SummaryAs mandated by State law, the California Department of Health Services requires acute care hospitals to maintain minimum nurse-to-patient staffing ratios. Required ratios vary by unit, ranging from 1:1 in operating rooms to 1:6 on psychiatric units. The legislation also requires that hospitals maintain a patient acuity classification system to guide additional staffing when necessary, assign certain nursing functions only to licensed registered nurses, determine the competency of and provide appropriate orientation to nurses before assigning them to patient care, and keep records of staffing levels. To assist with compliance, the legislation made grants available to hospitals and provided funding to college and university nursing programs to increase the pipeline of new nurses. The legislation has increased nurse staffing levels and created more reasonable workloads for nurses in California hospitals, leading to fewer patient deaths and higher levels of job satisfaction than in other states without mandated staffing ratios. Despite initial concerns from opponents, the skill mix of nurses used by California hospitals has not declined since implementation of the mandated ratios.Moderate: The evidence consists of pre- and post-implementation comparisons of nurse staffing levels in California hospitals, along with post-implementation comparisons of key nursing-related metrics in California to several other large states without mandated ratios; metrics include patients per shift, 30-day mortality rates, levels of job satisfaction and burnout, and nurse skill mix.
Developing OrganizationsCalifornia Department of Health Services; California Nurses Association
Use By Other OrganizationsCalifornia was the first state to implement minimum nurse-to-patient ratios in acute care hospitals; as of 2011, 14 other states have enacted some type of regulation related to nurse staffing levels, and 17 states have introduced legislation mandating minimum ratios.
Date First Implemented2004
The minimum staffing ratios went into effect on January 1, 2004; all other aspects of the legislation went into effect on January 1, 2000.
Problem AddressedHeavy patient workloads for nurses have been associated with poor patient outcomes and low job satisfaction. Yet few states require hospitals to maintain minimum nurse-to-patient ratios, leaving nurses to care for a significant number of patients at a time.
- Link between heavy workloads and poor patient outcomes: Many studies have found that heavier nursing workloads are associated with poor patient outcomes, including more patient deaths, complications, and medical errors.1 For example, one study found that each additional patient added to a nurse’s workload increased mortality within 30 days of admission by 7 percent, and increased the risk of an undetected medical complication leading to preventable death or harm (known as a "failure to rescue") by a similar amount.2 A meta-analysis of 90 studies found that increased registered nurse (RN) staffing was associated with lower mortality on intensive care, medical, and surgical units; reduced risk of hospital-acquired pneumonia, unplanned extubation, respiratory failure, cardiac arrest, and failure to rescue; and shorter lengths of stay for surgical (31 percent) and intensive care unit (ICU) patients (24 percent).3 Other studies have confirmed that higher nurse staffing yields better patient outcomes, including shorter lengths of stay and lower rates of urinary tract infections, upper gastrointestinal bleeding, pneumonia, shock, cardiac arrest, and failure to rescue.4
- Negative implications for nurses as well: The study cited above found that each additional patient assigned to a nurse led to a 23-percent increase in the risk of nurse-reported “burnout” and a 15-percent increase in the risk of a nurse being dissatisfied with his/her job.2 Another study found that nurses in states without mandated minimum staffing ratios reported greater levels of burnout, job dissatisfaction, and turnover; these nurses also felt that patients received poorer quality care.5
- Few states addressing minimum staffing levels through legislation: Despite the evidence cited above, only a handful of states have any type of legislation related to minimum nurse-to-patient ratios, with most having requirements that address only a specific unit or type of unit (e.g., the operating room or ICU). Legislators remain reluctant to require hospitals and health systems to hire more nurses, particularly with ongoing shortages in many areas. In 2001, there were 264,000 licensed nurses in California (544 working nurses per 100,000 population), compared to a national average of 782 per 100,000; California ranked next to last among the 50 states.6
Description of the Innovative ActivityAs mandated by California Assembly Bill 394,7 the California Department of Health Services requires acute care hospitals to maintain minimum nurse-to-patient staffing ratios. Required ratios vary by unit, ranging from 1:1 in operating rooms (ORs) to 1:6 on psychiatric units. The legislation also requires that hospitals maintain a patient acuity classification system to guide additional staffing when necessary, assign certain nursing functions only to licensed registered nurses, determine the competency of and provide appropriate orientation to nurses before assigning them to patient care, and keep records of staffing levels. To assist with compliance, the legislation made grants available to hospitals and provided funding to college and university nursing programs to increase the pipeline of new nurses. Key elements of the policy include the following:
- Minimum staffing ratios: The regulations specify minimum nurse-to-patient staffing ratios that must be maintained at all times—including during meals and other breaks—by different hospital units and departments. If necessary, hospitals can meet these requirements through use of contracted staff to supplement employed nurses. More details on these requirements are outlined below:
- Unit-specific staffing minimums: The minimum ratios vary by specialty and department. OR nurses can take care of no more than one patient (a 1:1 ratio). Required ratios in other areas are as follows: ICUs/neonatal ICUs and post-anesthesia recovery and labor/delivery (1:2); step-down units (1:3); emergency department, telemetry, antepartum, and postpartum units where nurses take care of both mother and child (1:4); medical/surgical units (1:5); and psychiatric units and postpartum care units where nurses take care of only the mother (1:6). Nurses in other specialty areas can take care of no more than 4 patients.
- Additional staffing when patient acuity is high: The legislation requires hospitals to maintain and use a classification system to measure patient acuity, and to add RNs if indicated by the system. The system must take into account patient severity of illness, need for specialized equipment and technology, patient self-care capabilities, and the scope of practice of the nursing staff.
- Regulated use of unlicensed staff: Hospitals may not assign unlicensed staff to perform nursing functions, including medication administration, venipuncture, and invasive procedures. These tasks must be performed by RNs.
- Competency determination and orientation: Nurses, including temporary nurses, must have their competency assessed and receive appropriate orientation before being assigned to a clinical area.
- Accommodations in areas with RN shortages: To accommodate hospitals in markets with severe nursing shortages, the legislation allows these institutions to meet the State mandate with a lower nursing skill mix. Specifically, hospitals in these areas can fill up to half of the required staff with licensed vocational nurses (who have less training and a more limited scope of practice than do RNs).
- Records of staffing to ensure compliance: To ensure compliance, hospitals are required to keep a record of staffing as a condition of licensure. The regulatory agency uses this information to ensure compliance if a complaint is filed against the hospital. If a hospital is found to be noncompliant, it could be issued a statement of deficiency with a specific plan of correction. If the hospital does not adhere to the plan of correction, the noncompliance could eventually lead to loss of Federal and State dollars and possible loss of license to operate.
- Support to help hospitals meet requirements: The legislation provided 3 years of funding to assist in hiring additional nurses and to bolster nursing education programs at colleges and universities.
- Hiring support for hospitals: Hospitals could apply for grant money to help them hire more RNs. For example, Long Beach Memorial Hospital received a grant that enabled it to hire between 200 and 300 additional nurses. Many hospitals used these grant funds to train licensed practical nurses, enabling them to become RNs. Long Beach Memorial Hospital instituted this type of training program in association with California State University, Long Beach and Long Beach Memorial Medical Center.
- Support for nursing education: Community colleges and universities received State funding to increase the capacity of their nursing programs. For example, they used these funds to hire more nursing instructors and to provide additional supervised clinical experiences to students.
Context of the InnovationIn response to pressures from the growing managed care sector, California experienced significant consolidation in its health care sector in the early 1990s, with many small community hospitals being acquired by large health systems in an effort to generate efficiencies. These large health systems began reducing bed capacity and nurse staffing levels, which in turn led colleges and universities to divert resources away from nursing programs. This confluence of factors led to a nursing shortage in the state, with nurse workloads increasing and nurse concerns about the quality of care rising. In response, the California Nurses Association (a labor union and professional organization with more than 86,000 members) and other stakeholders began to lobby for minimum nurse staffing ratios so as to ensure good patient outcomes and avoid nurse burnout. After a failed attempt to pass legislation that included minimum ratios in 1993, Governor Pete Wilson convened all stakeholders in 2006, including representatives from the California Department of Health Services, hospitals and health systems, labor unions, and nursing organizations. He charged them with developing other reforms to address the issue; proposed reforms included patient acuity assessment systems to guide nurse staffing levels, new nurse orientation requirements, and refined nurse competency validation systems. While nurses supported these reforms, they remained dissatisfied, and, led by the California Nurses Association, continued to lobby for mandated minimum staffing ratios. Their efforts ultimately proved successful, and in 1999 Governor Gray Davis signed California Assembly Bill 394 into law.6 The law itself did not mandate specific ratios, but rather required the California Department of Health Services to study the issue and come up with the mandated ratios.
ResultsThe legislation has increased staffing levels and created more reasonable workloads for nurses in California hospitals, leading to fewer patient deaths and higher levels of job satisfaction than in other states without mandated staffing ratios. Despite initial concerns from opponents, the skill mix of nurses used by California hospitals has not declined since implementation of the mandated ratios.
Moderate: The evidence consists of pre- and post-implementation comparisons of nurse staffing levels in California hospitals, along with post-implementation comparisons of key nursing-related metrics in California to several other large states without mandated ratios; metrics include patients per shift, 30-day mortality rates, levels of job satisfaction and burnout, and nurse skill mix.
- Higher staffing levels: Nurse hours per patient day (adjusted for severity of illness) in California hospitals grew from 6.03 in 2003 (before implementation of the mandate) to 7.11 in 2008. The 2008 level is approximately a half hour more than in comparable hospitals in four states without mandatory minimum ratios (Florida, New York, Pennsylvania, and Texas).1
- Reduced workload: After implementation of the mandated ratios, nurses in California had, on average, 4.1 patients per shift, compared to 5.4 patients in both New Jersey and Pennsylvania, which do not have mandatory minimum ratios. This difference was reflected across various types of units, including medical-surgical (4.8 in California versus 6.8 in New Jersey and 6.5 in Pennsylvania), pediatric (3.6 versus 4.6/4.4), ICU (2.1 versus 2.5/2.3), telemetry (4.5 versus 5.9/5.7), oncology (4.6 versus 6.3/5.7), psychiatric (5.7 versus 7.0/7.9), and labor/delivery (2.4 versus 2.6/2.8).5 A 2006 survey of more than 22,000 nurses in these 3 states found that higher percentages of nurses in California reported having reasonable workloads (73 versus 59/61 percent) and adequate staff to ensure high-quality care (58 versus 41/44 percent) and “get work done” (56 versus 40/44 percent). A higher percentage of California nurses also reported regularly receiving a 30-minute break during their workday (74 versus 51/45 percent).5
- Fewer patient deaths: A 2006 comparison of outcomes in California, Pennsylvania, and New Jersey hospitals found that 30-day mortality rates were 10 to 13 percent lower in California than in the other 2 states. California hospitals also had a significantly lower incidence of failure-to-rescue cases. In the aforementioned 2006 survey, a smaller percentage of California nurses reported that heavy workloads caused them to miss a change in a patient condition (33 versus 41/37 percent).5
- Less burnout, high satisfaction and retention: The aforementioned 2006 survey found that California nurses reported less burnout (29 versus 34/36 percent) and less job dissatisfaction (20 versus 26/29 percent) than their counterparts in New Jersey and Pennsylvania. Two-thirds of California nurses agreed that they are more likely to remain in their jobs as a result of the legislation.4
- No reduction in skill mix: The nursing skill mix in California hospitals did not fall after implementation of the mandate, as many critics had feared. In fact, it increased to a similar degree as in other states.1
Planning and Development ProcessSelected steps included the following:
- Drafting legislation: Beginning in 1997, the California Nurses Association worked with various stakeholders across the state to determine how the legislation could be shaped to minimize opposition. While initial drafts included actual staffing ratios, these ended up being removed in response to stakeholder concerns. The final language instead charged the California Department of Health Services with overseeing a process to establish the ratios and communicate them to hospitals. As noted above, the legislation passed in 1999, and most provisions (other than the mandated ratios) went into effect on January 1, 2000.
- Conducting staffing ratio study: In 2000, the California Department of Health Services contracted with researchers at the University of California–Davis Medical Center to evaluate appropriate staffing ratios. Conducted over a year, this comprehensive study evaluated staffing systems in all California hospitals and conducted surveys with nursing directors throughout the state.
- Holding hearings on appropriate ratios: The California Department of Health Services held several hearings so that stakeholders and academic researchers could offer their views on appropriate staffing levels, in some cases submitting their own studies on the topic.
- Determining and announcing final ratios: Using the findings from the University of California–Davis researchers and the contributions of stakeholders during the hearings, the Department set minimum staffing ratios for nurses in each type of unit, as outlined earlier. In 2002, the Department announced the final ratios, which had to be fully implemented by January 1, 2004 (after a phase-in period to allow time to increase the nursing supply; see the following bullet for more information). The final ratios did not come as a surprise, since the key stakeholders were closely involved in the process. The state formally communicated the ratios to hospitals via the State hospital association and to nurses via nursing professional organizations. In addition, the popular and health care media closely covered the development process and the announcement of the final ratios.
- Funding to increase nursing supply: After the final ratios were announced, the state released federally supplied training funds to colleges and universities to increase the capacity of their nurse education programs.
Resources Used and Skills Needed
- Staffing: The California Department of Health Services increased its staff by a small amount to handle the additional requirements created by the legislation (data unavailable). As noted earlier, nurse staffing levels at California hospitals also increased to meet the new requirements, with the level of increase varying by hospital.
- Costs: The State of California incurred the costs related to the staff added at the Department of Health Services and the contract with the University of California–Davis (data unavailable). In 2002-2004, the state allocated its $60 million Federal Workforce Investment Act funds to hospitals and educational institutions with nursing programs, with the goal of increasing the nursing supply. For individual hospitals, the costs of complying with the mandated ratios are estimated at $700,000 to $800,000 per year. In the first 2 years of the program, some or all of these costs were offset by State grant funding. After this time, the additional costs have been offset to some extent by reductions in poor outcomes and adverse events that have resulted from higher staffing levels.
Funding SourcesState of California
The Federal government has financially supported some aspects of this program through $60 million in Workforce Investment Act funds provided to the State of California for workforce development and training. The $60 million included the following components:7
- $24 million for 2,400 training and preceptorship positions in hospitals, community colleges, and State universities
- $6 million to expand the Central Valley Health Careers Training Program to train an additional 300 licensed nurses
- $24 million to expand 5 regional workforce collaboratives under development and for additional regional collaboratives to train 2,400 licensed nurses through community colleges and State universities
- $3 million for onsite health care facility approaches to upgrade training opportunities for Certified Nurse Assistants and Licensed Vocational Nurses to become RNs
- $1 million for workplace reforms designed to improve nurse retention
- $1 million for research and initiative evaluation
- Restoration of $800,000 from the Registered Nurse Education Fund to provide financial assistance to nursing students
- Addition funds to conduct a statewide media campaign to recruit individuals to the nursing profession, explore strategies to standardize nursing prerequisites and education curricula, and streamline the nurse licensing process
Getting Started with This Innovation
- Leverage existing research: Significant research exists on the negative impact of heavy nurse workloads on patient outcomes and on appropriate minimum staffing ratios. Those interested in enacting minimum staffing ratios can use this research to convince legislators of the merits of such mandates and/or to speed up the adoption process.
- Secure buy-in by emphasizing benefits to patients and bottom line: Unless they buy in to the need for minimum ratios, hospitals will likely spend significant time and money trying to fight them. Supporters can minimize their resistance by emphasizing the expected positive impact on patient outcomes (including lower patient mortality), costs (through reductions in adverse events and associated legal liability), nurse turnover, and hospital reputation.
Sustaining This Innovation
- Push for legislation rather than other types of policies: Legislation mandating minimum staffing ratios is required to ensure long-term sustainability, since such legislation will be more difficult to modify than general hospital policies or professional association recommendations.
- Require ongoing reporting: Legislation alone does not ensure compliance over time. As a result, hospitals should be required to report staffing ratios on an ongoing basis so as to create accountability and allow for monitoring and oversight.
- Support nursing education: Financial support for education can help ensure a steady stream of new nurses into the workforce, which helps hospitals meet the staffing requirements.
Contact the InnovatorJill Furillo, RN
National Bargaining Director
National Nurses United
E-mail: email@example.com or firstname.lastname@example.org
DeAnn McEwen, RN
Nursing Practice Specialist
California Nurses Association
Vice President of National Nurses United
E-mail: email@example.com or DMcEwen@CalNurses.Org
Innovator DisclosuresMs. Furillo and Ms. McEwen reported having no financial interests or business/professional affiliations relevant to the work described in this profile other than the funders listed in the Funding Sources section.
References/Related ArticlesMore information about nurse staffing ratios and the California policy is available at: http://www.nationalnursesunited.org/issues/entry/ratios/.
McHugh MD, Kelly LA, Sloane DM, et al. Contradicting fears, California's nurse-to-patient mandate did not reduce the skill level of the nursing workforce in hospitals. Health Affairs. 2011;30(7):1299-1306.
McHugh MD, Carthon MB, Sloane DM, et al. Impact of nurse staffing mandates on safety-net hospitals: lessons from California. Milbank Q. 2012 March;90(1):160-186. Available at: http://onlinelibrary.wiley.com/doi/10.1111/j.1468-0009.2011.00658.x/pdf. [PubMed]
Aiken LH, Sloane DM, Cimiotti JP, et al. Implications of the California nurse staffing mandate for other states. Health Serv Res. 2010;45(4):904-21. Available at: http://nurses.3cdn.net/f83005dfafc3cd0332_evm6bn5zg.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .). [PubMed]
Aiken LH, Clarke SP, Sloane DM, et al. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16):1987-93. [PubMed]
Aiken LH, Clarke SP, Sloane DM. Hospital staffing, organizational support, and quality of care: cross-national findings. Int J Qual Health Care. 2002;14(1):5-13. [PubMed]
1 McHugh MD, Kelly LA, Sloane DM, et al. Contradicting fears, California's nurse-to-patient mandate did not reduce the skill level of the nursing workforce in hospitals. Health Affairs. 2011;30(7):1299-1306.
Aiken LH, Clarke SP, Sloane DM, et al. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16):1987-93. [PubMed]
Kane RL, Shamliyan TA, Mueller C, et al. The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis. Med Care. 2007 Dec;45(12):1195-204. [PubMed]
Needleman J, Buerhaus P, Mattke S, et al. Nurse-staffing levels and the quality of care in hospitals. N Engl J Med. 2002 May 30;346(22):1715-22. [PubMed]
6 State of California. Governor Davis announces Nurse Workforce Initiative. Press Release. Sacramento. January 23, 2002.
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Original publication: September 26, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: October 09, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: August 12, 2013.
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