Policy Briefing DocumentPart I: Process of Legislation

The legislation process comprises the explanation of the critical factors that prompted this
legislation, the proposer of the legislation, the sponsors, and the person who drafted the
legislation. It also describes the legislation’s duration and steps from conceptualization to
implementation. More so, the process incorporates the critical elements passed within the
legislation.
The State of California was the first to pass legislation on the minimum registered nurse
(RN)-to-patient ratios for hospitals. The legislation was passed in 1999 through the California
Nurses Association’s sponsorship and lobbying. The legislature was later signed into law as
Legislature A.B 394 by the then Californian governor, Gray Davis (Bergmann, 1999). The bill
took 8 months from introduction to approval, from February 11, 1999, to October 10, 1999.
a. Purpose of the Bill
According to the Californian Nurses Association, most hospitals and other clinical
facilities in the state deliberately reduced the number of registered nurses in their roster to cut
operational costs. This move led to imbalanced nurse-patient care, increasing nurse burnout and
adversely reducing the quality and safety of care. Thus, the bill sought to analyze and improve
the minimum patient-nurse ratio to ensure healthy working conditions for the nurses and safer
healthcare by reducing mortality rate, hospital-acquired infection, and medical errors (Bergmann,
1999).
b. Resistance
The California Healthcare Association was against the bill because it only proposed ratios
of patients to nurses without providing a viable solution (California Healthline, 2004). The body

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stated that the focus should be on solving the nurses’ shortage by pushing for more uptake of
nurse graduates. The following concepts backed the refutation.
i. The proposed ratios did not have scientific backing.
ii. Patient care would deteriorate as healthcare facilities may limit the number of
accepted patients.
iii. The bill may increase the operational costs, leading to the laying off of other
workers, thus creating service gaps.

c. The Bill

The bill proposed different staffing ratios for different hospital departments. It
issued specific rations for acute care, specialty hospitals, and acute psychiatry in
California. The concern that led to this legislation was the acute nurse shortage in the 90s
in California, suffocating service delivery and reducing the quality and safety of care.
The bill proposed staffing ratios based on the defined patient classification policy
(Bergmann, 1999). It also barred authorization of unregistered personnel from carrying
out specific tasks. The table below shows the proposed ratios for different departments.
Table 1 : California RN to Patient Staffing Ratios
RN to Patients RN to Patients
Intensive/Critical Care 1:2
Neonatal Intensive Care 1:2
Operating Room 1:1
Post-anesthesia Recovery 1:2
Labor and Delivery 1:2
Antepartum 1:4
Postpartum couplets 1:4

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Postpartum women only 1:6
Pediatrics 1:4
Emergency Room 1:4
ICU Patients in the ER 1:2
Trauma Patients in the ER 1:1
Step Down, Initial 1:4
Step Down, 2008 1:3
Telemetry, Initial 1:5
Telemetry, 2008 1:4
Medical/Surgical, Initial 1:6
Medical/Surgical, 2008 1:5
Other Specialty Care, Initial 1:5
Other Specialty Care, 2008 1:4
Psychiatric 1:6

Part II: Outcome of Legislation

a. Whether Research Supports the Argument that Mandated Ratios Improved Nurse
Turnover Rates
Yes. Although research does not specifically support the argument that mandated ratios
can improve RN turnover, a better nurse staffing ratio has been found to potentially lower
attrition rates and improve patient outcomes. Initial research confirmed that hospitals that
enforced the rules recorded higher satisfaction levels for both patients and nurses (Griffiths et al.,
2020). Thus, the nurses stayed longer in those hospitals and reported less attrition.
b. Whether Research Supports that Mandated Ratios Improved Patient Outcomes

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A study by Griffiths et al. (2020) supports the policy’s proposal that higher nurse-to-
patient ratios can improve patient outcomes. Adhering to the mandated nurse-patient ratio can
improve the quality and safety of patients and lower mortality rates, rates of rehospitalizations,
cost of care, and overall patient satisfaction (Griffiths et al., 2020). A higher number of nurses in
hospitals lowers mortality rates.
c. Recommendations on Whether My Nursing Leader Should Support Working with
Other Nurse Leaders on Similar Legislation
Nurses, in general, must work together toward a common goal: delivering better, safe,
and high-quality care to patients. To render quality care, there is a need for all RNs to work in an
environment that supports positive goals for patients and general nursing practice. Working
collaboratively with other nurses allows nurses to share best practices and support each other’s
advocacy (Law et al., 2018). Collaborating with other organizations will be more effective and
structured if it starts with leaders. Top leaders can make information accessibility and
dissemination easier. The influence the leaders have on the organization’s members is more
significant and may gather more support from society.
d. Recommendations on a Drive for Similar Legislation by the Nursing Leaders
Nursing leaders must develop similar legislation to improve both the caregiver’s life and
healthcare quality. An example is a legislation requiring hospitals to adopt policies and
procedures for the training and orientation of nursing staff (Law et al., 2018). Another legislation
requires RNs to pass a standardized assessment exam before being designated to an area.
e. Pros and Cons of the Recommendation Based on Research
 Recommendation Pros Cons

1. Requiring hospitals to adopt
   policies and procedures for
2. Ensuring that all
   staff are trained with
3. Additional
   resources/expenses to

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training and orientation nursing
staff.

2. Requiring RNs to pass a
   standardized assessment exam
   before being designated to a
   practice area.

the required KPIs

2. It standardizes the
   level and quality of
   care rendered

the hospital

2. It is time-consuming

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References

Bergmann, J. (1999). Legislative developments: California enacts nurse-to-patient ratio law. The
Journal of Law, Medicine & Ethics, 27(4), 387.
California Healthline. (2004, Jan 5). California Healthcare Association files suit against the state
over new nurse-to-patient ratio rules. California Healthline Daily Edition.
https://californiahealthline.org/morning-breakout/california-healthcare-association-files-
suit-against-state-over-new-nursetopatient-ratio-rules/
Griffiths, P., Saville, C., Ball, J., Jones, J., Pattison, N., Monks, T., & Safer Nursing Care Study
Group. (2020). Nursing workload, nurse staffing methodologies, and tools: A systematic
scoping review and discussion. International Journal of Nursing Studies, 103, 103487.
Law, A. C., Stevens, J. P., Hohmann, S., & Walkey, A. J. (2018). Patient outcomes after the
introduction of statewide intensive care unit nurse staffing regulations. Critical Care
Medicine, 46(10), 1563.