Nurse Staffing Mandates Are Not a Silver Bullet

Fed up with inadequate staffing that exhausts staff and puts patients at risk, Washington, DC, nurses flooded their city hall earlier this month, clad in red scrubs and demanding specific nurse-to-patient ratios that would protect themselves and patients.

In response to their calls for action, D.C. Council Chairman Phil Mendelson said he plans to introduce legislation that would require the city's hospitals to increase nursing staff levels, according to The Washington Post.

Mandating nurse staffing levels is a move that seems like a good idea, but carries with it a lot of controversy and questions about its effectiveness.

There's plenty of research showing that inadequate staffing levels negatively impact patient care, and that makes sense. It's a simple question of manpower. One nurse on a 12-hour shift couldn't possibly take care of 10 patients as effectively as two nurses could.

Yet legislative mandates—which require minimum staffing levels at all hospitals within a jurisdiction—may not be the solution to this problem. The best example is California, where a nurse staffing mandate that's been in place since 2004 has been billed a national experiment. So far, the experiment has had mixed results.

For example, a study published in the journal Health Services Research, found that although the California law succeeded in boosting nurse staffing, the staffing increase had only "mixed effects on quality." Researchers couldn't be certain whether any recorded quality improvements were actually caused by staffing changes.

Using data from the American Hospital Association, the state of California, and the Agency for Healthcare Research and Quality, changes in staffing and in quality of care in California hospitals were compared to hospitals in 12 states that didn't have minimum staffing legislation.

Researchers found that California hospitals did increase nurse staffing levels more significantly than hospitals in the other states. Quality measures, however, didn't necessarily rise along with staffing levels.

For example, according to the researchers, "there were no statistically significant changes in either respiratory failure or postoperative sepsis." Other findings showed improvements in some areas, such as failure to rescue, which decreased significantly more in some California hospitals.

The causal relationship between the two factors isn't clear, however, and more research is needed, researchers say.

The California Nurses Association slammed the study, telling California Healthline that the study methodology was flawed and that the results "were not sufficient to support the authors' conclusions. In fact, the evidence derived from these tests points to the improvement in rescuing patients with nursing ratios in place."

But a National Bureau of Economic Research working paper from 2010 drew a similar mixed conclusion, with the authors finding "persuasive evidence that AB394 did have the intended effect of decreasing patient/nurse ratios in hospitals that previously did not meet mandated standards. However, our analysis suggests that patient outcomes did not disproportionately improve in these same hospitals. That is, we find no evidence of a causal impact of the law on patient safety."

Mandatory nurse staffing opponents argue that ever-changing healthcare landscape requires hospitals to be "nimble and flexible" when it comes to staffing, and that such mandates would to lead to "negative consequences for nurses involving the equity, efficiency, and costs of producing nursing care in hospitals."

Proponents, such as National Nurses United, argue that Washington, DC, needs a law like the one in California, which "has dramatically improved patient safety, brought 130,000 additional nurses back to the bedside, and has helped keep experienced nurses taking care of patients." In DC, 57% of nurses say staffing is always or almost always inadequate there, according to NNU.

Although appropriate nurse staffing is critical, researchers seem to agree that more study is needed to determine whether mandates like the one being proposed in Washington, DC, actually cause improvements in patient care.

One scenario that would render such mandates and studies moot: If  hospitals already had adequate nurse staffing.