Understaffing has long been a problem for nurses in the United States. With budget reductions causing hospitals to cut back on nursing staff, nurses are sometimes forced to care for more patients than is safe. The United States Congress has called understaffing of nurses a public health crisis. Moreover, Congress has determined that the health of patients in hospitals is directly related to the number of registered nurses working in the hospital. Understaffing can lead to patient care errors, legal liability for nurses who have been assigned more patients than they can manage, and nurses' disenchantment with the nursing profession.

California is the first state in the nation to establish minimum nurse-to-patient ratios for California's acute care hospitals. The California Safe Staffing law sets forth the minimum number of licensed nurses required to staff each unit of the hospital. Examples of the Safe Staffing ratios are as follows. The patient numbers represent the maximum number of patients per nurse:

• Antepartum: 1 nurse: 4 patients (not in active labor)
  
• Labor & Delivery: 1 nurse: 2 patients (in active labor)
  
• Neonatal ICU: 1 nurse: 2 patients
  
• Emergency Trauma: 1 nurse: 1 patient
  
• Emergency Critical Care: 1 nurse: 2 patients
  
• Emergency Visits: 1 nurse : 4 patients (plus a triage nurse)
  
• Operating Room Pediatric: 1 nurse: 1 patient
  
• Stepdown: 1 nurse: 4 patients (to reduce to 1:3 by January 2008)
  
• Telemetry: 1 nurse: 5 patients (to reduce to 1:4 by January 2008)
  
• Medical/Surgical: 1 nurse: 6 patients (to reduce to 1:5 by January 2005)

While most California nurses and nurse associations praise the Safe Staffing law, various arguments have been made in opposition. Some opponents claim that the law is ineffective because the mandated ratios still leave the hospitals understaffed. Others claim that nurse staffing is a decision that should be made by medical professionals, not legislators. Still others claim that there are not enough nurses in California to meet the required ratios.

A number of other states have introduced legislation that would require nurse-to-patient ratios. However, none have passed. The U.S. Congress is considering the Registered Nurse Safe Staffing Act of 2003. This bill would require hospitals that receive federal funding to "adopt and implement a staffing system that ensures a number of registered nurses on each shift and in each unit of the hospital to ensure appropriate staffing levels for patient care." The bill does not set minimum staffing ratios. It does, however, require hospitals to base the adopted policy on input from the direct care-giving registered nurse staff.

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