This is part seven of the Nursing Research Challenge.
The Article: Donaldson, N. & Shapiro, S. (2010). Impact of California mandated acute care hospital nurse staffing ratios: A literature synthesis. Policy, Politics, & Nursing Practice, 11(3): 184-201.
Big Idea: “California is the first state to enact legislation mandating minimum nurse-to-patient ratios at all times in acute care hospitals,” creating a natural experiment (p.184). This study examines 12 studies researching the impact of the mandated ratios. To be included in the research synthesis, studies had to have a pre-post design (comparing outcomes both before and after the law implementation). Cross-sectional studies, which study data at any given point – like snapshot – were excluded from this literature synthesis. The research looked at the impact of the California ratio mandates on the nursing workforce and acute care hospitals – operations, processes, structure, patient care costs, and clinical outcomes.
Survey Says!: The mandate reduced the number of patients per nurse and increased the number of nursing hours per patient per day, which are the most obvious purposes of the legislation. According to this article, the staffing measures did not significantly improve nursing quality indicators and patient safety indicators across hospitals throughout the state. Of particular interest, though, even as patient severity increased in California hospitals after the implementation of the legislation, adverse outcomes did not increase.
Quotable: “Collectively, the investigators are multidisciplinary and multimethod in their approach, clearly diverse in aims and yet bound together in the common quest to explore evidence revealing the impact of California’s legislatively mandated ratios on cost, quality, safety, and outcomes of patient care in acute care hospitals” (p. 185).
In regard to the patient severity increasing without adverse outcomes increasing: “We cautiously posit that this finding may actually suggest an impact of ratios in preventing adverse events in the presence of increased patient risk” (p. 196).
“The synthesis did not find evidence of an expected effect of mandated minimum staffing ratios on clinical and specific nursing sensitive outcomes. Efforts by investigators to explore these possible relationships are important, given the robust body of work derived from cross-sectional studies of large data sets that reports just such relationships…” (p. 198).
So What?: This is a lovely, neatly wrapped synthesis of the California mandated ratio-related studies. It includes several tables comparing the included studies. and anyone interested in mandated nurse ratios – no matter your position – should read the article. The synthesis pointed out numerous barriers impacting overall evaluation of the California mandate as well as identified both conflicting and supporting findings among included studies. Still, more research is needed to evaluate the impact of mandated ratios on the nursing workforce, the healthcare system, and patient outcomes.
Just Plain Interesting: This study was commissioned and funded by the Robert Wood Johnson Foundation for the Institute of Medicine Future of Nursing Committee.