In today’s world of nursing, there are efforts to improve patient care at hospitals. Severalstates across America are considering implementing nursing ratio laws. This ratio law wouldrequire hospitals to have strict nurse-to-patient ratios enforced at all times. Only California hasimplemented nursing ratios so far and it has been the subject of mixed reviews.
Steps the legislation went throughThroughout the 1990’s, health care labor unions in California tried to implement nursestaffing laws through legislation and ballot initiatives. The California Nurses Association (CNA)campaigned for several years to constitute a mandated nurse-to-patient ratio system in California.
The first endeavor was in 1993 when Assembly Bill (AB) 1445 was introduced into theAssembly. Unfortunately, the bill did not succeed. The nurse-to-patient ratios were also a part ofProposition 216, the health care reform initiative introduced by CNA in 1996. Governor PeteWilson vetoed another version of the ratio bill, AB 695, which was passed by the legislature in1997 (Institute for Health, 2001). The CNA organized a rally of nurses and patients throughoutCalifornia to win enactment of AB 394. More than 10,000 letters, post cards and phone callswere made to the governor in support of the bill. Registered nurses (RN) and senior citizens bythe thousands assembled on the Capitol Steps in support of the bill in September, 1999 (Dumpel,H. 2003).
Description of issue and recently enacted legislationAB 394 was passed and signed by Governor Gray Davis in 1999. This bill “directs theCalifornia Department of Health Services to establish minimum, specific, and numerical licensednurse-to-patient ratios by licensed nurse classification and by hospital unit” in acute carehospitals. Although it passed in 1999, it was not implemented until January 1, 2004 due to thefact that the California Department of Health Services could not base deductive evidence onwhich to base the actual ratios (Coffman, J., et al, 2002). The implementation was frozen as anemergency by California Governor Schwarzenegger due to the severe nursing shortage and highcosts. California courts upheld the Governor and enforced tougher standards (Anonymous,2007).
Under the legislation enacted, acute care hospitals in California need to have a minimumof one licensed nurse for every two patients in intensive care units, one nurse for every operatingroom patient and one nurse for every five patients on a medical surgical floor. The legislationcalls for half of the licensed personnel working in intensive and coronary care units to belicensed as an RN. The consequence of the nurse ratio law on quality and access to patientcare is still a subject of debate in California (Coffman, J., et al, 2002).
Impact of nursing practiceThe CNA claims that “ratios have been successful in creating safer workingenvironments in hospitals”. The CNA believes that having the ratio laws in effect will attractRNs that have left the field. Data obtained from the CNA shows that since the ratio law wassigned, the number of actively licensed RN’s in California have grown by more than 60,000,with an additional 60% increase in RN new applications. Turnover vacancy rates in California’sbiggest hospital systems have fallen below 5% as a result of this ratio law (CNA, 2005).
Supporters of the ratio law believe that staffing ratios help improve working conditions andattract more young people to the nursing profession. Working conditions within acute carehospitals have an impact on the number of RNs that choose to practice there (Coffman, J, et al,2002).
Impact on quality of health care delivery to the patientThere is a strong correlation between nurse-to-patient staffing ratios compared to lowrates of medication errors and patient deaths. Nurse staffing is key to influencing patientoutcomes. In a study of orthopedic and vascular surgery patients discharged from 168Pennsylvania hospitals, the risk of adverse outcomes were 31% higher in the hospitals thatstaffed 1 nurse to 8 patients, compared to 14% higher with hospitals that staffed 1 nurse to 4patients. Hospitals that staff 1 nurse to less than 5 patients also have a lower incidence of patientfalls, medication errors and nosocomial infections (MacPhee, M., et al, 2006). Improved RN topatient ratios also have a reduced rate of pneumonia, urinary tract infections, shock, cardiacarrest, gastrointestinal bleeding, and other adverse outcomes in acute care settings. Recentresearch indicates that the cost of the RN to patient ratio law is considerably lower than the costof basic safety interventions commonly used in hospitals such as PAP tests for cervical cancerand clot-busting medications to treat stroke and heart attacks.
Shorter lengths of stay have alsobeen reported since the ratio laws took place (Needleman, J., et al, 2002)HistoryCalifornia became the first state to mandate minimum nurse staffing ratios. Suggestionsfor nurse-to-patient ratios have been specified in union contracts at hospitals in several otherstates. Since California passed AB 394, related bills were introduced in many other states suchas Massachusetts, New Jersey, New York and Pennsylvania. The cause for staffing ratios was aresult of average patient acuity in the state of California rising and projected increases for acuitylevels to keep increasing through the next 20 years (Institute for Health, 2001). AB 394 mayhave a major impact on demand for nursing personnel, the adequacy of nursing supply and thequality of nursing care provided to consumers. Nursing unions in California representing nursessaw this bill as an aid for improving patient and employee safety. Hospitals throughoutCalifornia were concerned that AB 394 would increase the difficulties they face in recruiting andretaining nurses (Coffman, J., et al, 2002).
Position of various health organizations on the issueThe topic of nursing ratios seem to be a convincing tool in protecting patient safety andimproving working conditions for nurses. However, realistic thought must be taken inestablishing attainable and pragmatical ratio standards. It is expensive and difficult to attract andretain enough qualified nurses to meet these ratios. Many proponents feel there are not enoughnurses available to meet these requirements. Difficulties in recruiting and retaining hard-to-findnurses costs an estimated $422 million and is a factor in the closure of several hospitals and aleading cause for shutdowns of 11 ERs and psychiatric units throughout California (Leighty, J.,2005).
California ranks 49th across all states in the number of nurses per capita. The stateEconomic Development Department states, “California will be short more than 97,000 RNs bythe year 2010”. When the ratio law began in California in 2004, 85 per cent of hospitals were notable to be compliant with the regulations. The main contributing factor was not having enoughnurses to cover meal breaks (Anonymous, 2004).
Medical surgical nurses see understaffing as a problem that contributes to nurse burnout.
Three out of five nurses state that low staffing levels have a negative impact on patient care.
Three out of five nurses also state they have thought about leaving the hospital floor nursingsetting in the past two years. Nurses across the country feel that ratio regulations would improveworking conditions (AFT Healthcare, 2003).
Impact of this legislationThe CNA believes that nursing ratios protect patient’s safety and eliminatesdangers associated with patient overload. CNA President Deborah Burger strongly feels that theratio laws have alleviated the nursing shortage by attracting 30,000 RNs to the state. She feelsthat burned -out or retired nurses are coming back into the profession because of betterconditions in the workplace (Leighty 2005).
From a nurse’s point of view, the ratio regulations are what has been needed to improvepatient care and nurse satisfaction. For each extra patient above 4 added to a nurses assignment,there is a 23% increase in burnout and 15 % increase in job dissatisfaction. Research has shownthat better staffing for nurses in hospitals is reflected lower levels of absenteeism and higher jobsatisfaction (MacPhee, M., et al 2006).
Legal responsibilities and Ethical dilemmasThe recent ratio regulations have caused problems throughout California. Hospitals areat times unable to receive patients, ambulances are diverted to more far away hospitals andpatients are now waiting longer in the emergency rooms. Before the regulation was made inplace in California, many nurses felt they made decisions about patient care and were able toplan his or her workday to meet their patient’s needs. Many feel now, that the regulation is a”numbers game”. (Leighty, J., 2005). Some hospitals may look to cut costs to keep up with thecost of the ratio laws. They may look to decrease other personnel such as unlicensed caregivers,ward clerks, transporters and housekeepers. This could make nursing jobs in the hospital lessappealing to RNs. Higher personnel costs can also sway hospitals from ordering new medicalequipment with state of the art safety features (Coffman, J., et al 2002).
Although the ratios are a subject of mixed reviews, many nurses in California are happywith the regulation. As a newer nurse who recently entered the profession, I am overwhelmed attimes with my patient load of five patients. I am thankful to work in a state where nurse ratiolaws are in place. Adding more patients to my daily assignment would more than likely makeme leave the hospital setting due to burn-out due to high levels of job dissatisfaction.
AFT Healthcare (2003, April) Patient- to- Nurse Staffing Ratios: Perspectives from HospitalNurses. Retrieved February, 10, 2004 from http://www.aft.org/pubs-reports/healthcare/HartStaffingReport2003.pdfAnonymous (2004). California Hospitals Express Disappointment Over Court Ruling on NurseStaffing Regulation: Ruling Jeopardizes Hospital’s Ability to Guarantee Access to Care.
Retrieved February 13, 2007 from http://www.calhealth.org/public/press/Article%5C103%5CCHA%20News%20Release%20on%20Nurse%20Ratio%20Lawsuit%205-26-04.pdfAnonymous (2007). Does Nurse-To-Patient Ratio Legislation Help Patients or Harm Hospitalsin the United States? Retrieved February 10, 2007 from http://www. Globalinsight.com/Perspective/PerspectiveDetail6099.htmCalifornia Nurses Association (2005) RN to patient Ratios. Retrieved February 10, 2007 fromhttp://www.calnurses.org/nursing-practice/ratios/ratios_index.htmlCoffman, J., Seago, J., Spetz, J., (2002) Minimum Nurse-to-Patient Ratios in Acute CareHospitals. Health Affairs, 21(5), 53-64. Retrieved February 13, 2007, from Research LibraryDatabase.