Impact of California’s Licensed Nurse-Patient Ratios on Unit-Level Nurse Staffing and Patient Outcomes

Donaldson, Nancy; Bolton, Linda Burnes; Aydin, Carolyn E.; Brown, Diane Storer; Elashoff, Janet D.; Sandhu, Meenu

doi:10.1177/1527154405280107

Cited by 112 publications

(130 citation statements)

References 7 publications

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“…Generally outcomes over a given period were associated with averaged staffing over the same period. In only six studies was the temporal link between changes in staffing levels and outcomes established, either because one preceded the other or they were measured simultaneously , Donaldson et al, 2005, Needleman et al, 2011, Patrician et al, 2011, Tschannen et al, 2010 .…”

Section: Review Resultsmentioning

confidence: 99%

“…Three of the twelve found that having more nurses was significantly associated with lower rates of falls (Donaldson et al, 2005, Patrician et al, 2011, Potter et al, 2003.…”

Section: Other Outcomesmentioning

confidence: 99%

“…For example, 12 studies reported the association between staffing and pressure ulcers. Three found that higher staffing was significantly associated with lower rates of ulcers (Donaldson et al, 2005, Hart and Davis, 2011.…”

Section: Other Outcomesmentioning

confidence: 99%

“…A number of these studies found an association between a nursing skill mix that has a higher proportion of RNs and better outcomes including lower mortality / failure to rescue (Blegen et al, 2011, Estabrooks et al, 2005, lower rates of infections (Blegen et al, 2011, Cho et al, 2003, McGillis Hall et al, 2004, falls (Blegen and Vaughn, 1998, Donaldson et al, 2005, Patrician et al, 2011, pressure ulcers (Blegen et al, 2011, Ibe et al, 2008, and higher patient satisfaction (Potter et al, 2003). The overall pattern of results is largely consistent, with the only significant contradictory evidence coming from one of the weaker studies which showed that a higher proportion of registered nurses was associated with a higher nurse reported incidence of pneumonia (Ausserhofer et al, 2013).…”

Section: March 2016mentioning

confidence: 99%

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Nurse staffing and patient outcomes: Strengths and limitations of the evidence to inform policy and practice. A review and discussion paper based on evidence reviewed for the National Institute for Health and Care Excellence Safe Staffing guideline development

Griffiths

Ball

Drennan

et al. 2016

International Journal of Nursing Studies

207

216

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What is already known? A number of high quality reviews establish an association between lower registered nurse staffing levels, increased mortality rates and other adverse outcomes  Careful analysis of this evidence suggests that it is consistent with a causal relationship  Translation of this evidence into practice is disputedWhat this paper adds  This paper summarises and extends a recent systematic review on nurse staffing and outcomes undertaken for England's National Institute for Health and Care Excellence  Methodological limitations mean that existing studies may not give unbiased estimates of the benefits from increased nurse staffing, with over and underestimation of benefit both possible, which makes it difficult to directly translate evidence into guidance for practice. We identify avenues for progressing this important research so that future studies might be better able to provide the evidence needed to inform policy and practice, and provide a checklist to aid future study development AbstractA large and increasing number of studies have reported a relationship between low nurse staffing levels and adverse outcomes, including higher mortality rates. Despite the evidence being extensive in size, and having been sometimes described as "compelling" and "overwhelming", there are limitations that existing studies have not yet been able to address. One result of these weaknesses can be observed in the guidelines on safe staffing in acute hospital wards issued by the influential body that sets standards for the National Health Service in England, the National Institute for Health and Care Excellence (NICE), which concluded there is insufficient good quality evidence available to fully inform practice.In this paper we explore this apparent contradiction. After summarising the evidence review that informed the NICE guideline on safe staffing and related evidence, we move on to discussing the complex challenges that arise when attempting to apply this evidence to practice. Among these, we introduce the concept of endogeneity, a form of bias in the estimation of causal effects. Although current evidence is broadly consistent with a cause and effect relationship, endogeneity means that estimates of the size of effect, essential for building an economic case, may be biased and in some cases qualitatively wrong. We expand on three limitations that are likely to lead to endogeneity in many previous studies: omitted variables, which refers to the absence of control for variables such as medical staffing and patient case mix; simultaneity, which occurs when the outcome can influence the level of staffing just as staffing influences outcome; and common-method variance, which may be present when both outcomes and staffing levels variables are derived from the same survey.Thus while current evidence is important and has influenced policy because it illustrates the potential risks and benefits associated with changes in nurse staffing, it may not provide operational solutions. We conclude by posing a ser...

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Section: Review Resultsmentioning

confidence: 99%

“…Three of the twelve found that having more nurses was significantly associated with lower rates of falls (Donaldson et al, 2005, Patrician et al, 2011, Potter et al, 2003.…”

Section: Other Outcomesmentioning

confidence: 99%

Section: Other Outcomesmentioning

confidence: 99%

Section: March 2016mentioning

confidence: 99%

See 2 more Smart Citations

Nurse staffing and patient outcomes: Strengths and limitations of the evidence to inform policy and practice. A review and discussion paper based on evidence reviewed for the National Institute for Health and Care Excellence Safe Staffing guideline development

Griffiths

Ball

Drennan

et al. 2016

International Journal of Nursing Studies

207

216

View full text Add to dashboard Cite

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“…Other published evaluations of the mandated nurse-to-patient ratios in California (where minimum ratios were established by type of unit, for example medical-surgical units), found no evident change in adverse events or patient length of stay ( [Bolton et al, 2007], [Donaldson et al, 2005] and [Spetz et al, 2009]). …”

Section: Discussionmentioning

confidence: 99%

The impact of the nursing hours per patient day (NHPPD) staffing method on patient outcomes: A retrospective analysis of patient and staffing data

Twigg

Duffield

Bremner

et al. 2011

International Journal of Nursing Studies

112

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BackgroundIn March 2002 the Australian Industrial Relations Commission ordered the introduction of a new staffing method -nursing hours per patient day (NHPPD) -for implementation in Western Australia public hospitals. This method used a "bottom up" approach to classify each hospital ward into one of seven categories using characteristics such as patient complexity, intervention levels, the presence of high dependency beds, the emergency/elective patient mix and patient turnover. Once classified, NHPPD were allocated for each ward. ObjectivesThe objective of this study was to determine the impact of implementing the NHPPD staffing method on 14 nursing-sensitive outcomes: central nervous system complications, wound infections, pulmonary failure, urinary tract infection, pressure ulcer, pneumonia, deep vein thrombosis, ulcer/gastritis/upper gastrointestinal bleed, sepsis, physiologic/metabolic derangement, shock/cardiac arrest, mortality, failure to rescue and length of stay. Design and settingThe research design was an interrupted time series using retrospective analysis of patient and staffing administrative data from three adult tertiary hospitals in metropolitan Perth over a 4-year period. SampleAll patient records (N = 236,454) and nurse staffing records (N = 150,925) from NHPPD wards were included. ResultsThe study found significant decreases in the rates of nine nursing-sensitive outcomes when examining hospital-level data following implementation of NHPPD; mortality, central nervous system complications, pressure ulcers, deep vein thrombosis, sepsis, ulcer/gastritis/upper gastrointestinal bleed shock/cardiac arrest, pneumonia and average length of stay. At the ward level, significant decreases in the rates of five nursing-sensitive outcomes; mortality, shock/cardiac arrest, ulcer/gastritis/upper gastrointestinal bleed, length of stay and urinary tract infections occurred. ConclusionsThe findings provide evidence to support the continuation of the NHPPD staffing method. They also add to evidence about the importance of nurse staffing to patient safety; evidence that must influence policy. This study is one of the first to empirically review a specific nurse staffing method, based on an individual assessment of each ward to determine staffing requirements, rather than a "one-size-fits-all" approach.What is already known about the topic?• Higher nurse staffing levels have been linked with improved patient outcomes.• This evidence has resulted in some states and jurisdictions legislating or mandating nurse staffing.• The available evidence does not provide specific guidelines for nurse staffing, either in terms of the amount of care required or skill mix of the nurses providing care at a unit level. What this paper adds• This study empirically reviews a specific nurse staffing method, based on an individual assessment of each ward to determine staffing requirements, rather than a "one-size-fits-all" approach.• It provides evidence that implementation of the NHPPD staffing method decreased nursingsensi...

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Hospital nurse staffing models and patient and staff-related outcomes

Butler

Collins

Drennan

et al. 2011

Cochrane Database of Systematic Reviews

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Background Nurse staffing interventions have been introduced across countries in recent years in response to changing patient requirements, developments in patient care, and shortages of qualified nursing staff. These include changes in skill mix, grade mix or qualification mix, staffing levels, nursing shifts or nurses' work patterns. Nurse staffing has been closely linked to patient outcomes, organisational outcomes such as costs, and staff-related outcomes. Objectives Our aim was to explore the effect of hospital nurse staffing models on patient and staff-related outcomes.

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Impact of California’s Licensed Nurse-Patient Ratios on Unit-Level Nurse Staffing and Patient Outcomes

Cited by 112 publications

References 7 publications

Nurse staffing and patient outcomes: Strengths and limitations of the evidence to inform policy and practice. A review and discussion paper based on evidence reviewed for the National Institute for Health and Care Excellence Safe Staffing guideline development

Nurse staffing and patient outcomes: Strengths and limitations of the evidence to inform policy and practice. A review and discussion paper based on evidence reviewed for the National Institute for Health and Care Excellence Safe Staffing guideline development

The impact of the nursing hours per patient day (NHPPD) staffing method on patient outcomes: A retrospective analysis of patient and staffing data

Hospital nurse staffing models and patient and staff-related outcomes

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