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The issue of mandatory nurse-patient ratios remains widely controversial among many vested stakeholders, including nurses, patients, physicians, unions, nursing organizations/lobbyists, re - searchers, employers (in particular, hospitals), and federal and state governments (Douglas, 2010). Support for mandatory nurse-patient ratios is drawn from the belief that regulated registered nurse (RN) staffing will increase positive patient outcomes, decrease nursing shortages, and increase nurse recruitment and job satisfaction (Unruh, 2008). According to Blakeman Hodge and colleagues (2004), better RN staffing results in higher quality patient care (e.g. decreased hospitalization). What are the implications of mandatory nurse-patient ratios? What are the alternatives?
Background
In the early 1990s, health care financing and hospital restructuring led to a decrease in licensed caregivers and an increase in unlicensed caregivers (service aides). At the same time, managed care requirements led to increased patient acuity and decreased hospital lengths of stay. Mandatory nurse-patient ratios became law in California in 1999 with the passage of California Assembly Bill 394, which mandated minimum, specific, and numerical nurse-patient ratios in hospitals. Passage of this legislation led to changes in nurse staffing levels; RN workloads increased and RN job satisfaction decreased. Retaining and recruiting RNs became more difficult for hospitals (Blakeman Hodge et al., 2004). Additionally, the state of California was reported to have one of the lowest nurse populations in the nation (Buchan, 2005). These factors, combined with negative media attention related to patient care, gained the attention of stakeholders such as the Institute of Medicine (Buerhaus, 2010a). However, the successful lobbying for Bill 394 was due to the combined efforts of the California Nurses Association (CNA), California Hospital Association, and the Service Employees International Union over several years (Blakeman Hodge et al., 2004). Although motivated differently, these stakeholders influenced the bill's passage. Each stakeholder submitted nurse-patient ratio recommendations to the California Department of Health Services. The final bill, which was to be implemented in 2004, mandated a nurse-patient ratio of 1:5 in medicalsurgical units (smaller ratios were assigned to specialty units) (Buchan, 2005). Citing financial reasons, California Governor Arnold Schwarzenegger sought to delay this bill until 2008. However, he was overruled by a lawsuit filed by the CNA in 2005. The victory by CNA mandated the 1:5 nurse-patient ratios in medical-surgical units which are still in...