Ratio rebuttal studies
The Linda Aiken study “Implications of the California Nurse Staffing Mandate for Other States” has been used as evidence to support nurse staffing ratios. However, when looking at the literature on nurse staffing, a different picture arises regarding nurse staffing ratios.
While nurse staffing ratios have been touted as decreasing adverse health events and increasing quality of care, in fact they are not proven to do so.
- The nurse-sensitive outcome measures incidence of patient falls and incidence of pressure ulcers have not shown improvement with the implementation of nurse staffing ratios.[1]
- A recently-published analysis of nurse staffing and quality of care in California that examines nurse-sensitive outcome measures from 2000-2006 (post ratio implementation) concludes that “[h]igher registered nurse staffing per patient day had a limited impact on adverse health events in California hospitals.”[2]
- From the same article: “…the role of nursing care in improving patient outcomes is multidimensional; multiple structural and process factors are important.” And “[t]he net effect of nurse staffing legislation remains unknown. California’s fixed minimum staffing ratio regulations have not been consistently linked to improvements in the quality of care.”
- Mandatory ratios have not necessarily led to an increase in patient safety or quality.
- “Increased nurse staffing in hospitals is associated with better care outcomes, but this association is not necessarily causal.”[3]
- One report finds low rates of change post-staffing ratio implementation of patient length of stay, pressure ulcers, failure to rescue after a post-surgical complication, deep vein thrombosis/pulmonary embolism (DVT), pneumonia mortality, and postoperative sepsis. There were also some reports of emergency room diversions because of lack of staffing.[4]
In California, nurses have reported frustrations among nurses with a loss of autonomy and difficulty juggling the logistics of dealing with rigid ratios and other labor laws (meals, breaks, etc).[5]
[1] Joanne Spetz, David W. Harless, Carolina-Nicole Herrera, Barbara A. Mark, “Using Minimum Nurse Staffing Regulations to Measure the Relationship between Nursing and Hospital Quality of Care,” Medical Care Research and Review, XX(X) 1-20, published online Feb. 11, 2013; Linda Burnes Bolton, et al, “Mandated Nurse Staffing Ratios in California: A Comparison of Staffing and Nursing-Sensitive Outcomes Pre-and Postregulation,” Policy, Politics, & Nursing Practice, vol. 8, no. 4, Nov. 2007, 238-250; Nancy Donaldson and Susan Shapiro, “Impact of California Mandated Acute Care Hospital Nurse Staffing Ratios: A Literature Synthesis,” Policy, Politics & Nursing Practice, 11(3) 184-201.
[2] Spetz, et al.
[3] Robert Kane, et al, “Nurse Staffing and Quality of Patient Care,” prepared for the Agency for Healthcare Research and Quality, No. 07-E005, March 2007.
[4] California HealthCare Foundation, “Assessing the Impact of California’s Nurse Staffing Ratios on Hospitals and Patient Care,” Feb. 2009, 7-8.
[5]Susan A. Chapman, et al, “How Have Mandated Nurse Staffing Ratios Affected Hospitals? Perspectives from California Hospital Leaders,” Journal of HealthCare Management, 54:5, Sept./Oct. 2009, 321-334.