In both the United Stated and globally, patient safety and quality of care have been among the biggest concerns in healthcare. Several factors are associated with negative patient outcomes: heavy workloads and high job dissatisfaction. Unsatisfactory work environments result in nurse exhaustion and poor work quality, thus, putting patient care and safety at risk. To reduce these adverse effects on patient outcomes, reductions in nurse workload became obligatory in California when legislators approved Bill No. 394 (Tevington, 2011). The objective of this law is to increase nurse retention and reduce overworking by increasing nursing personnel. Unfortunately, this increase in nurse staffing will undoubtedly increase labor cost for hospitals and may in turn lead to a greater shortage of nurses due to a lack of resources. Research has yet to determine whether this type of regulation has any positive impact on patient safety and outcomes.
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Background and Significance
In an attempt to address patient safety and quality care, California passed a law regulating nurse to patient ratios but studies have yet to find evidence that the mandate improves patient safety and care. Studies did not find a significant positive relationship between lower nurse staffing levels and better patient outcomes, such as a lower Failure to Rescue (FTR) rate. In a study conducted by Cook, et al. (2012) patient care did not improve after implementation of the law. Studies analyzed nurse to patient ratios by comparing statistics before and after the implementation of the California law. Hospitals with reduced nurse to patient ratios as per the mandate did not exhibit any substantial change in patient outcomes. Likewise a study by Bolton et al, (2007) found an increase in direct patient care by RN, but no improvement in patient safety indicators such as fall rate, FTR, or reduced hospital acquired ulcers, was reported.
In response to California law, Pennsylvania also tried to reduce nurse to patient ratios. A study by Aiken et al. (2002) identified a significant relationship between mortality, failure-to-rescue and nurse staffing. The increase of one extra patient per nurse assignment was linked to a 7% increase in mortality rates, and an increase in FTR. The increases of patients from 4 to 6 and 4 to 8 per nurse would increase mortality rates of 14% and 31%. A study by Weichenthal and Hendey (2011) found that the percentage of patients left without being seen by a provider improved 0.7% after nurse to patient ratios were reduced. However, others indicators such as medication errors and administering aspirin in acute MI patient remained unchanged. Data from a study by Duffield et al. (2011) also noted that a higher number of nurses are linked with lower patient adverse outcomes such as decreased rate of pressure ulcer, pneumonia, and sepsis.
In relation to nurse workload with patient outcomes, the studies conducted by Aiken et al. (2002), and Rafferty et al. (2007) found a strong relationship between decreasing nurse workload, balancing work environment and improvement in patient mortality rate. In a study of a Belgian acute care hospital by Myny et al. (2011) identified 26 factors that impact nurse workload. Among those factors work interruptions and high patient turnover rate were the highest factors associated with nurse workload. Another study designed to address the nurse workload and improve patient outcomes by Twigg et al. (2011) discovered patient outcomes improved after implementation of the NHPPD staffing method which served to reduce nurse workloads. In study overall, mortality rates decreased by 25—26% and post-surgical complications were reduced. A study by Cho and Yun (2009) concerning acute stroke patients admitted to ICUs throughout the Korean healthcare system found that the hospitals with high nurse to patient ratio had high mortality rate among stroke patients than units with better staffing. In unit with better staffing, nurses were able to provide basic care to their patient and did not use help from family member. On the other hand a study by Van den Heede et al. (2009) did not find any major correlation between the acuity-adjusted NHPPD, patient outcomes, and RNs with bachelor degrees. Although on patient adverse event the FTR was 6.16% the highest rate noted. Thus evidence of the effect of nurse staffing levels on patient outcomes are inconsistent. An article by Lyneham, Cloughessy, & Martin (2008) found the increased workload related to inadequate staffing in an emergency department of Australia impacted patient safety.
Overall, the literature indicated a strong relationship between nurses staffing levels patient sensitive outcomes. Most studies found high nurse workload impaired patient safety, and increased burnout, and decreased job performance. But whether or not a legal mandate can improve patient outcomes, improve staffing, reduce workload remains unknown.
Identification of Knowledge Gap
After reviewing studies conducted in the U.S. and internationally, it is clear that studies have not produced an answer to staffing problems, nor identified a strong direct relationship between reduced nurse-to-patient ratios and patient outcomes. “Not only do the data fail to conclude that minimum standards would be beneficial, they fail to conclude that such standards would not be detrimental.†(Spetz et al., 2000, p. 57). Still, there are 17 other states considering similar legislation, despite a lack of evidence of successful nurse-to-patient regulation (Tevington, 2011). Closing the gap between nursing shortages, rising costs, and improving quality care have yet to be addressed in context with nursing environments and time management skills. Thus, it is necessary to continue to investigate the effectiveness (or lack thereof) of California’s nurse-to-patient law before other states enact this type of policy. In conclusion, it is imperative that research based evidence be produced to see if mandated nurse staffing ratios do actually improve patient safety and whether or not money may actually be saved.
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Proposed Solution
It is important to further investigate the mandated nurse to patient laws before being adopted by other states. These future studies should allow California and other states considering nurse-to-patient ratios to quantify the impact that mandated laws actually have on patient safety. All twelve articles investigate pros and cons of mandatory nurse-to-patient ratios and discussed several factors associated with patient outcomes. The California law was enacted on January 1, 2004, almost eight years ago. Since then, healthcare has experienced several changes such as like increased cost, increased nursing shortage, and increased labor cost. These adverse effects, combined with the California mandate may potentially cause hospital closures. Therefore a study of California should be conducted determine whether the mandate has had a positive or negative impact on healthcare within the last eight years. This information may be used by the State of California to determine if the current law should be sustained or divested. This would allow California and other states considering nurse patient ratio mandates to recognize the impact the ratio has on patient safety, hospital closures, and increased cost. It will also provide other states with the knowledge to make the most effective and beneficial decision regarding nurse-to-patient mandated laws.
Purpose statement
The purpose of the study is to examine the association between nurse to patient ratios in the state of California, on three nursing-sensitive outcomes: failure to rescue (surgical inpatients who experience a hospital-acquired complication such as pneumonia, pulmonary embolism, deep vein thrombus, acute renal failure, or gastrointestinal bleeding, and death), pressure ulcers (developed during hospital stay from stage I- stage IV), patient length of stay and any hospital closures due to increased labor cost.
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