In 1999, California became the first state in the nation to adopt specific nurse to patient ratios in acute care hospitals.

The law, Assembly Bill 394, was the result of a statewide campaign led by union nurses and their allies. These ratios were carefully designed—and backed up by research—to ensure that nurses would not be assigned more patients than they could safely care for. A long phase-in period gave hospitals and enforcement agencies time to prepare, and the law (which added language to CA code Title 22) went into effect in 2004.

Over time, it became clear that ratios worked, but without a strong enforcement mechanism, Californians couldn’t count on hospitals following the law. Profit-driven hospital corporations aggressively staffed to bare-bones, putting patients’ lives and nurses’ licenses at risk.

In California’s competitive healthcare environment, smaller community hospitals and independent non-profits followed suit. The existing law typically only resulted in a slap on the wrist for these violations. Staffing complaints would result only in a “plan of correction”, with monetary fines levied primarily for patient deaths. Some hospitals were cited with violations again and again for the same staffing issues, but refused to correct the problem because there were no real consequences.

In 2019 another statewide campaign—led by the union nurses of SEIU 121RN—resulted in the passage of SB227, the “Stop Repeat Offender Hospitals Bill.” SB227 created significant fines—up to $30,000 per instance—for hospitals that repeatedly violated Title 22 nurse to patient ratios. The bill also mandated that the California Department of Public Health conduct unannounced inspections of hospitals with a special focus on adherence to the law. The bill was targeted by the hospital lobby, because they knew that real enforcement of ratios meant an end to corner-cutting business practices that put patients at risk. Nurses heralded the bill’s passage as a massive success. They waited for full implementation which was set to occur on January 1, 2020.

The COVID-19 state of emergency was declared just two months after SB227 went into effect. Priorities suddenly shifted for agencies across government. But, in the brief time the law was in effect prior to the pandemic hit, no fines were levied by CDPH—and it appeared the agency was not prepared to enforce the law.

Our Patients Can’t Wait campaign launched in February 2023 as the COVID-19 Executive Order relaxing enforcement of Nurse-to-patient ratios expired. Through direct action, legislation and dutiful reporting of violations, SEIU 121RN members have demanded immediate enforcement by the California Department of Public Health.