The association between higher nurse staffing standards in the fee schedules and the geographic distribution of hospital nurses: A cross-sectional study using nationwide administrative data

BACKGROUND In Japan, the revision of the fee schedules in 2006 introduced a new category of general care ward for more advanced care, with a higher staffing standard, a patient-to-nurse ratio of 7:1. Previous studies have suggested that these changes worsened inequalities in the geographic distribution of nurses, but there have been few quantitative studies evaluating this effect. This study aimed to investigate the association between the distribution of 7:1 beds and the geographic distribution of hospital nursing staffs. METHODS We conducted a secondary data analysis of hospital reimbursement reports in 2012 in Japan. The study units were secondary medical areas (SMAs) in Japan, which are roughly comparable to hospital service areas in the United States. The outcome variable was the nurse density per 100,000 population in each SMA. The 7:1 bed density per 100,000 population was the main independent variable. To investigate the association between the nurse density and 7:1 bed density, adjusting for other variables, we applied a multiple linear regression model, with nurse density as an outcome variable, and the bed densities by functional category of inpatient ward as independent variables, adding other variables related to socio-economic status and nurse workforce. To investigate whether 7:1 bed density made the largest contribution to the nurse density, compared to other bed densities, we estimated the standardized regression coefficients. RESULTS There were 344 SMAs in the study period, of which 343 were used because of data availability. There were approximately 553,600 full time equivalent nurses working in inpatient wards in hospitals. The mean (standard deviation) of the full time equivalent nurse density was 426.4 (147.5) and for 7:1 bed density, the figures were 271.9 (185.9). The 7:1 bed density ranged from 0.0 to 1,295.5. After adjusting for the possible confounders, there were more hospital nurses in the areas with higher densities of 7:1 beds (standardized regression coefficient 0.62, 95% confidence interval 0.56-0.68). CONCLUSION We found that the 7:1 nurse staffing standard made the largest contribution to the geographic distribution of hospital nurses, adjusted for socio-economic status and nurse workforce-related factors.