Registered Nurses' Perceptions of Nurse Staffing Ratios and New Hospital Payment Regulations

Peter I. Buerhaus; Karen Donelan; Catherine DesRoches; Robert Hess


Nurs Econ. 2009;27(6):372-376. 

In This Article

Abstract and Introduction


While U.S. Policy discussions are dominated by reforming the health care delivery system, restoring the nation's financial system, and revitalizing the economy, two regulatory initiatives weigh heavily on the nursing workforce: (a) establishing minimum patient-to-nurse staffing ratios in hospitals and (b) eliminating payments to hospitals for negative consequences of care. Although the mechanisms are different, both of these regulatory initiatives carry a strong potential to change the organization and delivery of nursing care provided in hospitals.

Currently, only California has implemented mandatory nurse staffing ratios in hospitals. However, at least 13 states have introduced legislation that would mandate nurse staffing ratios (Washington, Arizona, Minnesota, Missouri, Illinois, Michigan, Kentucky, West Virginia, Florida, Pennsylvania, New York, New Jersey, and Texas). In addition, seven states have enacted laws affecting hospital staffing plans, including public reporting (Oregon, Illinois, New Jersey, Vermont, Rhode Island, Maine, Texas), and ten states have introduced legislation on staffing plans (Washington, Nevada, Colorado, Missouri, Michigan, Ohio, Maryland, Connecticut, Maine, and Florida) (Thrall, 2008).

On October 1, 2008, the Centers for Medicare and Medicaid Services (CMS) implemented new regulations that link Medicare hospital payment to patient outcomes. In effect, CMS no longer pays hospitals for the additional costs incurred by caring for patients who experience any of eight conditions that CMS has determined should never occur: pressure ulcers, falls with injury, catheter-associated urinary tract infections, vascular catheter associated infections, certain surgical site infections, objects mistakenly left inside surgical patients, air emboli, and blood incompatibility reactions (Kurtzman & Buerhaus, 2008). Research has established evidence that the first four of these "never conditions" are associated with nurse staffing (Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002; Kane, Shamlivan, Mueller, Duval, & Wilt, 2007). Because these conditions are relatively infrequent and because the regulations have only been in effect for a short period of time, the impacts of this payment change are unknown.

Although both of these regulatory initiatives will affect the nursing profession, no information exists about the views RNs' themselves hold about either staffing or payment regulations on a national basis. Without such information, actions by policymakers and hospital decision makers could be undertaken without understanding nurse's views about the desirability of and expected impact of either regulatory initiative. The purpose of the study described in this article is to determine RNs' perceptions of nurse staffing ratios and of payment policy that eliminates payment to hospitals for negative consequences of care associated with nursing care.


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