Nursing is one of the most challenging professions, as nurses work long hours and night shifts caring for severely ill and sometimes dying patients. Many experts argue that in order to reduce job-related burnout and job dissatisfaction, decrease nurse workloads and improve patient safety, there should be more nurses working in hospitals per patient. This is measured as the nurse-to-patient ratio. For example, if every nurse is taking care of six patients at one point time in a certain hospital unit, then the nurse-to-patient ratio is 1:6 in that unit.

Nurse-to-patient ratios became a controversial topic when the state of California, despite huge opposition from hospitals and Gov. Arnold Schwarzenegger, mandated ratios in all hospitals. The legislation, signed into law in 1999, took effect on January 1, 2004, and gave hospitals five years to phase in the changes.

According to the law, nurse-to-patient ratios should be 1:1 in the Operating Room and 1:2 in the intensive care, critical care, and neonatal intensive care units, as well as in post-anesthesia recovery and labor and delivery. The ratio is 1:4 in ante-partum (before delivery), post-partum (after delivery), pediatric care, and in the emergency room and other specialty care units. In general medical-surgical units (regular hospital units), the ratio is 1:5.

What makes the law especially controversial and hard to implement for hospitals is that it requires them to be in "continuous compliance" with ratios, which means that the number of patients assigned to each nurse should not exceed the ratio at any point in time during any shift on any unit. So if a nurse has to go to the restroom, the regulation requires him to reassign his patients to another nurse.

Since then, 11 other states (Connecticut, Illinois, Maine, Nevada, New Jersey, Ohio, Oregon, Rhode Island, Texas, Vermont, and Washington) plus the District of Columbia have enacted legislation and/or adopted regulations addressing nurse staffing, though most of them used approaches that were less rigid than the California law.

Five years after the California law took effect, nurses are very optimistic about the ratios. According to Zenei Cortez, RN, a member of the Council of Presidents of the California Nurses Association/National Nurses Organizing Committee “The ratio law has been a success. […] We have seen a large increase in the number of RNs licensed in California since the ratio law went into effect, and the rate of turnover has decreased because of increased satisfaction.” She also adds that “the law has improved patient safety and helped save patient lives, allowed nurses to be stronger advocates for their patients, and raised interest in nursing as a career.”

However, hospitals are still not convinced, especially that there is still no conclusive evidence as to whether the ratios actually improve care and reduce errors. In fact, the only study to date to look at the issue was published in 2002, two years before the law was implemented.

That study, though, had some alarming conclusions. It showed that when a nurse is assigned more than four patients, the risk of death goes up by 7% for each additional patient. So if the risk of death for each patient is 7% when a nurse is taking care of five patients at a time, that risk goes up to 42% for each patient when that nurse’s workload goes up to ten patients.