Alternative Approaches to Ensuring Adequate Nurse Staffing: The Effect of State Legislation on Hospital Nurse Staffing.

OBJECTIVE: The objective of this study was to addresses the basic question of whether alternative legislative approaches are effective in encouraging hospitals to increase nurse staffing. METHODS: Using 16 years of nationally representative hospital-level data from the American Hospital Association (AHA) annual survey, we employed a difference-in-difference design to compare changes in productive hours per patient day for registered nurses (RNs), licensed practical/vocational nurses (LPNs), and nursing assistive personnel (NAP) in the state that mandated staffing ratios, states that legislated staffing committees, and states that legislated public reporting, to changes in states that did not implement any nurse staffing legislation before and after the legislation was implemented. We constructed multivariate linear regression models to assess the effects with hospital and year fixed effects, controlling for hospital-level characteristics and state-level factors. RESULTS: Compared with states with no legislation, the state that legislated minimum staffing ratios had an 0.996 (P<0.01) increase in RN hours per patient day and 0.224 (P<0.01) increase in NAP hours after the legislation was implemented, but no statistically significant changes in RN or NAP hours were found in states that legislated a staffing committee or public reporting. The staffing committee approach had a negative effect on LPN hours (difference-in-difference=-0.076, P<0.01), while the public reporting approach had a positive effect on LPN hours (difference-in-difference=0.115, P<0.01). There was no statistically significant effect of staffing mandate on LPN hours. CONCLUSIONS: When we included California in the comparison, our model suggests that neither the staffing committee nor the public reporting approach alone are effective in increasing hospital RN staffing, although the public reporting approach appeared to have a positive effect on LPN staffing. When we excluded California form the model, public reporting also had a positive effect on RN staffing. Future research should examine patient outcomes associated with these policies, as well as potential cost savings for hospitals from reduced nurse turnover rates.

The Relationship Between Reported Staffing and Expenditures in Nursing Homes.

Dramatic improvements in reported nursing home quality, including staffing ratios, have come under increased scrutiny in recent years because they are based on data self-reported by nursing homes. In contrast to other domains, the key mechanism for real improvement in the staffing ratios domain is clearer: to improve scores, nursing homes should increase staffing expenditures. We analyze the relationship between changes in expenditures and reported staffing quality pre- versus post the 5-star rating system. Our results show that the relationship between expenditures and licensed practical nurse staffing is weaker in the post-5-star period, overall, and across subgroups; furthermore, there is a weaker relationship between expenditures and registered nurse staffing among for-profit facilities with a high share of Medicaid residents in the post-5-star period. The weaker relationship between staffing expenditures and staffing scores in the post-5-star era underscores the potential for gaming of the self-reported staffing scores and the need for more reliable sources.

Unmasking the enterprising nurse: migrant care workers and the discursive mobilisation of productive professionals.

Public care work organisations in Northern Europe often seek to increase their economic efficiency in ways that care workers criticise for reducing both their professional autonomy and the quality of care. Recently, the ideal of 'enterprising nursing' has emerged as a political belief according to which economic efficiency, care workers' autonomy and the quality of care can be improved in tandem by cultivating care workers' agential abilities. This article examines the reception of this belief among migrant care workers in Finland. Drawing on research interviews, the analysis demonstrates how migrant care workers may have difficulties in aligning themselves with the enterprising ideals but also in protesting them. Ethnicity, and the status of a migrant, can offer resources for both constructing enterprising subjectivities and reframing care workers' agency, and their organisational environment, in more critical terms.

I was never recruited: challenges in cross-Canada nurse mobility.

The internal migration of nurses within Canada has had limited study. This paper reports the results of a survey of registered nurses and licensed practical nurses who had migrated between the provinces and territories in Canada. Factors contributing to internal nurse mobility included seeking full-time work, opportunities for career advancement and flexible scheduling options. Few nurses received incentives to move between the provinces/territories to work. A number of challenges with internal migration are identified, including complexities related to licensing and limitations in available job information. Implications for nursing health human resources policy related to nurse retention in Canada are identified and discussed.

Mapping nurse mobility in Canada with GIS: career movements from two Canadian provinces.

Recent years have witnessed the publication of a growing number of studies of nursing which, from a disciplinary perspective, are geographical in their orientation. Conceptually, while the emphasis in much of this research has been focused at the micro scale on the dynamics between nursing and "place," curiously there has been scant attention to geometrical "space," and the basic yet important locational and distributive features of nursing at the macro scale. Noting this gap in the literature, the authors of this paper used a Geographical Information System (GIS) to map the movement of 199 nurses from two Canadian provinces where they were educated - Manitoba and Newfoundland - to the provinces where they currently live and work. While the findings show that nurses who move tend to move to nearby provinces, more generally they illustrate the effectiveness of GIS for managing data and representing findings from workforce studies.

LPN perspectives of factors that affect nurse mobility in Canada.

Although the licensed practical nurse (LPN) workforce represents an ever-growing and valuable human resource, very little is known about reasons for practical nurse mobility. The purpose of this study was to describe LPN perspectives regarding motives for inter-provincial/territorial (P/T) movement in Canada. Participants included 200 LPNs from nine P/T, and data were analyzed using a qualitative descriptive approach. Three primary themes were identified regarding motivators for LPN migration, including (a) scope of practice, (b) education and advancement opportunities and (c) professional respect and recognition. Although current economic forces have a strong influence on nurse mobility, these findings emphasize that there are other equally important factors influencing LPNs to move between jurisdictions. As such, policy makers, administrators and researchers should further explore and address these themes in order to strengthen Canada's nursing workforce.