Has California's Nurse Staffing Ratio Improved Patient Care?


The California Legislation

A recent study on the effect of nurse-to-patient ratios on care in California hospitals has concluded that hiring more RegisteredNurses has little effect on patient care especially in two areas, namely, patient falls and bed sores (Donaldson, 2005). In this context, California is the first state in the United States to enact a legislation requiring hospitals to meet minimum staffing standards, limiting the numbers of patients that Registered Nurses and Licensed Vocational Nurses may care for at any one time. Further, the California Department of Health Services (CDHS) regulations implementing new ratios requirements have came into effect from 2004 after a Sacramento Superior Court Judgment upheld the California Department of Health Services (CDHS) nurse staffing regulation that requires hospitals to reassign patients to a different nurse anytime their assigned nurse takes a break rejecting the arguments made by the California Healthcare Association challenging the state's mandated nurse-to-patient staffing ratios. The ratios range from one nurse per patient in trauma units to one nurse to six patients in a medical/surgery unit. Research studies have found that the mean total RN hours of care per patient day has increased by 20.8% in medical-surgical units and that the number of patients per RN has decreased by 17.5% following CDHS regulations (Donaldson et.al, 2005).

The Core Issues

Although, assessment of the impacts of the mandated ratios on patient care quality based on the indicators of quality, namely, Patient falls and Bed sores has shown that hiring more RegisteredNurses has little effect on patient care, it is important to address some core issues of care in such assessments like, Patient Anti-Dumping Law, Nurse Burnout and Nurse Shortage that have serious implications in Patient Care. Thus, it is important to address the issue of hiring more nurses also from the view point of the Nursing Profession instead of Patient Care alone and it is better to take up more complex care indicators from Emergency nurse care, ICU Nurse Care, Operating Room Nurse Care or Cancer care for assessment of the impact of the mandated ratios instead of simple indicators like Nurse Care in Patient falls and Bed Sores.

Nurse Burnout has serious consequences on account of the medical errors that can occur in an emergency department. A recent study has elucidated the role of work stressors and shown that depersonalization and reduced personal accomplishment are two important dimensions of nurse burnout (Sabine Stordeur et.al, 2001). Mark Gillespie and Vidar Melby (2003) in their quantitative and qualitative study on emergency nurse burnout using the Maslach Burnout Inventory conclude that stress and burnout have far reaching effects both for nurses in their clinical practice and personal lives.

Further, the Federal Emergency Medical Treatment and Active Labor Act, also known as the Patient Anti-Dumping Law commonly referred to as EMTALA passed in 1986 warrants proper emergency attention in USA and the emergency departments of most hospitals operate around the clock. With lower staffing levels at night, there are reports on the work-related stress and on emergency nurse burn out as evidenced by the published literature.

Statistics show that the total number of nurses working in the healthcare field in the United States has decreased from 2,669,603 in the year 2000 to 2,262,020 in year 2001(World Health Organization, 2006) with a simultaneous increase in nurse responsibilities, decrease in the number of applicants to baccalaureate programs and an aging workforce. This shortage can be defined by either a need based approach or a ratio technique. The need based approach identifies the number of professionals needed to perform certain tasks based on the judgment of a nursing or a medical professional. The ratio technique compares the current professional population ratio to a projected future ratio and identifies a difference as a shortage (Lane and Gohmann, 1995). The nurse shortage in US by the year 2020 is projected to be 1 million (Brush, 2004) and an American Hospital Association survey has revealed a shocking 1, 26,000 unfilled nursing positions in 715 hospitals in US (Trossman, 2002).

Published Evidence

A complex study to investigate the relation between patient outcomes in orthopedic, vascular and general surgery wards and patient-to-nurse ratios has shown that there is a significant association between patient-to-nurse ratio and nurse burnout with a risk for surgical mortality taking us to the conclusion that nurse staffing ratios do matter for positive patient outcomes (Schwenk, 2002). A study to determine the relationships between nurse staffing and specific nurse-sensitive outcomes especially in central line blood-associated infections, pressure ulcer, fall and medication errors across specialty units including cardiac and noncardiac intensive care, cardiac and noncardiac intermediate care and medical-surgical care has shown that the impact of staffing on outcomes is highly variable across specialty units taking us to the firm conclusion that specialty care aspects are better indicators for care assessment (Whitman et.al, 2002).

A study to evaluate the effect of extended work shifts and overtime on patient safety has shown that the risks of making an medical error increases significantly when work shifts are longer than twelve hours or when the nurses work more than forty hours per week (Rogers et.al, 2004). A longitudinal cohort study to evaluate previous research findings of the relationship between nurse staffing and quality of care by examining the effects of change in Registered Nurse staffing on change in quality of care has shown that increasing Registered Nurse staffing has a diminishing marginal effect on reducing mortality ratio and improves quality of care (Mark et.al, 2004). Another multilevel analytical study to examine the effects of nurse staffing on adverse events including patient fall, injury, pressure ulcer, adverse drug event, pneumonia, urinary tract infection, wound infection, sepsis, morbidity, mortality, and medical costs has shown significant relationships between poor nurse staffing and adverse events highlighting the need for having appropriate nurse staffing (Cho et.al, 2003). A cross-sectional descriptive study to examine the impact of nurse staffing on selected adverse events sensitive to nursing care has shown an inverse relationship between RN hours per adjusted inpatient day and pneumonia (p<.05) for routine and emergency patient admissions taking us to the conclusion that proper staffing level has an impact on minimizing adverse events (Kovner et.al, 2002). A Cross-Sectional Analytical Study to determine the association between the patient-to-nurse ratio and patient mortality, failure-to-rescue following complications among surgical patients and factors related to nurse retention has shown that each additional patient load per nurse is associated with a 23% increase in nurse burnout and a 15% increase in job dissatisfaction with a higher mortality and failure-to-rescue rates (Aiken et.al, 2002). Statistically, If respect for patient's values, preferences and expressed needs can be dependant variables of Patient Care, then, Nurse welfare should be considered as the moderating variable that has an effect on the dependant variables.


It is important to see Patient Care as a direct outcome of Nurse Welfare. It is because of the fact that core issues like Nurse Burnout and Nurse Shortage hinder the care process by contributing to depersonalization and reduced personal accomplishment of the nurses. Thus, any care process that ignores nurse welfare cannot be deemed complete. California's Nurse Staffing Ratio has definitely improved patient care by addressing core issues in Nursing Profession today like Nurse Burnout and Nurse Shortage that seriously affect the quality of care. It is better to take up more complex care indicators to assess the quality of care with reference to staffing ratio. Thus, hiring more Registered Nurses is not the issue of how many nurses care for how many patients-but an issue of how patients are being taken care of by nurses whose welfare is being taken care of. It is time to strive towards Nurse Welfare to achieve better Patient Care.


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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

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