How Have Mandated Nurse Staffing Ratios Affected Hospitals? Perspectives from California Hospital Leaders

Department of Social and Behavioral Sciences, University of California, San Francisco School of Nursing, USA.
Journal of healthcare management / American College of Healthcare Executives (Impact Factor: 0.73). 09/2009; 54(5):321-33; discussion 334-5.
Source: PubMed


In 1999, California became the first state to pass legislation mandating minimum nurse-to-patient ratios. Regulations detailing specific ratios by type of hospital unit were released in 2002, with phased-in implementation beginning in 2004 and completed in 2008. These ratios were implemented at a time of severe registered nurse (RN) shortage in the state and a worsening financial position for many hospitals. This article presents an analysis of qualitative data from interviews with healthcare leaders about the impact of nurse staffing ratios. Twenty hospitals (including public, not-for-profit, and for-profit institutions) representing major geographic regions of California were approached. Twelve agreed to participate; semistructured in-person and telephone interviews were conducted with 23 hospital leaders. Several key themes emerged from the analysis. Most hospitals found it difficult and expensive to find more RNs to hire to meet the ratios. Meeting the staffing requirements on all units, at all times, was challenging and had negative impacts, such as a backlog of patients in the emergency department and a decrease of other ancillary staff. Hospital leaders do not believe that ratios have had an impact on patient quality of care. Findings related to nurse satisfaction were mixed. Increased RN staffing improved satisfaction with patient workload, but dissatisfaction with issues of decision-making control (e.g., decisions on when best to take a meal break) were taken out of the nurse's hands to meet ratio requirements. Further research should continue to monitor patient outcomes as other states consider similar ratio regulations. Results of this study will be useful to healthcare managers searching for ways to reduce unnecessary administrative costs while continuing to maintain the level of administrative activities required for the provision of safe, effective, high-quality care.

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    • "Research regarding ED staffing requirements has arisen from a number of countries (including Australia, UK, USA, Canada, South Africa, Germany, Israel, Hong Kong, Kuwait, Oman, Korea and Taiwan); across a variety of professions (nursing, medical, allied health); and across a variety of settings (metropolitan and rural environments). Four major areas of research emerging from these countries regarding ED staffing include: (i) descriptions/profiling of existing workforce arrangements (Hobgood et al. 2005, Bennett et al. 2007, Drescher et al. 2007, Hwang & Cheng 2007, Lyneham et al. 2008, Nixon 2008, Paw 2008, Kalish & Leo 2009); (ii) predictions of future workforce requirements (Camargo et al. 2009, Sullivan et al. 2009, Mueleman et al. 2010, Jelinek et al. 2011); (iii) descriptions and evaluations of current and new models of staffing arrangements (Robinson et al. 2005, Sinreich & Jabali 2007, Geelhoed & Geelhoed 2008, Chapman et al. 2009, Dreyer et al. 2009, Wai et al. 2009, Chan et al. 2010, Hu et al. 2010, Callander & Schofield 2011); and (iv) developments and applications of specific tools used to inform workforce numbers (Ghosh & Cruz 2005, Crouch & Williams 2006, O'Brien & Benger 2007, Korn et al. 2008, Sucov et al. 2009, Ahmed & Alhhamis 2009, Gedmentis et al. 2010, Williams et al. 2010). Common to most of these research reports is the realisation that adequate staffing in the ED is imperative in order to meet patient safety needs and health service key priority indicators. "
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