With the passage of Assembly Bill 394 in 1999, California became the first state in the nation to establish minimum registered nurse (RN)–to-patient ratios for hospitals. The idea behind minimum RN:patient ratios was to increase quality of care and decrease nurse burnout. As implemented in 2004, RN-to-patient ratios vary according to type of care, from 1:1 (one nurse to one patient) in operating rooms to 1:6 for postpartum care of mothers.
The backers of AB 394 used the standard trope of protecting innocent victims (i.e., nurses and patients) from greedy evildoers willing to sacrifice all that is good for all that is profitable. Doesn't matter that just one-in-five hospitals are for-profit. Or that the quality of care and patient outcomes of for-profit hospitals are no worse than that of non-profits and better than government hospitals. It's the narrative that matters. Good versus evil sells. Incremental problem-solving approaches don't sell.
So what were the effects of California's strict RN: patient staffing ratios? More RNs were hired. RN hours worked per patient increased. However, increased RN staffing was not associated with most quality of care indicators, e.g., average length of patient stay, incidents of pressure ulcer, failure to rescue after post-surgery complication, and pneumonia mortality. This lack of clear patient benefit may be one reason why California remains the only state in the nation that regulates nurse-patient ratios.
What about RN workload, stress levels and job satisfaction? Have things gotten better for nurses in California? Hard to say, although the California Board of Registered Nursing provides some interesting survey data:
It looks like job stress has gone up a bit over the years, while work hours and satisfaction with work load and level of RN staff levels haven't changed much since the implementation of AB 394. Kinda disappointing when you think of the added expense of all those extra RNs and RN hours. This is not at all to say that nurses haven't benefited from the implementation of strict staffing ratios. It just doesn't look like the benefit has been all that great. And then you've got to ask if it's worth it. Because...
...there are costs to these extra costs. For instance, in response to mandated nurse-patient ratios, California hospitals have reduced budgets in other areas and cut back on ancillary staff like LVNs and aides. But there is only so much room for cost cutting measures. Much of the added expense of mandated nurse staffing levels has been passed on to purchasers of healthcare: government agencies, insurers, employers, and households. One more reason why US healthcare is the most expensive in the world.
Next: How to achieve optimal nurse staffing levels without breaking the bank.
References:
The California Health Care Foundation Assessing the Impact of California’s Nurse Staffing Ratios on Hospitals and Patient Care (2009)
Spetz J, Harless DW, Herrera CN, Mark BA. Using minimum nurse staffing regulations to measure the relationship between nursing and hospital quality of care. Med Care Res Rev. 2013; 70(4):380-99.