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Contradicting fears, California's nurse-to-patient mandate did not reduce the skill level of the nursing workforce in hospitals.

ABSTRACT: When California passed a law in 1999 establishing minimum nurse-to-patient staffing ratios for hospitals, it was feared that hospitals might respond by disproportionately hiring lower-skill licensed vocational nurses. This article examines nurse staffing ratios for California hospitals for the period 1997-2008. It compares staffing levels to those in similar hospitals in the United States. We found that California's mandate did not reduce the nurse workforce skill level as feared. Instead, California hospitals on average followed the trend of hospitals nationally by increasing their nursing skill mix, and they primarily used more highly skilled registered nurses to meet the staffing mandate. In addition, we found that the staffing mandate resulted in roughly an additional half-hour of nursing per adjusted patient day beyond what would have been expected in the absence of the policy. Policy makers in other states can look to California's experience when considering similar approaches to improving patient care.

SUBMITTER: McHugh MD

PROVIDER: S-EPMC3209821 | biostudies-literature | 2011 Jul

REPOSITORIES: biostudies-literature

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Contradicting fears, California's nurse-to-patient mandate did not reduce the skill level of the nursing workforce in hospitals.

McHugh Matthew D MD Kelly Lesly A LA Sloane Douglas M DM Aiken Linda H LH

Health affairs (Project Hope) 20110701 7

When California passed a law in 1999 establishing minimum nurse-to-patient staffing ratios for hospitals, it was feared that hospitals might respond by disproportionately hiring lower-skill licensed vocational nurses. This article examines nurse staffing ratios for California hospitals for the period 1997-2008. It compares staffing levels to those in similar hospitals in the United States. We found that California's mandate did not reduce the nurse workforce skill level as feared. Instead, Calif ...[more]

PMID: 21734204

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Project description:OBJECTIVES:To determine the association of hospital nursing skill mix with patient mortality, patient ratings of their care and indicators of quality of care. DESIGN:Cross-sectional patient discharge data, hospital characteristics and nurse and patient survey data were merged and analysed using generalised estimating equations (GEE) and logistic regression models. SETTING:Adult acute care hospitals in Belgium, England, Finland, Ireland, Spain and Switzerland. PARTICIPANTS:Survey data were collected from 13?077 nurses in 243 hospitals, and 18?828 patients in 182 of the same hospitals in the six countries. Discharge data were obtained for 275?519 surgical patients in 188 of these hospitals. MAIN OUTCOME MEASURES:Patient mortality, patient ratings of care, care quality, patient safety, adverse events and nurse burnout and job dissatisfaction. RESULTS:Richer nurse skill mix (eg, every 10-point increase in the percentage of professional nurses among all nursing personnel) was associated with lower odds of mortality (OR=0.89), lower odds of low hospital ratings from patients (OR=0.90) and lower odds of reports of poor quality (OR=0.89), poor safety grades (OR=0.85) and other poor outcomes (0.80<OR<0.93), after adjusting for patient and hospital factors. Each 10 percentage point reduction in the proportion of professional nurses is associated with an 11% increase in the odds of death. In our hospital sample, there were an average of six caregivers for every 25 patients, four of whom were professional nurses. Substituting one nurse assistant for a professional nurse for every 25 patients is associated with a 21% increase in the odds of dying. CONCLUSIONS:A bedside care workforce with a greater proportion of professional nurses is associated with better outcomes for patients and nurses. Reducing nursing skill mix by adding nursing associates and other categories of assistive nursing personnel without professional nurse qualifications may contribute to preventable deaths, erode quality and safety of hospital care and contribute to hospital nurse shortages.

Project description:ObjectivesThe best way to determine nurse staffing requirements on hospital wards is unclear. This study explores the precision of estimates of nurse staffing requirements made using the Safer Nursing Care Tool (SNCT) patient classification system for different sample sizes and investigates whether recommended staff levels correspond with professional judgements of adequate staffing.DesignObservational study linking datasets of staffing requirements (estimated using a tool) to professional judgements of adequate staffing. Multilevel logistic regression modelling.Setting81 medical/surgical units in four acute care hospitals.Participants22 364 unit days where staffing levels and SNCT ratings were linked to nurse reports of "enough staff for quality".Primary outcome measuresSNCT-estimated staffing requirements and nurses' assessments of staffing adequacy.ResultsThe recommended minimum sample of 20 days allowed the required number to employ (the establishment) to be estimated with a mean precision (defined as half the width of the CI as a percentage of the mean) of 4.1%. For most units, much larger samples were required to estimate establishments within ±1 whole time equivalent staff member. When staffing was lower than that required according to the SNCT, for each hour per patient day of registered nurse staffing below the required staffing level, the odds of nurses reporting that there were enough staff to provide quality care were reduced by 11%. Correspondingly, the odds of nurses reporting that necessary nursing care was left undone were increased by 14%. No threshold indicating an optimal staffing level was observed. Surgical specialty, patient turnover and more single rooms were associated with lower odds of staffing adequacy.ConclusionsThe SNCT can provide reliable estimates of the number of nurses to employ on a unit, but larger samples than the recommended minimum are usually required. The SNCT provides a measure of nursing workload that correlates with professional judgements, but the recommended staffing levels may not be optimal. Some important sources of systematic variations in staffing requirements for some units are not accounted for. SNCT measurements are a potentially useful adjunct to professional judgement but cannot replace it.Trial registration numberISRCTN12307968.

Project description:ObjectiveTo examine the impact of nurse staffing on patient-perceived quality of nursing care. We differentiate nurse staffing levels and nursing skill mix as two facets of nurse staffing and use a multidimensional instrument for patient-perceived quality of nursing care. We investigate non-linear and interaction effects.SettingThe study setting was 3458 hospital units in 1017 hospitals in Germany.ParticipantsWe contacted 212 554 patients discharged from non-paediatric, non-intensive and non-psychiatric hospital units who stayed at least two nights in the hospital between January and October 2019. Of those, 30 174 responded, yielding a response rate of 14.2%. Our sample included only those patients. After excluding extreme values for our nurse staffing variables and removing observations with missing values, our final sample comprised 28 136 patients ranging from 18 to 97 years of age (average: 61.12 years) who had been discharged from 3458 distinct hospital units in 1017 hospitals.Primary and secondary outcome measuresPatient-perceived quality of nursing care (general nursing care, guidance provided by nurses, and patient loyalty to the hospital).ResultsFor all three dimensions of patient-perceived quality of nursing care, we found that they significantly decreased as (1) nurse staffing levels decreased (with decreasing marginal effects) and (2) the proportion of assistant nurses in a hospital unit increased. The association between nurse staffing levels and quality of nursing care was more pronounced among patients who were less clinically complex, were admitted to smaller hospitals or were admitted to medical units.ConclusionsOur results indicate that, in addition to nurse staffing levels, nursing skill mix is crucial for providing the best possible quality of nursing care from the patient perspective and both should be considered when designing policies such as minimum staffing regulations to improve the quality of nursing care in hospitals.

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Contradicting fears, California's nurse-to-patient mandate did not reduce the skill level of the nursing workforce in hospitals.

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Contradicting fears, California's nurse-to-patient mandate did not reduce the skill level of the nursing workforce in hospitals.

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