Study compares three types of state legislations aimed at ensuring adequate nurse staffing

Reviewed by Emily Henderson, B.Sc.Sep 10 2021

Across the nation, states are grappling with alternative approaches to address the heightened problem of low nurse staffing in hospitals. A new national study finds that while legislation to mandate hospital nurse-to-patient staffing ratios is associated with a significant increase in nurse staffing, two other popular approaches – mandating public reporting of nurse staffing levels and hospital staffing committees that include frontline nurses – have had little or no impact on nurse staffing levels. The study appears in a special supplement to the October issue of Medical Care focused on Health Workforce Equity. Medical Care is published in the Lippincott portfolio by Wolters Kluwer.

The new study, led by Xinxin Han, PhD, MS, of Tsinghua University School of Medicine, Beijing, China, analyzed 16 years of nationally representative, hospital-level data from the American Hospital Association annual survey, 2003 to 2018. They compared three different types of state legislations aimed at ensuring adequate nurse staffing:

• Mandated staffing ratios: setting established minimum nurse-to-patient staffing ratios at hospitals.
• Staffing committees: requiring hospitals to establish committees, including at least 50 percent RNs, to develop a nurse staffing plan based on patient needs.
• Public reporting: requiring hospitals to make staffing data available to the public, with the goal of putting market pressure on understaffed hospitals to improve staffing ratios.

The effects of the three legislative approaches were analyzed, controlling for hospital- and state-level factors. The analysis included data on approximately 425 hospitals in one state (California) with mandated staffing ratios, 1,000 hospitals in seven states that legislated staffing committees, 325 hospitals in five states that legislated public reporting, and 3,400 hospitals in states with no nurse staffing legislation.

Consistent with previous studies, the California law setting mandated staffing ratios led to a significant increase in RN staffing: by about 1 hour per patient per day. The staffing mandate also brought a small increase in staffing by nursing assistive personnel (NAPs), who assist with patient care under the supervision of RNs (about 0.25 hour per patient), but had no effect on LPN staffing.

In the main analysis, staffing committees and public reporting had no effect on RN or NAP staffing. The staffing committee approach had a small negative effect on LPN staffing, while public reporting had a small positive effect.

The report is the first national study comparing the effects of alternative policy approaches to increasing hospital nurse staffing. The findings support the positive effects of California's mandated staffing ratios, and suggest the need to identify ways that the two alternative approaches – staffing committees and public reporting – might be strengthened. Further research is also needed to answer the critical question about the impact of nurse staffing laws: whether they lead to improvements in patient outcomes.

The study is part of a special supplement presenting new insights on the role of health workforce in achieving health equity.

"There is no healthcare without the people who provide service," according to an introductory article by Patricia (Polly) Pittman, PhD, and colleagues of the Milken Institute School of Public Health at George Washington University. "As such, the health workforce has a central role in addressing (or maintaining) health disparities."

Dr. Pittman and colleagues outline a health workforce equity framework, including six interconnected equity domains: the diversity of people entering the workforce, whether their training is grounded in the idea of social mission, whether they locate in rural and underserved areas, whether they provide service to those most in need, such as Medicaid beneficiaries, whether they practice in ways that acknowledge and help address social determinants of health, and whether the health workers themselves work under fair and safe conditions.

These domains are determined by "a complex ecosystem of policies, programs, and practices driven by stakeholder interests," Dr. Pittman and colleagues argue. They believe their framework can help to guide further research, interventions, and policy to ensure that the health workforce plays a positive role in advancing health equity.