California's mandatory nurse staffing ratios: Key lessons 2 decades in

Nearly two decades since California passed legislation mandating nurse-to-patient ratios, it remains the only state to have done so. For decades, staffing ratios have continuously sparked debate between hospitals and nurse associations, and have led to volumes of research pointing to benefits on both sides of the coin.

Now several other states including Washington, Oregon, Massachusetts and Connecticut are looking to do the same. Colorado and New York both recently passed laws that require more nurse oversight into staffing ratios, but still at this time do not have mandatory staffing ratios. 

The mandatory nurse-to-patient ratio minimum is something that for decades has continuously sparked debate between hospitals and nurse associations and has led to volumes of research pointing to benefits on both sides of the coin. The onset of COVID-19 only spurred further debate on the issue. 

Nurses point to research that illustrates improvement in care quality, patient outcomes and nurse retention.

"Hospital nurse staffing ratios mandated in California are associated with lower mortality and nurse outcomes, predictive of better nurse retention in California," a study from 2010 states.

Furthermore, more recent research, from 2017, in a white paper from National Nurses United found that when comparing hospitals in California, Pennsylvania, New Jersey and Florida, nurse-to-patient ratios were linked to improved patient care and lower patient mortality rates.

Meanwhile, hospital associations look to other research that suggests this may not always be the case, which found "mixed effects on quality" in a 2013 study.

Additional research sometimes lands somewhere in the middle. The same 2010 study mentioned above surveyed nurses from various states in addition to California and collected self-reported data from nurses measuring stressors and perceived insights about staffing, and also looked at this data in relation to patient outcomes. It found that in general, nurses in California reported being happier and having better workloads. As for patient outcomes? Signs pointed toward a link in improvement, but limitations were also prevalent. 

"In the study, they were only looking at a single year of data at a single point in time. They weren't doing a comparison of what happened before versus after the ratios were implemented," Joanne Spetz, PhD, professor and researcher at the University of California San Francisco's Center for Health Workforce Research, told Becker's. "So although the analysis essentially corroborated what had been found in many other studies — that there was an association between hospitals staffing better and having better patient outcomes — because they didn't do a pre- and post-analysis, it didn't really quite prove that the ratios had achieved benefits that they were able to achieve; but it suggested that they might have." 

Dr. Spetz has led and been part of several research efforts related to California's nurse to patient ratio law and specializes in economic research of the healthcare workforce.

However, Gerard Brogan, RN, the director of nursing practice at National Nurses United, which the California Nurses Association is affiliated with, pointed out that additional research from 2014 does reflect improvement in patient outcomes.

"Registered nurse staffing levels that facilitate safe, competent, therapeutic and effective care is vital to the safety of patients in U.S. hospitals," the study reads. "Allowing hospitals to set staffing levels that are primarily budget driven, while not setting up a system of accountability, has created a threat to patient safety. Without necessary safeguards, hospitals may engage in nurse staffing cuts to save money, thereby adversely affecting patient outcomes."

The main point of contention continues to revolve around strained and short-staffed nursing teams needing ratios to maintain quality of care and reduce burnout. Meanwhile, hospitals already experiencing difficulty with staffing express strain on being able to adequately fulfill enough roles to adhere to the ratios. 

Dr. Spetz points out that some of the research and California's ratio requirement are both growing older with each year. The law hasn't been revised since it was enacted, she noted, suggesting that perhaps there is room for improvement and finding common ground in years to come.

What nurses say 2 decades in

Mr. Brogan has been working in healthcare for nearly 40 years. When he initially came to California, he worked at the University of California San Francisco as a charge nurse in a child psychiatry unit and quickly became involved with the state's nursing association in 1993 — six years before the nurse-to-patient ratio legislation would be voted on and about 10 before it would become fully implemented throughout the state. 

He told Becker's the ratios have "unequivocally" made a difference in the profession for the better.

"You could probably speak to 100 nurses, or take a straw poll of nurses from various states across this country, and if you ask them, 'What would keep you in the profession?' I guarantee you 90 percent of those nurses would say nurse-to-patient ratios. They would cite burnout and moral distress as why they cannot take this anymore." Mr. Brogan said. "There are limits on how many children are taken care of in a day care. There are limits on dog kennels. We need limits for safety."

Guaranteed staffing ratios were also cited by travel nurses in previous coverage done by Becker's as one thing that would lure them back to hospitals for full-time positions. 

Anita Girard, DNP, RN, chief nursing officer and vice president of nursing at Los Angeles-based Cedars-Sinai, echoed the benefits she has seen the ratios make for California nurses.

"I do think that ratios have made a positive difference upon patient care and nursing satisfaction," she told Becker's. "I want to point out, though, that even trying to maintain the mandated ratio of 1-to-5 on a medical/surgical unit is difficult with the intense acuity of our patient populations." 

Right now, California's ratios for various care units include: 

  • 1-to-1 in operating rooms
  • 1-to-2 in intensive care, labor and delivery, ICU patients in the ER, and neonatal care
  • 1-to-3 in step down
  • 1-to-4 in emergency rooms, postpartum/antepartum and telemetry units
  • 1-to-5 in medical-surgical units
  • 1-to-6 in postpartum (women only) and psychiatry units

During the pandemic, many put off health issues they were dealing with at the time, which have now grown worse, Dr. Girard said, with more patients now requiring higher-acuity care for various issues, creating a challenge for nurses and hospitals to keep up with in terms of staffing. However, staffing nurses is not something Cedars-Sinai has faced challenges with itself, she pointed out.

"Many of the nurses that we hired have expressed how much they appreciate ratios being defined in the state of California," Dr. Girard said.

Challenges hospitals face because of ratios 

Despite the benefits and improved working conditions nurses report feeling as a result of the ratios, the California Hospital Association argues that the mandatory patient-to-nurse minimum is ineffective and requires more money and resources to staff, which can become cumbersome for hospitals. 

Hospitals in other states looking at legislation have noted concerns about potentially having to cut services to finance the positions for nurses needed to meet staffing standards.  

"California is currently short more than 40,000 RNs — despite having nurse staffing ratios in place for almost 20 years," Jan Emerson-Shea, vice president of external affairs for the California Hospital Association, told Becker's

Ms. Emerson-Shea pointed to a study, also led by Dr. Spetz, that highlights the shortage of nurses in California is estimated to take at least until 2026 before it evens out. 

Once enacted, the ratios became a lot to finance for some hospitals, Dr. Spetz said. In certain areas, they chose to finance some of the now additionally needed nurse positions by cutting from other areas like nurse aids. 

"That worried us, because for some patient outcomes, the presence of aids to help licensed nursing staff would be very important to affecting some patient outcomes," she said. 

Another area of contention between California's hospitals and nurses after the ratios went into effect, Dr. Spetz said, was "around whether the ratios truly applied at all times, including scheduled breaks." 

Scheduled breaks are something that California's labor law is very strict around, so if a hospital did not have enough nurses on a shift to staff up to ratio standards, the difficulty became: How do nurses take their breaks if hospitals have to operate below a patient-to-nurse minimum for a short time, but cannot by law? 

However, Mr. Brogan told Becker's this is a non-issue and said this is solvable by having break relief nurses.

Dr. Spetz also noted that in some research she did early on, she and her colleagues looked at hospitals that had poor staffing before the ratios went into effect, expecting to see vast improvements in patient outcomes after the law was fully implemented, but instead found that it was really more of a wash. 

In those cases with poor staffing before the ratios, "we did not find any consistent evidence that there were improvements in patient outcomes," she said.

However, Dr. Spetz also said that during some of the research she has done around the California nurse-to–patient ratios, even a few hospital executives expressed positivity about the implementation of them.

"We've had some nursing leaders in hospitals say that they did not really mind the ratios at all," Dr. Spetz told Becker's. "They acknowledged that there were logistical challenges, but they also felt like it empowered them as leaders and their hospitals to really demand the budgets that they always wanted to have to staff nursing."

Finding common ground for future laws 

Both sides continue to share one common goal: Ensuring the best possible quality of care for the patients that enter their walls. As such, for states looking to approach new legislation around nurse-to-patient ratios, Dr. Spetz and Dr. Girard agree that designing it with flexibility is key. 

With flexibility as part of the legislation, this would allow hospitals and nurses to perhaps take more of a collaborative approach to what is necessary and adjust as needed.

"Thread the needle between flexibility and accountability, having some kind of clearly enforceable minimum," Dr. Spetz recommended. "If you're going to have the minimum ratios, I would recommend that states think holistically about staffing. Not just focus on the licensed nurses." 

Dr. Girard underscored this, adding that ratios would do better if they could be based on the "acuity of the patients and the skill mix of the nursing staff."

"My recommendation would be for more flexibility in determining what is right for an organization. A community hospital may have different needs than an academic medical center, depending on nursing skill mix and the patients they serve, and night shift may have different needs than day shift," Dr. Girard said. "The same ratios may not always be needed on night shift due to fewer procedures and other interventions."

Mr. Brogan added that for states and nurse associations looking to create ratios or staffing laws, it is important to focus on the numbers and acuity. He said the California Nurses Association feels that overall, "if ratios were installed [in other states], we actually think hospitals, in the long term, would not [be] losing money because by doing that, they'd rather certainly have a happier workforce, there'd be less turnover."

Editor's note: This article was updated February 16 at 4:17 p.m. CT to add an additional comment from Mr. Brogan.

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