Implications of the California Nurse Staffing Mandate for Other States

Center for Health Outcomes and Policy Research, University of Pennsylvania, 418 Curie Blvd, Philadelphia, PA 19104-4217, USA.
Health Services Research (Impact Factor: 2.78). 08/2010; 45(4):904-21. DOI: 10.1111/j.1475-6773.2010.01114.x
Source: PubMed


To determine whether nurse staffing in California hospitals, where state-mandated minimum nurse-to-patient ratios are in effect, differs from two states without legislation and whether those differences are associated with nurse and patient outcomes.
Primary survey data from 22,336 hospital staff nurses in California, Pennsylvania, and New Jersey in 2006 and state hospital discharge databases.
Nurse workloads are compared across the three states and we examine how nurse and patient outcomes, including patient mortality and failure-to-rescue, are affected by the differences in nurse workloads across the hospitals in these states.
California hospital nurses cared for one less patient on average than nurses in the other states and two fewer patients on medical and surgical units. Lower ratios are associated with significantly lower mortality. When nurses' workloads were in line with California-mandated ratios in all three states, nurses' burnout and job dissatisfaction were lower, and nurses reported consistently better quality of care.
Hospital nurse staffing ratios mandated in California are associated with lower mortality and nurse outcomes predictive of better nurse retention in California and in other states where they occur.


Available from: Jeannie P Cimiotti
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    • "To address these issues, we instructed the respondent to report the frequency with which he/she individually missed specific care activities on the last shift worked. Obtaining cross-sectional estimates of nursing care delivery and nurse working conditions on the last shift worked is an approach used in previous studies of nurse workloads and quality of hospital care (Friese et al. 2008, Kutney-Lee et al. 2009, Aiken et al. 2010, 2011). We recognized the potential for social desirability bias with this approach, but anticipated that this would be overcome through anonymous reporting. "
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    ABSTRACT: AimsThe aims of this study are to describe: (1) the frequency of nurse-reported missed care in neonatal intensive care units; and (2) nurses’ reports of factors contributing to missed care on their last shift worked.Background Missed nursing care, or necessary care that is not delivered, is increasingly cited as a contributor to adverse patient outcomes. Previous studies highlight the frequency of missed nursing care in adult settings; the occurrence of missed nursing care in neonatal intensive care units is unknown.DesignA descriptive analysis of neonatal nurses’ self-reports of missed care using data collected through a cross-sectional web-based survey.MethodsA random sample of certified neonatal intensive care nurses in seven states was invited to participate in the survey in April 2012. Data were collected from nurses who provide direct patient care in a neonatal intensive care unit (n = 230). Descriptive statistics constituted the primary analytic approach.ResultsNurses reported missing a range of patient care activities on their last shift worked. Nurses most frequently missed rounds, oral care for ventilated infants, educating and involving parents in care and oral feedings. Hand hygiene, safety and physical assessment and medication administration were missed least often. The most common reasons for missed care included frequent interruptions, urgent patient situations and an unexpected rise in patient volume and/or acuity on the unit.Conclusion We find that basic nursing care in the neonatal intensive care unit is missed and that system factors may contribute to missed care in this setting.
    Journal of Advanced Nursing 11/2014; 71(4). DOI:10.1111/jan.12578 · 1.74 Impact Factor
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    • "McHugh et al. 2011). For example, California hospitals had better staffing and related patient outcomes compared with those hospitals in states without a similar staffing law (Aiken et al. 2010). Although longitudinal increases in nurse staffing are associated with better patient outcomes, the findings in California, both before the legislation and covering the pre-and postlegislation period, are mixed (Burnes Bolton et al. 2007; Cook et al. 2010; Donaldson and Shapiro 2010; Harless and Mark 2010; Hickey et al. 2011; Sochalski et al. 2008). "
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    ABSTRACT: California is the first and only state to implement a patient-to-nurse ratio mandate for hospitals. Increasing nurse staffing is an important organizational intervention for improving patient outcomes. Evidence suggests that staffing improved in California hospitals after the mandate was enacted, but the outcome for hospitals bearing a disproportionate share of uncompensated care-safety-net hospitals-remains unclear. One concern was that California's mandate would burden safety-net hospitals without improving staffing or that hospitals would reduce their skill mix, that is, the proportion of registered nurses of all nursing staff. We examined the differential effect of California's staffing mandate on safety-net and non-safety-net hospitals. We used a time-series design with Annual Hospital Disclosure data files from the California Office of Statewide Health Planning and Development (OSHPD) for the years 1998 to 2007 to assess differences in the effect of California's mandate on staffing outcomes in safety-net and non-safety-net hospitals. The mandate resulted in significant staffing improvements, on average nearly a full patient per nurse fewer (-0.98) for all California hospitals. The greatest effect was in those hospitals with the lowest staffing levels at the outset, both safety-net and non-safety-net hospitals, as the legislation intended. The mandate led to significantly improved staffing levels for safety-net hospitals, although there was a small but significant difference in the effect on staffing levels of safety-net and non-safety-net hospitals. Regarding skill mix, a marginally higher proportion of registered nurses was seen in non-safety-net hospitals following the mandate, while the skill mix remained essentially unchanged for safety-net hospitals. The difference between the two groups of hospitals was not significant. California's mandate improved staffing for all hospitals, including safety-net hospitals. Furthermore, improvement did not come at the cost of a reduced skill mix, as was feared. Alternative and more targeted designs, however, might yield further improvement for safety-net hospitals and reduce potential disparities in the staffing and skill mix of safety-net and non-safety-net hospitals.
    Milbank Quarterly 03/2012; 90(1):160-86. DOI:10.1111/j.1468-0009.2011.00658.x · 3.38 Impact Factor
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    • "The review concluded that the studies show an association between increased RN staffing and a lower rate of hospital-related mortality and adverse patient events. More recently, research on the effect of mandated minimum staffing levels in California reports that the lower patient per nurse ratios that it produced are associated with significantly lower mortality rates (Aiken et al., 2010). "
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    ABSTRACT: Academic research and public enquiries demonstrate the link between adequate staffing levels and patients’ experiences and outcomes. Health care providers have a legal duty to ensure (and demonstrate to care regulators) that staffing levels are safe. Yet evidence of effective workforce planning, locally or nationally, is scarce. A plethora of tools exist to help employers to determine nurse staffing required. Although not perfect, the technical resource is none the less available to support planning, but are we willing to use it? In England the different systems have not been reviewed or tested and there is no consensus about the best approach to use. This paper asserts that decisions about current and future configurations of the nursing workforce are currently taken in a data vacuum. Fundamental aspects of nurse deployment – the proportion of registered nurses, the ratio of patients to nurse – are not systematically captured or recorded, either nationally or locally. We argue that a first step in planning is to establish this baseline. We need data on nursing inputs to relate to the growing body of data on patient outcomes, to enable managers and policy makers to understand the efficacy of current workforce configurations and inform future plans.
    11/2011; 16(6):551-558. DOI:10.1177/1744987111422425
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