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California Study Offers New Perspective on Relationship Between Staffing Ratios and Patient Safety

Study Sponsor a Recipient of American Academy of Nursing Award for

Innovation in Healthcare Research

SACRAMENTO, Calif., March 12 /PRNewswire/ -- A study of the potential impact of state mandated nurse-to-patient staffing ratios in California hospitals revealed little impact on patient outcomes in two critical areas of patient care. The findings were published in the March 2008 issue of Policy, Politics & Nursing Practice, a peer-reviewed journal that explores the multiple relationships between nursing and health policy. However, the study's researchers caution the results are far from conclusive in scientifically determining the required number of staff to provide quality care.

"Mandated alterations in the volume of direct-care staff alone have not resulted in expected reductions in the incidence of patient falls or the prevalence of pressure ulcers. Instead, we have found there are many variables we do not yet fully understand. As previous studies have suggested, further research is needed to closely examine numerous factors, including nursing unit data, organizational differences and characteristics of the workforce," said Linda Burnes Bolton, Dr.P.H., R.N. FAAN, vice president and chief nursing officer at Cedars-Sinai Medical Center and co-author of the study.

The findings are significant on a national level in that California serves as a bellwether in being the first state to enact legislation in 1999 mandating licensed nurse-to-patient ratios in acute-care hospitals. Ratios were phased in gradually based on the type and intensity of care. For instance, hospital medical and surgical units now have a ratio of one nurse to five patients; in 2004, the ratio stood at one to six. The study of pre- and post-regulation outcomes was conducted by the California Nursing Outcomes Coalition (CalNOC). Acute care facilities report nursing quality data to the coalition which was recently honored with a prestigious American Academy of Nursing "Edge Runner" award for enhancing health care system performance through its research. CalNOC is a collaborative effort of more than 185 hospitals to measure and benchmark statewide nursing quality outcomes. CalNOC member hospitals submit monthly reports on unit-level nurse staffing, patient days and falls. They also conduct pressure ulcer prevalence studies at least annually as well as other nurse sensitive indicators. Data from these sources were used to compare pre- and post-regulation staffing and incidence statistics.

"CalNOC started as a collaborative grassroots research project between the Association of California Nurse Leaders (ACNL) and the American Nursing Association/California, to improve awareness about patient safety," said Patricia McFarland, MSN, RN, FAAN, chief executive officer of ACNL and CalNOC administrative manager. "Now, CalNOC is viewed as one of the nation's most reliable databases for the study of staffing levels to prevent nurse-sensitive adverse events and achieving evidence-based policy objectives."

CalNOC's latest study bolsters its 2005 preliminary report on staffing and patient care quality in medical, surgical and definitive-observation units (step-down and telemetry units) from the pre-ratio period through the early implementation period. Then, as now, no statistically significant change was seen in the patient safety and quality (falls and pressure ulcer) outcomes monitored.

As anticipated, the study found significant increases in hours of care provided by registered nurses coinciding with decreases in the number of patients per RN. Accordingly, the skill mix data reflected an overall reduction in the use of licensed vocational nurses/licensed practical nurses on both medical-surgical units and step-down units. There also was a decline in the use of unlicensed nursing care staff.

While these staffing changes appeared to produce no statistically significant changes in the numbers of falls or the prevalence of pressure ulcers in the period from 2002 to 2006, several trends emerged that the CalNOC researchers expect to follow over time. Among them:

-- On medical-surgical units, a larger percentage of contracted, temporary

staff was associated with fewer injury falls but also with more

hospital-acquired pressure ulcers.

-- On medical-surgical units, there appeared to be an association between

falls and hospital size, with smaller hospitals showing a decrease in

falls while larger hospitals showed an increase.

-- A general decrease was seen in the percentage of patients with

community-acquired and/or hospital-acquired pressure ulcers from 2002

to 2006. On step-down units, the number of ulcers increased between

2002 and 2004 with a slight decrease in 2006. But the percentage of

patients on step-down units with more severe pressure ulcers increased

over the total time period.

Even as hospitals were increasing licensed staff to meet California's requirements, several state and national organizations were targeting falls and pressure ulcers as major elements of patient safety initiatives. These and many other unaccounted for variables and external factors make it difficult to accurately and independently measure the impact of staffing levels. Also, as the researchers point out, the study is based on data from CalNOC member hospitals, and it is not known how similar data from other hospitals might differ.

"Our findings must be considered preliminary at this time, providing an initial assessment while contributing to the growing understanding of the impact of mandates on hospital operations and patient outcomes," said study co-author Nancy E. Donaldson, DNSC, RN, FAAN, Director, UCSF Center for Research and Innovation.

Citation: Policy, Politics and Nursing Practice, "Mandated Nurse Staffing Ratios in California: A Comparison of Staffing and Nursing-Sensitive Outcomes Pre- and Post-Regulation," March 2008

CalNOC was established in 1996 as a joint project of the American Nurses Association/California and the Association of California Nurse Leaders. It is the largest regional nursing quality database in the nation. Cedars-Sinai's Department of Nursing Research and Development provides data management and analysis services.

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