Nurse - To - Patient Mandate Did Not Reduce The Skill Matthew

When California passed a law in 1999 establishing minimum nurse-to-patient staffing ratios for hospitals, it was feared that hospitals might respond by disproportionately hiring lower-skill licensed vocational nurses. This article examines nurse staffing ratios for California hospitals for the period 1997–2008. It compares staffing levels to those in similar hospitals in the United States. We found that California’s mandate did not reduce the nurse workforce skill level as feared. Instead, California hospitals on average followed the trend of hospitals nationally by increasing their nursing skill mix, and they primarily used more highly skilled registered nurses to meet the staffing mandate. In addition, 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. Policy makers in other states can look to California’s experience when considering similar approaches to improving patient care. I n 1999 then–California Governor Gray Davis signed Assembly Bill 394 into law, requiring the California Department of Health Services to adopt regulations establishing minimum nurseto-patient staffing ratios for hospitals. The law came in response to growing concern about patient safety as the complexity of care in hospitals increased and California experienced a severe nurse shortage in the late 1990s. Influence from unions, including the California Nurses Association and the Service Employees International Union, helped propel staffing issues into the political agenda, despite opposition from organizations such as the California Healthcare Association, which represents hospitals. California’s minimum nurse staffing ratios were intended 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. These ratios have been associated with a number of negative patient outcomes, such as higher surgical mortality and higher complication rates due to errors. Higher patientworkloads for nurses have also been linked to negative nurse outcomes, such as job dissatisfaction and burnout, that are associated with staff retention problems. The California Department of Health Services spent two years holding hearings and inviting stakeholders to make recommendations regarding which nurse-to-patient ratio minimums should be mandated. In 2002 the department announced the final ratios, which went into effect on January 1, 2004. The department’s regulations specified staffing ratios for different specialties. For example, minimum staffing in general medical and surgical units were set at one licensed nurse for six patients for an eighteen-month phase-in period, and then reduced to onenurse for five patients. Hospitals could staff with more nurses per set number of patients than specified, but not fewer. doi: 10.1377/hlthaff.2010.1118