First evaluation of California's much-watched ratios law

There has been much controversy regarding implementation of legislation to regulate hospital nurse-patient staffing ratios and its impact on patient safety and quality outcomes.

According to a new study published in the August 2005 issue of the journal Policy, Politics & Nursing Practice, nurse staffing levels have increased significantly in California hospitals following implementation of that state's landmark legislation requiring nurse-patient staffing ratios.

This groundbreaking study--the first evaluation of California's much-watched ratios law–was written by a team of researchers headed by Nancy E. Donaldson, DNSc, RN, FAAN, of the University of California, San Francisco. The researchers are affiliated with the California Nursing Outcomes Coalition (CalNOC), which collects and analyzes data on nurse staffing and outcomes from participating hospitals.

In 1999, California became the first state in the nation to enact legislation requiring hospitals to meet minimum staffing standards, limiting the numbers of patients that registered nurses (RNs) and licensed vocational nurses (LVNs--known in most other states as licensed practical nurses) may care for at any one time. That legislation , AB 394, charged the California Department of Health Services (CDHS) with determining those staffing standards. CDHS regulations implementing the new ratios requirements went into effect in January 2004. The bill's proponents cited a growing body of research linking nurse staffing levels and positive patient care outcomes.

In the study, Donaldson's team examined staffing and outcomes data from 268 medical-surgical and step-down units in 68 hospitals. They found that mean total RN hours of care per patient day increased by 20.8% in medical-surgical units and that the number of patients per RN decreased by 17.5%. Despite concerns that hospitals might seek to meet the ratios requirements by increasing their use of LVNs (since the regulations permit the complement of licensed nurses to include up to 50% LVNs), this did not occur. Similarly, there was no significant increase in use of contracted nursing staff (i.e., nurses supplied by outside staffing agencies or registries). Staffing in step-down units did not increase significantly.

The authors found no significant changes in the incidence of patient falls or the prevalence of pressure ulcers (bedsores), but they emphasized the preliminary nature of these findings and the limitations of the study, concluding that more research would be needed to determine the effect of mandatory staffing ratios on patient outcomes.

In an accompanying editorial, the journal's editor, David M. Keepnews, PhD, JD, RN, FAAN, noting that "California's decision to mandate staffing ratios was hotly debated [and] continues to be closely watched throughout the United States and beyond," pointed to the value of the Donaldson team's research in providing an "initial assessment" of the impact of staffing ratios. He explained that "Regardless of how anyone feels about government-mandated staffing ratios, it should be clear that California's experience with ratios will produce valuable and important policy lessons. The work of evaluating that experience has begun, which is a welcome development for anyone concerned with nurse staffing and patient care quality."

The authors of this study included Nancy E. Donaldson, DNSc, RN, FAAN, Linda Burnes Bolton RN, DrPH, FAAN, Diane Brown RN, PhD, FNAHQ., Janet Elashoff PhD, and Meenu Sandhu, MS.