Home to Hollywood and year-round sunshine, California is what dreams are made of, except, perhaps, when it comes to nursing. For the past several years, it has been anything but ideal. The most-populated state ranks 49th in the country for nurses per capita, with approximately 550 nurses per 100,000 people. Hospital administrators, members of nursing organizations, policymakers, and consumer advocates all agreed something had to change in order to increase nursing's presence in the clinical setting. Their answer? Passing mandatory nurse-to-patient ratio legislation.

Some applaud this move as a step toward better healthcare services, while others assert it will only exacerbate the current nursing shortage, drive up costs, and force hospitals to close their doors. The controversy stirs up heated debates within the industry as more states consider following in California's footsteps.

Testing a formula California has led the country in many ways, from technology to pop culture, so it comes as no surprise it is taking on the role of trailblazer by enacting mandatory nurse-to-patient ratios. In 1999, then-Governor Gray Davis signed the Safe Staffing Law, which took effect this past January. Now, hospitals and medical centers of all sizes are mandated to employ a minimum number of registered nurses (RNs) per unit, for every shift. For example, critical care units must operate with no less than one nurse for every two patients. The emergency department (ED) must staff at least one RN for every four patients. While specific numbers vary between units, the common thread across the state is the significantly increased demand for clinicians.

Guidelines apply only to RNs. Neither certified nurse assistants (CNAs) nor licensed practical or licensed vocational nurses (LPNs/LVNs) can factor into the ratios. Not even charge nurses or unit managers can be counted as part of the equation. While facilities may opt to employ CNAs and LPNs/LVNs, they must also hire enough RNs to meet legal parameters.

More specifically, distinctions are not drawn between day and night shifts, weekdays or weekends, or even when clinicians step off the unit for a break. Managers must uphold the minimum number of RNs on the floor at all times. "Covering nurses so they can take breaks and meals is probably the most challenging aspect of the mandatory ratios," comments Pamela Johnson, RN, operations director at Kaiser Permanente in Oakland, California. This mandate also is a substantial change for hospitals that routinely operate with leaner staffs during the night. "The night shift has traditionally required less personnel, but now we have to provide the same nurse-to-patient ratios throughout the day and night," states Cathi Brunner, human resources recruiter for the in-house travel division at 100-bed University Community Medical Center (UCMC) in San Diego, California. "That, of course, increases expenditures."

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From the supporters One of the arguments in favor of preset ratios is the more prominent role of RNs in the clinical environment. Multiple studies confirm that a greater number of registered nurses equates to more positive patient outcomes. Under current practices, such as using obligatory overtime to deal with staffing shortages, nurses are often overtired and overworked. In fact, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) states that nurses, on average, work an extra 811⁄42 weeks per year in overtime. Ratio proponents assert that less-stressed clinicians provide a higher level of care to their patients.

Indeed, JCAHO reports that a shortage of nurses is a factor in about one-fourth of patient injuries or deaths in acute care settings. There have already been two known malpractice lawsuits naming inadequate nursing staff as a litigating factor. Additional research from the Institute of Medicine of the National Academies found that long hours and fatigue contribute to clinical errors, leading the organization to recommend that facilities prohibit nurses from working longer than 12-hour shifts.

Under the ratios, California nurses are responsible for fewer patients during a shift and, therefore, can dedicate more time to an individual. Ms. Brunner comments, "For nurses, I think the ratios are a positive development, especially on med/surg units where they were overworked. Providers are now able to look at patients more holistically-to meet more needs than just the medical basics...which is the real reason why so many nurses chose the profession in the first place."

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From the opponents On the other side, opponents claim mandatory ratios will only serve to worsen the already critical nursing shortage. Well before Governor Davis signed the Safe Staffing Law, California hospitals-like so many across the country-were struggling to meet a mounting demand for practitioners. The Department of Health and Human Services (DHHS) released a report in 2000 that placed the national nursing shortage at 110,000 vacancies (6 percent). It also predicted the rate would grow to 12 percent by 2010, 20 percent by 2015, and 29 percent by 2020. Those statistics were based on the employment picture of 2000, and did not factor in the additional demand ratios would create.

"Did legislative supporters really look at whether the numbers of active professionals were available to sustain the ratios once passed? Are there opportunities to insure academic programs maintain pace with emerging technology to push the profession forward? Do nurse practitioners and physician assistants have a place in a staffing model?" asks Karen Flaster, executive vice president and chief operating officer for HRN

Services Inc., located in Beverly Hills, California. "The query about nationwide ratios is not a simplistic question. Ratios now have to be a part of the care-delivery approach. There does appear to be greater use of the primary care model, in which RNs are assigned to provide comprehensive care to patients, versus team models and those that utilize non-licensed assistants. As a result, there is a shift toward having more registered nurses which is apparent in the type of orders our company is receiving, along with the surge of inquiries from certified nursing assistants who have been laid off or displaced."

Without the prescribed nurses per shift, administrators voice concerns about being able to supply communities with quality healthcare services. Emergency departments nationwide are stretched to their limits, with increasing numbers of patients deferred to other facilities. The American Hospital Association (AHA) reports overcrowding in 38 percent of facilities' EDs and patient diversion in 25 percent. For example, the four-bed ED at UCMC receives a staggering average of between 1,000 and 1,300 patients per month. Explains Ms. Brunner, "Some hospitals in San Diego County, in the past few years, have had to shut down, and that has impacted our emergency department tremendously."

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Whenever staffing patterns are evaluated, costs also play a substantial role in administrators' decision-making. Many hospital associations oppose the mandatory ratios because of the perceived increase in operating expenses. The California Healthcare Association, for example, estimates ratios will cost facilities $400 million a year in added wages and benefits. Among those increased expenditures is an extended orientation. The Safe Staffing Law requires all clinicians to undergo the same training procedures. "It used to be that mobile professionals were expected to hit the floor running," notes Ms. Brunner. "Now, if we give new hires three days of unit-specific orientation, then travelers also get three days-which we have to fit into our budget and time schedule."

"I do not believe that ratios should be legislated," admits Ms. Johnson. "Such a law creates a financial hardship for states."