Limiting Nurse Workloads Good for RNs and Patients

Megan Brooks

April 21, 2010

April 21, 2010 — A law passed in California in 2004 limiting the number of patients that can be assigned to a nurse has contributed to lower mortality rates among general surgery patients and increased job satisfaction among the state's nurses, according to the first comprehensive evaluation of the legislation, published online April 9 in Health Services Research.

The California law, the first in the nation, specifies that nurses may care for no more than

  • 5 patients in a medical-surgical unit,

  • 4 pediatric patients,

  • 2 intensive care patients,

  • 6 psychiatric patients, or

  • 3 patients in labor and delivery.

Linda H. Aiken, PhD, RN, director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing, Philadelphia, and colleagues examined general surgery outcomes data and hospital staffing information from California in 2006, 2 years after the law was enacted. The researchers did the same in Pennsylvania and New Jersey — 2 states without mandated nurse staffing requirements — and compared how nurse and patient outcomes are affected by differences in nurse workloads across the hospitals in these 3 states.

The analysis included 22,336 hospital staff nurses working in 604 adult nonfederal acute care hospitals in California (n = 9257 registered nurses [RNs] in 353 hospitals), New Jersey (n = 5818 RNs in 73 hospitals), and Pennsylvania (n = 7261 RNs in 178 hospitals). Small (<100 beds), medium (101 - 250 beds), and large (>251 beds) hospitals were represented.

The authors report that average workloads were significantly lower (P < .05) for RNs in California than in New Jersey and Pennsylvania (mean patients per shift, 4.1 in California vs 5.4 in New Jersey and Pennsylvania). The percentage of California nurses on medical-surgical wards who reported overseeing 5 or fewer patients on their last shift, as mandated under California law, was 88%; the same was true of only 19% and 33% of medical-surgical nurses in New Jersey and Pennsylvania, respectively. On medical-surgical wards, California RNs cared for 2 fewer patients on average than New Jersey RNs and 1.7 fewer patients than Pennsylvania RNs.

"Sizeable" Effects on Surgical Inpatient Mortality

Dr. Aiken's team used logistic regression models to estimate the effects of nurse staffing on 30-day inpatient mortality. The results suggested that there would have been 13.9% fewer deaths among surgery patients in New Jersey and 10.6% fewer in Pennsylvania if hospitals in those states had been staffed at the same average level as California hospitals .

"In these two states alone, 468 lives might have been saved over the 2-year period just among general surgery patients if the California nurse staffing levels were adopted," Dr. Aiken notes in a university-issued statement. "Because all hospitalized patients are likely to benefit from improved nurse staffing, not just general surgery patients, the potential number of lives that could be saved by improving nurse staffing in hospitals nationally is likely to be many thousands a year," she predicted.

Better Work Environment

The survey also found significantly and consistently greater job satisfaction among California RNs. Higher percentages of nurses in California than in New Jersey and Pennsylvania reported that

  • their workloads are reasonable (73% vs 59% and 61% for New Jersey and Pennsylvania, respectively),

  • they receive substantial support in doing their jobs (66% vs 53% and 55%, respectively),

  • there are enough staff RNs to provide quality care (58% vs 41% and 44%, respectively),

  • there are enough staff RNs to get their work done (56% vs 40% and 44%, respectively), and

  • 30-minute breaks are part of their typical workday (74% vs 51% and 45%, respectively).

All of these differences were significant to the P < .01 level.

In addition, a smaller percentage of nurses in California than in New Jersey and Pennsylvania reported that their workloads caused them to miss changes in patient conditions (33% vs 41% and 37%, respectively; P < .01). There was also evidence that a significantly lower proportion of California RNs experience high burnout (29% vs 34% and 36%, respectively).

Dr. Aiken's team notes that although nurse self-reports of workloads may be prone to bias, in previous research they found them to have "considerable predictive validity and better predictive validity than [American Hospital Association] measures of nurse staffing." The researchers also say they rigorously controlled for a variety of nurse characteristics that might affect the data, such as education and experience, as well as patient and hospital characteristics that might affect the results.

"The California experience may inform other states that are currently debating nurse ratio legislation," Dr. Aiken and colleagues conclude, noting that Massachusetts, Minnesota, New Jersey, Illinois, and Oregon are among 18 states currently evaluating nurse staffing issues.

The study was supported by the National Institute of Nursing Research, National Institutes of Health, the Robert Wood Johnson Foundation, and AMN Healthcare Inc. The authors have disclosed no relevant financial relationships.

Health Serv Res. Published online April 9, 2010.


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