The California Nurse Staffing Mandate: Implications for Other States

In 2004, California became the first state to implement minimum nurse-to-patient staffing requirements inacute care hospitals. It remains the only state to enact such requirements, although at least 18 states have introduced nurse staffing legislation. The goals of the legislation were to reduce nurse workloads, improve recruitment and retention of nurses, and improve quality of care. This Issue Brief summarizes the first comprehensive evaluation of the California mandate in achieving these goals

The Case for Baccalaureate-Prepared Nurses

The nursing workforce plays a central role in our present health care system, and will likely have an even greater role in the future. Nurses already provide the vast majority of care to patients in hospitals, and so it should come as no surprise that the quality of nursing care affects patient outcomes. Over the past decade, studies have linked certain nursing characteristics—such as staffing levels, education, job satisfaction, and work environment—with better outcomes in hospitals. This Issue Brief adds to that evidence with a longitudinal study that links changes in nurse education with improvements in surgical patients’ survival. It also discusses how a more educated nurse workforce could fill a range of new roles in primary care, prevention, and care coordination as health reform is implemented

Staffing National Health Care Reform: A Role for Advanced Practice Nurses

Expanding access and coverage while containing costs can only be accomplished by getting more health care value for our money. Two facts about our current system make this seem possible. First, the currently uninsured are not costless. Providing stop-gap health care to those who lack health insurance is extremely expensive -- people without formal coverage cannot afford preventive services, delay treatment of illness and face substantial barriers to reaching appropriate providers. When they receive care, it is often degrading, usually complicated and costly, and more than occasionally too late. The cost of this uncompensated care is borne by all of us in higher prices for our own health insurance, in taxes and in the federal deficit. Moreover, this cost is not distributed evenly, and reduces our ability to determine whether the price of our own health care is fair. In addition, the need for last resort care for the uninsured locks us into continued support of aging public health facilities that are often underequipped and inefficient. The second characteristic of our current system is that the utilization of health care services is tremendously wasteful. Gaps in our knowledge as to what works and what doesn\u27t, fee-for-service payment that creates incentives to do more rather than less, lack of coordination between providers, high patient expectations and fear of malpractice litigation all predispose to overutilization. We are fascinated by expensive technology, and use it uncritically. Moreover, these influences have elevated the illness-based model of care over the health-based model. As a result, a disproportionate amount of our health care budget is devoted to the treatment of acute illness, often in institutional settings, rather than to primary, preventive and long-term community and home-based care. These observations suggest a prescription for change. Improving the cost effectiveness of health care delivery -- in particular by emphasizing preventive and primary care and adopting a more discriminating approach to the use of expensive, referral services -- can free up the resources needed to include all Americans in the health care system. This effort must be undertaken by health care providers, by communities and by government

Staffing National Health Care Reform: A Role for Advanced Practice Nurses

Expanding access and coverage while containing costs can only be accomplished by getting more health care value for our money. Two facts about our current system make this seem possible. First, the currently uninsured are not costless. Providing stop-gap health care to those who lack health insurance is extremely expensive -- people without formal coverage cannot afford preventive services, delay treatment of illness and face substantial barriers to reaching appropriate providers. When they receive care, it is often degrading, usually complicated and costly, and more than occasionally too late. The cost of this uncompensated care is borne by all of us in higher prices for our own health insurance, in taxes and in the federal deficit. Moreover, this cost is not distributed evenly, and reduces our ability to determine whether the price of our own health care is fair. In addition, the need for last resort care for the uninsured locks us into continued support of aging public health facilities that are often underequipped and inefficient. The second characteristic of our current system is that the utilization of health care services is tremendously wasteful. Gaps in our knowledge as to what works and what doesn\u27t, fee-for-service payment that creates incentives to do more rather than less, lack of coordination between providers, high patient expectations and fear of malpractice litigation all predispose to overutilization. We are fascinated by expensive technology, and use it uncritically. Moreover, these influences have elevated the illness-based model of care over the health-based model. As a result, a disproportionate amount of our health care budget is devoted to the treatment of acute illness, often in institutional settings, rather than to primary, preventive and long-term community and home-based care. These observations suggest a prescription for change. Improving the cost effectiveness of health care delivery -- in particular by emphasizing preventive and primary care and adopting a more discriminating approach to the use of expensive, referral services -- can free up the resources needed to include all Americans in the health care system. This effort must be undertaken by health care providers, by communities and by government

Needlestick Injuries to Nurses, in Context

Injuries with used needles and other “sharps” put health care workers at risk for serious bloodborne infections, such as HIV and hepatitis B and C. To some extent, this risk can be lessened through safer techniques (such as not recapping needles) and safer devices (such as needleless and self-sheathing equipment). But these injuries occur within a context (often a hospital unit) with organizational features that may themselves contribute to an increased or decreased risk. This Issue Brief summarizes a series of studies that investigate whether workplace aspects of the hospital (such as staffing levels, and organizational structure and climate) affect the risk of needlestick injuries to nurses

Medical Migration to the U.S.: Trends and Impact

The United States is in the midst of a prolonged nursing shortage, one that could reach a deficit of 800,000 registered nurses (RNs) by 2020. Increasingly, foreign-trained nurses are migrating to the U.S., particularly from low-income countries, seeking higher wages and a higher standard of living. Increased reliance on immigration may adversely affect health care in lower-income countries without solving the U.S. shortage. This Issue Brief analyzes trends in medical migration, and explores its short and long-term effects on the health care workforce in the U.S. and in developing countries

Hospital Nurse Staffing, Education, and Patient Mortality

A serious shortage of hospital nurses in the U.S., evident in the past decade, is expected to continue and worsen in the next 15 years. Increasingly, the public and the health professions are acknowledging that nurse understaffing represents a serious threat to patient safety in U.S. hospitals. Although anecdotal evidence has linked patient deaths to inadequate nurse staffing, the numbers and kinds of nurses needed for patient safety is unknown. This Issue Brief highlights two studies that clarify the impact of nurse staffing levels on surgical patient outcomes, and examine the effect of nurses’ experience and educational level on patient mortality in the 30 days after a surgical admission

Randomized Clinical Trial of the Effectiveness of a Home-Based Advanced Practice Psychiatric Nurse Intervention: Outcomes for Individuals with Serious Mental Illness and HIV

Individuals with serious mental illness have greater risk for contracting HIV, multiple morbidities, and die 25 years younger than the general population. This high need and high cost subgroup face unique barriers to accessing required health care in the current health care system. The effectiveness of an advanced practice nurse model of care management was assessed in a four-year random controlled trial. Results are reported in this paper. In a four-year random controlled trial, a total of 238 community-dwelling individuals with HIV and serious mental illness (SMI) were randomly assigned to an intervention group (n=128) or to a control group (n=110). Over 12 months, the intervention group received care management from advanced practice psychiatric nurse, and the control group received usual care. The intervention group showed significant improvement in depression (P=.012) and the physical component of health-related quality of life (P=.03) from baseline to 12 months. The advanced practice psychiatric nurse intervention is a model of care that holds promise for a higher quality of care and outcomes for this vulnerable population

Organization and Outcomes of Inpatient AIDS Care

The establishment of AIDS hospitals and AIDS units within hospitals has been controversial. Unlike other specialty care, AIDS care arrangements were initially developed as much to segregate AIDS patients from other patients and staff as to provide the best possible care. Ten years after many of these units opened, little evidence was available about whether the benefits of aggregating AIDS patients outweighed the potential hazards of segregating people from the mainstream of hospital care. This Issue Brief describes a national study to determine how different organizational settings affect the outcomes of inpatient AIDS care

Nurse employment contracts in Chinese hospitals: impact of inequitable benefit structures on nurse and patient satisfaction

PURPOSE: Ongoing economic and health system reforms in China have transformed nurse employment in Chinese hospitals. Employment of ‘bianzhi’ nurses, a type of position with state-guaranteed lifetime employment that has been customary since 1949, is decreasing while there is an increase in the contract-based nurse employment with limited job security and reduced benefits. The consequences of inequities between the two types of nurses in terms of wages and job-related benefits are unknown. This study examined current rates of contract-based nurse employment and the effects of the new nurse contract employment strategy on nurse and patient outcomes in Chinese hospitals. METHODS: This cross-sectional study used geographically representative survey data collected from 2008 to 2010 from 181 hospitals in six provinces, two municipalities, and one autonomous region in China. Logistic regression models were used to estimate the association between contract-based nurse utilization, dissatisfaction among contract-based nurses, nurse intentions to leave their positions, and patient satisfaction, controlling for nurse, patient, and hospital characteristics. PRINCIPAL RESULTS: Hospital-level utilization of contract-based nurses varies greatly from 0 to 91%, with an average of 51%. Contract-based nurses were significantly more dissatisfied with their remuneration and benefits than ‘bianzhi’ nurses who have more job security (P <0.01). Contract-based nurses who were dissatisfied with their salary and benefits were more likely to intend to leave their current positions (P <0.01). Hospitals with high levels of dissatisfaction with salary and benefits among contract-based nurses were rated lower and less likely to be recommended by patients (P < 0.05). CONCLUSIONS: Our results suggest a high utilization of contract-based nurses in Chinese hospitals, and that the inequities in benefits between contract-based nurses and ‘bianzhi’ nurses may adversely affect both nurse and patient satisfaction in hospitals. Our study provides empirical support for the ‘equal pay for equal work’ policy emphasized by the China Ministry of Health’s recent regulations, and calls for efforts in Chinese hospitals to eliminate the disparities between ‘bianzhi’ and contract-based nurses