By Glenna Murdock, RN, contributor
April 30, 2010 - Are lower nurse-to-patient ratios a life saver or a money waster? That debate has been going on for years. Now, a new study of surgical patients in New Jersey and Pennsylvania has found that as many as 14 percent fewer patients would have died if hospitals in those states had required the same number of nurses as in California’s law. The study also highlighted some additional benefits for nurses with a lighter workload.
With the October 1999 signing of Staffing Ratio Law AB394 by then-Governor Gray Davis, California became the first state in the nation to mandate the maximum number of patients a nurse could be assigned on a given shift. There had been fierce opposition to the passage of the bill by hospitals, and even by some nurse executives, who argued that too many variables such as the severity of patients’ conditions plus increased costs made the mandate impractical.
“Although the bill was signed into law in 1999, hospitals were given until 2004 to begin the implementation of the standards set forth in the bill,” explained Deborah Burger, RN, president, council of presidents, for the California Nurses Association (CNA), who was among the nurses who actively worked to get the bill passed.
Since that time, discussions about the law’s effectiveness have been ongoing. This new study, published in Health Services Research, is the first major research project to compare states without mandated staffing ratios to California where ratios have been in effect for 6 years.
“There was interest in a scientific evaluation of the effects of the California legislation to determine if nurse staffing ratios actually improved outcomes for patients and nurses,” stated Linda H. Aiken, Phd, FAAN, FRCN, RN, a distinguished professor and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing, who has researched nurse staffing issues for more than two decades.
Using data from 2006, two years after California’s law was enacted, a team led by Aiken examined outcomes of general surgery patients in California hospitals and compared the findings there to those at hospitals in Pennsylvania and New Jersey, two states without staffing mandates. The comparisons yielded dramatic numbers.
“Our study found that had those two states staffed their surgical units based on the California legislation, mortality would have been reduced by 11 percent in Pennsylvania and by 14 percent in New Jersey,” Aiken said. “In just those two states the lives of 486 patients might have been saved during the two-year study period if the California staffing ratio had been in place.”
“Improved staffing benefits not only patients in general surgery units, but all hospital patients,” Aikens continued, “so it is likely that many thousands of lives could be saved each year if hospitals nationwide improved nurse staffing.”
The study also highlighted the positive effects of improved staffing on nurses themselves, showing that California nurses were more likely to stay in their jobs due to a significant reduction in burnout and job dissatisfaction. Nurses in Pennsylvania and New Jersey reported a greater number of complaints by patients and their families, a higher incidence of verbal abuse by patients and co-workers, and felt their increased workloads caused them to miss changes in their patients’ conditions, increasing the likelihood of mortality.
“The California legislation has set a standard for nursing that has saved the nursing profession,” said Burger, “and I don’t use those words lightly. So many nurses had left the profession or were considering doing so because of the exhausting workload, mandatory overtime and the concern of losing their license if the lack of time for each patient caused a patient to be harmed in some way.”
Burger was working with diabetic patients in a clinic outside the hospital when the legislation was enacted and she quickly began to see positive results from improved hospital staffing.
“Recently hospitalized patients who were coming to us for follow-up care had a better understanding of their condition, the part insulin played in it and were able to give themselves injections. They understood the signs that indicated they should call the doctor, all because the nurses in the hospital had the time to educate them,” she explained. “The evidence bears out that patients leaving the hospital now do so with a better understanding of their medications and are able to determine if the meds are working or if they are experiencing signs of infection, for example. They seek care earlier and complications are lessened or prevented.”
David Desler, RN, recently retired after a 42-year career spent primarily as an ICU nurse in California, remarked, “My job was recovering patients immediately following open heart surgery, which was a one-nurse-to-one-patient situation. The important difference the staffing law made for me was my being able to take a dinner break and feel confident that my patient was being cared for by a knowledgeable nurse who wasn’t caring for other patients at the same time. For the first time in many years I could leave the patient’s bedside with peace of mind and could actually relax.”
Although Pennsylvania does not have a staffing law, Victoria Rich, PhD, RN, FAAN, chief nursing executive, University of Pennsylvania Medical Center, has used evidence from Aikens’s research papers and studies to advocate for improved staffing at her institution.
“I used her studies when I talked to my CEO about ratios and better educated nurses,” Rich stated. “I said if I were given the budget for improved staffing, I would make it cost effective.”
“I knew that better nurse-to-patient ratios would result in fewer turnovers, fewer patient injuries, fewer malpractice suits and improved nurse and patient satisfaction,” she continued.
As of September 2009, 14 states and the District of Columbia had enacted nurse staffing legislation or adopted regulations addressing nurse staffing, and another 17 states had introduced legislation. None, however, are as stringent as California’s.
“The study is of value to all nurses,” Aiken said. “They can use it to show their hospital the benefits of safe staffing standards. It is a practical way to evaluate the effects of lower nurse-to-patient ratios.”
“Most things hospitals do, no matter how technologically advanced, don’t come close to saving 14 percent more lives,” she added. “Legislation is not the only way to accomplish safe staffing, but no matter how it is achieved it is beneficial.”
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