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Study Examines California Staffing Mandate

Publish Date: 8/3/2011

Health Affairs recently published a study examining nurse staffing ratios in California in comparison to those in similar United States hospitals. The article adds to the debate on whether nurse staffing ratio mandates actually improve the quality of patient care. The study found that California’s 2004 legislative mandate for nurse-to-patient ratios resulted in roughly an additional half-hour of nursing per adjusted patient day beyond what would have otherwise been expected and did not reduce the nurse workforce skill level as some feared.

AORN Government Affairs monitors nurse staffing ratio and safe staffing legislation. There are generally two approaches to nurse staffing bills: (i) mandatory nurse-to-patient staffing ratios determined by state law, and (ii) requirements in state law that each facility establish its own nursing plan in accordance with its needs. Neither approach directly addresses perioperative nursing.

Mandatory nurse staffing ratio bills would establish minimum staffing levels and nurse-to-patient ratios for each department or unit of the hospital and sometimes include ASCs. California implemented its staffing ratio bill in 2004 and remains the only state to have implemented nurse staffing ratios. At least six states have seen staffing ratio bill activity this year – Florida, Illinois, Massachusetts, New York, Pennsylvania and Texas. AORN is monitoring these bills and does not expect significant movement in any of these states at this time.

The American Nurses Association has taken an alternate approach for nurse staffing levels at the federal level but has not developed an approach at the state level. ANA would not legislate minimum staffing levels, but would require hospitals to set their own staffing plans for each department or unit based on patient acuity, patient numbers, nurse skills and experience, support staff and technology. ANA’s legislative model supports nurses creating staffing plans specific to the facility, unit and patient population, and then holding facilities accountable for adherence to those staffing plans. We have seen bills modeled after the ANA approach in Florida, Iowa, Massachusetts, Missouri and Pennsylvania this year.

The Health Affairs study noted that none of the alternatives to fixed nurse staffing mandates – mandating mechanisms at the hospital level to determine evidence-based staffing levels without mandating the actual levels, requiring public reporting of hospital nurse staffing, and limiting mandatory overtime by nurses – have been rigorously evaluated for effectiveness. The study recommended evaluation of these other policy options to help inform the choices currently being considered by states and hospitals.

As to the effectiveness of California’s mandate, the Health Affairs study found that whether the cost of increased staffing provides adequate returns compared to other quality-improving initiatives remains to be determined, although the cost associated with increasing numbers of registered nurses may be offset by the costs of avoided poor outcomes and adverse events. The study authors recommended that policy makers consider linking any staffing mandate with registered nurse workforce development and training programs to provide adequate numbers of qualified nurses to meet a mandate. The Health Affairs study did not directly address perioperative nursing or operating room staffing. AORN Government Affairs will continue to monitor nurse staffing initiatives and work with our state legislative coordinators and NLC members to identify activities and developments in each state.

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