Kathy Dennis, RN, has worked in the float pool for nine of her 11 years at Mercy General Hospital in Sacramento, Calif. She firmly believes the state’s mandatory nurse staffing ratios — in place since 2004 — allow herself and her colleagues to provide better patient care. She can’t imagine going back to the days when she sometimes managed care for seven patients at a time, including some with complicated conditions.
“I wonder how I was able to provide the adequate education, the appropriate assessment,” says Dennis, who belongs to the California Nurses Association, the labor organization that helped push a law through the state legislature, making California the only state with mandatory staffing ratios.
But to the surprise of Dennis and many others, data from the first two years after ratios were enacted so far show no improvement in certain nursing-related outcomes in California hospitals. Though some studies show ratios have increased the number of nurses in the state’s hospitals, improved the skills mix, and may have contributed to greater nurse satisfaction, the jury still is out on whether ratios actually improve patient care, researchers say.
“It takes a lot of data and years of data to do the kind of analysis that demonstrates whether or not a policy works,” says Matthew McHugh, RN, PhD, JD, MPH, CRNP, assistant professor of nursing at the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing in Philadelphia. McHugh works with researcher Linda Aiken, RN, PhD, FAAN, FRCN, professor of nursing and sociology at the University of Pennsylvania, who has published widely cited studies linking nurse staffing to outcomes. Aiken’s most recent report in Health Affairs associates reduced nursing workloads with greater patient satisfaction.
About a dozen states are considering some version of a mandatory ratio law, and national legislation has been introduced in the U.S. House of Representatives and the Senate. Most nursing labor groups see mandatory ratios as the only way to reduce potentially dangerous workloads and increase nurses’ time with patients, thus improving patient care. Hospital organizations fear mandatory ratios will exacerbate an expected nursing shortage and put an economic strain on already stressed facilities, forcing them to cut services or even close units.
Many studies have shown a strong correlation between staffing levels and patient outcomes. A 2002 report, published in the Journal of the American Medical Association, found surgery patients faced increased risk of mortality and failure-to-rescue in hospitals with high patient-to-nurse ratios. A 2007 report by the Agency for Healthcare Research and Quality showed hospitals with higher levels of nurse staffing had lower hospital-related mortality, decreases in failure to rescue, and shorter hospital stays, though it did not prove a causal relationship between the number of nurses and fewer adverse events.
When California enacted ratios five years ago — after a lengthy battle between unions and hospitals — the state became a testing ground for how mandated nurse staffing levels would work. The California law requires one nurse for every five patients in med/surg units; one for every four patients in telemetry, pediatrics, and emergency care; and one for every two in labor and delivery and intensive care. It also requires hospitals to staff beyond the ratios if patient acuity demands it.
In February 2009, the California HealthCare Foundation released a report on the California ratios that found ratios had increased the number of RNs, as well as the nursing skills mix (number of RNs versus licensed vocational nurses and aides) in California hospitals. It could not identify any impact on hospital finances, particularly because hospitals faced other demands, such as seismic requirements and changes in Medicare and Medi-Cal payments, although some hospital administrators reported having to reduce services and cut auxiliary staff in order to hire more nurses. Many administrators also said it was especially difficult to meet ratios “at all times,” including breaks and meals.
But most important, the CHCF report found nothing suggesting ratios changed the average length of hospital stay nor the number of certain nursing-sensitive adverse events, including pressure ulcers and failure to rescue.
“So far, there is no evidence that the ratios have improved patient outcomes,” says Joanne Spetz, PhD, associate professor at the UCSF School of Nursing, associate director at the Center for California Health Workforce Studies, and one of the authors of the CHCF report. Other reports have linked the California ratios to greater nurse satisfaction and higher nurse salaries, but none so far — and researchers emphasize there haven’t been many — have shown improved nursing-sensitive outcomes.
Researchers speculate there could be any number of reasons for this. Some outcomes, such as falls and pressure ulcers, may have depended as much on care from aides as from nurses; and if aides were cut, there may have been no improvement, Spetz says. Two years may not have been enough time to improve outcomes. Outcomes related to certain nursing duties possibly affected by the ratios, such as assessment and teaching, have not been measured.
Some believe hospitals that hired adequate numbers of nurses may have done other things to improve patient care, and that these things, as much as or more than the number of nurses, contributed to better patient outcomes in earlier studies. “There’s so much more to it than hours of care and skill mix,” says Nancy E. Donaldson, RN, DNSc, FAAN, clinical professor and director of the Center for Research and Innovation in Patient Care at the University of California, San Francisco School of Nursing.
McHugh says he expects further research will show mandated higher staffing levels do affect outcomes. Based on previous research, he believes they are an important — though not the only — factor in safe patient care. Aiken’s team expects to publish further research based on interviews involving more than 100,000 nurses in more than 800 hospitals in California, Pennsylvania, New Jersey and Florida. Spetz and Barbara Mark, RN, PhD, FAAN, a professor and researcher at the University of North Carolina, Chapel Hill, also are working on more comprehensive studies comparing a wider variety of nursing-related patient outcomes in California with those in other states.
Legislators Take Action
National legislators aren’t waiting. They say there is enough evidence to show inadequate nurse staffing impacts both patient care and nurse satisfaction. “We need minimum standards to ensure patient safety and help retain nurses,” Sen. Barbara Boxer, D-Calif., says in an e-mail response to questions. Boxer is sponsoring a Senate bill for a national ratio plan similar to California’s. “Patients do not get the quality of care they deserve when nurses are overstretched.”
National ratios are supported by nurse labor groups and opposed by hospital associations and some nursing groups, including the American Nurses Association. The ANA instead supports national legislation similar to that enacted in Washington, Oregon and other states, which requires nurse staffing committees to set staffing limits according to nurse skills mix, patient population and acuity.
In Washington, the committees — made up of half staff nurses and half nurse leaders and administrators — have received mixed reviews since they were put in place two years ago. “Even at this early juncture, it is clear that the commitment of hospital leadership is essential to the success of the committees and their work,” says Gladys M. Campbell, RN, MS, MSN, executive director of the Northwest Organization of Nurse Executives.
One possibility, says Julie Sochalski, RN, PhD, FAAN, associate professor at the school of nursing and a senior fellow at the Leonard Davis Institute of Health Economics, University of Pennsylvania, is to enact legislation requiring hospitals to set safe staffing goals through nurse committees or other means, and if those goals aren’t met, to automatically trigger mandatory ratios.
“If you can’t get hospitals to ensure there will be a sufficient number of staff, then [ratios] need to be done,” Sochalski says. “They are a starting point. The question is, are they able to improve patient safety? I don’t know if we have the answer to that.”
Cathryn Domrose is a staff writer for Nursing Spectrum.
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