One suggested approach to ensure safe and effective patient care has been to mandate nurse staffing ratios. In 1999 California became the first state to mandate minimum nurse-to-patient ratios in hospitals. California is not the only state to enact minimum nurse staffing ratios for hospitals, over the past four years at least eighteen other states have considered legislation regarding nurse staffing in hospitals. Policymakers are forced to consider alternatives to nurses ratios due to nurse shortages. Whether minimum staffing ratios will improve working conditions enough to increase nurse supply is unknown.
The United States healthcare system has changed significantly over the past two decades. Advances in technology and an aging population (baby boomers) have led to changes in the structure, organization, and delivery of health care services (Spetz, 2001). Low nurse staffing levels in acute care hospitals are jeopardizing the quality of patient care and is the leading cause for Registered Nurses (RNs) to leave the profession (Spetz, Seago, et al., 2000). Apprehension for the nursing workforce and the safety of patients in the U.S. healthcare system now has the unprecedented attention of healthcare policy leaders at every level (Spetz, 2001). One suggested approach to ensure safe and effective patient care has been to mandate nurse staffing ratios (Donaldson, FAAN, Bolton, Janet, Meenu Sandhu, 2005).
In 1999 California did just that, it became the first state to enact legislation mandating minimum nurse-to-patient ratios in acute care hospitals (Donaldson, FAAN, Bolton, Janet, Meenu Sandhu, 2005). Assembly Bill 394 (1999), directed the California Department of Health Services (DHS) to establish specific nurse-to-patient ratios for inpatient units in acute care hospitals. This was done by creating a hospital Licensed nurses classification to include both RNs and licensed vocational nurses (LVNs) also referred to as licensed practical nurses (LPNs) (California, 2002 July).
This was not the first time a legislation had contemplated a nurse-to-patient ratio. In 1996, proposition 216 would have established staffing standards for all licensed health care facilities in addition to creating a statewide health insurance system (California, 2002 Janurary). The ballot proposition that was rejected by the voters in 1996. Again in 1998, Assembly Bill 695 was introduced and approved by the state legislature but vetoed by then Gov. Pete Wilson (California, 2002 Janurary). Intense lobbying by unions representing California nurses would change everything with the passage of Assembly Bill 394 (California, 2002 July).
The intense lobbing paid off with the election of a new governor, Gray Davis, in November 1998, who was endorsed by unions representing nurses and other workers (Spetz, Seago, et al., 2000). California DHS proposed the minimum nurse-to-patient ratios (California Hospital, 2004). Thus ranged from one nurse per patient in operating rooms to one nurse per eight infants in newborn nurseries. The DHS proposed that the minimum ratios for medical-surgical and rehabilitation units be phased in (California Hospital, 2004). They initially set minimum ratios for these units at one RN or LVN per six patients and within twelve to eighteen months the goal was to shift to one nurse per five patients (California, 2002 July).
Prior California law regarding nurse staffing in acute care hospitals were extended under Assembly Bill 394 (1999). State and federal regulations affect the demand for licensed nurses. Under the 1976-77 state legislative session, California hospitals must have a minimum ratio of one licensed nurse per two patients in intensive care and coronary care units (California Hospital, 2003). Federally certified nursing homes are required to have a RN director of nursing and a RN on duty 8 hours a day, seven days a week (California state). If the facility has under 60 beds, the director of nursing can serve as the RN on duty (Harrington, 2001).
This legislation also requires that at least half of licensed nurses working in intensive care and coronary care units be RNs (California state ,Title 22, Division 5, Chapter 1, Article 6, Section 70495(e).) Legislation enacted in the early 1990s requires hospitals to use patient classification systems to determine nurse staffing needs for inpatient units on a shift-by-shift basis and to staff accordingly (California state ,Title 22, Division 5, Chapter 1, Article 6, Section 70495(e)).
In January 2004, hospitals also will face minimum licensed nurse-to-patient ratio requirements in other hospital units, as established by Assembly Bill 394 (California state, Chapter 945, Statutes of 1999). Numerous estimates of the effect of these ratios on demand for licensed nurses have been published. The DHS analysis, conducted by researchers at the University of California, Davis, predicts that 5,820 new nurses will be needed in California hospitals to meet the staffing requirements (Kravitz, Sauve, Hodge, et al., 2002). Other analyses conducted by independent researchers have reported that the increased demand for nurses due to the ratios could be as low as 1,600 (Spetz, 2002).
Growing numbers of research associates important benefits for patients and nurses will arise with the Assembly Bill 394 (Aiken, Clarke, Sloane, 2002). It has been argued that nurse staffing levels are now so low as to jeopardize the well-being of hospital patients (California. Office of the Governor, 2002). Supporting Assembly Bill 394, minimum nurse-to-patient ratios assure quality by establishing a minimum standard below which no hospital can fall (Assembly Bill 394, 1999). Researchers disagree with California’s statute requiring use of acuity-based patient classification systems because it is inadequate and difficult to determine whether hospitals are complying with this mandate (California Hospital, 2004). Instead they support a, simple minimum ratios to enable nurses, patients, and family members to easily identify and report inpatient units with dangerously low staffing levels (Donaldson, FAAN, Bolton, Janet, Meenu Sandhu, 2005).
It is believed that working conditions have a large influence on the number of persons willing to practice nursing in hospitals (Kravitz, Sauve, Hodge, 2002). To most, minimum staffing ratios would improve working conditions, which would in turn reduce the numbers of nurses leaving hospital positions and the nursing profession (Donaldson, FAAN, Bolton, Janet, Meenu Sandhu, 2005). Creating a better work environment and conditions also may attract more young persons to nursing (Kravitz, Sauve, Hodge, 2002). Increased attention to nursing and rising salaries are already raising interest levels; the American Association of Colleges of Nursing reports that enrollments in baccalaureate nursing programs increased in 2001, for the
first time in six years (American Association of Colleges of Nursing, 2001).
The Assembly Bill 394 (1999), is great and will create a safer environment for patients, and staffing ratios would help to alleviate the nursing shortage but without nurses to meet the ratios one cannot uphold and follow the nurse-patient-ratios. This is why California Governor Gray Davis announced the Nurse Workforce Initiative in his January 2002 State-of-the-State speech (California. Office of the Governor, 2002). The purpose of the Nurse Workforce Initiative (NWI) is to develop and implement proposals to recruit, train, and retain nurses both to address the current shortage of nurses in California and to support implementation of new hospital nurse-to-patient staffing ratios also announced in late January 2002 (Seago, Spetz, Coffman, Rosenoff, O’Neil, 2003).
The Governor made available $60 million over three years for the NWI (California, 2002 July). His goal is to use components designed to address the nurse shortage using both short and longer term strategies. This can range from working in partnership with local hospitals, scholarships for nursing students, career ladder projects, workplace reform efforts, and other strategies to increase the number of nurses (California, 2002 July). An evaluation will be done to determine which strategies to increase the supply of nurses are most effective and improve the understanding of the labor market dynamics for nurses (Seago, et al, 2003).
Whether minimum staffing ratios will improve working conditions enough to increase nurse supply is unknown. The experience of hospitals in Victoria, Australia, one of the few jurisdictions to implement minimum nurse-to-patient ratios in hospitals, is instructive (Needleman, Buerhaus, Mattke, Stewart, Zelevinsky, 2001). Large numbers of nurses returned to the nursing profession after the minimum ratios were established. However, hospitals continued to face a shortage of nurses, because there were not enough returning nurses to meet demand, forcing hospital to close hospital beds (Needleman, Buerhaus, Mattke, Stewart, Zelevinsky, 2001).
Besides, minimum staffing ratios address only one piece of the ‘ dissatisfaction with hospital nursing. Staffing is a major concern of many nurses, but RN job satisfaction indicates that they are also dissatisfied with other aspects of their work, including low salaries, lack of control over work schedules, lack of opportunities for advancement, lack of support from nursing administrators, lack of input into policy and management decisions, and inadequate support staff to perform non nursing tasks (Spetz, 2002).
Maine and Massachusetts state affiliates cut their ties with the American Nurses Association (ANA) in 2001, in large part because they did not fully agree with the ANA’s opposition to minimum nurse-to-patient ratios (American Nurses Association, 2003). This led to the establishment of the American Association of Registered Nurses in February 2002, leaders of unions representing nurses in California, Maine, Massachusetts, Missouri, and Pennsylvania joined to establish a new national association (New England, 2005). The unions will join forces on national projects and support one another’s state legislative, collective bargaining, and organizing campaigns.
Further research is needed to establish the number of states in which nurses’ unions have sufficient political power to enact minimum nurse-to-patient ratios. In the short term, the number of states is likely to be small. California’s rate of unionization among nurses, approximately 25 percent, is much higher than that of most states (Aiken, Clarke, Sloane, 2002). In addition, ANA affiliates are more powerful in other states than in California. Proactive ANA affiliates may be able to persuade policymakers to implement other reforms that address nurses’ concerns about hospital staffing (American Nurses Association, 2003). Other important variables include the political influence of state AHA affiliates and elected officials’ ties to organized labor (American Nurses Association, 2003).
California is not the only state to enact minimum nurse staffing ratios for hospitals, over the past four years at least eighteen other states have considered legislation regarding nurse staffing in hospitals (New England, 2005). Twelve states have considered bills that would mandate minimum nurse-to-patient ratios in hospitals. Fourteen states have considered legislation that attempts to address nurses’ concerns about staffing through other means, such as requiring hospitals to develop staffing plans based on patient acuity, mandating disclosure of nurse staffing ratios, and establishing a task force to study and monitor nurse staffing. Oregon, has enacted legislation that requires acuity-based staffing plans (New England, 2005).
Policymakers in other states may wish to consider a well-designed acuity-based ratio system as an alternative to minimum nurse-to-patient ratios (New England, 2005). Many states have regulations that require hospitals to use patient classification systems to determine nurse staffing, but these regulations face much criticism, as discussed above. Although many of these regulatory systems do not function well today, they could form the basis for strong but flexible staffing regulations in the future (New England, 2005). States could mandate particular patient classification systems, develop methods of ensuring that staff and patients are aware of the required staffing during every shift, and establish effective enforcement mechanisms (New England, 2005).
Alternatively, states could require that hospitals submit information relevant to their staffing needs every quarter and could mandate a ratio for that quarter based on an analysis of patients’ needs, availability of support staff, and other factors (New England, 2005). Texas is pursuing a totally different approach to the nursing situation that is tailored to the unique circumstances of individual hospitals. Under regulations issued 24 March 2002, hospitals are required to establish committees to develop nurse staffing plans and to use data on nurse-sensitive patient outcomes to assess and adjust staffing plans (Texas Nurses Association, 2002). At least one-third of the members of these committees must be RNs engaged primarily in direct patient care (Institute, 1999).
The minimal nurse staffing on patient acuity or nurse-sensitive outcomes respond to nurses’ justifiable concerns about hospital staffing without imposing rigid mandates (Harrington, 2001). The flexible staffing approaches seem more appropriate than ratios, given the complexity and rapid pace of technology changing the delivery of hospital care. (Harrington, 2001). Nurses’ job satisfaction and retention may enhance the opportunities for hospital nurses to play a more direct role in staffing decisions (Kravitz, Sauve, Hodge, 2002).
The key is without more nurses no ratio can be met. So the focus needs shift on reaching as many young people as possible by showing them that they to could be a good fit in the nursing community. They need to know that nurses are people too, and the traits of a nurse, such as not being squeamish over the sight of blood comes with time. Stepping out into the high schools and broadcasting information about nurses can translate into only one thing, more students who pursue a nursing career. There is no better way to start, than by planting a seed in the mind of a young person who is about to step out into the world and choose a career. The more educating and qualified young people health care workers can get to chose a nursing career, the better off the nurse-to-patient ratio becomes, allowing for a safer environment for future patients, by permitting more effective health care.
Aiken, L., & Clarke, S., & Sloane, D. (2002). Hospital Restructuring: Does It AdverselyAffect Care and Outcomes? Journal of Nursing Administration, 30(10), 457-465.
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t%20Sheet%20finaCalifornia Hospital Association. (2003, September). Hospital minimum nurse-to-patient ratios asrequired by AB 394. Retrieved April 13, 2005 fromhttp://www.calhealth.org/public/press/Article/113/Nurse%20Ratio%20chart.pdfCalifornia. Office of the Governor. (2002, January 22). Governor Gray Davis Announces Proposed Nurse-to-Patient Ratios. Press Release, Sacramento: Office of the Governor.
California. Office of the Governor. (2002, July 15). Sets Nation’s First Safe Nursing Standards: Governor Davis Announces Nurse-to-Patient Ratios, Press Release, Retrieved 10 June, 2007, fromhttp://www.calnurses.org/nursing-practice/ratios/ratios_index.htmlCalifornia state legislature Retrieved 10 June, 2007, from http://www.legislature.ca.gov/Donaldson, N., & FAAN, B., & Bolton, L., & Janet E., & Meenu Sandhu, M. (2005, August 08). New study examines impact of nurse-patient ratios law, California. Retrieved 10 June, 2007, from Policy, Politics & Nursing Practice’s website: http://ppn.sagepub.comHarrington, Charlene. 2001. “Nursing Facility Staffing Policy: A Case Study for Political Change.” Policy, Politics, and Nursing Practice, 2(2), 117-127.
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