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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