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California’s COVID-19 Surge Sparks Battle Between Hospitals and Nurses Over Workload

California's powerful nurses union is pushing back against recent state rules that temporarily relax the state's unique nurse-to-patient ratios amid staffing shortages.
April Dembosky
A group of nurses in Southern California hold a rally on Aug. 5, 2020 as part of national day of action for safer hospital working conditions. Nurses in California have been protesting recent rollbacks to California's nurse-to-patient ratio law.  (Courtesy of Nerissa Black)

Telemetry nurses in California normally take care of four patients at once. But after the state relaxed California’s unique nurse-to-patient ratios in mid-December, Nerissa Black has to keep track of six.

And those six patients are really sick: They all need constant electronic monitoring and many of them are being treated simultaneously for a stroke and COVID-19, or a heart attack and COVID-19. Black says she’s worried she’ll miss something or make a mistake.

“We are given 50% more patients and we’re expected to do 50% more things with the same amount of time,” says Black, who has worked at the Henry Mayo Newhall Hospital in Valencia, California for the last seven years. “I go home and I feel like I could have done more. I don’t feel like I’m giving the care to my patients like a human being deserves.”

As COVID-19 patients continue to flood California emergency rooms, hospitals are increasingly desperate to find enough staff to care for all of them. Now the state is asking nurses to take care of more patients at once than they normally would, watering down their union’s most sacrosanct job protection: a nurse-to-patient ratio law that exists only in California.

“We need to temporarily — very short-term, temporarily — look a little bit differently in terms of our staffing needs,” said Gov. Gavin Newsom on Dec. 11, after quietly allowing hospitals to shift their nurse-to-patient ratios without first getting approval from the state.

Since then, 170 hospitals, mainly in Southern California, have been operating under the new pandemic ratios: ICU nurses can now care for three patients instead of two. Emergency room and telemetry nurses can now 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 socially distant demonstrations across the state, shouting and carrying posters that read “Ratios Save Lives.” The union — the California Nurses Association — says the staffing shortage is a result of bad hospital management: It accuses hospitals of putting profits over preparing for a surge by laying off nurses over the summer, then not hiring or training enough for the winter.

“It seems hospitals have been more reactive than proactive in their staffing,” Black said.

But hospitals say this is an unprecedented pandemic that has spiraled beyond their control. Now, in the current surge, four times as many Californians are testing positive for the coronavirus as did during the summer peak. Up to 7,000 new coronavirus patients could soon be coming to California hospitals every day, according to Carmela Coyle, president and CEO of the California Hospital Association.

“This is catastrophic and we cannot dodge this math,” Coyle said. “We are simply out of nurses, out of doctors, out of respiratory therapists.”

Nerissa Black, a telemetry nurse at Henry Mayo Newhall Hospital in Valencia, California on December 13, 2020. ‘As you can see,’ she said, ‘that’s a lot of PPE that we’re donning and doffing in between each patient. It takes time to remove them safely (so we don’t contaminate ourselves), and then put a new set for the next patient.’ (Courtesy of Nerissa Black)

The state has asked the federal government to send additional staff, including 200 medical personnel from the U.S. Department of Defense. It’s also tried to revive 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 COVID-19 patients.

And hiring contract nurses from temporary staffing agencies or other states is all but impossible, Coyle says.

“Because California surged early during the summer and other parts of the United States then surged afterwards,” she said, “those travel nurses are taken.”

The next step for hospitals is to try team nursing, Coyle says, which entails pulling nurses from other departments, like the operating room, for example, and partnering them with experienced critical care nurses to help care for COVID-19 patients.

Joanne Spetz, an economics professor and expert in health care workforce issues at UCSF, says hospitals should have started training nurses for team care over the summer in anticipation of a winter surge, but they didn’t, either because of costs – hospitals lost a lot of revenue from canceled elective surgeries that could have paid for training – or because of excessive optimism.

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“California was doing so well,” she said. “It 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.”

The nurses union has reason to be defensive of the patient ratio law, Spetz says. It took 10 years before it was passed by the Legislature in 1999, then several more to get through multiple court challenges, including one from then-Gov. Arnold Schwarzenegger.

“I’m always kicking their butt, that’s why they don’t like me,” Schwarzenegger famously said of nurses, drawing broad ire from the union and its allies.

Nurses prevailed, in both the court of public opinion and the law, and the ratios took effect in 2004. But the long battle has made the union fiercely protective of its win. It’s even accused hospitals of “disaster capitalism;” using the pandemic to try to roll back ratios for good. Hospitals deny this and Spetz says it’s unlikely.

The public can see that nurses are overworked and burned out by the pandemic, she says, so there would be little support for cutting back their job protections once it’s over.

“To go in and say, ‘Oh, you clearly did so well without ratios when we let you waive them, so let’s just eliminate them entirely,’ I think would be just adding insult to moral injury to nurses,” Spetz said.

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