Is California's Nurse to Patient Ratio working?


On January 1, 2008, California's staffing law regarding nurse staffing ratios entered the last stage of a five-year phase-in. There are those who don't believe staffing ratios do much good. And others who believe that the law has changed hospital care for the better and improved patient safety. The law mandates that California hospitals maintain minimum, specific nurse-to-patient staffing ratios all the time for all hospital units. In addition, the ratios are a minimum, and based on patient acuity hospitals are required to increase registered nurse staffing as needed.

According to reports, because of California's staffing ratio law, 80,000 more licensed RNs have entered California's workforce, there are more nurses doing bedside care thereby alleviating the nursing shortage, and lives are being saved. The law, AB 394, was sponsored by the California Nurses Association/National Nurses Organizing Committee (CNA/NNOC), and was signed in 1999 by then Governor Gray Davis. There have been several failed attempts to block the law because of support from legislators, public support, and success in improving patient care. Since then, similar proposed bills have been sponsored by CNA/NNOC in Arizona, Texas, Ohio, Maine, and Illinois.

Of course, hospitals administrators say they cannot operate safely and efficiently with mandated nurse/patient ratios, and if forced to do so by law, some units may need to close. However, a 2002 report by the California State Department of Health Services (DHS) regarding nurse-to-patient ratios states, "......there is a growing body of evidence showing a relationship between nurse staffing levels and patient, employee, and organizational outcomes." In addition, the report states, "the evidence suggests statistical.....relationships between nurse staffing and rates of nosocomial infections, urinary tract infections, pressure ulcers, and identification of patient problems" and, "......increasing the number of RNs or enriching the RN skill mix does not appear to increase costs and may even reduce costs when the expense of adverse patient outcomes are considered."

Indeed, nurses have long believed that nurse-to-patient ratios have an effect of patient mortality rates, the quality of patient care in hospitals, and nursing recruitment and retention. Higher staffing ratios have been shown to be associated with higher patient mortality, an increase in adverse events, decreased job satisfaction and burnout. Medical-surgical nurses in hospitals that don't have a mandatory staffing ratio are caring for an average of 8 patients on day shift, and a growing number of nurses on all types of units are saying that they are responsible for more patients than they should be, or that is safe and appropriate. Nurses do not have enough time to do the things that patients have come to associate with nursing: comfort, and assist and educate patients and families. In fact, many times, that is the number one issue in a patient grievance - that nurses were not available, and patient needs were not met in a timely fashion.

In January, 2007 a bill, S.73, was introduced and referred to the Senate committee which would amend title XVIII of the Social Security Act to provide for patient protection by establishing minimum nurse staffing rations at certain Medicare providers. Its companion bill, H.R. 4138, introduced in November, 2007, seeks to amend the same title of the Social Security Act to impose minimum nurse staffing ratios in Medicare participating hospitals. Both bills have been referred to other committees.


Cortez, Z. California's Nurse-Patient Ratio Law Saving Lives, Reducing the Nursing Shortage. California Progress Report, Jan. 4, 2008.

Kravitz, R. & Sauve', M. (May, 2002). Hospital Nursing Staff Ratios and Quality of Care: Final Report on Evidence, Administrative Data, an Expert Panel Process,  and a Hospital Staffing Survey. UC Davis Center for Health Services Research in Primary Care and UC Davis Center for Nursing Research.


Copyright 2008- American Society of Registered Nurses (ASRN.ORG)-All Rights Reserved


Articles in this issue:


  • Masthead

    Editor-in Chief:
    Kirsten Nicole

    Editorial Staff:
    Kirsten Nicole
    Stan Kenyon
    Robyn Bowman
    Kimberly McNabb
    Lisa Gordon
    Stephanie Robinson

    Kirsten Nicole
    Stan Kenyon
    Liz Di Bernardo
    Cris Lobato
    Elisa Howard
    Susan Cramer

Leave a Comment

Please keep in mind that all comments are moderated. Please do not use a spam keyword or a domain as your name, or else it will be deleted. Let's have a personal and meaningful conversation instead. Thanks for your comments!

*This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.