The Patient-to-Staff Ratios Won By California Nurses Save Lives. We Need More of Them.

California nurses fought for over a decade to win safe-staffing legislation, a crucial set of rules protecting both nurses' rights on the job and the well-being of hospital patients. So far, no other state has followed suit — but nurses nationwide are struggling to change that.

A registered nurse with the Florida Department of Health cares for a nursing home resident in Northeast Florida. (Sgt. Michael Baltz / Flickr)

The COVID-19 pandemic has highlighted the underlying weaknesses of the US health care system. Large swathes of the country in rural areas lack hospitals. Long-term care facilities are centers of disease transmission, responsible for some 40 percent of the country’s 380,000 COVID-19 fatalities. Existing hospitals lack adequate personal protective equipment. And understaffing has emerged as a critical frailty in the country’s ability to handle the disease.

Understaffing and overwork among the country’s approximately three million registered nurses (RNs) — a problem even before the pandemic — is now an emergency. Privately owned facilities in particular tend to cut corners on staffing levels; lowering labor costs is a key strategy for boosting profit. Nurses, facing high stress and anxiety as well as exposure to the virus — according to the National Nurses Union, hundreds of RNs have died of COVID-19, with hundreds of thousands more infected — are under more pressure than ever before.

Hospitals are increasingly relying on traveling nurses, employed by staffing agencies, to fill in the gaps. Pay for these workers has skyrocketed — while median pay for an RN is around $73,000, some travel nurses can now make upward of $5,000 a week. (Rumors abound inside hospitals of $10,000-a-week travel-nurse jobs.) The result is a migration of nurses from stable but lower-paying work in a single hospital to contract work, a process only intensifying the problem of understaffing.

As a recent New Yorker article tracing the Bay Area’s pandemic response argues, nurse staffing levels are “the most crucial determinant” in the level of care in nursing homes. These institutions were ground zero for the spread of COVID-19 in the United States; staffing levels can either cause an uncontrollable outbreak, or prevent it.

Too little staffing leads to a failure to catch the disease before an outbreak begins; underpayment leads workers at the facilities to take on extra work at other nursing homes, causing them to unwittingly spread the disease as they move between facilities. As the New Yorker puts it, “If you want to predict how many infections a given area will have, you can start by asking a series of questions: How many nursing homes are there? How understaffed are they?”

There is a wealth of evidence that inadequate staffing levels — tasking an ICU nurse with caring for four or five patients rather than one or two, for example — lead to worse patient outcomes, and higher turnover among nurses.

Such circumstances resulted in a series of nurses’ strikes in recent months in regard to what they refer to as “ratios” or “safe staffing” levels. When I spoke to nurses who went on strike in the Philadelphia area in November 2020, chronic understaffing was a key point of contention. Despite the high stakes of striking during a pandemic, the nurses felt they had no other means of protecting patient safety. And they weren’t the only ones: nurses in several other states also struck over staffing levels.

One measure that would contribute to resolving unevenness in nurses’ working conditions, and the quality of care that follows from it, is safe-staffing legislation. Currently, most hospital administrators are free to staff facilities as they see fit, but there are important exceptions. Unionized nurses bargain over staffing levels, with the issue — as was the case for those nurses who have struck in the past year — central to negotiations. The other exception is hospitals in California, the only state with safe-staffing legislation.

Safe-Staffing Legislation in California

AB 394 was signed into law in 1999 by then-governor Gray Davis. The legislation directed the state’s health department to come up with nurse-to-patient ratios. After a multi-year process, levels were agreed upon. They vary based on the type of unit in which a nurse works: for example, nurses caring for trauma patients in an emergency room have a 1:1 ratio, while those in psychiatric wards work under a 1:6 ratio. These standards are a floor, not a ceiling; should they choose to do so, health care facilities can staff more nurses than is mandated by law.

In the years since the legislation went into effect, research suggests the law has had its intended effect: improving patient care. Nurses’ working conditions are patients’ care conditions, and the experience of minimum staffing levels proves it. A 2010 study found better patient outcomes in California than in states without safe-staffing laws. For example, New Jersey hospitals would have nearly 14 percent fewer patient deaths were they to adopt California’s ratios.

As the authors conclude, “Hospital nurse staffing ratios mandated in California are associated with lower mortality and nurse outcomes predictive of better nurse retention in California and in other states where they occur.” And beyond improving health outcomes, AB 394 has also helped nurses, lowering occupational injury and illness rates by 30 percent as well as reducing self-reporting job dissatisfaction.

How did California come to pass such legislation? Much of the explanation comes down to nurses’ collective strength in the state as expressed in their unions.

During the height of the AIDS epidemic, San Francisco’s General Hospital created a hospital ward specifically for AIDS patients. The influx of new patients led the ward’s nurses to demand nurse-to-patient ratios in their contract, making them some of the first nurses in the country to win such a provision. In the following years, nurses elsewhere began adopting the same approach.

By the 1990s, the California Nurses Association (CNA), eager to remove the need to bargain over staffing, began agitating for legislation. It cosponsored AB 1445 in the 1992–93 legislative session, but the bill did not make it out of committee. During the 1997–98 legislative session, the union again cosponsored a safe-staffing bill: AB 695 was approved by the state legislature only to be vetoed by then-governor Pete Wilson.

Undeterred, CNA along with other unions tried again in the next legislative session. After mobilizing thousands of nurses to rally in favor of the bill at the state’s capitol as well as the governor’s office, they won. Then-governor Davis signed the legislation on October 10, 1999.

The nurses’ opposition didn’t give up easily. Opponents, such as health care executives, argued for high ratios that would have rendered the new legislation ineffective. Hospitals, organized as the California Hospital Association, lobbied to block the legislation, even filing a lawsuit in 2003 to repeal parts of the bill. When the lawsuit failed, they turned to then-governor Arnold Schwarzenegger for help. Governor Schwarzenegger issued an emergency regulation blocking certain ratios that were to go into effect January 1, 2005, leading the CNA to sue the governor while also organizing protests against him. Ultimately, a state court overturned Schwarzenegger’s exemption.

Safe-staffing legislation isn’t foolproof: California health care facilities are still suffering as the state experiences the uncontrolled spread of COVID-19. Governor Gavin Newsom has begun granting hospitals exemptions from the law as the pandemic intensifies, which has led some nurses to set up picket lines in the past month. But it’s a standard, one that stabilizes the industry and puts limits on administrators’ cost-cutting.

Other states are currently considering safe-staffing legislation, and in 2019, Senator Sherrod Brown and Rep. Jan Schakowsky reintroduced federal legislation on the issue, the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act. It’s possible that the chaos brought on by the pandemic will strengthen the urgency and argument for legislating staffing levels; the evidence that this is an issue that affects all of us, not just nurses, is now overwhelming. If we don’t act on the lessons offered by the still-unfolding public health disaster, we can’t be surprised if we repeat them the next time.