Changes in staffing patterns before and after California's nurse-to-patient ratios

Research Objective: This study identified and described changes in nurse and "non-nurse" staffing that may have occurred as a result of the enactment of nurse-to-patient ratios between Fiscal Year (FY) 2000 and FY 2006 in California's acute care hospitals. Population Studied: Inclusion into the study required that a California general medical/surgical acute care hospital (N=273) with (a) Hospital Annual Financial Disclosure Reports for FY 2000 and FY 2006, (b) complete reporting of mean productive hours (MPHs) for registered and registry nurses (also known as contract, agency and/or traveling nurses) for both time periods, and (c) thirty or more acute adult medical/surgical beds.. Methods: This study utilized a secondary analysis of state administrative data with a pre-post design in which individual hospitals were observed at two time points. Descriptive analysis was conducted on all nurse and “non-nurse” staff. A matched paired t-test was performed for all nurse and “non-nurse” staffing categories to determine if there were statistically significant differences in mean productive hours per patient day or unit of service between FY 2000 and FY 2006 values. Principal Findings: Analysis of MPHs for nurse staffing indicated there was an increase from 4.36 hours in 1999/2000 to 5.16 in 2005/2006. Also, medical/surgical registry nurse time per patient day increased from 0.30 in 1999/2000 to 0.88 in 2005/2006. Despite speculation that unit-support and/or non-nurse staff may be reduced to offset increased nurse expenditures, there was little change in MPHs for the other medical/surgical nurse categories of Licensed Vocational Nurse (LVN) and unit-support staff: nurse aid and clerical/administrative staff. Additionally, MPHs for ‘non-nurse' staffing indicated an increase in diagnostic radiology (0.53 to 1.27) and respiratory therapy (0.35 to 0.83). Conclusions: Three important conclusions are supported by this analysis: (1) MPHs per patient day of registered and registry nurses increased between 1999/2000 and 2005/2006; (2) hospitals staffing above the minimum 1:5 nurse-to-patient ratio in 1999/2000 increased their staffing by a smaller amount between 1999/2000 and 2005/2006; (3) unit-based support staff and non-nurse staff MPHs per patient day or per service were not reduced. Implications for Policy, Delivery or Practice: Study findings suggest that mandated ratios may have contributed to a positive trend towards creating more time for nurses at the bedside without affecting hours of unit-based support staff and non-nurse staff. Thus mandating specific nurse-to-patient ratios may be a necessary step in creating an environment of quality patient care.