Impact of nurse staffing regulations in California: Perspective of hospitals leaders

In 1999, California became the first state to pass legislation mandating minimum nurse to patient ratios. Regulations detailing specific nurse ratios by type of hospital unit were released in 2002 with a phased-in implementation beginning in 2004 and completed in 2008. Nurse staffing regulation is on the agenda in many states with legislation introduced in 13 states in 2008. Ratios were implemented at a time of severe RN shortages in California and a worsening financial position for many hospitals. The purpose of this study was to assess the impact of nurse staffing ratios from the perspective of hospital leaders. Semi-structured in-person and telephone interviews were conducted with 23 hospital leaders from across the state including private and public hospitals. Analysis identified key themes including: preparation for the ratios, hiring additional RNs, cost and financial challenges, impact on nurse satisfaction and retention, and impact of patient safety. Most hospitals found it difficult and expensive to find more RNs to hire to meet the ratios. Rising costs for nursing included the use of more registry nurses and paying incentive bonuses. Meeting the minimum staffing on all units, at all times, was challenging and had negative impacts such as a backlog of patients in the E.R. and a decrease of hospital ancillary staff. Hospital leaders did not believe that ratios have had an impact on patient quality of care. Other research to date on patient safety impact from the ratios concurs. Increased staffing improved RN satisfaction with patient workload yet created dissatisfaction with rigid rules about break times. Further research should continue to monitor patient outcomes as other states consider similar ratio regulations.