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

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

[Human Resources for Intensive Care Medicine in Portugal in the Post-COVID Era]

N/a.

Infection preventionist staffing in nursing homes

Infection preventionist (IP) staffing in nursing homes (NHs) is now required as part of new federal regulations. In this study, we examined IP staffing changes from 2014 to 2018 and found relatively few changes over time. IP staffing in NHs remains low but does vary between for profit and non-profit facilities.

Reassessing the labor market effects of California's minimum nurse staffing regulations

California implemented hospital-unit level licensed nurse minimum staffing regulations in 2004, with more stringent regulations applying for certain units in 2005 and 2008. All analyses agree that there were significant increases in Registered Nurse (RN) staffing levels, especially in hospitals with lower preregulation staffing. Analyses of the labor market effects of the regulations, however, come to mixed conclusions. I revisit the labor market effects of the regulations using different data and a different analytical model for RN wages. For the analysis of growth of RN employment, I use information from the National Sample Survey of Registered Nurses, the largest and most complete source of information on nurse employment, and find that RN employment grew significantly faster in California than in other states after the regulations were implemented. For the analysis of changes in RN wages, I apply a panel difference-in-difference-in-difference model to wage averages in Metropolitan Statistical Areas, controlling for MSA-, occupation-, and time-fixed effects, and all their two-way interactions. Analysis of changes in the differential between RN wages and wages in four other selected occupations indicates significant growth in RN wages after the regulations were implemented.

[Medical continuity in the supply psychiatry before and after implementation of the new working hours act based on the example of the psychiatric department in the Danube hospital Vienna]

A successful and sustainable treatment of psychiatric patients is based on intensive relationship work. After the introduction of the new Working Hours Act the standards of evidence-based treatment are endangered. Using the data of the official working schedule of the Psychiatric Department of the Danube hospital in Vienna, before and after the introduction of the new Working Hours Act, we demonstrate a significant decrease of the medical consistency of the patient-related doctors. New approaches must be considered in order to solve this problem of quality.

Changes in Resident Well-Being at One Institution Across a Decade of Progressive Work Hours Limitations

PURPOSE

To measure changes in markers of resident well-being over time as progressive work hours limitations (WHLs) were enforced, and to investigate resident perceptions of the 2011 WHLs.

METHOD

A survey study of internal medicine residents was conducted at the University of Washington's multihospital residency program in 2012. The survey included validated well-being questions: the Maslach Burnout Inventory, the two-question PRIME-MD depression screen, and career satisfaction questions. Chi-square tests were used to compare 2012 well-being questionnaire responses against nearly identical surveys conducted in 2001 and 2004 at the same institution. In addition, residents were asked to rate the impact of WHLs on resident well-being and education as well as patient care, and to state preferences for future WHLs.

RESULTS

Significantly different proportions of residents met burnout criteria across time, with fewer meeting criteria in 2012 than in 2001 (2001: 76% [87/115]; 2004: 64% [75/118]; 2012: 61% [68/112]; P = .039). Depression screening results also differed across time, with fewer screening positive in 2012 than in 2004 (2001: 45% [52/115]; 2004: 55% [65/118]; 2012 [35/112]: 31%; P = .001). Residents, especially seniors, reported perceived negative impacts of WHLs on their well-being, education, and patient care. Most senior residents favored reverting to the pre-July 2011 system of WHLs. Interns were more divided.

CONCLUSIONS

Validated measures of resident well-being changed across the three time points measured. Residents had the lowest rates of burnout and depression in 2012. Resident perceptions of the 2011 WHLs, however, were generally negative.

[The new methods to define the staffing requirements for doctors,<BR>nurses and nurses aides: an example of their implementation in an Italian hospital]

. The new methods to define the staffing requirements for doctors, nurses and nurses aides: an example of their implementation in an Italian hospital. The Italian government, after the transposition of European Union legislation on working hours, made a declaration of commitment to increase the number of staff of the National Health Service (NHS). The method for assessing the staffing needs innovates the old one that dated back a few decades.

AIM

To implement the method proposed by the Ministry of Health to an Italian hospital and assess its impact on staffing and costs.

METHODS

The model was implemented on all the wards, multiplying the minutes of care expected in 2016, dividing the result by 60 to obtain the hours of care, and further dividing by the number of yearly hours of work of a nurse (1418). Same was done for nurses aides. The minutes of care were related to mean weight of the Diagnosis Related Groups of the ward and the results obtained compared to the actual staffing of nurses and nurses aides. The costs of the differences were calculated.

RESULTS

The implementation of the model produced an excess of 23 nurses and a scarcity of 95 nurses aides compared to the actual staffing, with an increase of the costs of € 1.828.562,00.

CONCLUSIONS

The results obtained and the criticisms received so far show the need of major changes. The data from international studies that associate staffing and patients outcomes and the nurse/patient ratio are macro-indicators already available that may orient choices and investments on the health care professions.

Preparing Safety Cases for Operating Outside Prescriptive Fatigue Risk Management Regulations

INTRODUCTION

Transport operators seeking to operate outside prescriptive fatigue management regulations are typically required to present a safety case justifying how they will manage the associated risk. This paper details a method for constructing a successful safety case.

METHODS

The method includes four elements: 1) scope (prescriptive rules and operations affected); 2) risk assessment; 3) risk mitigation strategies; and 4) monitoring ongoing risk. A successful safety case illustrates this method. It enables landing pilots in 3-pilot crews to choose the second or third in-flight rest break, rather than the regulatory requirement to take the third break. Scope was defined using a month of scheduled flights that would be covered (N = 4151). These were analyzed in the risk assessment using existing literature on factors affecting fatigue to estimate the maximum time awake at top of descent and sleep opportunities in each break. Additionally, limited data collected before the new regulations showed that pilots flying at landing chose the third break on only 6% of flights.

RESULTS

A prospective survey comparing subjective reports (N = 280) of sleep in the second vs. third break and fatigue and sleepiness ratings at top of descent confirmed that the third break is not consistently superior. The safety case also summarized established systems for fatigue monitoring, risk assessment and hazard identification, and multiple fatigue mitigation strategies that are in place.

DISCUSSION

Other successful safety cases have used this method. The evidence required depends on the expected level of risk and should evolve as experience with fatigue risk management systems builds.Gander P, Mangie J, Wu L, van den Berg M, Signal L, Phillips A. Preparing safety cases for operating outside prescriptive fatigue risk management regulations. Aerosp Med Hum Perform. 2017; 88(7):688-696.

PENALTY RATES

In February 2017, the Fair Work Commission (FWC) handed down a decision which cut penalty rates for employees in the retail, hospitality and fast food industries. In particular, it cut the level of penalty rates for working on Sundays and public holidays by 25% to 50%.

Scotland to enshrine safe staffing in law

The Scottish Government has announced it will consult on enshrining in law the use of planning tools to set nurse staffing numbers in the NHS.

EMPLOYER CAMPAIGN TO DEREGULATE WORKING HOURS

Over the past five years the ANMF has been resisting a concerted campaign by aged care employers to remove important protections that give part time employees a level of predictability in their hours and days on which they are required to work.

Staffing levels law will bolster the front line

Sustaining a sufficient, well-educated nursing workforce that can meet growing healthcare needs is an important challenge in many countries.

Prime minister urged to re-examine safe staffing

Nursing leaders have pressed new prime minister Theresa May to re-examine key issues affecting the profession as a matter of urgency.

Call for unity on safe staffing

Last month, Scotland's first minister Nicola Sturgeon declared Scotland would enshrine safe nurse staffing levels in law.

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.