The California Legislation on Staffing Ratios: Policy Briefing Document

Executive Summary

California registered nurse (RN) was introduced in 1999 but came into effect in 2004. The law requires hospitals to establish minimum nurse-patient ratios for different units. The law was enacted after the California nurse’s association (CNA) provided a proposal to the legislative assembly of the state. Before the enactment of the law, there were many attempts by the association to have the law adopted. Nurse leaders should participate in the formation of similar legislation because of the potential benefits. Hospitals may face budgetary problems when implementing new policies as evidenced in the California staffing law.

The Legislation

California registered nurse staffing ratio law came into effect on January 1, 2004. The law was sponsored by the Californian Nurses Association. The proposal to change the staffing laws was based on patient safety. In every hospital, the nurses are assigned to patients to ensure that the sick receive care that is specific to their needs. Nurses assigned to many patients may experience challenges providing quality care to all the patients (Spetz et al., 2009). This means that it is important for nurse leaders to ensure that the patient-nurse ratio follows the required regulations.

The registered nurses of California prepared the legislation before passing it to the assembly to deliberate. The law was passed in 1999 by the assembly and was then signed into law by the Governor. The law was assigned the sign A.B. 394 and it made California the first state to enact a law that mandated hospitals to have specific nurse-patient ratios. The CNA is an organization that comprises registered nurses within the state. The organization has made various policy proposals that are intended at making the health care industry safer and more effective. The A.B. 394 was the biggest policy change implemented by the association.

The CNA relied on research and data from the University of California-Davis medical center. Researchers from the university had conducted surveys on nurse directors throughout the state. This data was used to understand the issue of staff ratio throughout the state. The study by the Davis medical center had also made recommendations on the staff ratios which were based on their survey. Therefore, the CNA relied on dependable research and expert opinions to determine the staff ratios for different units within a hospital. The nurses wanted to change the situation within various hospitals in the state. The legislation has been viewed by nurses as helpful to the provision of quality care.

The process of drafting the legislation was lengthy because it involved conducting campaigns and rallies to sensitize the public. The registered nurses in the state had attempted to pass the law multiple times within the decade. The attempts had always failed because of a lack of support from the general public. The nurses organized several grassroots campaigns targeted at patients and the public. Letters and calls were two of the main communication tools used by the RNs. The final effort was a large public rally at the Capitol in Sacramento during the day of the legislative vote.

The law faced various hurdles before being rolled out for full implementation in 2004. The hospital association filed lawsuits seeking to block the implementation of the law. Hospitals within the state have to adhere to the stipulated guidelines. The law provides that there should be minimum, specific, and numerical ratios for different departments within the hospital (Spetz et al., 2009). Nurses are assigned to patients based on their specific needs. Patient classification systems should be used to measure patients’ needs and the nursing care required. Hospitals have to include additional registered nurses to the minimum ratio.

The law also focuses on the use of unlicensed staff by hospitals. Assistive personnel who are not licensed should not perform any nursing function within the hospital even if they are being supervised by an RN (Spetz et al., 2009). Nurses should receive similar orientation and competency determination exercises. This guideline prevents the strategy used by most hospitals where nurses are assigned to any department without orientation. Hospitals are also restricted from averaging the number of patients and registered nurses (Spetz et al., 2009). After the implementation of the law, some of the hospitals reduced their licensed vocational nurses and assistive personnel (Spetz et al., 2009). However, the law maintains that safe staffing standards utilize the various personnel available.

Critique of the Legislation

Even though the legislation was intended on providing better care to patients, there have been challenges along the way. Research shows that the law did not provide significant improvements in the quality of care for patients (Spetz et al., 2009). Most of the hospitals within the state had challenges implementing the changes because of the high costs involved (Spetz et al., 2009). Hospitals had to reduce their budgets which affect services in other areas of the institution. However, the legislation had the positive effect of increasing the employment rates of registered nurses. The health facilities had to hire more registered nurses for the staff ratio policy to work as outlined.

Unlicensed staff members lost their jobs because of the limitations placed on the tasks they can take up at the workplace. The purpose of establishing the law was to improve the quality of care provided to patients. Implementing staffing ratios does not mean that the level of care will automatically improve (Spetz et al., 2009). One of the challenges is the break-in continuity when one of the nurses goes for a break because of the meal break rules (Burnes Bolton et al., 2009). The level of care may be different between the two nurses which may affect patient satisfaction rates.

Policy Recommendations

The California legislation on staffing ratios has had positive effects on the health care industry. The nurses have benefited greatly by having better schedules that help them provide quality care to patients (Spetz et al., 2009). The policy also ensures that registered nurses access essential employment opportunities. Nurse leaders should work with other colleagues to create legislation that is intended on proving better care to patients. Working on such legislation can be rewarding because of the possibility of proving solutions to challenges within the industry. Nurse leaders are supposed to guide other nurses on important health care matters.

Participating in the process of passing legislation can be a learning experience for the nurse leaders. This is because for the legislation to be passed several stakeholders have to be convinced. The process of deliberating with stakeholders can provide a leader with new ways of negotiating. However, creating new legislation can result in added operational costs for most hospitals. New laws need to be considerate to different situations. Staffing issues are the biggest challenge in a hospital and policies that address the issue can help health care facilities provide quality care.


Spetz, J., Chapman, S., Herrera, Carolina., Kaiser, Jennifer., Seago, J.A., Dower, Catherine. (2009). Assessing the impact of California’s nurse staffing ratios on hospitals and patient care. California Health Care Foundation.