Legislating Nurse-to-Patient Ratios:
California Legislation Falls Short

By Amy Dilcher, LL.M. Candidate

On October 10, 1999, California became the first state in the nation to mandate minimum nurse-to-patient ratios in acute care hospitals and psychiatric hospitals.  California law already establishes the number of nurses per patient in hospital operating rooms, intensive care units and neonatal nurseries.  Californiaís Governor Gray Davis signed bill AB394 (see bill text at http://www.leginfo.ca.gov) which directs the State Department of Health Services to establish nurse-to-patient ratios by January 1, 2001.  Assemblywoman Sheila Kuehl, the legislationís author, has agreed to postpone the billís effective date until January 1, 2002.

This legislation recognizes that the market based health care model advocated by opponents of AB394, namely the California Chamber of Commerce and the California Healthcare Association, is not functioning to ensure quality patient care in California.  Two recent studies document the decline in nurse-to-patient ratios and increase in patient acuity levels in California.  According to the 1999 Dartmouth Atlas of Health Care data, which uses data from the American Hospital Association, the nation average of registered nurses is 3.22 per 1,000 population.  In contrast, the California average is 2.27 per 1,000, the second lowest in the nation.  The Institute for Health and Socio-Economic Policy (IHSP) completed a research report, utilizing 18.2 million patient discharge records, and found a 9% increase in the average number of nurses for which full-time registered nurses were responsible from 1994-1997.  Additionally, the IHSP reports that the severity of illness of California hospital patients has increased by 3% while the number of full-time, employed registered nurses and number of staffed hospital beds has declined.  See http://www.calnurse.org/staff/staffratio.htm.

The setting of minimum nurse-to-patient ratios has the potential to enhance patient care in hospitals, encourage nursing education programs, and attract former nurses, who have become frustrated with inadequate ratios, to the nursing profession and hospital practice.  However, AB394 faces four potential problems.  First, there is the difficulty of a state agency, a non-health care provider, in setting minimum requirements for a wide variety of units within acute care and psychiatric hospitals where staffing needs vary hourly according to hospital bed availability and patient acuity.  The California Nurses Association (CNA) intends to combat this issue by collecting data and testifying in public hearings to ensure that the Department of Health Services sets safe nurse-to-patient ratios.

Second, AB394 sets only the minimum number of nurse-to-patient ratios.  As a result, hospitals may staff only the minimum number of nurses as required by law despite the actual need for more nurses.  To make hospitals accountable to the public, the California legislature should amend AB394 to require hospitals to report the actual number of nurses staffed, their patient caseloads, and patient acuity levels to the State Department of Health Services and make this information available to consumers.

Third, minimum nurse-to-patient ratios may increase hospital health care costs.  AB394 is a weakened version of an original bill that set specific ratios, and it was  estimated to increase nursing costs by $700 million.  At present, hospitals operate on lower-than-expected payments from government payers and managed care companies.  Health maintenance organizations (HMOs) are increasing premium rates, and HMO pressure on hospitals to reduce costs may continue to increase.  The full financial impact of the measure wonít be known until specific ratios are determined.

Fourth, although AB394 authorizes the State Department of Health Services to adopt regulations to establish ratios, the law doesnít provide for an enforcement mechanism to monitor hospital adoption of nurse-to-patient ratios.  The California legislature should amend the law to authorize the State Department to enforce and monitor ratios.  A spokesperson from the CNA states that it intends to work with nurses to guarantee that the ratios, once adopted, are fully and effectively implemented and enforced.  See http://www.calnurse.org/cna/press/101099.html.

Californiaís AB394 appears to be the first measure in a nationwide trend for research of nurse-to-patient ratios, state-mandated ratios, and disclosure of actual ratios to state agencies and the public.  In 1999, 21 bills in 15 states were introduced and three bills passed.  In addition to California, New Mexico appropriated $150,000 to do a nursing workforce study, and New Hampshire approved a Health Care Quality Commission to report on nurse-to-patient ratios.  Pending legislation in Hawaii, Massachusetts, Oregon, Rhode Island, Tennessee, and West Virginia would establish requirements that each medical facility maintain sufficient and appropriate nursing staff and each measure offers parameters to determine evaluation requirements.  See http://www.ana.org/gova/state/hod99/staffrat.htm for more information on pending state legislation.

In addition to state legislatures, the House of Representatives and Senate introduced companion bills that would require Medicare providers to disclose staffing levels and patient outcomes.  See The Patient Safety Act of 1999, HR 1288 (introduced March 25), S966 (introduced May 5) at http://thomas.loc.gov.