If California's mandatory nurse-patient ratios had been in effect in Pennsylvania and New Jersey hospitals in 2006, those states would have seen 10.6% and 13.9% fewer deaths among general surgical patients, according to a Pennsylvania researcher's analysis.
That equated to 468 lives that might have been saved, says Linda Aiken, director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing and the study's lead author.
Her report was published in the journal Health Services Research, and is considered the first comprehensive evaluation of California's controversial 2004 nurse staffing ratio mandate and may inform decisions in 18 other states that are considering lowering their nurse-staff ratios, such as Massachusetts, Minnesota, and Illinois.
Aiken's study received funding support from the Robert Wood Johnson Foundation and the National Institute of Nursing Research at the National Institutes of Health.
Aiken, a registered nurse and a well-known nursing workforce investigator, says that the difference between staffing at hospitals in California versus New Jersey and Pennsylvania "is very large, about two more patients per nurse [in medical surgical units]. And that's very significant."
To explain the decline in California mortality that she attributes to better nurse-patient ratios, Aiken says, "Nurses are the main surveillance system in hospitals.
"Nurses detect the majority of complications; the majority of medication errors that are detected by anyone are detected by nurses first. And nurses can distinguish between patients who are shivering after surgery because the operating rooms are cold, or who are shivering because they are in shock and are going into multiple organ failure that can't be reversed if it isn't caught early enough."
"All hospitalized patients are likely to benefit from improved nurse staffing, not just general surgery patients," Aiken says, adding that "the potential number of lives that could be saved by improving nurse staffing in hospitals is likely to be many thousands a year."
A spokeswoman for the California Hospital Association, which opposed the patient-nurse ratios and has criticized their effectiveness, said the organization was reviewing the report, but did not yet have a comment.
However, officials for the 155,000-member California Nurses Association were delighted with the report because it sponsored the law that mandated the lower ratios.
"This research documents what California RNs have long known–safe staffing saves lives," says Malinda Markowitz, CNA and National Nurses United co-president. "We see the effects every day at the bedside in improved patient care, an enhanced quality of life for patients, and nurses able to more safely practice the profession to which we have dedicated our lives."
Her study compared patient outcomes data reported by hospitals to state agencies and surveyed 22,236 hospital staff nurses in those three states. The report was long anticipated because California remains the first and only state to implement minimum nurse-patient staff ratios in its acute care hospitals, as of Jan. 1, 2004.
The law says a nurse must care for no more than five patients on a medical-surgical unit, four pediatric patients, two in intensive care, six in a psychiatric unit, and three in labor and delivery.
According to a table in Aiken's report, adjusted 30-day inpatient mortality in California was also significantly lower than in New Jersey or Pennsylvania.
Also, Aiken reported, 88% of nurses surveyed in a medical-surgical unit reported having five patients, but in New Jersey only 19% and in Pennsylvania only 33% reported those ratios. The rest had higher ratios.
Similar disparities were seen for nurses working in intensive care, telemetry, oncology, labor and delivery, and pediatric units, according to Aiken's report.
Aiken's surveys of nurses in those three states revealed that in California, nurses had better job satisfaction, less burnout, and said they provided better quality of care than did nurses who responded in Pennsylvania and New Jersey. "California nurses were more likely to rate quality of care as excellent than nurses in the other two states," she says.
Aiken's report from 2002 found that each patient added to a nurse's workload added 7% to the mortality rate for patients undergoing common surgeries. Also, she reported, higher nurse to patient ratios were also associated with more nurse burnout, job dissatisfaction, and precursors of voluntary turnover.
Since 2004, the state has increased the number of actively licensed RNs by more than 110,000, tripling the average annual increase before 1999 when the law was enacted, and five years before it took effect.
"From a policy perspective, our findings are revealing," Aiken wrote in her conclusion. "The California experience may inform other states that are currently debating nurse ratio legislation."