Heavy 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 Activity
As 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 Long Beach Community College.
- 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.
More 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]
Contact the Innovator
Jill Furillo, RN
National Bargaining Director
National Nurses United
E-mail: firstname.lastname@example.org or email@example.com
DeAnn McEwen, RN
President of California Nurses Association
Vice President of National Nurses United
Ms. Furillo and Ms. McEwen reported having no financial interests or business/professional affiliations relevant to the work described in this profile.