When California Set Minimum Staffing Levels for Overworked Nurses, Better Patient Outcomes Followed
When Catherine Kennedy began her career as a registered nurse in California in 1980, staffing situations often resembled the Wild West. On some overnight shifts in San Francisco, Kennedy said, she and one other RN shared responsibility for a 48-bed facility. Their only help was four aides.
“It was unmanageable,” Kennedy remembered. “You would work as a team, get through the night, and pray nobody would code [i.e. suffer a cardiac or respiratory arrest].”
It took years of prodding, much of it coming from union-organized RNs, to get state legislation passed that mandated far stricter nurse-to-patient ratios than those Kennedy and her colleagues faced back then. The result has been profoundly positive. California’s safe-staffing laws, in practice since 2005, have led to fewer patient deaths, less burnout and higher retention rates among nurses than under policies in other states.
They’re also a complete outlier. Despite abundant evidence that increasing nurse staffing saves lives and leads to better patient outcomes (and potentially saves money), no other state has enacted specific ratios that cover all hospital and skilled nursing settings. Few have even come close.
Why?
“Pretty simple: The hospital industry has a lot of money,” said Nerissa Black, an RN at Henry Mayo Newhall Hospital in Valencia. “We advocate for our patients. The industry advocates for its profits. That’s the problem.”
The forces aligned against each other meet again on a national scale this year. In both the U.S. Senate and the House of Representatives, the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2023 has been introduced — the fourth go-round for the legislation, which stalled in committee in 2017, 2019 and 2021.
The proposal mirrors California’s current staffing laws, mandating that RNs be assigned a limited number of patients: one in trauma and operating rooms, two in intensive care units, three in emergency rooms and no more than five in rehabilitation and skilled nursing settings. The bill is a loud endorsement of the only such staffing requirement in the country.
“We know that safe staffing levels mean better outcomes for patients,” Sen. Sherrod Brown (D-Ohio) said in introducing the bill in March. “But too often, nurses are stretched too thin, caring for too many patients with not enough support.”
Researchers at the University of Pennsylvania found that each surgical patient added to a nurse’s workload results in a 7% increase in mortality.
That’s true across the country, as staffing ratios vary wildly from state to state — including Brown’s home of Ohio, which for years was the only state that did not license its hospitals before a new law took effect in 2022. But all of them are consistently higher overall than California’s ratios, which have gone almost unchanged since they were implemented.
It wasn’t without a struggle. Lobbyists for the health industry in California fought furiously against any set ratios, said Kennedy, a pediatric ICU nurse who eventually rose to become co-president of the powerful California Nurses Association, part of National Nurses United. It was the CNA/NNU that sponsored the legislation signed into law by then-Gov. Gray Davis in 1999, taking effect six years later. (Disclosure: CNA is a financial supporter of Capital & Main.)
“And even then, we had to fight to keep it, because Gov. [Arnold] Schwarzenegger came in and wanted to roll the ratios back, if not get rid of them,” Kennedy said. “So it was constant enforcement — we never gave up. And we’re not going to stop until we get this done on a federal level, too.”
The case for strict staffing ratios in American hospitals and skilled nursing facilities is remarkably straightforward: They save lives and reduce nurse turnover.
According to research by Linda Aiken and others at the University of Pennsylvania, each surgical patient added to a nurse’s workload results in a 7% increase in mortality and a 7% increase in failure to rescue, “which is just what it sounds like: patients experiencing an adverse outcome with nobody there to witness, monitor it and intercede,” said CNA board member Michelle Moran.
In another study, published in 2020, Aiken and researchers at the Center for Health Outcomes and Policy Research at Penn’s School of Nursing concluded that New Jersey hospitals would have 14% fewer deaths and Pennsylvania’s 11% fewer deaths if they adopted California’s 1:5 ratios in surgical units. The study also found less burnout and lower job dissatisfaction among nurses in all three states whose employers applied California’s ratios.
That is a significant note. While hospital administrators, even pre-pandemic, spoke of an ongoing nursing shortage, those in the business say it’s not the case. What is happening, they say, is that nurses are being driven out of the workforce by burnout and stress over hospital conditions that the nurses feel lead to inferior care of their patients.
“It’s a real sense of moral distress when I cannot do what I know needs to be done for each of my patients.”
~ Nerissa Black, registered nurse
Black was working in the telemetry unit at Henry Mayo when COVID arrived in 2020. Within a couple of months, the hospital closed an entire wing that had previously handled elective procedures, she said, and laid off the RNs and staff in the unit. But when the COVID surge hit that winter, the hospital received a waiver from the state to relax its nurse to patient ratios, arguing that it didn’t have enough nurses.
RNs in the telemetry unit, who are charged with constantly monitoring the cardiac conditions of each patient, suddenly found themselves with 50% more people to care for — six, rather than the usual four. “That may not seem like much, but it meant that we had only 10 minutes out of each hour for each patient,” Black said. Her duties included cardiac monitoring, making patients’ beds, helping them eat, taking them to the bathroom and speaking with family members, all while taking extreme COVID precautions.
“That went on for three straight months, and it was heartbreaking. It’s a real sense of moral distress when I cannot do what I know needs to be done for each of my patients,” Black said. By the fall of 2021, she left the telemetry unit, moving to a less stressful nursing job after pondering leaving the profession altogether.
An analysis of 2021 Bureau of Labor Statistics data by NNU determined that there are roughly 1 million licensed nurses in the U.S. who are not working — generally, the union contends, because hospital conditions and staffing levels are so dire that the available jobs are unappealing. Earlier this year, the National Council of State Boards of Nursing projected that another 900,000 — about a fifth of all RNs in the nation — plan to exit the field within five years.
California survived the nursing crunch of the pandemic in part because it was able to hire travelers, nurses who go from one assignment to the next, often far from their home states. “We needed travelers because our nurses were getting sick in record numbers, because the hospitals weren’t giving them the protective equipment they needed,” Moran said. “And we seemed to have no problem hiring them. When I spoke to some of the travelers about why they’d come all the way to California, they said, ‘Well, you guys have ratios.’”
But RNs cost money. In California, for example, the average RN wage is $60 an hour, or about $125,000 a year for a full-time nurse working 40 hours a week. And the latest push for federal staffing guidelines is set against a backdrop that isn’t new: the decade-long infusion of private equity investment in the health care sector, a place investors see as ripe for massive profits.
How to maximize those profits? Slice nursing staff levels to the bone, thus eliminating a significant percentage of operating costs, and push digital health practices as an alternative.
When nurses in Massachusetts qualified a ballot initiative in 2018 to establish safe staffing ratios, they were outspent more than 2 to 1.
“What we have seen is that corporations and people who want to make money have gotten more into health care in general,” Rep Jan Schakowsky (D-Ill.), who introduced the safe staffing bill alongside Brown, told Modern Healthcare in a recent interview. “We need to make sure … more money is going to go into nursing itself.”
The hospital industry has consistently and effectively pushed back against any such legislation, either at the state or federal level. When nurses in Massachusetts qualified a ballot initiative in 2018 to establish safe staffing ratios, they were outspent more than 2 to 1, and voters ultimately rejected the measure. Opponents, including the powerful American Hospital Association, marshaled more than $25 million to ensure the proposal’s defeat.
The AHA is gearing up to fight the latest federal legislation as well. “Mandated nurse staffing ratios are a static and ineffective tool that does not guarantee a safe health care environment or quality level to achieve optimum patient outcomes,” said Robyn Begley, the association’s senior vice president of workforce. “Staffing ratios are usually informed by older care models and do not consider advanced capabilities in technology or interprofessional team-care models.”
Begley, whose association spent $27 million on lobbying last year, was referring not only to the rise of telehealth during the pandemic, but also to farther-flung models, such as fewer RNs operating out of central command centers while lesser-paid, lesser-trained nursing assistants and other staffers carry out directives at the actual hospitals or care centers — a “generic workforce,” as some nurses put it.
“We are seeing an absolute explosion of untested and unproven technologies in our facilities,” Moran said. “What we’ve been watching, through the pandemic and now beyond, is disaster capitalism in action in the health care industry.”
The irony is that having an adequate number of nurses on staff can save money. In a 2021 study, Aiken and a group of researchers found that, if New York had applied a proposed 1:4 nurse to patient ratio in medical-surgical units over a recent two-year period, hospitals would have saved $658 million each year because of shortened hospital stays due to improved care.
Those estimates included only about 25% of Medicare hospitalizations; the actual cost savings when taking into account all patients, Medicare and non-Medicare, would “likely be many-fold higher,” the researchers wrote. They also projected that there would have been nearly 4,400 fewer in-hospital deaths.
New York eventually enacted a law that mandates safe staffing committees in each hospital, although the precise nurse-to-patient ratios are up to those committees to determine. A recently passed bill in Washington state would essentially do the same thing after a stronger measure, which set specific staffing ratios, faced lobbying pushback from the hospital industry. A bill in Oregon would establish staffing levels with local control to amend them, and Massachusetts has a statewide law concerning ICU ratios.
How the federal legislation will fare is unclear, but history is not kind. Brown’s Senate proposed bill has been referred to the Committee on Health, Education, Labor and Pensions, the same place where it stalled two years ago.
Nurses say they are undeterred. Their organized numbers have grown tremendously in recent years; NNU’s membership is up to 225,000 nationally, and the Service Employees International Union, which represents perhaps 80,000 nurses, has endorsed the federal legislation as well.
During National Nurses Week, which ends Friday, union members are lobbying members of Congress for support of a number of measures, including the bill introduced by Sen. Brown and Rep. Schakowsky. California, they say, continues to be the model of success.
“Nurses around the country see what’s happening in California,” said Sandy Reding, an operating room nurse who began working in 1983 and routinely handled 12 to 15 patients per shift before joining the fight for safe staffing ratios.
“We got it done all those years ago because we were organized, and we’ve seen the good results of that bill — and that’s what every patient deserves, that level of care. That’s why we want a federal bill.”
Mark Kreidler is a California-based writer and broadcaster, and the author of three books, including Four Days to Glory.
Capital & Main is an award-winning nonprofit publication that reports from California on the most pressing economic, environmental and social issues of our time. Winner of the 2016 Online Journalist of the Year prize from the Southern California Journalism Awards and a 2017 Best in the West award, Capital & Main has had stories co-published in more than 30 media outlets, from The Atlantic, Time, Reuters, The Guardian and Fast Company to The American Prospect, Grist, Slate and the Daily Beast. Working with top writers, editors and visual artists, we cover income inequality, climate change, the green economy, housing, health care, public education, immigration, race, and criminal justice. Capital & Main is a 501(c)3 tax exempt organization.