hospital Central California
Coalinga regional Medical Center
College Hospital of Costa Mesa
Colusa Regional Medical Center
Community Hospital of Long Beach
Community Hospital of San Bernardino
Corona Regional Medical Center
Enloe Medical Center
Garden Grove Hospital and Medical Center
Gateways Hospital and Mental Health Center
Glenn Medical Center
Henry Mayo Newhall Memorial Hospital
Huntington Beach Hospital
John F. Kennedy Memorial Hospital
John Muir Health
Kindred Hospital, San Francisco Bay Area
La Palma Intercommunity Hospital
Lodi Memorial Hospital
Lompoc Valley Medical Center
Los Alamitos Medical Center
Madera Community Hospital
Mammoth Hospital
Marian Medical Center
Mercy San Juan Medical Center
Mercy Medical Center
Methodist Hospital
Mission Hospital in Mission Viejo
Modoc Medical Center
Palo Verde Hospital
Paradise Valley Hospital
Pomona Valley Medical Center
Rady Children's Hospital- San Diego
Saint Francis Memorial Hospital
San Antonio Community Hospital
Sequoia Hospital
Sharp HealthCare
Sierra Kings Health Care District
St. Bernardine Medical Center
St. Elizabeth Community Hospital
St. Joseph's Behavioral Health Center
St. Joseph Hospital of Orange
St. Mary's Medical Center
Surprise Valley Health Care District
STAFF ANALYSIS OF SENATE BILL SB 360 (Yee) Page 9
Sutter Delta Medical Center
United Hospital Association
Whittier Hospital Medical Center
Several individuals
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