California Legally Mandated Nurse to patient ratios

Introduction
As of now, at least fourteen states across the country have legislations on safe staffing. Although California is among the fourteen jurisdictions, it is unique in the sense that its legislation includes a nurse to patient ratio clause. The allowed ration of patients to nurses is five to one. Half of the remaining states mandate hospital boards/ committees to set the nurse to patient rations in their hospitals, while five other states require hospitals to disclose their staffing ratios publicly (Abraham). Staffing ratios are important especially when the ratio is set by the state such as is the case in California.
This is because when states do not set standards as is the case in most states across the country, facilities usually get short-staffed. In other cases, nurses get overworked and exhausted leading to high staff turnover in health facilities, poor health outcomes, and compromised patient safety. A recent survey by Kronos Incorporated showed that nearly ninety percent of nursing staff want to leave their current work station because they feel they are overworked (Abraham). Other surveys and studies are showing that in places where nurses are way fewer than patients, patients are losing their lives especially in ICU wards.
Despite the clear risks and dangers of having more patients than available nurses can handle, hospitals and other health facilities are pushing back claiming that not enough studies support the need for them to employ more nurses. They also argue that not many nursing staff are available for hiring anyway so even if they decided to hire more people their argument is that they would not find enough people (Abraham). However, states are not relenting. More states have expressed their intention to set a standard ratio or at least to ask hospitals to disclose their nurse to patient ratios publicly. It is the argument of this paper that all states should use the California law as a model to set official nurse to patient ratios that should be strictly adhered to so as to avoid the many ills of having way fewer nurses than patients.
Proponents’ arguments
California enacted a state legislation in 2004 that in brief stated that for every five patients there should be one nurse. This law essentially set the limit. It necessitated more nurses to be employed to ensure that there are enough numbers to provide patients with the quality healthcare they need. Different limits were, however, set for different health facilities. For example, in an operating room, the ratio was set as one nursing staff per patient, while for psychiatric wards the ratio was set at one nursing staff for every six patients. Lastly, for emergency rooms and pediatric rooms, the limit was four patients per nursing staff (Terasawa).
It has been argued that the California state legislation improves health outcomes, is cost-effective, and has led to high turnover rates because of increased opportunities for nurses. It has also been argued by those who support the inclusion of the ratios in law that the annually increasing number of graduates will fill in the opening positions. In other words, highly skilled nurse graduates are helped to find work by the legislation, while shortages are also simultaneously filled by the nurses so they do not exist for long. Between 2004 and 2008, the vacancies for registered nurses reduced by sixty nine percent. This shows that no expected shortages were experienced after the enactment of the law and that vacancies have reduced courtesy of the fact that more nurses are filling in the opening positions faster (Abraham).
Proper staffing is important for the delivery of quality healthcare. Staffing levels should definitely be flexible and they should also take into account other factors including resource availability, unity layouts, experience levels of available staff, transfers during shit, admission numbers, and patient needs. Laws like the one in California have set the standards for optimal staffing, however, new legislations can improve it to make it more comprehensive so that it can take into account factors such as availability of support resources, nursing unit layout, physical design of health facilities, expertise of available staff, number of admissions, number of discharges, patient condition, and so on (Lippincott Solutions). As more and more jurisdictions focus on quality/ value care, proper nurse staffing is expected to be key towards the implementation of related policies since nurses are often at the forefront of providing health care services. Optimal nursing levels can achieve not only better healthcare but also better patient outcomes and better job satisfaction levels.
Those who support the setting of nurse to patient ratios in legislation argue that such laws usually improve the care quality provided. They argue that this was the effect in hospitals in the state of California. Furthermore, many studies have revealed in the past that higher staffing levels often mean better health outcomes for patients (Livanos, 68-70). Advocates of nurse to patient laws also argue that low nursing levels are putting patients at risk and that only the setting of patient to nurse ratio limits can help to guarantee quality standards below which hospitals should not fall or risk penalties. Proponents are also of the opinion that patient categorization methods based on acuity, in the California statute, are not enough since they make it difficult to know which health facilities are complying. It is, therefore, their recommendation that simpler minimum ratios are recommended and publicly disclosed to make it easier for all stakeholders to quickly identify and alert authorities about the hospitals not complying with the law.
Advocates for the setting of nurse to patient ratios in statutes are also of the notion that setting ratios will eliminate or reduce nursing shortage. Their belief is that qualified nurses are refusing to work in certain institutions because of working conditions in most hospitals including being overworked and high negative outcomes. It is the belief of the proponents of ratios that when the ratios are put in law, they will automatically improve working conditions and things like overworking would be things of the past, while negative outcomes will surely reduce (Nantsupawat et al., 91-98). This, they believe, will help reduce the shortage of nurses as those who are out of work because of the conditions will most likely join when the conditions are improved.
When California passed the legislation on nurse to patient ratios, the number of registered nurses in the state’s hospitals increased significantly over the next few years. It is not clear if the increase in RN numbers is only related to better working conditions. Generally, it is expected that more nurses would help reduce negative outcomes in hospitals. However, this has not been overwhelmingly supported by research (Terasawa). Nevertheless, conditions did improve in California hospitals after the legislations including better wage rates and wage growth than in other states at that time. This is thought to have been part of the reason for the increase in nurse numbers in the state’s healthcare system.
California optimal staffing mandates are also thought to have helped improve working conditions in other ways. It was found that hospitals whose nurse to patient ratios were as recommended by the state had higher job satisfaction scores, lower nurse burnout numbers, better work environments, and lower turnover rates (Terasawa; Nantsupawat et al., 91-98). It was also found that nurses in hospitals with optimal RN staffing numbers were less likely to report poor care quality, abuse by patients or staff, or complaints from families or patients themselves. From the above findings, it can be stated that the California nurse staffing mandates helped improve conditions for nurses and that this attracted nurses to work in the state’s hospitals reducing the previously existing shortage of nurses.
The last point by proponents of the California nursing staff mandates is that they help to improve the quality of care. Nurses exist to provide care. They have other jobs in hospital settings but their main duty is to provide care to patients. Institutions with poor nurse staffing cannot provide good quality care. This is because their nurses will be constantly overworked. The overworking and resulting exhaustion could increase length of hospital stays, could result in medical errors, could increase patient mortality, could increase the number of patient falls, and could also lead to increase in the number of hospital-acquired infections (Nantsupawat et al., 91-98). However, if the limit of patients nurses are supposed to handle at any given time is lowered, it will ensure that nurses are not overworked and that they are ready to provide good quality care. Additionally, it will ensure that nurses are also able to fulfil their other nursing roles e.g. discharge planning and case management more effectively. A recent survey by the American Nurses Association revealed that more than 50 percent of the nurses said that they felt they did not spend enough time with their patients(“Mandated nurse-to-patient staffing…”). This obviously affects the quality of care and is often due to poor nurse staffing. This situation can, however, be reversed through mandated nurse to patient staffing numbers.
Opponents’ arguments
The number one argument by opponents of nurse to patient staffing mandates is that there is no enough evidence that shows that setting minimum ratios for nurse staffing usually enhances patient outcomes. They argue that setting optimal nurse staffing ratios suggests that there exists in theory a threshold ratio of nurse to patients below which outcomes for patients are bad and above which outcomes are good. Their argument is that this threshold does not exist and that, therefore, setting limits is an exercise in futility (Driscoll et al., 6-22).
According to opponents of nurse staffing mandates, nurse to patient ratios are not usually helpful. A couple of years ago, the Commonwealth of Massachusetts established a law in which they required two to one or one to one patient to nurse ratios for their state’s ICU units depending on expected care intensity and patient acuity. However, a recent report revealed that the ratios were not behind the improvement in healthcare outcomes (Thew). The conclusion was based on the idea that the overall change brought by the mandated staffing ratio was very minimal from one nurse for every 1.38 patients to one nurse for every 1.28 patients. In other words, the recommended ratios were not much higher than what was already the case.
Another big argument by opponents of nurse staffing mandates is that nurse burnout and stress is usually not just affected by work volume/ patient numbers and/ or acuity. The study commonly cited is a new one by researchers at Ohio State who concluded that patient numbers and the intensity of care needed are not the only things that cause nurses to feel overloaded at work. The researchers found that other factors that also contributed to the feelings of burnout included time constraints and mental pressures for completing the tasks beforehand (Thew). As part of their conclusion, the researchers end the study by suggesting the innovation of workload distribution strategies as a way of improving the quality of care delivered.
The third and last opponents’ argument against mandated nursing ratios is that the ratios alone are not the solutions to the many challenges facing the field of nursing. That there are other innovative solutions that can be used instead of forcing hospitals to hire more nurses yet their little funds could be dedicated towards other equally important areas of hospital administration that may be lacking funds. One solution is that which was proposed by Patricia Hickey. Hickey proposed the updating of acuity instruments to ensure that their more efficient in measuring complexity and workload. This could help reduce workload, enable nurses to better manage their times, and assist nurses to make better decisions (Thew).
Counter Argument
There is little evidence that the California nursing numbers statute will have a negative impact on the quality of care delivered by burses in the state. The statute helped improve conditions and helped reduce the number of unlicensed staff. It improved the personnel skill mix in the state by also increasing the number of registered nurses employed by the state. And research studies show that the more registered nurses present in healthcare the better the healthcare outcomes (Driscoll et al., 6-22).
One of the most repeated arguments by opponents of mandated nurse to patient ratios is that hiring more nurses will cost more. However, this is not the truth. Already the majority of hospitals in California have got nurse to patient numbers in above the minimum limits introduced by the California statute. Only 41 percent of observation units and 15 percent of labor units and operation rooms did not have the required compliance (“Mandated nurse-to-patient staffing…”). This means that it would not cost the out of compliance hospitals much more money to get the right number of nurses for all their units. Moreover, hiring of more nurses would reduce the expenses on traveling nurses and registry nurses and the funds spent on them could be spent on the wages of the new staff nurses.
Conclusion
As it is evident in the arguments in this paper, states across the country should use the California model to form statutes for the purpose of established minimum patient to nurse ratios. Since California enacted its minimum patient to nurse ratios for various hospital units and scenarios, they have recorded better healthcare outcomes and higher staff job satisfaction scores. It is clear from the opponents’ arguments that not everyone agrees that staff nursing minimum ratios ought to be out in law. Some think it is unnecessary to do so, while others think that there are better ways of addressing the challenges that the minimum mandated staff nursing ratios intend to address. However, the arguments are neither here nor there. They do not attack the actual ills which minimum nurse staffing ratios aim to cure: nursing shortages and lower patient outcomes due to the shortages. Ensuring that the optimal number of staff are available in hospitals countrywide will help to significantly improve patient outcomes, to improve the quality of healthcare and to avoid avoidable negative outcomes e.g. patient falls and lack of satisfaction. It will also improve the work environment for patients and reduce the alarming turnover rates due to overworking.


Works cited
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Driscoll, Andrea, et al. "The effect of nurse-to-patient ratios on nurse-sensitive patient outcomes in acute specialist units: a systematic review and meta-analysis." European Journal of Cardiovascular Nursing 17.1 (2018): 6-22.
Kim, Yunmi, Seon?Ha Kim, and Young Ko. "Effect of nurse staffing variation and hospital resource utilization." Nursing & health sciences 18.4 (2016): 473-480.
Lippincott Solutions. “Update on Nursing Staff Ratios.” 2018. Web.
Livanos, Nicole. "A broadening coalition: Patient safety enters the Nurse-to-Patient ratio debate." Journal of Nursing Regulation 9.1 (2018): 68-70. Web.
Nantsupawat, A., Kunaviktikul, W., Nantsupawat, R., Wichaikhum, O. A., Thienthong, H., & Poghosyan, L. (2017). Effects of nurse work environment on job dissatisfaction, burnout, intention to leave. International nursing review, 64(1), 91-98. Web.
Terasawa, Emi. California's minimum nurse-staffing law and its impact on hospital closure, service mix, and patient hospital choice. University of Pennsylvania, 2016. Web.
Thew, R.N. Jennifer. “ Nurse Staffing isn't Straightforward. Here's Why.” Healthleadersmedia. 2018. Web.
Votroubek, Wendy. “The Pros and Cons of Required Minimum Nurse-to-Patient Ratios.” Integrity Legal Nurse Consulting PDX. 2017. Web.