As more than a dozen states consider laws to establish hospital nurse-to-patient ratios, what has been the experience in California—the first state to establish such a rule—since the policy took full effect in 2005?
Do patients get better care, experience fewer adverse events, and have shorter lengths of stay and lower mortality? Are nurses doing a better job, and by extension, are doctors and other hospital workers? And how much has the increased expense affected hospitals' bottom lines?
Unfortunately, a solid answer remains elusive. As one might expect, hospitals and nursing organizations are divided in their perception of how things are going. The California Nurses Association says the ratios have improved nurse retention, raised the numbers of qualified nurses willing to work, reduced burnout, and improved morale.
Advocates also say narrower ratios in high-intensity areas, such as the emergency room, have improved patient satisfaction and have reduced medical errors, including medication mistakes and falls.
But Jan Emerson, spokeswoman for the California Hospital Association, which fought implementation of the ratios with an unsuccessful court challenge, says they are tough for hospitals to enforce.
"The most onerous aspect to the ratios is the requirement that hospitals be in 'continuous compliance'—that means in compliance every minute of every shift on every unit every day," Emerson says.
"If a nurse steps away to use the bathroom down the hall, the regulations require he/she to reassign all the patients to another nurse. That doesn't make sense and frankly is very difficult to adhere to," she adds.
The other problem Emerson points to is with ratios in the emergency room, where the ratio is one nurse to four patients. "The only time a hospital can go above this ratio is when there is a local or state declared emergency. This rigid ratio is one of the reasons that ER waiting times can be lengthy—especially if there is an unexpected surge of ER patients because of a car crash.
"Hospitals do the best they can to predict how many nurses they will need during different parts of the day and staff accordingly," Emerson adds. "But the rigid nature of the ratio doesn't provide any flexibility when the unexpected occurs."
California's nurse-to-patient ratios, which were fully phased in by April 7, 2005, call for one nurse for every two patients in the intensive care, critical care, and neonatal intensive care units, as well as in post-anesthesia recovery, labor and delivery, and when patients in the emergency room require intensive care.
One-to-three patient ratio is called for in step down units. One-to-four patient ratio is required in antepartum, postpartum, pediatric care, and in the emergency room, telemetry, and other specialty care units.
One nurse for every five patients is required in medical-surgical units and one for every six in psychiatric units.
"We've been fighting for a similar bill in Massachusetts," says David Schildmeier, director of communications for the Massachusetts Nurses Association. He says similar legislative proposals are working their way through 13 other states as well.
"We know 90% of our nurses support and desperately want it," he says. The association in 2008 hired a polling organization to survey patients who had spent time as inpatients "and 30% said safety was compromised because nurses had too many patients."
DeAnn McEwen, an RN and member of the California Nurses Association board of directors, says the ratios have helped reverse the number of nurses exiting from the profession over the last decade because of burnout.
"Since the ratios took effect in California," McEwen says, "I don't see the big turnover of nurses that I used to see and the RN vacancy rate in hospitals has dropped dramatically."
Before the ratios took effect, she says, "Hospitals in California, in general, had a 'one-size fits all' mentality about how many nurses should work in a unit based solely on their bottom-line budget."
"Legislated standards for safe staffing provides a public safety net and hospitals are still required to staff-up from these minimums based on the acuity of the patients."
Although she believes quantitative, unbiased scientific studies on the California ratio experience will validate a reduction in adverse events, McEwen says that nurses "feel that their ability to provide safer care is protected because they have a ratio law in place."
She adds, "Increased moral distress and greater job dissatisfaction in nurses are strongly and significantly associated with high patient-to-nurse ratios when nurses are unable to provide the comprehensive care patients need."
She and other ratio advocates point to a 2002 study, published in the Journal of the American Medical Association, which said hospitals can "avert both preventable mortality and low nurse retention in hospital practice" by increasing the number of nurses.
The author Linda Aiken, of the Center for Health Outcomes and Policy Research, wrote: "Higher emotional exhaustion and greater job dissatisfaction in nurses were strongly and significantly associated with patient-to-nurse ratios."
"We're looking forward to a reputable study in California, similar to Aiken's and others, that show that complication rates can be reduced by having nursing ratios in place," McEwen says.
Studies of the actual California experience since the ratios were implemented have not produce conclusive results.
An issue brief published by the California Healthcare Foundation 11 months ago looked at the impact of the ratios on safety measures, such as failure to rescue, post-operative sepsis, pneumonia mortality, deep vein thrombosis, and decubitus ulcers.
"Many of the health care leaders interviewed for the study expressed an expectation that the minimum staffing ratios would increase the quality of care due to increased interaction with patients; however, there was no evident change in patient length of stay or adverse patient safety event," the report said.
It added that hospital administrators interviewed for the study "found that it was (a) challenge to meet the staffing requirements, particularly in ensuring that staff were available at all times, including during breaks and meals."
Additionally, hospital officials "reported difficulties in absorbing the costs of the ratios, and many had to reduce budgets, reduce services, or employ other cost-saving measures," the authors wrote.
However, the report, prepared by Joanne Spetz and colleagues at the Center for California Health Workforce Studies at the University of California San Francisco, said that the minimum nurse staffing regulations did achieve one goal of the legislation: skill mix increased in California hospitals.
"The hours worked per patient by RNs and registry RNs significantly increased," the study said.
The authors acknowledged that "more detailed analysis of this and other nursing-sensitive outcomes is needed to fully explore the effect of nurse staffing ratios on the quality of patient care."