Several studies have linked lower nurse-to-patient ratios with fewer medical errors and deaths, better overall treatment, and reduced rates of nurse burnout. These findings led California, in 1999, to pass the country’s first law mandating a minimum nurse-to-patient staffing ratio.
By 2004, the mandated ratio was one licensed nurse for every six patients; that was decreased in 2005 to one nurse for every five patients. Since then, similar bills have been passed or proposed in at least 25 more states. The benefits to patients and nurses of these improved ratios are clear. However, their effect on hospitalists, other staff members, and hospitals have not been widely studied. Further, the mandates often do not come with additional money to implement them.
In this month’s issue of the Journal of Hospital Medicine, Patrick Conway, MD, and colleagues examine nurse staffing trends in California hospitals since the mandate went into effect. They were particularly interested in what they called “safety net” hospitals: urban, government-owned, resource-poor institutions with at least 36% of patients uninsured or on Medicaid.
Dr. Conway, a pediatric hospitalist and assistant professor of pediatrics at the Cincinnati Children’s Hospital Medical Center, and his coauthors hypothesized that cash-strapped hospitals would find it hard to meet the mandate and might shortchange other programs in an effort to comply. Laudable as such legislation might be, “we wanted to make it clear to hospitalists and hospitals that the ratios could have an impact on other goals they wanted to achieve, such as meeting pay-for-performance targets,” he says.
Using financial data from the California Office of Statewide Health Planning and Development, they examined staffing trends on adult general medical surgical units in short-term, acute-care general hospitals from 1993 to 2004, the most recent years for which complete data was available. For 2003 and 2004, they also analyzed staff ratios according to five characteristics: hospital ownership (profit, nonprofit, government-owned), market competitiveness, teaching status, location (urban vs. rural), and whether or not the hospital met the definition of a safety net facility.
From 1993-99, nurse staffing ratios remained flat; they rose steadily thereafter. Not surprisingly, the largest increase occurred between 2003 and 2004, the year implementation was slated to go into effect. During that period, the median ratio for all hospitals studied went from less than one nurse per four patients to more than 1:4, exceeding the mandated figure. Fewer than 25% of hospitals fell short of the minimum mandate of 1:5.
However, further analysis reveals more nuances. The mandate requires a minimum ratio of licensed nurses to patients; those nurses can be registered nurses (RNs), licensed vocational nurses (LVNs), or a combination. In 2004, only 2.4% of hospitals fell below the mandated minimum for that year of 1:6, compared with 5% from the year before—but 11.4% were below 1:5 (RNs plus LVNs). When RNs only were considered, 29.5% of hospitals fell short of one for every five patients.
Further, some states are considering a minimum mandate of one licensed nurse per every four patients—yet 40.4% of the hospitals in this study did not meet that standard. “This demonstrates the substantial increase in the proportion of hospitals that are below minimum ratios as the number of nurses or required training level of nurses is increased,” the authors point out.
The finding that nearly 30% of hospitals had less than one registered nurse for every five patients was surprising, says Dr. Conway, whose wife is a registered nurse. In other words, “if you or I or our parents were admitted to a hospital, your chances are about one in three that they will have less than one nurse for every five patients. That means each nurse has less time to spend per patient.”
For-profit hospitals, non-teaching hospitals, and hospitals in urban or more competitive locations fared best at achieving the mandated ratios. However, hospitals with high Medicaid or uninsured populations were significantly more likely to fall below the minimum ratios than their more affluent counterparts and did not achieve the marked gains in staffing ratios achieved in other facilities.
All in all, more than 20% of safety net hospitals failed to achieve the 2004 mandate of 1:5, compared with about 12% of the other types of hospitals.
Of the safety net hospitals that did achieve the mandate, one wonders what types of tradeoffs they had to make, Dr. Conway adds: “Are they closing emergency rooms? Investing less in new equipment and facilities? Hiring less-trained staff? This study raises those questions, although it doesn’t answer them.”
More and more, hospitalists are being held responsible for quality improvement programs and outcomes measures within hospitals. The targets monitored often are those most strongly influenced by nurse presence, such as the number of central line infections, pressure ulcers, urinary tract infections, ventilator-acquired pneumonia, and similar conditions.
On the other hand, “no one has yet studied what happens when a hospital goes from a ratio of 1:5 to 1:4,” Dr. Conway says. It is possible that the [patient] gains realized may not be large enough to justify the compromises a hospital might have to make in other areas to meet that goal. “We must determine what the tradeoffs are and identify optimal nurse staffing ratios. Adequate nurse staffing is a significant key to achieving a successful team management approach in a hospital.” TH
Norra MacReady is a medical writer based in California.
Editor’s note: Dr. Conway was featured in the February 2008 issue (p. 28) as a member of the White House Fellows Program.