California is the only state in the US that requires a minimum nurse-to-patient ratio to be maintained at all times. The legislative campaign to mandate nurse staffing levels was presented as a "patients over profits" issue and implemented in 2004, as follows:
The problem with the California system is that it's insensitive to changes in patient needs, nurse skill mix and nurse workloads. Maybe strict nurse/patient ratios would be worth it if they saved lives, improved quality of care, or reduced nurse burnout. Unfortunately, the data does not swing that way. See Part IV of this Series for details on that.
So how do hospitals work out nurse staffing levels in countries with single-payer universal care health care systems? Where there's no profit to be made? In the case of Britain, not with mandatory minimum nurse-patient ratios.
A recent study of the British National Health Service (NHS) concluded that patient risk increases at about a 1:8 nurse-to-patient ratio, which is a lot lower than what is required in California. But that's just in general. The British NHS recognizes that optimal nurse staffing for a given number of patients depends on the levels of nursing care required for those particular patients. So they use flexible staffing systems where patients needing more care get more nurses, like the following:
Beautiful, eh?
What does this have to do with reducing healthcare costs? Ironically, as a percentage of total labor costs, California hospitals don't pay much more for nursing staff than hospitals in other states. But the California system disincentivizes labor-saving innovations in nursing care. That's because California hospitals would still be stuck* with the same minimum RN:patient ratios even if ways were found to reduce time spent on some nursing tasks (e.g., documentation). The California system thus gets in the way of making healthcare more affordable: a prerequisite for universal care.
* Of course, the law could be changed - but given the politics in this state, good luck with that.
References:
Gooch, K. Optimal nurse staffing leads to clinical and economic improvements: 5 findings Becker’s Hospital Review November 24, 2015.
Griffiths P et al (2017) How many nurses do we need: what does the evidence say? Nursing Times 114 (12): 36-37.
Fenton K. and Casey A. (2015) A tool to calculate safe nurse staffing levels. Nursing Times 111(3):12-4.
The Sheffield Group Safer Nursing Care Tool (2013) Shelford Chief Nurse Group Produced in conjunction with the Association of UK University Hospitals.
Spetz J, Harless DW, Herrera CN, Mark BA (2013) Using minimum nurse staffing regulations to measure the relationship between nursing and hospital quality of care. Medical Care Research Review 70(4):380-99.