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Nursezone: New Evidence of Success of California’s Patient Staffing Law

New Evidence of Success of California’s Patient Staffing Law

By Debra Wood, RN, contributor

Matthew D. McHugh, Ph.D., JD, MPH, RN, CRNP, said the California staffing law has succeeded in improving nurse staffing without adversely affecting the skill level mix.

July 21, 2011 – California’s patient staffing law has added registered nurses to the hospital staffing mix rather than the feared decrease, further chipping away at naysayers’ concerns about potential unforeseen consequences, according to researchers at the University of Pennsylvania School of Nursing in Philadelphia and Arizona State University in Tempe.

“California’s mandate worked in increasing nurse staffing and didn’t do so at the expense of the skill mix,” said Matthew D. McHugh, Ph.D., JD, MPH, RN, CRNP, assistant professor at the University of Pennsylvania School of Nursing in Philadelphia, working at the school’s Center for Health Outcomes and Policy Research. “Hospitals maintained a rich staff mix of registered nurses.”

The staffing law allowed hospitals to add more licensed vocational/practical nurses, up to 50 percent of the mandate. Some people worried that hospitals might disproportionately hire LVNs to meet the mandate, McHugh said. But the Penn study did not find any evidence of that.

“Research has shown that if skill mix is eroded, there could be some problems with patient outcomes,” McHugh said. If the increased staffing came at the expense of skill mix, he added, “that would be problematic and undermine the intent of the policy.”

The team, which included the Center’s director, Linda Aiken, Ph.D., FAAN, FRCN, RN, found that California facilities staffed similarly to matched hospitals in other parts of the country, including New York, Texas, Florida and Pennsylvania—together making up the five states with the most hospitals. Not only did the researchers compare California staffing to other states, they also evaluated staffing levels before and after the minimum staffing law went into effect on January 1, 2004.

RN staffing increased in California hospitals by about one-half hour per day. California facilities had about five times as many registered nursing care hours as New York hospitals and twice as many as Texas hospitals.

“Most hospitals wanted to increase their registered nurse staffing, and that was the goal of the mandate,” McHugh said. “There were more RNs available for staffing.”

Previous Penn research has shown nurse overload affected patient safety and that increased staffing at California hospitals was associated with better outcomes. Other researchers have also found links between better nurse staffing in California with lower mortality and improved surgical failure-to-rescue rates.

Karen Higgins, RN, calls legislation setting limits on nurses’ patient assignments the gold standard for staffing and is supporting such legislation in Massachusetts.

“This study brings home once again what California nurses could readily tell you,” said Deborah Burger, RN, a co-president of National Nurses United and the California Nurses Association in a written statement. “The safe staffing law has improved the quality of care in California hospitals, ensured that RNs have more time to spend with patients, respond to patient care incidents and reduced the nursing shortage by keeping experienced, professional RNs where they belong, at the bedside.”

California is the only state in the nation with a nursing staff ratio law, which passed in 1999. Nurses and consumer groups are trying to pass legislation in other states, including Massachusetts where a similar bill to California’s is pending (HB1469/SB543), and at the federal level (S 992, the National Nursing Shortage Reform and Patient Advocacy Act, in the Senate, and a companion House bill, HR 2187) to set the maximum number of patients assigned to each nurse, varying by the needs of the patient.

“All of us, not just in Massachusetts but across the country, know by our practice that the California law would work for all of us in keeping our patients safe,” 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.

“The law saves patient lives, prevents injuries, [decreases] length of stay and leads to better outcomes for patients,” said Higgins, who considers legislation setting limits on nurses’ patient assignments the gold standard for staffing. “No one should go to the hospital and be fearful that the nurse has too many patients and [that they could] get hurt while they are there.”

From a policy perspective, the authors indicated the new study should be useful information to the states currently debating legislation on nurse-to-patient ratios.

“Our findings demonstrate that the nurse-to-patient ratio mandate in California was effective in increasing registered nurse staffing in hospitals,” McHugh said.

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