Mandating Nurse-Patient Ratios
1) WRITE a 750 word paper; using the two (2) articles: Abood (2007) and Aikan et al., (2010), and your textbook assigned chapter readings; as references. See the Nursing Student Writing Guidelines Checklist for paper requirements and answer the following questions:
a) After reading Aikan, et al (2010) on staffing ratios, you have decided that you want your state’s legislature to pass similar legislation mandates on nurse-patient ratios.
?b) RECOMMENDED: REVIEW Chapter 11: The nurse as advocate. In K.K. Blais& J.S. Hayes (2010) Professional nursing practice: Concepts and perspectives (6th ed.). Upper Saddle River, NJ: Prentice Hall. ?
c) Using all of these references, develop your plan for influencing votes of legislators on nurse-patient ratios.
?d) Paper title: Mandating Nurse-Patient Ratios.
Implications of the California Nurse
Staffing Mandate for Other States
Linda H. Aiken, Douglas M. Sloane, Jeannie P. Cimiotti,
Sean P. Clarke, Linda Flynn, Jean Ann Seago, Joanne Spetz,
and Herbert L. Smith
To determine whether nurse staffing in California hospitals, where
state-mandated minimum nurse-to-patient ratios are in effect, differs from two states
without legislation and whether those differences are associated with nurse and patient
Primary survey data from 22,336 hospital staff nurses in California,
Pennsylvania, and New Jersey in 2006 and state hospital discharge databases.
Nurse workloads are compared across the three states and we examine
how nurse and patient outcomes, including patient mortality and failure-to-rescue, are
affected by the differences in nurse workloads across the hospitals in these states.
California hospital nurses cared for one less patient on average
than nurses in the other states and two fewer patients on medical and surgical units.
Lower ratios are associated with significantly lower mortality. When nurses’ workloads
were in line with California-mandated ratios in all three states, nurses’ burnout and job
dissatisfaction were lower, and nurses reported consistently better quality of care.
Hospital nurse staffing ratios mandated in California are associated with
lower mortality and nurse outcomes predictive of better nurse retention in California
and in other states where they occur.
Nurse staffing, California nurse ratios
In 2004, California became the first state to implement minimum nurse-
to-patient staffing requirements in acute care hospitals (Coffman, Seago,
and Spetz 2002; Spetz 2004).
As of September 2009, 14 states and the District of Columbia had enac-
ted nurse staffing legislation and/or adopted regulations addressing nurse
staffing and another 17 states had introduced legislation (American Nurses
Association 2009). California remainstheonlystateto have enacted minimum
nurse staffing requirements, and as the amount of legislative and regulatory
Health Research and Educational Trust
Health Services Research
activity suggests, there is widespread interest in what can be learned from
For two decades, nurses have reported that there are not enough nurses
in hospitals to provide high-quality care (Aiken and Mullinix 1987; Aiken,
Sochalski, and Anderson 1996; Aiken et al. 2001). In response to these con-
cerns, Congress, in 1993, requested an Institute of Medicine (IOM) study of
the adequacy of nurse staffing in hospitals and nursing homes. The IOM
report concluded that there was insufficient evidence to support specific nurse
staffing ratios in hospitals and called for additional research (Wunderlich,
Sloan, and Davis 1996). Since then, the evidence supporting an association
between nurse staffing and better patient outcomes has grown. We reported in
2002 that each patient added to nurses’ workloads was associated with a 7
percent increase in mortality following common surgeries, and that nurse
burnout and job dissatisfaction, precursors of voluntary turnover, also in-
creased significantly as nurses’ workloads increased (Aiken et al. 2002). Rep-
lications in Canada, England, and Belgium produced similar findings as did
other studies in the United States (Aiken, Clarke, and Sloane 2002; Needle-
man et al. 2002; Estabrooks et al. 2005; Rafferty et al. 2007; Tourangeau et al.
2007; van den Heede et al. 2009). A meta-analysis of 90 studies commissioned
by the Agency for Healthcare Research and Quality (AHRQ) subsequently
concluded that there is an evident association between nurse staffing and
patient outcomes (Kane et al. 2007).
Registered nurse (RN) staffing in California hospitals increased sub-
stantially following the passage of the legislation and implementation of the
regulations (Donaldson et al. 2005; Bolton et al. 2007; Spetz et al. 2009).
Whether the increase in nurses is associated with improved outcomes has
been more difficult to determine. Researchers were unable to detect an impact
Address correspondence to Linda H. Aiken, R.N., Ph.D., F.A.A.N., Center for Health Outcomes
and Policy Research, University of Pennsylvania, 418 Curie Blvd, Philadelphia, PA 19104-4217;
e-mail: [email protected] Douglas M. Sloane, Ph.D., is with the Center for Health Out-
comes and Policy Research, University of Pennsylvania, School of Nursing, Philadelphia, PA.
Jeannie P. Cimiotti, R.N., D.N.Sc., is with the Center for Health Outcomes and Policy Research,
University of Pennsylvania, Philadelphia, PA. Sean P. Clarke, R.N., Ph.D., F.A.A.N., is with the
Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, University Health Network,
Toronto, ON, Canada. Linda Flynn, Ph.D., R.N., is with the School of Nursing, University of
Maryland, Baltimore, MD. Jean Ann Seago, Ph.D., R.N., F.A.A.N., is with the School of Nursing,
University of California, San Francisco, 2 Koret Way, San Francisco, CA. Joanne Spetz, Ph.D., is
with the School of Nursing, University of California, San Francisco, UCSF Laurel Heights, CA.
Herbert L. Smith, Ph.D., is with the Department of Sociology, Population Studies Center, Center
for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, PA.
2 HSR: Health Services Research
of improved nurse staffing on falls or hospital-acquired pressure ulcers (Don-
aldson et al. 2005; Bolton et al. 2007), but research findings in general on the
association between hospital nurse staffing and falls and pressure ulcers have
been inconsistent in the literature (Lake and Cheung 2006). While not related
to the impact of the legislation on patient outcomes, Mark, Harless, and Spetz
(2009) found that wage growth for RNs in California after implementation of
mandated minimum nurse staffing increased more than RN wage growth in
other states; the researchers could not rule out alternative explanations for the
wage increases including the impact of the nurse shortage.
Research by Sochalski et al. (2008) using data before implementation of
mandated minimum ratios offers a glimpse of the possible impact on patient
outcomes. During the study period between 1993 and 2001, when RN levels
rose by roughly 1.2 percent per year, they found that more RN hours per
patient day were associated with lower mortality for patients with acute myo-
cardial infarction. They also found, as would be expected, that mortality re-
ductions associated with increased nurse staffing were greatest for hospitals
that began with the worst staffing ratios. If this result can be replicated when
hospital outcome data become available for the years following implemen-
tation, many would conclude the legislation produced a desirable outcome.
The California Department of Health undertook a multiyear process to
determine the minimum ratios to be mandated based upon research and other
factors. The California mandates can be viewed as a benchmark against which
to compare hospitals within California and between California and other
states. We compare patient-to-nurse ratios in California hospitals with similar
ratios in New Jersey and Pennsylvania hospitals, states without nurse staffing
legislation at the time of the study, and compare associated outcomes. We
report findings from California nurses about the impact of the legislation on
factors affecting the quality of hospital care. We examine potential unintended
consequences of the legislation: whether RNs in California perceive that
nursing skill mix in hospitals has been negatively affected by increased em-
ployment of licensed vocational nurses (LVNs), and whether non-nurse an-
cillary support services have been reduced——two issues that were concerns at
the outset of the legislation (Coffman, Seago, and Spetz 2002). We compare
the outcomes for nurses and indicators of quality of care across hospitals in all
three states according to the proportion of nurses with workloads consistent
with the benchmarks derived from the California-mandated ratios. Finally, we
compare patient outcomes——30-day inpatient mortality and failure-to-rescue
(FTR)——across hospitals in which nurses care for fewer and more patients
each. This provides an estimate of the possible impact on nurse retention,
Implications of the California Nurse Staffing 3
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