Impact of Nurse Staffing Mandates on Safety‐Net Hospitals: Lessons from California

Abstract

Context: 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. Methods: 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. Findings: 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. Conclusions: 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.

“Can nurse work environment influence readmission risk?” – a systematic review

“…For instance, California in the US implemented a mandate of a minimum patient-to-nurse staffing ratio, which has resulted in some success in improving nurse staffing in general as well as in hospitals serving vulnerable patients. 50 In addition, reshaping the current health care payment system may be considered in order to give hospitals more incentives to improve nurse work environment beyond strict regulations such as the readmission penalties. 27,34 In this review, it was found that readmissions were not uncommon and readmission rates were very high for some conditions.…”

Hospital Use of Agency‐Employed Supplemental Nurses and Patient Mortality and Failure to Rescue

“…; McHugh et al. ). Finally, negative perceptions about the impact of SRNs on quality of care seem contrary to the large literature documenting an association between better nurse staffing and lower mortality (Kane et al.…”

“…SRNs have been successfully used to reduce overtime and to provide coverage for weekends, holidays, and vacations, reportedly providing the same quality of care as permanent staff according to nurse managers (Warren and Rozell 1995). In California, the first state with mandated nurse staffing legislation, increased use of SRNs was associated with hospitals meeting mandated ratios, resulting in improved nurse staffing, including in safety net hospitals and possibly improved patient outcomes (Aiken et al 2010;McHugh et al 2012). Finally, negative perceptions about the impact of SRNs on quality of care seem contrary to the large literature documenting an association between better nurse staffing and lower mortality (Kane et al 2007;Aiken et al 2011;Needleman et al 2011), as presumably staffing with SRNs is an improvement over what staffing levels might have been in their absence.…”

Use of temporary nursing staff and nosocomial infections in intensive care units

“…, McHugh et al . ). But it is well known that temporary nurses are paid higher wages than permanent staff, which can increase costs (May et al .…”