Nurse staffing ratios: Trends and policy implications for hospitalists and the safety net

Authors

  • Patrick H. Conway MD, MSc,

    Corresponding author
    1. Center for Health Care Quality and Division of Health Policy and Clinical Effectiveness, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
    2. Division of General Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
    3. Robert Wood Johnson Foundation Clinical Scholars Program, University of Pennsylvania, Philadelphia, Pennsylvania
    4. Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
    • Center for Health Care Quality, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2044, Cincinnati, OH 45215
    Search for more papers by this author
  • R. Tamara Konetzka PhD,

    1. Department of Health Studies, University of Chicago, Chicago, Illinois
    Search for more papers by this author
  • Jingsan Zhu MBA,

    1. Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
    Search for more papers by this author
  • Kevin G. Volpp MD, PhD,

    1. Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
    2. Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
    3. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, Pennsylvania
    4. Department of Health Care Systems, the Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania
    Search for more papers by this author
  • Julie Sochalski PhD, RN

    1. Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
    2. University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
    Search for more papers by this author

Abstract

BACKGROUND:

Mandated minimum nurse-to-patient staffing ratio legislation was passed in California in 1999 and implemented January 1, 2004. Nurse staffing legislation is being considered in at least 25 other states.

OBJECTIVES:

The objectives of this study were: (1) to evaluate nurse staffing trends in California from 1993 to 2004, (2) to identify types of hospitals below minimum staffing ratios and staffing changes in 2004, the first year post-implementation; and (3) to discuss possible implications of nurse staffing on hospitalists and their hospital-based initiatives.

DESIGN, SETTING, PATIENTS:

We analyzed data from the medical-surgical units of all short-term acute-care general hospitals in California from 1993 to 2004. The annual hospital staffing ratio is composed of the combined hours of registered nurses and licensed vocational nurses and total number of patient days on medical-surgical units.

RESULTS:

Nurse staffing ratios were relatively unchanged from 1993 to 1999 and then increased significantly from 1999 to 2004, with the largest increase in 2004, the year the nurse staffing ratio was implemented. Types of hospitals more likely to be below minimum ratios had a high Medicaid/uninsured patient population and were government owned, nonteaching, urban, and in more competitive markets. Most hospitals below ratios were considered part of the health care “safety net.”

CONCLUSIONS:

Nurse staffing legislation may increase nurse staffing. However, mandated nurse staffing ratios without mechanisms to help achieve ratios may force hospitals, especially safety-net hospitals, to make tradeoffs in other services or investments with unintended negative consequences for patients. Nurse staffing likely influences the outcomes of hospitalist-led quality initiatives, but these effects need to be explored further. Journal of Hospital Medicine 2008;3:193–199. © 2008 Society of Hospital Medicine.

Ancillary