Nurse staffing ratios: trends and policy implications for hospitalists and the safety net.
BACKGROUND
Mandated minimum nurse-to-patient staffing ratio legislation was passed in California in 1999 and implemented January 1, 2004. Nurse staffing legislation is being considered in at least 25 other states.


OBJECTIVE
The objectives of this study were: (1) to evaluate nurse staffing trends in California from 1993 to 2004, (2) to identify types of hospitals below minimum staffing ratios and staffing changes in 2004, the first year post-implementation; and (3) to discuss possible implications of nurse staffing on hospitalists and their hospital-based initiatives.


METHODS
We analyzed data from the medical-surgical units of all short-term acute-care general hospitals in California from 1993 to 2004. The annual hospital staffing ratio is composed of the combined hours of registered nurses and licensed vocational nurses and total number of patient days on medical-surgical units.


RESULTS
Nurse staffing ratios were relatively unchanged from 1993 to 1999 and then increased significantly from 1999 to 2004, with the largest increase in 2004, the year the nurse staffing ratio was implemented. Types of hospitals more likely to be below minimum ratios had a high Medicaid/uninsured patient population and were government owned, nonteaching, urban, and in more competitive markets. Most hospitals below ratios were considered part of the health care "safety net."


CONCLUSIONS
Nurse staffing legislation may increase nurse staffing. However, mandated nurse staffing ratios without mechanisms to help achieve ratios may force hospitals, especially safety-net hospitals, to make tradeoffs in other services or investments with unintended negative consequences for patients. Nurse staffing likely influences the outcomes of hospitalist-led quality initiatives, but these effects need to be explored further.
Center for Health Care Quality and Division of Health Policy and Clinical Effectiveness, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45215, USA. patrick.conway@cchmc.org
Patrick H
PH
Conway
R
R
Tamara Konetzka
Jingsan
J
Zhu
Kevin G
KG
Volpp
Julie
J
Sochalski
D002140:California; D006302:Health Services Research; D020445:Hospitalists; D006801:Humans; D009741:Nursing Staff, Hospital / Q000331:legislation & jurisprudence / Q000458:organization & administration*; D010561:Personnel Staffing and Scheduling; D011785:Quality Assurance, Health Care; D016526:Workload