Minimum Nurse-to-Patient Ratios in Acute Care Hospitals in California

Janet M. Coffman, Jean Ann Seago, and Joanne Spetz

Health Affairs. 2002;21(5) 

In This Article

Background on A.B. 394

A.B. 394 directs the California Department of Health Services (DHS) to establish "minimum, specific, and numerical licensed nurse-to-patient ratios by license nurse classification and by hospital unit" for inpatient units in acute care hospitals. Licensed nurses include both RNs and licensed vocational nurses (LVNs, called licensed practical nurses, or LPNs, in other states). Draft nurse-to-patient ratios were announced in January 2002 and will undergo an extensive review and comment process required under California law. The regulations are expected to be in force by July 2003.[2]

The passage of A.B. 394 in 1999 followed several years of intense lobbying by unions representing California nurses. Proposition 216, a ballot proposition that would have established staffing standards for all licensed health care facilities (in addition to creating a statewide health insurance system), was rejected by the vote's in 1996. A.B. 695, a bill similar to A.B. 394, was approved by the state legislature in 1998 but vetoed by then Gov. Pete Wilson. The political scales tipped in favor of the nurses' unions with the election of a new governor, Gray Davis, in November 1998, who was endorsed by unions representing nurses and other workers.[3]

A.B. 394 extends prior California law regarding nurse staffing in acute care hospitals. Under legislation enacted during the 1976-77 state legislative session, California hospitals must have a minimum ratio of one licensed nurse per two patients in intensive care and coronary care units. This legislation also requires that at least half of licensed nurses working in intensive care and coronary care units be RNs [Title 22, Division 5, Chapter 1, Article 6, Section 70495(e)]. Legislation enacted in the early 1990s requires hospitals to use patient classification systems to determine nurse staffing needs for inpatient units on a shift-by-shift basis and to staff accordingly [Title 22, Division 5, Chapter 1, Article 6, Section 70495(e)].

The minimum nurse-to-patient ratios proposed by the California DHS range from one nurse per patient in operating rooms to one nurse per eight infants in newborn nurseries. The DHS proposes that the minimum ratios for medical-surgical and rehabilitation units be phased in. Minimum ratios for these units would be set initially at one nurse (RN or LVN) per six patients and then shift to one nurse per five patients within twelve to eighteen months of enactment. Proposed ratios for other types of inpatient units would not be phased in.[4]

The proposed minimum ratios generally call for fewer patients per nurse than hospitals recommend and more patients per nurse than unions recommend. The differences in the ratios that major stakeholders have proposed for medical-surgical units are particularly noteworthy, because these units constitute the largest category of inpatient units in California hospitals. Whereas the DHS proposes a final ratio of one nurse per five patients in medical-surgical units, the California Healthcare Association (the state American Hospital Association affiliate) has proposed a ratio of one nurse per ten patients. The union representing the largest number of California nurses, the California Nurses Association (CNA), has recommended a ratio of one RN per three patients. Another large union, Service Employees International Union (SEIU), has recommended a ratio of one nurse per four patients.[5] In addition, the California DHS proposal differs greatly from the CNA proposal with regard to the intensity of RN staffing. The California DHS proposal sets forth ratios of licensed nurses (RNs and LVNs) to patients, whereas the CNA proposed ratios of RNs to patients.

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