Diane Storer Brown

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.

Mandated Nurse Staffing Ratios in California: A Comparison of Staffing and Nursing-Sensitive Outcomes Pre- and Postregulation:

This article examines the impact of mandated nursing ratios in California on key measures of nursing quality among adults in acute care hospitals. This study is a follow-up and extension of our first analysis exploring nurse staffing and nursing-sensitive outcomes comparing 2002 pre-ratios regulation data to 2004 postratios regulation data. For the current study we used postregulation ratios data from 2004 and 2006 to assess trends in staffing and outcomes. Findings for nurse staffing affirmed the trends noted in 2005 and indicated that changes in nurse staffing were consistent with expected increases in the proportion of licensed staff per patient. This report includes an exploratory examination of the relationship between staffing and nursing-sensitive patient outcomes. However anticipated improvements in nursing-sensitive patient outcomes were not observed. This report contributes to the growing understanding of the impacts of regulatory staffing mandates on hospital operations and patient outcomes.

How Many Nurses per Patient? Measurements of Nurse Staffing in Health Services Research

OBJECTIVE To compare alternative measures of nurse staffing and assess the relative strengths and limitations of each measure. DATA SOURCES/STUDY SETTING Primary and secondary data from 2000 and 2002 on hospital nurse staffing from the American Hospital Association, California Office of Statewide Health Planning and Development, California Nursing Outcomes Coalition, and the California Workforce Initiative Survey. STUDY DESIGN Hospital-level and unit-level data were compared using summary statistics, t-tests, and correlations. DATA COLLECTION/EXTRACTION METHODS Data sources were matched for each hospital. When possible, hospital units or types of units were matched within each hospital. Productive nursing hours and direct patient care hours were converted to full-time equivalent employment and to nurse-to-patient ratios to compare nurse staffing as measured by different surveys. PRINCIPAL FINDINGS The greatest differences in staffing measurement arise when unit-level data are compared with hospital-level aggregated data reported in large administrative databases. There is greater dispersion in the data obtained from publicly available, administrative data sources than in unit-level data; however, the unit-level data sources are limited to a select set of hospitals and are not available to many researchers. CONCLUSIONS Unit-level data collection may be more precise. Differences between databases may account for differences in research findings.

Leveraging nurse-related dashboard benchmarks to expedite performance improvement and document excellence

Using nursing quality benchmarks in operational dashboards and translating those data to drive performance excellence is a strategic imperative. Since access to unit-level, hospital-generated nurse-related benchmarks is an emerging arena, the authors provide an overview of aggregated trends and benchmarks gleaned from the California Nursing Outcome Coalition acute care database for 2 established nurse-related quality indicators—patient falls incidence and hospital-acquired pressure ulcer prevalence. Integrating these acute care benchmarks into clinical dashboards can be invaluable to clinicians, administrators, and policy makers who share a common commitment to expediting evidence-based improvement in patient care safety, outcomes, and excellence.

Nurse staffing and patient perceptions of nursing care.

Objective To examine the relationship between nurse staffing and patient perceptions of nursing care in a convenience sample of 40 California hospitals. Background Growing concern about the adequacy of nurse staffing has led to an increased emphasis on research exploring the relationships between nurse staffing and patient outcomes. Patient satisfaction with nursing care is one of the 21 indicators identified by the American Nurses Association as having a strong “theoretical link to the availability and quality of professional nursing services in hospital settings.” This prospective study examined the relationship between nurse staffing and patient perceptions of nursing care in multiple hospitals using common definitions of both nurse staffing and patient perceptions of care. Methods Nurse staffing (structural variables) and patient perceptions of nursing care (outcome variables) from hospitals participating in both the ongoing California Nursing Outcomes Coalition statewide database project and the statewide Patients’ Evaluation of Performance in California project, with data available on both measures for the same time periods, were examined. Analytic methods included both descriptive and inferential statistics. Results Hospitals with wide ranges of staffing levels showed similar results in patient perceptions of nursing care. Regression analysis revealed a statistically significant relationship between nursing hours per patient day, and 1 of the 6 dimensions of care measured (“respect for patient’s values, preferences, and expressed needs”). Conclusions Nurse staffing alone showed a significant but weak relationship to patient perceptions of their care, indicating that staffing is likely only one of several relevant variables influencing patient perceptions of their nursing care. This research contributes data to the body of knowledge regarding nurse staffing. It is essential that nurse executives integrate results from this and other studies in developing strategic and tactical staffing plans that yield positive patient care outcomes.

The value of reducing hospital-acquired pressure ulcer prevalence: an illustrative analysis.

OBJECTIVE: The aim of this study was to assess the cost savings associated with implementing nursing approaches to prevent hospital-acquired pressure ulcers (HAPU). BACKGROUND: Hospitals face substantial costs associated with the treatment of HAPUs. Interventions have been demonstrated as effective for HAPU prevention and management, but it is widely perceived that preventative measures are expensive and, thus, may not be a good use of resources. METHODS: A return-on-investment (ROI) framework from the Agency for Healthcare Research and Quality (AHRQ) Quality Indicators Toolkit was used for this study. The researchers identified achievable improvements in HAPU rates from data from the Collaborative Alliance for Nursing Outcomes and measured costs and savings associated with HAPU reduction from published literature. RESULTS: The analysis produced a baseline ROI ratio of 1.61 and net savings of

The Impact of Nursing Interventions Overview of Effective Interventions, Outcomes, Measures, and Priorities for Future Research

127.51 per patient. CONCLUSIONS: Hospital-acquired pressure ulcer surveillance and prevention can be cost saving for hospitals and should be considered by nurse executives as a strategy to support quality outcomes.

Eliminating Hospital-acquired Pressure Ulcers: Within Our Reach

The purpose of this article is to present findings from a review of published systematic/integrative reviews and meta-analyses on nursing interventions and patient outcomes in acute care settings. A literature search was conducted for the period 1999-2005, producing 4,000 systematic/integrative reviews and 500 meta-analyses covering seven topics selected by the authors: elder care, caregivers, developmental care of neonates and infants, symptom management, pressure ulcer prevention/treatment, incontinence, and staffing. The association between nursing care interventions/processes and patient outcomes in acute care settings was found to be limited in the articles reviewed. The strongest evidence was for the use of patient risk-assessment tools and interventions implemented by nurses to prevent patient harm. We observed significant variation in methods to measure the effect of independent variables (nursing interventions) on patient outcomes. Results indicate the need for more research measuring the effect of specific nursing interventions that may impact acute care patient outcomes.

Quartile Dashboards: Translating Large Data Sets into Performance Improvement Priorities

Hospital-acquired pressure ulcers (HAPUs) are a serious nosocomial problem that has been viewed as a ubiquitous consequence of immobility. This article provides data from the Collaborative Alliance for Nursing Outcomes (CALNOC) that shows a significant reduction in HAPUs in adults from 78 acute care hospitals over 8 years (2003-2010).

Nurse Staffing in California Hospitals 1998-2000: Findings from the California Nursing Outcome Coalition Database Project

&NA; Quality professionals are the first to understand challenges of transforming data into meaningful information for frontline staff, operational managers, and governing bodies. To understand an individual facility, service, or patient care units comparative performance from within large data sets, prioritization and focused data presentation are needed. This article presents a methodology for translating data from large data sets into dashboards for setting performance improvement priorities, in a simple way that takes advantage of tools readily available and easily used by support staff. This methodology is illustrated with examples from a large nursing quality data set, the California Nursing Outcomes Coalition.