California nurse staffing mandate did not reduce nursing workforce skill levels

Research Activities, January 2012, No. 377

In 1999, California passed legislation requiring minimum nurse-to-patient staffing ratios for hospitals. The same law allowed up to 50 percent of the nursing staff to be licensed vocational nurses, as opposed to registered nurses who have a broader scope of practice. A new study found that California did not reduce the nurse workforce skill level as had been feared; instead, average skill levels increased, in keeping with a national trend.

The staffing mandate resulted in roughly an additional half-hour of nursing per adjusted patient day beyond what would have been expected in the absence of the policy. Although hospitals in other States also experienced increases in nurse staffing, the rate of increase was steeper in California (from 6.44 hours in 2004 to 7.11 hours in 2008, compared to 5.75 hours to 6.22 hours in comparison hospitals in the other States).

A team of researchers led by Matthew D. McHugh, Ph.D., of the University of Pennsylvania, compared the changes in staffing in California to Texas, New York, Florida, Pennsylvania, and the nation as a whole between 1999 and 2008. California remains the only State to have implemented minimum nurse staffing ratios. For general medical and surgical units, minimum staffing is set at one nurse for five patients.

Whether the cost of increased staffing provides adequate returns compared to other quality-improvement initiatives remains to be determined. Other research following the implementation of California's staffing mandate has shown that the increased staffing in California hospitals was associated with better outcomes compared with patients treated in hospitals in other States. This study was supported by the Agency for Healthcare Research and Quality (HS17551).

See "Contradicting fears, California's nurse-to-patient mandate did not reduce the skill level of the nursing workforce in hospitals," by Dr. McHugh, Lesly A. Kelly, Ph.D., Douglas M. Sloane, Ph.D., and Linda H. Aiken, Ph.D., in Health Affairs 30(7), pp. 1299-1306, 2011.

Page last reviewed January 2012
Internet Citation: California nurse staffing mandate did not reduce nursing workforce skill levels: Research Activities, January 2012, No. 377. January 2012. Agency for Healthcare Research and Quality, Rockville, MD.