UCSF report describes nurse-patient ratios in California hospitals

UCSF researchers have collected and analyzed the largest, descriptive sample of nurse staffing in California hospitals. The report, published in the February edition of Policy, Politics and Nursing Practice, describes nurse staffing in 330 critical care, medical-surgical , and step-down units (intermediate care, monitoring, and transitional care units) in 52 acute care California hospitals from April 1998 to June 2000.

Findings from the California Nursing Outcome Coalition (CalNOC) Database Project, which was used to produce the report, are especially timely as the nursing profession, policy makers and regulators, including the California Department of Health Services (DHS), respond to the AB 394 legislative mandate to establish nurse-to-patient staffing ratios for general acute care hospitals, acute psychiatric hospitals, and special hospitals. The regulations are to be implemented in 2002, according to co-principal investigator Nancy Donaldson, DNSc, director of the UCSF Stanford Center for Research and Innovation in Patient Care and associate dean for practice, UCSF School of Nursing.

"Given the lack of prospective, longitudinal, empirical evidence establishing staffing thresholds that ensure patient safety and optimize clinical outcomes, this report may provide an important source of baseline staffing data that accurately reflects current staffing patterns," said Donaldson.

"Our data, based on monthly staffing patterns, indicate that California hospitals are meeting the current requirements for intensive care unit nurse staffing and providing nurse care hours within industry standards for step-down and general care units. Having worked closely with our hospital sites since 1996 to maximize data accuracy, we were aware of the relative stability of staffing and the presence of wide variation in staffing ratios across the state. Therefore, we weren't surprised by our findings," she said.

� Findings revealed relatively stable staffing over nine quarters from April 1998 to June 2000.
� Researchers noted that staffing in the 52 CalNOC hospitals varied widely, even within groups of similar hospitals.
� Descriptive findings reveal that RNs provided 92 percent of the care in critical care units, 87 percent in step-down units, and 57 percent in medical-surgical units.
� The average number of clinical hours worked per day by RNs with direct patient care responsibilities ranged from 15.3 in critical care units to 6.1 in step-down units to 4.2 in medical-surgical units.
� RN-to-patient ratio means were 1:1.6 for critical care units, 1:4.2 for step down units, and 1:5.9 for medical-surgical units. These averages include extreme values due to error or unusual staffing patterns.
� According to the researchers, staffing patterns vary widely across the state and may be influenced by factors not measured by CalNOC: 1) severity and complexity of the patient's illness and 2) factors that influence a nurse's workload (including the experience and competency of the patient care staff and the availability of administrative and ancillary support services).
� In addition, small hospitals may have fewer patients per nurse as they maintain minimum staffing required by California hospital codes.

California is the first of 16 states grappling with public policy intervention as a remedy to ensure safe staffing. "Without large prospective samples like the CalNOC data, regulators do not have a clear picture of current staffing ratios and must rely on secondary or administrative data sources in order to establish thresholds for nurse staffing ratios," said Donaldson. "These findings are the first in CalNOC's new research that will examine the links between nurse staffing and patient care quality and safety."

In future studies the CalNOC investigative team will examine links between staffing and patient falls, hospital-acquired pressure ulcers, and other adverse events that arise in hospital patient care settings, she said. Today, 72 acute care hospitals are collecting CalNOC data. It is projected that 100 hospitals will be enrolled by June, 2001.

The California Nursing Outcome Coalition (CalNOC) was established in 1996 and is an unprecedented, collaborative initiative that draws on a diverse team of staff nurses, advanced practice clinicians, educators, researchers, administrators, and leaders to evaluate a statewide nursing outcomes data base. CalNOC maintains the data repository, publishes quarterly reports for participating hospitals, conducts research, and provides data to help resolve public policy and clinical dilemmas associated with hospital quality, costs, nurse staffing, and patient care. The CalNOC Project, a joint venture project sponsored by the American Nurses Association/California (ANA/C) and the Association of California Nurse Leaders (ACNL), is in the process of establishing itself as a nonprofit entity.

The CalNOC investigative team includes co- principal investigator Diane Storer Brown, RN, PhD, the quality outcomes director for the North East Bay Service Area, Kaiser Permanente Northern California Regions. Co-investigators include Linda Burnes Bolton, RN, DrPH, FAAN, chief nursing officer at Cedar Sinai Medical Center; and Carolyn Aydin, PhD, senior research analyst at Cedar Sinai Medical Center.

CalNOC is funded by data management fees from participating hospitals, and has received grants from ANA/C, ACNL, Kaiser Permanente, the California Health Care Foundation, and the American Nurses Association. The Agency for Health Care Research and Quality (AHRQ) provided funding to enable CalNOC site staff and stakeholders statewide to meet, review findings, and plan for ongoing research and project development.

The California Health Care Foundation is an Oakland-based, independent, non-profit, philanthropic organization. Its mission is to expand access for underserved individuals and communities and to promote fundamental improvements in health status of the people of California. The Agency for Healthcare Research and Quality provides evidence-based information on health care outcomes; quality; and cost, use, and access.

For more information visit http://www.CalNOC.org