Safe Minimum Nurse Staffing Requirements for Hospitals

BACKGROUND: The Pennsylvania legislature is considering limiting the number of patients nurses care for to promote safe care. OBJECTIVE: To determine whether variation in nurse workloads is associated with adverse consequences for patients, nurses, and hospital costs in Pennsylvania. METHODS: Observational study of 547,689 medical and surgical patients and 2782 direct care nurses in 132 Pennsylvania hospitals. The independent variable was medical-surgical nurse staffing ratios. Patient outcomes included 30-day mortality, 30-day readmissions, and length of stay. Nurse outcomes included burnout, job dissatisfaction, intent to leave, and evaluations of hospital management and patient care. Hospital outcomes were HCAHPS Star Ratings and cost offsets associated with better staffing. RESULTS: Hospital nurse staffing ranged from 3 to 9 patients per nurse (average 5.9). Each additional patient per nurse was associated with higher odds of 30-day mortality (AOR: 1.08, 95% CI: 1.03, 1.13, P<0.001), longer length of stay (IRR: 1.02, 95% CI: 1.00, 1.04, P<0.05) and higher odds of readmission (AOR: 1.04, 95% CI: 1.01, 1.07, P<0.05). Worse staffing was associated with higher odds of nurse burnout, job dissatisfaction, and intent to leave, and lower patient satisfaction. Cost savings from patient outcomes and nurse retention were projected to offset costs of additional nurses needed for hospitals to meet a minimum safe nurse staffing level proposed in legislation. CONCLUSIONS: Large differences across Pennsylvania hospitals in the amount of nursing care patients receive are associated with negative consequences. A state policy establishing minimum safe nurse staffing requirements in hospitals is in the public's interest.