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Mandated Nurses Patient Ratios for California

A mandated nurse-patient ratio is a legislative regulation that was passed as a law in the state of California, about thirteen years ago. The idea of the minimum nurse-to-patient ratios was first proposed and implemented in the State, where it was enacted into law. The enactment would facilitate significant changes in health care units within the state where a proposed nurse-patient ratio was implemented, to replace the actual ratios. The mandated minimum nurse-patient ratio for step-down health care units across the state was changed from 1:4 to 1:3, while the ratio in telemetry and other specialty care facilities was brought down to 1:4 from 1:5 (Donaldson et al., 2005). The introduction of the mandate was facilitated by the California Nurses Association. Members of the association had sponsored a bill whose main aim was to ensure better staffing of RNs in the state. For many years, there had been a constant concern about inadequate nurse staffing across the state. This inadequate staffing stood as a major threat to the overall well-being of patients, and therefore it was necessary for the nurses to introduce a policy that would take care of this demanding situation. As it was observed, implementation of this mandate in the state would yield immense benefits to the nursing professionals and the patients in various health care units.

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History of the Law

The bill proposing this regulation to be enforced was eventually signed into law in the year 1999. There had previously been two attempts to pass this bill, but both of them failed. However, things changed in 1999, when the bill was eventually enacted as a law by then Governor of California, Gray Davis. As a result, the California Department of Health Services was to determine and implement the proposed nurse staffing ratios according to the requirements of the new law (Spetz, 2005). The proposed ratios of the mandate were officially announced to the general public in theateginning of 2002, but the implementation of the law was set to begin by the mid of the following year. This saw the mandated nurse-to-patient ratios for the step step-down and specialty care units go down to 1:3 and 1:4, respectively. Phased-in implementation of this regulation, which detailed the specific ratios for the different units, would kick off in the year 2004 and be completed four years later. The implementation of this regulation came as a timely opportunity for the state of California, as it was suffering a severe shortage of registered nurses in most of its health care facilities.

Impact of the Regulation on Nursing Work Environment

As it can be observed from various reports, the potential benefits associated with this regulation have undoubtedly outweighed the costs of its implementation. For instance, the mandate is highly effective in supporting a positive working environment for nurses. The staffing law has also proved to be effective in improving patient safety within various health units. This has strengthened nurses in their work, thus contributing to work satisfaction and promoting better outcomes for the patients. More importantly, the idea of minimum nurse-to-patient ratios would also ensure that quality accountability is well-maintained, through the establishment of the standards which are to be followed by all hospital units (Gordon, Buchanan, and Bretherton, 2008). Many nurses in California and other states have expressed their confidence in the regulations, due to a number of reasons. Most of these health care professionals believe that these changes can play a crucial role in the eradication of some common problems which they have to deal with in their work, thus boosting the hiring and retention of the new staff in the demanding profession. This proves to be possible, considering the fact that improved working conditions will surely attract more young people to join the profession.

Controversy Surrounding the Regulation

Despite the fact that there were many potential benefits associated with the staffing law in California, the issue has raised a lot of controversy among health care professionals from all over the country. There have been constant debates between the proponents of the law and those against it. As it would be observed, the controversy in the mandate revolves around people in the nursing profession, health care institutions, patients, and researchers. The first criticism of the proposal was introduced by some of the health care administrators who had come out to express their concerns that it would be hard for them to meet the proposed ratios effectively (Chapman et al., 2009). On the contrary, reports from the Californian Board of Registered Nurses showed a massive increase in the number of registered nurses in possession of valid licenses, following the implementation of the regulations in the state. There have also been constant claims from other states that health care facilities would be forced to cut expenditure on other personnel in the institutions, in order to cope with the increase in the salaries for nurses. In this regard, many people would see the idea of the ratios as a burden to the nursing professionals and a curse to the patients, who are likely to end up receiving low-quality nursing care.

My Opinion

I think that majority of those against the mandate have failed to accept it simply because they are yet to see its benefits. However, I believe that most of the potential benefits associated with the regulation are long-term, and they don’t show up just immediately after the implementation. I consider the regulation to be an effective approach that can be used to improve the quality of care given to patients, considering the lowered gaps of nurse-to-patient ratios. However, the mandate may have helped to improve the environment for the nursing profession, but it has done nothing to improve the working conditions for nurses since there is no clause in the law that advocates for nurses’ benefits and rights in work.

Editorial Summary

Regardless of the controversial nature of the law, it has proved to be an effective intervention when it comes to the management of nursing workloads in various care units. With minimum nurse-to-patient ratios, nurses would have fewer patients assigned to them, thus having reduced workloads. Even though there may be a decrease in the number of other ancillary staff as a result of the regulations, health institutions could hire more RNs to fill in any vacant positions. So far, the idea of ratios in California seems to have played an important role in many health care units. For instance, the state had experienced a massive increase in nurse staffing as well as improved patient care, in the course of the implementation of the law. As a result of all these reasons, there has been a positive response towards the mandate, from other states that have been considering adopting this policy.


Chapman, S., Spetz, J., Seago, J., Kaiser, J., Dower, C., & Herrera, C. (2009). How have mandated nurse staffing ratios affected hospitals? Perspectives from California hospital leaders. Journal of Healthcare Management, 54(5), 321-333.

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Donaldson, N., Bolton, L., Aydin, C.,Brown, D., Elashoff, J., & Sandhu, M. (2005). Impact of California’s licensed nurse-patient ratios on unit-level nurse staffing and patient outcomes. Policy, Politics & Nursing Practice, 6(3), 198-210.

Gordon, S., Buchanan, J., & Bretherton, T. (2008). Safety in numbers: nurse-to-patient ratios and the future of health care. New York: ILR Press.

Spetz, J. (2005). Public policy and nurse staffing: what approach is best? Journal of Nursing Administration, 35(1), 14-19.

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