News & Events

Health Affairs Study on Achievements of California Safe Staffing Law

New Study Adds to Evidence on Success of California’s RN-Patient Staffing Law to Improve Nursing, Patient Care

Study Bolsters Case for Pending Legislation to Set Safe Patient Limits in Massachusetts Acute Care Hospitals

CANTON, MA — Another major study has reinforced a growing body of evidence that California’s landmark law requiring minimum, specific nurse-to-patient staffing limits enhances registered nurse staffing and the quality of patient care. The study is the latest piece of scientific research to bolster the case for increasing RN staffing in hospitals and for limiting the number of patients assigned to a nurse at one time. A bill that would do this is the Patient Safety Act (HB1469/SB543), currently pending before the Massachusetts legislature.

In fact, the study’s authors specifically highlight the Massachusetts safe staffing bill and a hearing on the measure scheduled for Sep. 20, 2011 before the Joint Committee on Public Health, stating “California’s state-mandated nurse staffing ratios have been shown to be successful in terms of increasing registered nurse staffing. From a policy perspective, this should be useful information for policy makers considering appropriate nurse staffing policy.”

The new study, conducted by eminent University of Pennsylvania and Arizona State University researchers, appears in the July 2011 issue of Health Affairs.

The report provides important data about the impact on RN staffing and patient care following the implementation of the California staffing law in 2004. The study found that California hospitals have significantly increased the number of registered nurses compared to other states, while dramatically increasing patient access to professional RN care, a factor long associated with positive patient outcomes in a broad range of care barometers.

“This study validates what nurses in Massachusetts have been hearing from their colleagues in California for years, and what we have been communicating to our legislators — the safe staffing law works and has improved the quality of care in California hospitals, ensured that RNs have more time to spend with patients and to respond to patient care incidents, and reduced the nursing shortage by keeping experienced, professional RNs where they belong, at the bedside,” said Karen Higgins, RN, a co-president of National Nurses United and the co-chair of the Coalition to Protect Massachusetts Patients, an alliance of 125 health care, consumer and labor organizations promoting the Massachusetts safe staffing bill.

Overall, the authors write, “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.”

The study directly compared California hospitals to institutions in New York, Texas, Florida, and Pennsylvania – the five states with the most hospitals. While many states nationally saw increases in nurse staffing the past decade, in the period following implementation of the law, California readily surpassed the national average, and California had five times as many registered nursing care hours as New York hospitals and twice as many as Texas hospitals.

Authors of the new study include Matthew McHugh and Douglas Sloane of the University of Pennsylvania’s Center for Health Outcomes and Policy Research in Philadelphia, University of Pennsylvania nursing professor and well known RN researcher Linda Aiken, and Lesley Kelly, RN assistant professor at Arizona State University in Phoenix.

In the new study, McHugh, Aiken, et al note that the intent of the California legislature in passing the safe staffing law was to “improve quality of care and patient safety, and to retain nurses in employment in hospitals. Another primary goal of the law was to avoid high patient-to-nurse ratios, especially for registered nurses.”

Poor ratios, they note, are widely associated with “a number of negative patient outcomes, such as higher surgical mortality and higher complication rates due to errors” as well as with “job dissatisfaction and burnout” that drive nurses away from the patient bedside.

The authors make the point that “Research following the implementation of California’s staffing mandate has shown that the increased staffing in California hospitals was associated with better outcomes, compared to outcomes for patients treated in hospitals in states without a similar law.”

Aiken in particular is one of the nation’s foremost RN researchers and just last year led a study comparing California hospitals to facilities in Pennsylvania and New Jersey which documented that New Jersey hospitals would have 14% fewer patient deaths and Pennsylvania 11% fewer deaths if they matched California’s 1:5 ratios in surgical units.

In the study, the authors raise the issue of cost related to improved RN staffing, and point to research demonstrating the savings associated with better RN staffing, and specifically highlight the potential cost benefits for hospitals under new health reform initiatives.

“The costs associated with increasing the number of nurses employed in hospitals may be offset by the costs of avoided poor outcomes and adverse events,” the author states. “The potential for offsets and savings may be increased as value-based purchasing programs are implemented in response to the Affordable Care Act of 2010. For example, higher nurse staffing levels have been associated with fewer of the hospital-acquired conditions and infections that the Centers for Medicare and Medicaid Services no longer pays for, unless the complication was present when the patient was first admitted to the hospital.

“The California law has clearly met all the goals, a major reason why legislation setting limits on nurses patient assignments is considered the gold standard by direct care RNs across the nation,” said Higgins.

The Patient Safety Act, which is co-sponsored by State Representative Christine Canavan (D-Brockton) and State Senator Marc R. Pacheco (D-Taunton), calls upon the Massachusetts Department of Public Health (DPH) to set safe limits on the number of hospital patients a nurse is forced to care for at one time.  The limits would be based on scientific research and testimony from public hearings and, once established, could be adjusted in accordance with patient needs and requirements using a standardized, DPH-approved system. The Bill protects against the reduction in the number of other members of the health-care team including LPNs, aides, and technicians.  Patients would have the right to know and demand safe limits.

A hearing on the bill is scheduled for Sep. 20, 2011 before the Joint Committee on Public Health. A similar bill passed the House of Representatives by overwhelming margins during two previous legislative sessions, but failed to win passage in the Senate. 

“In the past, some legislators and our opponents pointed to California, claiming they first needed to see if the law would work there,” Higgins said, “Well now we have the answer.  It’s time to act.”

The Coalition to Protect Massachusetts Patients comprises more than 125 leading health care and consumer organizations, including the American Lung Association, Massachusetts Association of Councils on Aging, Fenway Community Health Center, League of Women Voters, and a number of health care, nursing and labor organizations.

NNU is sponsoring federal legislation, S 992, the National Nursing Shortage Reform and Patient Advocacy Act, in the Senate, and a companion House bill, HR 2187.