Nurse Staffing Levels and Patient Safety

In a comprehensive analysis comparing nurse staffing in California hospitals to similar hospitals in the U.S. over nearly a decade, researchers at the University of Pennsylvania School of Nursing have found that controversial legislation setting nurse-to-patient ratios added more registered nurses to the hospital staffing mix, not fewer as feared.

California was the first state to pass legislation setting staffing levels. However, mindful of the ongoing nurse shortage California legislators determined that hospitals could employ licensed practical nurses (LPN) as well as registered nurses (RN) to meet the requirements of the law.

Nevertheless, "California's statemandated 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 to the states currently debating legislation on nurse-to-patient ratios," wrote lead researcher Matthew McHugh, a nursing professor at the University of Pennsylvania, in the current issue of the policy journal Health Affairs.

Currently, Massachusetts is considering enacting similar legislation that would set the maximum number of patients assigned to each nurse, varying by the needs of the patient. For example, the intensive care unit would be set at a lower level of patients per nurse than the medical-surgical ward.

California, the researchers wrote, experienced a more serious nurse shortage than other areas of the country but made up the gap by hiring "travel nurses"temporary workers who move from hospital to hospital as needed and not less educated LPNs. The researchers examined hiring practices from 1997 to 2008, pre- and post- implementation of the legislation, concluding that the increase in nurse staffing did not come at the expense of decreasing RNs.

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

Previous Penn research showed that nurse overload affects patient safety. For every patient added to a nurse's workload of four, the patient's risk of dying goes up by seven percent, even for everyday surgeries. And that if New Jersey and Pennsylvania had enacted the same legislation as California, there would have been 14 percent fewer patient deaths in New Jersey and 11 percent fewer deaths in Pennsylvania, saving hundreds of lives for the period studied.