1. Rosenberg, Karen


Hospitals' nurse staffing has increased without sacrificing skill mix.


Article Content

Low nurse-patient ratios are associated with poor outcomes among both patients and nurses. A 1999 California law requiring the establishment of minimum nurse-patient staffing ratios in hospitals was intended to improve care and patient safety and to help hospitals retain nurses. Because the law allowed for 50% staffing by LVNs, however (purportedly because of the nursing shortage), there was concern that a lower skill mix could undermine the intent of the law. Now researchers seeking to determine the effect of the law on hospital staffing and skill mix (the ratio of RNs to total licensed nursing staff) have found that implementation of the mandated nurse staffing levels led to an increase in RN staffing in hospitals, not to a decrease as some had predicted.

Figure. Then-governo... - Click to enlarge in new windowFigure. Then-governor Gray Davis of California speaks to hospital nurses at a 2002 news conference in Los Angeles, where he announced new state-mandated nurse-patient ratios in hospitals. Photo by Reed Saxon / Associated Press.

The researchers compared staffing levels in California hospitals with those in all U.S. hospitals and in four matched comparison states before and after implementation of the staffing mandate.


Nurse staffing increased in California during the implementation period, and contrary to expectations, the nursing skill mix increased, in keeping with the trend in hospitals nationally. Hospitals primarily used RNs rather than LVNs to meet mandated levels. It's estimated that the mandate resulted in approximately one additional half hour of nursing per adjusted patient day beyond what would have been expected without the policy.


The authors note that California is the only state to have established minimum nurse staffing ratios and its experience may be useful for other states considering such a policy. It remains to be determined whether the cost of increased staffing provides adequate returns in comparison with other approaches to quality improvement, but it's possible that the costs may be offset by better patient outcomes and fewer adverse events.-Karen Rosenberg




McHugh MD, et al. Health Aff (Millwood) 2011;30(7):1299-306.