By Victoria Colliver
San Francisco Chronicle
April 20, 2010

California's law limiting the number of patients that can be assigned to a nurse has resulted in fewer deaths and a belief among the state's nurses that they were able to provide better care, according to the first comprehensive evaluation of the landmark legislation.

The study by the University of Pennsylvania, published today in the policy journal Health Services Research, compared deaths from common surgeries in California in 2006, two years after the law was enacted, to surgical deaths in Pennsylvania and New Jersey.

The study concluded there would have been nearly 14 percent fewer deaths from general surgeries in New Jersey and 10.6 percent fewer surgical deaths in Pennsylvania if hospitals in those states had been staffed at California's level of 1 nurse to every 5 patients. California is the only state in the nation with legally mandated patient-to-nurse ratios.

Researchers also surveyed more than 22,000 nurses in all three states and found California nurses consistently reported higher job satisfaction than nurses in the other states. The study attributed the finding to the California nurses' ability to provide better care to their patients and spend more time with them.

"The differences between California and the other states are striking," said Linda Aiken, lead author and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania's School of Nursing. "Nurses in California take care of two fewer patients on average than nurses in Pennsylvania and New Jersey in general surgery. These differences lead to the prevention of literally thousands of deaths."

California's nurse-to-patient staffing law, implemented in 2004, required hospitals to meet minimum staffing levels that varied by the demands of each unit. For example, the law limits nurses to no more than five patients on a medical-surgical unit, three in labor and delivery and just two in the intensive care unit.

About 18 states are evaluating whether to adopt nurse-to-patient ratios. "It's important to know what the impact on California is because the whole country is looking at this legislation," Aiken said.

The ratios have been controversial, with some critics noting the lack of evidence to support the ratios. In late 2004, Gov. Arnold Schwarzenegger unsuccessfully sought to suspend the law, arguing it was too hard on financially strapped hospitals.

"What this study doesn't do is compare California before the ratios to California after the ratios," said Joanne Spetz, faculty researcher at UCSF's Center for the Health Professions and one of the study's authors. She said funding for the study was secured after the ratios were enacted.

But she said the findings on how nurses perceive their workload and ability to be more attentive to their patients is important in evaluating the success of the law because nursing satisfaction rates have a direct impact on quality of care.

"It really tells us what difference that (the law) makes in the ability of nurses to do their work," said Jack Needleman, a professor at UCLA School of Public Health who researches nursing workloads, but who was not involved in the study. Needleman is critical of the ratio law, preferring instead a system in which nurse staffing would be based on the specific needs of each hospital.

Since the law was signed in 1999, California has increased the number of actively licensed registered nurses by more than 110,000, according to the California Nurses Association/National Nurses United, a strong proponent of the law.

Findings of the nurses-to-patients ratio study

-- California nurses cared for two fewer patients on average than nurses in New Jersey and 1.7 fewer than in Pennsylvania,

-- 468 more Californians would have died in 2006 from general surgical deaths if the state had the same nursing ratios as Pennsylvania and New Jersey.

-- Adding one patient to nurses' workloads increased patients' odds of dying by 13 percent in California, 10 percent in New Jersey and 6 percent in Pennsylvania.

Source: University of Pennsylvania School of Nursing's "Implications of the California Nurse Staffing Mandate for Other States."