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CA Nurse Staffing Law Generates More Debate

 |  By  
   July 26, 2011

Nursing unions are angling for mandatory nurse staffing laws, which they say ensure safe patient care. It's a potent message. Studies show better patient outcomes for everything from mortality to healthcare-acquired infections when RN-to-patient ratios are higher.

The debate continues as to whether mandating staffing actually makes patients safer. Allowing hospitals flexibility to staff according to patient need is more effective than legislating blanket rates, say many patient safety advocates because the rates don't account for patient acuity or staff skill mix and experience. Unions use safe patient staffing arguments as a powerful mobilizer and recruiting tool.

A recent study in Health Affairs examined the effects of staffing laws on patient care in California, the first state to pass mandatory staffing laws.

Patients in California hospitals receive 30 minutes more nursing care per day due to the state's mandatory nurse staffing laws than they would have received without the laws, according to the study. That equals a rise from 6.44 hours per adjusted day in 2004 to 7.1 hours per adjusted day in 2008.

For patients, that extra half hour of hands-on care from an RN makes a big difference. It's a significant amount more face time each day between patient and RN, allowing more communication, assessment, and education.

Before the law took effect, there were concerns that hospitals would hire lower-skilled staff—licensed practical nurses or licensed vocational nurses—to meet the ratios. But the study showed that skill mix actually increased following the law's implementation and California hospitals hired more RNs.

The law effectively increased RN staffing in California hospitals, the study found, which supports proponents of staffing ratio laws. Those arguments, however, fail to address the number of travelers and temporary staff that hospitals must hire to meet requirements and that is expensive and inconvenient. 

The staffing ratio debate will heat up as hospitals feel the first effects of payments for quality and patient experience. To head off legislation, hospitals must demonstrate that existing staffing plans provide safe patient care. Top performing hospitals often staff better than the laws require, but they do so with the freedom to adjust as necessary, depending on patient need and the organization's resources.

Patient acuity systems can be invaluable for maximizing staffing and saving money. So can offering nurses scheduling options beyond the 12-hour shift, such as peak-time shifts, multi-task shifts, group sharing, or job sharing.

To provide a reasonable argument against legislating ratios, hospitals must demonstrate optimal nurse staffing and a commitment to high-quality patient care. Involving RNs in the staffing decisions is the best way to head off union action.

See Also:
Inpatient Mortality Linked to Nurse Understaffing

Does Mandating Nurse-Patient Ratios Improve Care?

Linking Medical Errors, Nurses' 12-Hour Shifts

Rebecca Hendren is a senior managing editor at HCPro, Inc. in Danvers, MA. She edits and manages The Leaders' Lounge blog for nurse managers. Email her at

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