California Study Offers New Perspective on Relationship Between Staffing Ratios and...

California Study Offers New Perspective on Relationship Between Staffing
Ratios and Patient Safety
Study Sponsor a Recipient of American Academy of Nursing Award for Innovation
in Healthcare Research

SACRAMENTO, Calif., March 12 /PRNewswire/ -- A study of the potential
impact of state mandated nurse-to-patient staffing ratios in California
hospitals revealed little impact on patient outcomes in two critical areas of
patient care. The findings were published in the March 2008 issue of Policy,
Politics & Nursing Practice, a peer-reviewed journal that explores the
multiple relationships between nursing and health policy. However, the
study's researchers caution the results are far from conclusive in
scientifically determining the required number of staff to provide quality
care.
"Mandated alterations in the volume of direct-care staff alone have not
resulted in expected reductions in the incidence of patient falls or the
prevalence of pressure ulcers. Instead, we have found there are many
variables we do not yet fully understand. As previous studies have suggested,
further research is needed to closely examine numerous factors, including
nursing unit data, organizational differences and characteristics of the
workforce," said Linda Burnes Bolton, Dr.P.H., R.N. FAAN, vice president and
chief nursing officer at Cedars-Sinai Medical Center and co-author of the
study.
The findings are significant on a national level in that California serves
as a bellwether in being the first state to enact legislation in 1999
mandating licensed nurse-to-patient ratios in acute-care hospitals. Ratios
were phased in gradually based on the type and intensity of care. For
instance, hospital medical and surgical units now have a ratio of one nurse to
five patients; in 2004, the ratio stood at one to six. The study of pre- and
post-regulation outcomes was conducted by the California Nursing Outcomes
Coalition (CalNOC). Acute care facilities report nursing quality data to the
coalition which was recently honored with a prestigious American Academy of
Nursing "Edge Runner" award for enhancing health care system performance
through its research. CalNOC is a collaborative effort of more than 185
hospitals to measure and benchmark statewide nursing quality outcomes. CalNOC
member hospitals submit monthly reports on unit-level nurse staffing, patient
days and falls. They also conduct pressure ulcer prevalence studies at least
annually as well as other nurse sensitive indicators. Data from these sources
were used to compare pre- and post-regulation staffing and incidence
statistics.
"CalNOC started as a collaborative grassroots research project between the
Association of California Nurse Leaders (ACNL) and the American Nursing
Association/California, to improve awareness about patient safety," said
Patricia McFarland, MSN, RN, FAAN, chief executive officer of ACNL and CalNOC
administrative manager. "Now, CalNOC is viewed as one of the nation's most
reliable databases for the study of staffing levels to prevent nurse-sensitive
adverse events and achieving evidence-based policy objectives."
CalNOC's latest study bolsters its 2005 preliminary report on staffing and
patient care quality in medical, surgical and definitive-observation units
(step-down and telemetry units) from the pre-ratio period through the early
implementation period. Then, as now, no statistically significant change was
seen in the patient safety and quality (falls and pressure ulcer) outcomes
monitored.
As anticipated, the study found significant increases in hours of care
provided by registered nurses coinciding with decreases in the number of
patients per RN. Accordingly, the skill mix data reflected an overall
reduction in the use of licensed vocational nurses/licensed practical nurses
on both medical-surgical units and step-down units. There also was a decline
in the use of unlicensed nursing care staff.
While these staffing changes appeared to produce no statistically
significant changes in the numbers of falls or the prevalence of pressure
ulcers in the period from 2002 to 2006, several trends emerged that the CalNOC
researchers expect to follow over time. Among them:
-- On medical-surgical units, a larger percentage of contracted, temporary
staff was associated with fewer injury falls but also with more
hospital-acquired pressure ulcers.
-- On medical-surgical units, there appeared to be an association between
falls and hospital size, with smaller hospitals showing a decrease in
falls while larger hospitals showed an increase.
-- A general decrease was seen in the percentage of patients with
community-acquired and/or hospital-acquired pressure ulcers from 2002
to 2006. On step-down units, the number of ulcers increased between
2002 and 2004 with a slight decrease in 2006. But the percentage of
patients on step-down units with more severe pressure ulcers increased
over the total time period.

Even as hospitals were increasing licensed staff to meet California's
requirements, several state and national organizations were targeting falls
and pressure ulcers as major elements of patient safety initiatives. These and
many other unaccounted for variables and external factors make it difficult to
accurately and independently measure the impact of staffing levels. Also, as
the researchers point out, the study is based on data from CalNOC member
hospitals, and it is not known how similar data from other hospitals might
differ.
"Our findings must be considered preliminary at this time, providing an
initial assessment while contributing to the growing understanding of the
impact of mandates on hospital operations and patient outcomes," said study
co-author Nancy E. Donaldson, DNSC, RN, FAAN, Director, UCSF Center for
Research and Innovation.
Citation: Policy, Politics and Nursing Practice, "Mandated Nurse Staffing
Ratios in California: A Comparison of Staffing and Nursing-Sensitive Outcomes
Pre- and Post-Regulation," March 2008
CalNOC was established in 1996 as a joint project of the American Nurses
Association/California and the Association of California Nurse Leaders. It is
the largest regional nursing quality database in the nation. Cedars-Sinai's
Department of Nursing Research and Development provides data management and
analysis services.
SOURCE CalNOC

Patricia McFarland of CalNOC, +1-916-552-7529