Minimum Staffing Ratios Research Articles

Defining minimum workforce standards for intensive care physiotherapy in Australia and New Zealand: A Delphi study

BackgroundIntensive care staffing guidelines provide recommendations for the safe and effective delivery of health care while recognising professional requirements of the workforce. To guide recommendations for physiotherapy staffing guidelines, profession-specific consultation is needed. ObjectivesThe objective of this study was to develop consensus-based recommendations for minimum workforce standards for physiotherapy in intensive care. MethodsA Delphi survey process was conducted involving physiotherapists from Australia and New Zealand. ResultsThe panel consisted of 65 physiotherapists in the first round and 60 in the second round (92% retention). Respondents were from both Australia (49, 76%) and New Zealand (16, 24%) who had been physiotherapists for an average of 18.8 ± 9.0 years and were primarily senior intensive care physiotherapists (44, 68%). Respondents had experience across level 3 (50, 77%), level 2 (18, 28%), and level 1 (5, 8%) adult intensive care units (ICUs), adult high-dependency units (27, 42%), and paediatric intensive care (6, 9%). A total of 42 statements were presented, with 37 reaching consensus after two rounds. After two rounds, consensus was achieved for a minimum staffing ratio in paediatric ICUs of one physiotherapist per six (1:6) beds. For adult ICUs, use of the median value of the participant's responses was supported to establish minimum staffing ratios of 1:8, 1:7, 1:6, and 1:8 for levels 1, 2, and 3 ICUs and high-dependency units, respectively. The requirement for an additional allocation for senior physiotherapist staffing for each ICU level was also established. Statements that also gained consensus included recommendations for access to on-call and weekend services for all ICU settings and the consideration of evening shifts specifically for level 3 and paediatric ICUs. ConclusionsRecommendations for minimum staffing for physiotherapy in intensive care settings were achieved and supported requirements for clinical service delivery, supervision, and training.

Protecting Patients And Society In An Era Of Private Equity Provider Ownership: Challenges And Opportunities For Policy.

Private equity (PE) acquisitions in health care delivery nearly tripled from 2010 to 2020. Despite concerns around clinical and economic implications, policy responses have remained limited. We discuss the US policy landscape around PE ownership, using policies in the European Union for comparison. We present four domains in which policy can be strengthened. First, to improve oversight of acquisitions, policy makers should lower reporting thresholds, review sequential acquisitions that together affect market power, automate reviews with potential denials based on market concentration effects, consider new regulatory mechanisms such as attorney general veto, and increase funding for this work. Second, policy makers should increase the longer-run transparency of PE ownership, including the health care prices garnered by acquired entities. Third, policy makers should protect patients and providers by establishing minimum staffing ratios, spending floors for direct patient care, and limits on layoffs and the sale of real estate after acquisition (forms of "asset stripping"). Finally, policy makers should mitigate risky financial behavior by limiting the amount or proportion of debt used to finance PE acquisitions in health care.

How other countries address safe staffing

Mandated approaches and minimum staffing ratios acknowledge and attempt to solve this long-term problem, while England’s lack of a system-wide mechanism leaves nursing exposed

Estimating the effect of dialysis staffing ratio regulations on mortality and hospitalizations for Medicare hemodialysis patients.

Eight states and Washington, DC have implemented regulations mandating a minimum ratio between treatment staff and patients receiving hemodialysis in a facility in an effort to improve the quality of hemodialysis treatment. Our investigation examines the association between minimum staffing regulations and patient mortality for four states and hospitalizations for two states that implemented these rules during our sample period. We utilized a synthetic difference in differences estimation to analyze the effect of minimum staffing ratios on hemodialysis treatment quality, measured by deaths and hospitalizations for end-stage renal disease patients. We used data gathered by the US Renal Data System and aggregated at the state level. We are unable to find evidence that mandated dialysis staffing ratios area associated with a reduction in mortality or hospitalizations. We estimate a slight reduction in deaths per 1000 patient hours and a slight increase in hospitalizations, but neither are statistically significant. We were unable to find evidence that minimum staffing ratios for hemodialysis facilities are associated with improved patient outcomes. Our findings highlight the need for future work, studying the impact of these regulations at the facility level.

Alternative Approaches to Ensuring Adequate Nurse Staffing: The Effect of State Legislation on Hospital Nurse Staffing.

The objective of this study was to addresses the basic question of whether alternative legislative approaches are effective in encouraging hospitals to increase nurse staffing. Using 16 years of nationally representative hospital-level data from the American Hospital Association (AHA) annual survey, we employed a difference-in-difference design to compare changes in productive hours per patient day for registered nurses (RNs), licensed practical/vocational nurses (LPNs), and nursing assistive personnel (NAP) in the state that mandated staffing ratios, states that legislated staffing committees, and states that legislated public reporting, to changes in states that did not implement any nurse staffing legislation before and after the legislation was implemented. We constructed multivariate linear regression models to assess the effects with hospital and year fixed effects, controlling for hospital-level characteristics and state-level factors. Compared with states with no legislation, the state that legislated minimum staffing ratios had an 0.996 (P<0.01) increase in RN hours per patient day and 0.224 (P<0.01) increase in NAP hours after the legislation was implemented, but no statistically significant changes in RN or NAP hours were found in states that legislated a staffing committee or public reporting. The staffing committee approach had a negative effect on LPN hours (difference-in-difference=-0.076, P<0.01), while the public reporting approach had a positive effect on LPN hours (difference-in-difference=0.115, P<0.01). There was no statistically significant effect of staffing mandate on LPN hours. When we included California in the comparison, our model suggests that neither the staffing committee nor the public reporting approach alone are effective in increasing hospital RN staffing, although the public reporting approach appeared to have a positive effect on LPN staffing. When we excluded California form the model, public reporting also had a positive effect on RN staffing. Future research should examine patient outcomes associated with these policies, as well as potential cost savings for hospitals from reduced nurse turnover rates.

Chapter 11 - Video-EEG

Indications for video-EEG monitoring (VEM) include differential diagnosis of paroxysmal events including epileptic seizures, organic nonepileptic seizures, and psychogenic nonepileptic seizures; classification of seizure types and electroclinical syndromes; quantification of seizures and of interictal and ictal epileptiform discharges; and presurgical evaluation in medically refractory epilepsy patients. Standardized questionnaires and examinations should be used on admission to the epilepsy monitoring unit (EMU). Patients should be provided with comprehensive information concerning purpose and procedures during VEM and need to sign informed consents. Staff working in the EMU needs to be properly trained in the management of seizures and periictal testing according to written protocols as well as in cardiopulmonary resuscitation. Minimum staffing ratios of dedicated healthcare professionals to patients have been recommended. Antiepileptic drug tapering/withdrawal needs to be individualized for each patient. EEG recordings have to be performed according to established guidelines. Cardiorespiratory monitoring including continuous ECG monitoring and continuous measurement of oxygen saturation is strongly recommended. Patient safety is of utmost importance during VEM. Indicators for reporting quality and safety have been developed. Standardized ictal testing protocols and standardized computer-based organized reporting should further improve standards of VEM and training of EMU staff, and facilitate data exchange and collaborations between EMUs.

Current Status of Nursing Law in the United States and Implications

Methods: This systematic review was guided by a preliminary literature review that identified relevant research terms including nurse(ing) staffing, license, certification, healthcare professionals, and nursing law. An online search of the electronic bibliographic databases MEDLINE, CINAHL, OVID, Westlaw (International materials- Jurisdiction), U.S. National Conference of State Legislatures, and Google Scholar yielded journal articles, nursing acts, and websites from 2009 to 2015. Results: Most nursing laws require staffing committees in each hospital to develop staffing strategies. Staffing committees should include direct-care nurses. Illinois, Oregon, Washington, and Texas require at least 50~60% registered nurses on the committee. Nursing laws in California, New York, and Massachusetts proposed a specific nurse–patient staffing ratio in consideration of the severity of need of patients or units. Furthermore, California enacted minimum staffing ratios. California reported decreased patient mortality, decreased turnover of nursing staff, and increased satisfaction and retention of nurses. Conclusion: It is timely to have nursing laws worldwide that establish minimum numbers of nurses with professional competencies for the health and safety of global citizens.

Chief nursing officer rejects union calls for minimum staffing ratios

England’s most senior nurse has defended the government’s refusal to introduce national minimum nurse staffing levels.

Using minimum nurse staffing regulations to measure the relationship between nursing and hospital quality of care.

This study tests whether changes in licensed nurse staffing led to changes in patient safety, using the natural experiment of 2004 California implementation of minimum staffing ratios. We calculated counts of six patient safety outcomes from California Patient Discharge Data from 2000 through 2006, using the Agency for Healthcare Research and Quality Patient Safety Indicators (PSI) software. For patients experiencing nonmortality-related PSIs, we measured mean lengths of stay. We estimated difference-in-difference equations of changes in PSIs using Poisson models and calculated the marginal impact of nurse staffing on outcomes from fixed-effect Poisson regressions. Licensed nurse staffing increased in the postregulation period, except for hospitals in the highest quartile of preregulation staffing. Growth in registered nurse staffing was associated with improvement for only one PSI and reduced length of stay for one PSI. Higher registered nurse staffing per patient day had a limited impact on adverse events in California hospitals.

Comparisons of the Nursing Workforce with Japan, and the U.S.

This study aims to derive implications on current problems in the nursing manpower management in Korea through the comparison with the nursing workforce and employmentrent in the United States and Japan. There are various issues in nursing policy, such as nursing shortage, quality of the nursing service, and the increased cost of management due to the high turnover rate of nursing staffs and it is urgent to seek various policy measures to resolve this. Although nursing shortage is a commom problem in the world, the U.S. and Japan were higher rate of employment than Korea in nursing staffs, which implicates the importance of the legislation of mandatory minimum staffing ratios, the establishment of policies such as the fees and charge policy and the nursing work environments. For quality nursing care and patient safety through the stable workforce of qualified nursing staffs, administrative mechanisms that support adequate nurse staffing and promote positive work conditions are needed, for which the improvement of legal system is required.

Australian union wins battle to retain minimum staffing ratios

Australian union wins battle to retain minimum staffing ratios

Australian union wins battle to retain minimum staffing ratios

Australian union wins battle to retain minimum staffing ratios

Nurse staffing ratios: Trends and policy implications for hospitalists and the safety net

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. 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. 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. 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." 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.

Research Challenges in Examining Nurses as a Resource

Every practice environment today is concerned with nurse staffing and patient safety, which have become concerns globally and in every type of practice setting. While research has provided evidence that the number and type of nurses in a given setting is important for the delivery of high-quality health care, critical questions still remain. Framing nurse staffing in terms more specific than minimum ratios or care requirements based on minutes or hours of direct care required is difficult. While these may be necessary variables, most would agree they are not sufficient for matching nurse as resource with the highly variable needs of patients. The question of how many nurses are needed? can be approached from a macro or a micro perspective. At the macro level, key insights are available, at least when examining numbers of nurses in comparison to other types of health workers. A recent report from the World Health Organization (2006) analyzes the relationship of the health workforce to key health outcomes across countries. Several key outcome indicators, such as immunization rates or newborn birth weights, are directly related to the density or proportion of various types of health care workers to the population. Data indicate that the proportion of nurses to population is a better determinant than the density of physicians on many key outcome variables. While this may seem intuitive to us in nursing, data have not been available in the past that demonstrate this striking relationship to this degree. It provides an important next step toward looking at specific health workforce interventions to address health needs in a global context. At the micro level, several empirical insights have been reported in recent years. The work by Aiken, Clarke, Sloane, Sochalski, and Silber (2002) indicates that in hospitals with high patient-to-nurse ratios, risk-adjusted mortality and failure-to- rescue rates are higher in surgical patients. This research has frequently been used to support the mandated or minimum staffing ratios in some states in the United States and in many acute care settings as well. The study provides a metric for the strength of the relationship of nurse staffing levels and their effect on patient outcomes, but it does not provide the type of insight or understanding we would like to have to guide specific staffing decisions. The relationships among total hours of nursing care, nursing skill mix, and adverse patient outcomes have also been examined at the level of the nursing care unit. Blegen, Goode, and Reed (1998) looked at a variety of adverse outcomes including unit rates of medication errors, patient falls, skin breakdown, infections, and family complaints. They found that the proportion of hours of care delivered by registered nurses was inversely related to the unit rates of medication errors, patient complaints, and decubiti. They also found unexpectedly that the relationship between the proportion of care provided by registered nurses and the total hours of care from all nursing personnel, including both RN and assistive personnel, was curvilinear; as the proportion provided by registered nurses increased, rates of adverse outcomes decreased up to 87. …

A certain ratio? The policy implications of minimum staffing ratios in nursing

The debate about how best to determine nurse staffing levels continues. The conventional wisdom is that determining staffing levels is something best left to local management, taking account of local workload and resources. This 'bottom up' philosophy has now been challenged by the use of a different approach--the use of 'top down'standardized, and mandatory, nurse:patient or nurse:bed ratios. This paper examines the characteristics and early results of the use of staffing ratios in the two health systems where nurse staffing ratios are now mandatory--the states of Victoria (Australia) and California (USA). It then discusses the policy implications of using ratios. The paper identifies the main weaknesses of the use of nurse:patient ratios as being their relative inflexibility and their potential inefficiency, if they are wrongly calibrated. Their strength is their simplicity and their transparency. Their impact will be most pronounced when ratios are mandatory and where they offer a mechanism to improve and then to maintain staffing levels at some pre-determined level. The biggest challenges in their use are calibration (what is 'safe'? or 'minimum'?) and achieving the support of all stake-holders. The paper concludes that nurse:patient ratios are a blunt instrument for achieving employer compliance, where reliance on alternative, voluntary (and often more sophisticated) methods of determining nurse staffing have not been effective.

Impact of California’s Licensed Nurse-Patient Ratios on Unit-Level Nurse Staffing and Patient Outcomes

This article presents the first analysis of the impact of mandated minimum-staffing ratios on nursing hours of care and skill mix in adult medical and surgical and definitive-observation units in a convenience sample of 68 acute hospitals participating in the California Nursing Outcomes Coalition project. Findings, stratified by unit type and hospital size, reveal expected changes as hospitals made observable efforts toward regulatory compliance. These data cannot affirm compliance with ratios per shift, per unit, at all times; however, they give evidence of overall compliance. Assessment of the impacts of the mandated ratios on two common indicators of patient care quality, the incidence of patient falls and the prevalence of pressure ulcers, did not reveal significant changes despite research linking nurse staffing with these measures. These findings contribute to understanding unit level impacts of regulatory staffing mandates and the preliminary effect of this legislation on core quality of care indicators.

Nurse staffing and hospital ownership in California.

The purpose of this study is to describe the relationship between nurse staffing and owner type or specific corporate owner in California acute care hospitals. Little empirical data exist regarding nurse staffing as it relates to owner type or specific corporate owner. With minimum staffing ratios scheduled to be implemented in January 2004, this study provides baseline data for evaluating the impact of minimum staffing ratios in California. The study design is descriptive and cross-sectional. Data used in this study are for short-term general hospitals that reported to the California Office of Statewide Health Planning and Development database for fiscal years ending in 1997 through 1999. Six regression models were estimated using pooled data from the 3 years of data. The most consistent significant findings are: increased patient days or patient discharges predict increased registered nurse (RN) hours; lower RN wages predict increased RN hours; higher technology scores predict increased RN hours; and in 1998 there was an across-the-board decrease in RN hours. Other significant findings include that for-profit hospitals and for-profit systems had fewer RN productive hours for medical-surgical nursing, and select corporate owners, unrelated to profit status, had consistently fewer RN productive hours for medical-surgical nursing. For-profit hospitals and systems behaved differently in the healthcare market environment of the late 1990s. Select nonprofit systems were also using significantly less RN staffing. Other findings support the implication that as technology sophistication increases, there will be a need for increased RN hours to manage the advanced technology. This runs counter to the argument that increasing technology will decrease the need for RN hours. Finally, as discharges go up, the need for RN hours increases.

Nurse Staffing and Patient Outcomes

Nurse Staffing and Patient Outcomes

Legislative Imposition of Minimum Staffing

Legislative Imposition of Minimum Staffing