By: Roman P. Mosqueda, Esq.


            California is the first and still the only state in the nation to require minimum registered nurse-to-patient ratios that are binding on general acute care hospitals.

            Beginning January 1, 2004, and pursuant to AB 394, the Safe Staffing Law, signed by former Gov. Gray Davis in October, 1999, the California Department of Health Services (DHS) is requiring all hospitals to be staffed with the minimum ratios for registered nurses RNs.

            On July 1, 2003, Gov. Davis and the DHS issued the final regulations implementing the RN staffing ratio law, after conducting numerous hearings and accepting public comments.


DHS Minimum

RN-To-Patient Ratios:


            No hospital can assign responsibility for more patients to a registered nurse than the specific ratio at all times during a shift.

            But once the DHS minimum ratios are in place, the law requires that additional staffing be assigned based on patient needs and nursing care, including severity of illness and complexity of clinical judgment.


            The specific RN-to-patient ratios under DHS regulations are:


1.      Intensive/Critical Care: 1:2;

2.      Neo-natal Intensive Care: 1:2;

3.      Operating Room: 1:1;

4.      Post-anesthesia Recovery: 1:2;

5.      Labor and Delivery: 1:2;

6.      Antepartum: 1:4;

7.      Postpartum couplets: 1:4;

8.      Postpartum women only: 1:4;

9.      Pediatrics: 1:4;

10.      Emergency Room: 1:4;

11.      ICU patients in the ER: 1:2;

12.      Trauma patients in the ER: 1:1;

13.      Step Down Initial: 1:4;

14.      Step Down in 2008: 1:3;

15.      Medical/Surgical Initial: 1:6;

16.      Medical/Surgical in 2005: 1:5;

17.      Other Specialty  Care Initial: 1:5;

18.      Other Specialty Care in 2008: 1:4;

19.      Psychiatric: 1:6;

20.      Telemetry Initial: 1:5; and

21.      Telemetry in 2008: 1:4.


The specific ratios are constant for all shifts, 24 hours a day, and 7 days a week for the different hospital units.

Licensed vocational nurses (LVN) are not allowed to have overall responsibility for patients.  And competent break RNs, RN managers or charge nurses should relieve RNs during their breaks.


Gov. Schwarzenegger’s

Failed Attempt to Delay

Staffing Ratio in Medical

Or Surgical Unit:


The medical or surgical unit usually houses the most patients in a hospital.  Under the staffing ratio law, the registered nurse-to-patient ratio for the said unit was scheduled to be reduced to 1:5 from 1:6, effective January 1, 2005.


In November 2004, Gov. Arnold Schwarzenegger issued an emergency regulation to delay or suspend the January 1, 2005 effective date for the reduction of registered nurse-to-patient ratio in medical or surgical unit, arguing that the new staffing ratio could cause financial hardship for hospitals forced to hire during a nursing shortage.


Generating oppositions from two main nursing unions, the California Nurses Association and the Service Employees International Union, the Governor’s regulation was invalidated by Sacramento Superior Court Judge Judy Holzer on March 4, 2005, finding the regulation “capricious, arbitrary and an abuse of discretion, and was based on no relevant evidence”.  The Schwarzenegger administration has vowed to appeal the judge’s decision.


Reasons for Safe

Staffing Law:


            According to the California Nurses Association, the sponsor of AB 394, authored by then Assembly Member, now State Senator, Sheila Kuehl (D-Los Angeles), California is second to the last in the nation in the number of registered nurses to patients, and has among the highest RN vacancy and turnover rates in the United States.

            Indeed, Section 1 of AB 394, which adds Section 2725.3 to the Business and Professions Code and Section 1276.4 to the Health and Safety Code, states:  “The Legislature finds and declares all of the following:


(a)   Health care services are becoming complex and it is increasingly difficult for patients to access integrated services.

(b)   Quality of patient care is jeopardized because of staffing changes implemented in response to managed care.

(c)   To ensure the adequate protection of patients in acute care settings, it is essential that qualified registered nurses and other licensed nurses be accessible and available to meet the needs of patients.

(d)   The basic principles of staffing in the acute care setting should be based on the patient’s care needs, the severity of condition, services needed, and the complexity surrounding those services.”


Thus, the staffing ratio law addresses the growing crisis in patient care in California hospitals caused by market-based decisions on hospital care by managed care.

The DHS ratios are expected to produce improvements in patient care in California hospitals and significant relief for nursing shortage, according to the California Nurses Association.

            Indeed, the minimum nurse staffing ratios are also intended to bring back thousands of registered nurses laid-off by market-driven changes and those unwilling to work in unsafe hospitals.


Recruitment of Additional



            As of February 28, 2005, California has 297,039 actively licensed registered nurses, according to statistics of the Board of Registered Nursing.

            And every year, California’s 72 nursing schools graduate approximately 5,100 new registered nurses.  Since the numbers of new registered nurses in California have been growing by about 10,000 per year, one-half comes from other states or other countries.

            The California Department of Health Services estimates that a total of 4,880 additional registered nurses are needed to meet the staffing ratio in 2004 and another 2,350 in 2005.

            The more registered nurses are recruited by hospitals, the safer patient care normally becomes.  Indeed, research in the Journal of the American Medical Association reportedly found that:


1.   up to 20,000 patient deaths each year can be linked to preventable patient deaths;

2.   for each additional patient assigned to a registered nurse, the likelihood of death within 30 days increased by 7 percent; and

3.   four additional patients increased the risk of death by 31 percent.


The Philippines is reportedly the biggest supplier of registered nurses to the United States, according to Philippine government statistics.


(The Author, Roman P. Mosqueda, has been personally practicing immigration law for over twenty (20) years, including Form I-140, Immigrant Petition for Alien Worker, for registered nurses.