Nurses Contend with the Suspension of Regulatory Nurse-to-Patient Ratios


By Kendra J. Muller

On December 11, 2020, and again on January 24, 2021, Heidi W. Steinecker, Deputy Director of the California Department of Public Health (CDPH), announced a suspension of regulatory enforcement for hospitals that is valid until March 1, 2021. As COVID-19 continues to strain hospital capacity, the All Facilities Letters (AFL 20-26.4 and 20-26.5) detail temporary changes in licensing, hospital space, and staffing among other things. This suspension is pursuant to Governor Newsom’s March 2020 state of emergency declaration and Executive Order N-39-20, which grants CDPH the right to temporarily waive hospital requirements during the state of emergency.

The suspension consists of several parts, all focused on relieving the hospital strain caused by a surge of patients and staffing shortages caused by COVID-19 cases. First, a hospital seeking a waiver must file with CDPH, but can start to provide patient care before CDPH confirms their specific waiver. Second, hospitals can now temporarily reconfigure hospital space and can apply to CDPH for more permanent structural modifications to account for the influx of patients. The third suspension describes the change in minimum nurse-to-patient ratios.

The nurse-to-patient ratio suspension gives hospitals two potential options: (1) apply for an Expedited Waiver Process, or (2) remain with the Existing Waiver Process. A hospital may now apply for an expedited waiver of minimum nurse-to-patient ratios if their hospital can show an increasing need to meet demand for surge either by regional surge or incoming transfers, daycare or school closures, COVID-19 staffing absenteeism for multiple reasons, or an emergency such as a fire or public safety power shutoff.  A hospital must submit the waiver to CDPH, but the hospital can immediately implement alternative nurse-to-patient ratios before CDPH notifies them of approval. Unlike the Expedited Waiver Process, the existing waiver process does not allow hospitals to implement alternative nurse-to-patient ratios until they receive approval from CDPH.

Under the waiver, an intensive care unit can now have one nurse monitor three patients, instead of the minimum 1:2 nurse-to-patient ratio. Likewise, a step-down unit is approved for a nurse-to-patient ratio of 1:4, an emergency department is approved for a nurse-to-patient ratio of 1:6, and a surgical care unit is approved for a nurse-to-patient ratio of 1:7. These waivers will only be issued for sixty days, and CDPH may revoke a staffing waiver for hospitals unable to demonstrate diligent efforts to recruit and retain staff. Thus far, according to news reports, about 190 hospitals have received waivers to increase nurse-to-patient ratios.

Many nurses, including the California Nurses Association, have been outspoken about the harm that will come from altering the nurse-to-patient ratios, arguing that the suspension will ultimately leave patients sicker and with less care than before. In addition, nurses have expressed that they are already overworked and exhausted because of the demands. Other options include canceling elective surgeries or other less dangerous solutions to the patient influx.

While the Board of Registered Nursing (BRN) has yet to address the increased ratios, BRN has released an expedited nurse licensure process for certain refugees, asylees, and immigrants, which may assist in filling the healthcare provider gaps caused by the surge in COVID-19 hospital admissions pursuant to AB 2113 (Low) (Chapter 186, Statutes of 2020), effective January 1, 2021.


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