BILL ANALYSIS                                                                                                                                                                                                    �






                           SENATE COMMITTEE ON HEALTH
                       Senator Ed Hernandez, O.D., Chair

          BILL NO:       SB 554
          AUTHOR:        Yee
          AMENDED:       January 4, 2012
          HEARING DATE:  January 11, 2012
          CONSULTANT:    Trueworthy

           SUBJECT  :  Health facilities: direct care nurses.

           SUMMARY  :  Requires each direct care registered nurse to 
          receive and complete an orientation to the hospital and 
          patient care unit in which he or she will be working and to 
          have demonstrated competency.  Precludes a nurse who has 
          not completed this orientation and had validation of 
          competency from being assigned direct patient care or from 
          being counted as staff for the purposes of meeting minimum 
          nurse-to-patient ratios.  Clarifies 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.  Exempts specified hospitals, 
          as defined.  

          Existing law:
          1.Provides for the licensing and regulation of health 
            facilities, including general acute care hospitals, by 
            the Department of Public Health (DPH).

          2.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 requires that these ratios constitute the 
            minimum number of registered and licensed nurses that 
            must be allocated.   

          3.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.
                                                                     



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          4.Requires hospitals to adopt written policies and 
            procedures for the training and orientation of nursing 
            staff, and further prohibits a registered nurse from 
            being  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 regulations further require patient 
            care personnel to receive an annual written performance 
            evaluation which includes an assessment of competency. 

          5.Specifies and limits the duties and responsibilities of 
            all patient care personnel, prior to the 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.
          6.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 
            accordance with standardized procedures, and the 
            initiation of emergency procedures.
          
          This bill:
          1.Requires the competency of direct care registered nurses 
            (RN) assigned to specific units or clinical areas may 
            only be demonstrated and validated by the direct 
            observation of the orientee by another direct care RN who 
            has demonstrated current competency with the relevant 
            patient population, and may not be based on 
            self-assessment.

          2.Requires the observing direct care RN 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 




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            requirements established by the Board of Registered 
            Nursing.  

          3.Exempts state inpatient mental hospitals, state 
            developmental centers, state veterans' homes, and 
            correctional institutions, as defined, from these new 
            requirements.

          4.Clarifies that current requirements, under which general 
            acute care, acute psychiatric, and special hospitals must 
            ensure that all direct care RN 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.  

          5.Prohibits an orientee from being counted as staff for the 
            purposes of meeting minimum nurse-to-patient ratios 
            required in existing law.

           FISCAL EFFECT  :  This bill has not been analyzed by a fiscal 
          committee.

           COMMENTS  :
          1.Author's statement.  The requirement for acute care 
            hospitals to validate competency of RNs has been in 
            existing law and regulation since 1994.  This is an 
            important patient protection because RNs develop 
            expertise and competencies specific to clinical areas 
            such as the intensive care unit (ICU); pediatric 
            oncology; medical-surgical; cardiac care; labor and 
            delivery; neonatal ICU and other clinical areas of their 
            practice.  An RN must be able to demonstrate competency 
            in that clinical area prior to practicing on their own.  
            However, due to lack of uniform and consistent standards 
            for validating demonstrated RN competency, RNs have been 
            accepted into clinical areas where they are not competent 
            and this has resulted in patient harm.  This has been 
            particularly problematic when hospitals contract with 
            outside agencies for RNs.

            Hospitals are placing an undue reliance on competency 
            validation performed by temporary agencies, or 
            self-assessments.  Self-assessments performed by the 
            individual RN consists of checking off a list of tasks, 




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            functions or procedures based on the RN's own subjective 
            perspective and opinion of his or her own ability rather 
            than an objective assessment of those skills and 
            abilities by a qualified RN. 

            This bill will increase patient safety by ensuring that 
            all direct patient care 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.

          2.Prior legislation. SB 360 (Yee) of 2009 contained 
            provisions similar to the provisions of SB 360.  SB 360 
            was held in Senate Appropriations.
          
            SB 1721 (Yee) of 2008 contained provisions similar to the 
            provisions of SB 360.  SB 1721 was held in Assembly 
            Appropriations.
          
            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 as specified in AB 394 (Kuehl) of 1999.

            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.
          
          3.Support. This bill is sponsored by the California Nurses 
            Association (CNA) to increase the uniformity and 
            availability of training to direct care nursing staff 
            particularly for temporary agency, registry and traveler 
            staff.  A direct care RN is responsible, along with other 
            health care professionals, for the treatment, safety, and 
            recovery of acutely or chronically ill or injured people, 
            health maintenance of the healthy, and treatment of 




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            life-threatening emergencies in a wide range of health 
            care settings.  According to the sponsor, the lack of 
            training and validated nurse competencies has resulted in 
            negative patient outcomes, including increased morbidity 
            and mortality. The sponsor indicates self-assessments 
            currently used and a reliance on temporary nurses reduce 
            the efficacy and defeat the purpose of nurse-to-patient 
            ratios established by the Legislature to ensure patient 
            safety. 

            CNA writes that due to lack of uniform and consistent 
            standards for validating demonstrated RN competency, RNs 
            have been accepted into clinical areas where they are not 
            competent and this has resulted in patient harm.  CNA 
            argues this has particularly been problematic when 
            hospitals contract with outside agencies for RNs who rely 
            heavily on self-assessment.  Supporters contend that RNs 
            who have not had their competency validated are given 
            access to patients and are made responsible for direct 
            care without the hospitals having taken objective steps 
            to ensure competency of the new RN hire or potential 
            hire.  
          
          4.Opposition. The California Hospital Association (CHA) 
            writes in opposition to SB 554 stating rules already 
            exist to address both the competency of RNs and the 
            orientation of temporary staff.  Current law requires 
            hospitals to adopt written policies and procedures for 
            training and orientation of nursing staff, including a 
            requirement that temporary personnel receive orientation 
            and be subject to competency validation.  CHA further 
            argues that current law requires hospitals to provide 
            unit-specific orientation and ensure that all nurses, 
            including temporary staff, have demonstrated competency 
            to provide care in that unit.  CHA states that while 
            hospitals prefer to employ regular staff, nursing 
            shortages and nursing ratios have made use of agency 
            staff a necessity and existing rules are more than 
            adequate to protect the public without restricting 
            patient care by imposing undue burdens on hospitals.  
            Finally, CHA states this bill will increase the cost of 
            engaging a traveler or registry nurse by $3,600.

          5.Policy questions.
               a.     Five standard nursing shifts.  The bill 




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                 requires the observing direct care RN to directly 
                 observe and assess the orientee for a minimum of 
                 five standard nursing shifts in order to determine 
                 whether the orientee displays the required knowledge 
                 and skills.  It is not clear there is evidence to 
                 show five shifts is a reasonable and appropriate 
                 requirement.  
               b.     Should the bill allow for documentation of 
                 prior comparable training and observation?  If a 
                 nurse, including a temporary agency RN, has worked 
                 in the same unit of one hospital as the unit they 
                 will be working in at another hospital or even in 
                 the same hospital and unit, should they be required 
                 to undergo the direct observation for five nursing 
                 shifts again, as required by the bill?  In these 
                 cases, would it make sense for the hospital to 
                 credit previous training and observation in lieu of 
                 the requirement to observe the RN for five standard 
                 nursing shifts? 
               c.     Use of the phrase "nursing shift."  Nursing 
                 shifts vary in lengths of 8-hour, 10-hour or 12-hour 
                 shifts.  This bill uses the term "nursing shift" but 
                 does not specify the number of hours required per 
                 nursing shift.  This ambiguity could lead to a 
                 hospital-to-hospital discrepancy in the number of 
                 hours an RN is required to be observed in order to 
                 demonstrate competency.  The author may wish to 
                 clarify the number of hours required.
               d.     Prohibition on self-assessments.  SB 554 
                 prohibits the use of self-assessments as a way to 
                 demonstrate competency.  However, self-assessments 
                 can be a valuable starting point to determine the 
                 competency of an RN.  SB 554 would require 
                 competency to only be demonstrated and validated by 
                 direct observation, and therefore would not allow a 
                 self-assessment to fulfill the requirements of this 
                 bill.  The language strictly prohibiting 
                 self-assessments, even as a starting point, does not 
                 seem necessary.  Committee staff recommends amending 
                 the language as follows: Self-assessments are 
                 prohibited from meeting the requirements of this 
                 section.
               e.     Should state mental hospitals, developmental 
                 centers, correctional institutions, and veterans' 
                 homes be exempted from the orientation and 




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                 competency validation of requirements of this bill?  
                 As drafted, this bill exempts state-administered 
                 hospitals from the requirement that nurse competency 
                 be validated through direct observation over five 
                 nursing shifts.  This would create a different 
                 standard from other hospitals.
               f.     Is the observing direct care RN included in the 
                 nurse-to-patient ratio?  Currently, the bill is 
                 silent on whether or not the observing direct care 
                 RN is included in the nurse-to-patient ratio 
                 required by current law.  The author may wish to 
                 clarify whether the observing direct care RN is 
                 included in the nurse-to-patient ratio.
               g.     Need for definitions. SB 554 uses the terms 
                 "casual, per diem, temporary agency, registry, and 
                 traveler staff" to describe the RNs the provisions 
                 of this bill apply to.  However, these terms are not 
                 defined in law but rather are industry terms.  The 
                 author may wish to define these terms, or use terms 
                 in existing law to provide clarity and avoid any 
                 discrepancy.
               h.     Competency requirement.  SB 554 requires every 
                 direct care RN to have current demonstrated and 
                 validated competency.  Committee staff recommends 
                 clarifying the term "current."
               i.     What facilities are required to comply with the 
                 provisions of 1276.45(2)?  Currently, the bill is 
                 silent on what type of health facilities will have 
                 to comply with the requirement that an RN be 
                 observed for a minimum of five standard nursing 
                 shifts before being assigned to direct patient care.
          
           SUPPORT AND OPPOSITION  :
          Support:  California Nurses Association (sponsor)
                    Consumer Attorneys of California

          Oppose:   California Hospital Association
                    California Children's Hospital Association

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