1. Potera, Carol


California's staffing ratio benefits both patients and nurses.


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A major new study suggests that California's 2004 law setting nurse-patient staffing levels reduces mortality rates, allows nurses to spend more time with patients, prevents nurse burnout, and promotes the retention of trained nurses.

Figure. Charlene Arr... - Click to enlarge in new windowFigure. Charlene Arrington, RN, was one of more than 200 other nurses and supporters in 2004 who protested a lawsuit challenging California's nurse-patient staffing ratio law. Photo by Rich Pedroncelli / Associated Press.

The researchers surveyed 22,336 nurses working in California, Pennsylvania, and New Jersey in 2006. California established mandatory minimum staffing levels for hospital units in 2004, but neither Pennsylvania nor New Jersey had such laws when the study was conducted. (New Jersey now has a law requiring hospitals to report staffing levels.) Nurses on different units were asked how many patients they were responsible for during their last shift. The researchers examined the nurses' job satisfaction and how patient outcomes, such as mortality, were affected by the nurses' workloads.


Tallying the benefits. Depending on the unit, nurses in Pennsylvania and New Jersey care for as many as two additional patients than nurses working in California. For example, the average workload on medical-surgical units in California was 4.8 patients, compared with 6.8 in New Jersey and 6.5 in Pennsylvania. And greater nurse staffing was associated with better mortality rates: the researchers estimated that New Jersey hospitals would have had 14% fewer deaths and Pennsylvania 11% fewer deaths if they'd matched California's staffing ratio on surgical units.


"In these two states alone, 468 lives might have been saved over the two-year period just among general surgery patients. Because all hospitalized patients-not just general surgery patients-are likely to benefit from improved nurse staffing, the number of lives that could be saved by improving nurse staffing in hospitals nationally is likely to be many thousands a year," says Linda H. Aiken, lead author and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing.


Lower patient loads also translated into better work environments. Nurses in California spent more time with patients and were less likely to experience burnout and job dissatisfaction than those in the other two states. Nurses in California also believe the staffing law reduced workloads: four times as many nurses reported decreases (as opposed to increases) in the number of patients assigned to them since the law went into effect.


"Most California nurses, bedside nurses as well as managers, believe the ratio legislation achieved its goals of reducing nurse workloads, improving recruitment and retention of nurses, and having a favorable impact on quality of care," conclude the authors. "[W]e find little evidence of unintended consequences of the California legislation that are likely to negatively affect the quality of the [nurses'] work environment or patient care," they add. Moreover, the findings help to inform efforts in those states that are debating staffing laws. Eighteen states are currently considering some form of staffing legislation, according to Aiken.


Although the California cutoffs haven't been proved to be optimal, they at least provide a reasonable baseline for setting practical staffing levels. The new study provides scientific evidence that when staffing levels fall below the California benchmarks, there are negative consequences for patients and nurses.


Laws aren't the only option. "Legislation isn't the only strategy to improve nurse staffing," says Aiken. Voluntary actions and advocacy can also lead to better nurse-patient ratios. "Nurses who work in hospitals should be discussing the results of this paper among themselves and with their hospital management. We hope this scientific evaluation will give policymakers the benefit of sound information," Aiken says.-Carol Potera


Aiken LH, et al. Health Serv Res 2010 Apr 9. [Epub ahead of print]