Minimum nurse-to-patient ratios were required after legislation passed in 1999 in California, and the number of nurses increased, but the resulting quality of care is mixed. Those hospitals with shortfalls had increases in staffing, though some of these increases were with less skilled nurses, according to a study published in Health Services Research.

“This was a wonderful opportunity to examine whether minimum staffing levels made any real difference in a variety of different outcomes that are of interest not only to researchers, but to health professionals, policy makers, and the public,” said lead author Barbara A. Mark, PhD, RN, at the University of North Carolina School of Nursing.

The researchers studied changes in staffing at California hospitals from 2000 to 2006, and compared those to staffing changes at hospitals elsewhere that did not have a staffing ratio mandate. They found that those hospitals with the largest staffing shortfalls had the largest increase in staffing. The researchers were surprised to find that even hospitals that probably did not have shortfalls also increased staffing, though not nearly as much. Notably, the hospitals with the greatest shortfalls relied more on licensed vocational nurses to meet the ratios than other hospitals did.

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Staffing increases were associated with a decrease in the number of patients who died following a complication, which is known as “failure to rescue.” This decrease was most obvious in the hospitals that had the largest increase in staffing and in those hospitals that were well-staffed when the legislation was implemented.

Surprisingly, some rates of infections due to medical care, such as those related to intravenous lines and catheters, increased more in California than in hospitals without nurse staffing regulations. The researchers suspect that the staffing increases may have led to both better discovery and reporting of hospital-acquired infections.

“What we as researchers still don’t know, and what this study doesn’t answer is what is the best, most effective nurse-to-patient ratio and what factors play into determining that ratio?” Mark said. “Obviously, patients that are more or less sick need more or less time from nurses.”

Source: Mark BA, Harless DW, Spetz J, et al. California’s minimum nurse staffing legislation: Results from a natural experiment [published online ahead of print September 21, 2012]. Health Serv Res.  doi:10l1111/j.1475-6773.2012.01465.x. Accessed October 2, 2012.