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.

Immunity from Civil Liability, Part 1.

A timely primer on what nurses should understand.

Seventeen states enacted executive orders expanding advanced practice nurses' scopes of practice during the first 21 days of the COVID-19 pandemic.

CONTEXT: Rural hospitals in the USA are often served by advanced practice nurses, due to the difficulty for such facilities to recruit physicians. In order to facilitate a full range of services for patients, some states permit advanced practice nurses to practice with full independence. However, many states limit their scopes of practice, resulting in the potential for limited healthcare access in underserved areas. The COVID-19 pandemic temporarily upended these arrangements for several states, as 17 governors quickly passed waivers and suspensions of physician oversight restrictions. ISSUES: Physician resistance is a primary hurdle for states that limit advanced practice nurse scopes of practice. Longstanding restrictions were removed, however, in a short period of time. The pandemic demonstrated that even governors with strong political disagreements agreed on one way that healthcare access could potentially be improved. LESSONS LEARNED: Despite longstanding concerns over patient safety when advanced practice nurses practice with full autonomy, governors quickly removed practice restrictions when faced with a crisis situation. Implied in such behavior are that policymakers were aware of advanced practice nurses' capabilities prior to the pandemic, but chose not to implement full practice authority, and that governors appeared to disagree as to whether to temporarily waive specific restrictions or suspend restrictions entirely, consistent with their political affiliation. We propose more research into understanding whether or not such changes should become permanent.

[Nurse and Patient Dispute Litigation in Independent Nursing Practice].

BACKGROUND: Although medical dispute and other contentious cases involving patients and nurses have risen significantly in recent years, few studies have examined the litigation issues involved in nurse-patient disputes. PURPOSE: This study was designed to explore the background, categories, and degrees of harm to patients and the judgments made by the courts. METHODS: Qualitative research was used. Cases of criminal, written judgments related to nurse practice negligence and recorded in district courts in Taiwan from 2008 to 2017 were selected. Data were analyzed using content analysis. RESULTS: A total of 41 hospitals and 55 nurses were identified. The largest number of cases involved regional hospitals (36.6%), internal medicine departments (31.7%), general wards (46.3%), night shifts (40.0%), and staff nurses (85.5%). Four categories of independent nurse practice negligence were identified, including observation-evaluation, environmental security, physician notification, and nursing records. Negligent homicide (58.2%) was the most common court judgment and ten nurses (18.2%) were found guilty of the charges brought against them. CONCLUSIONS / IMPLICATIONS FOR PRACTICE: The results of this study highlight for nurses the content of nurse practice negligence and the related judgments by the courts, which hopefully may guide nurses to avoid practice negligence in the future.

Improvement Plan of Nurse Staffing Standards in Korea.

PURPOSE: This study compares the expected nurse-to-patient ratio, penalties for violating these regulations, and the laws enacted in the medical and nursing fields in Korea and advanced countries like Germany, Australia, the United States, and Japan. METHODS: This study deployed an integrative review method and used search terms such as "nursing law," "nurse ratio," "nurse," "nurse staffing," "health," and "staffing" to find articles published in English, Korean, German, or Japanese through Cumulative Index to Nursing and Allied Health Literature Plus with Full Text, the Westlaw (International Materials-Jurisdiction) site, US government and state sites (federal parliament, National Conference of State Legislatures), and Google Scholar. RESULTS: Compared with medical laws in other advanced countries, Korean laws are quite crude and its nurse-to-patient ratio does not reflect patients' status. Korea also lacks strict penalties for nurse staffing ratio violations. CONCLUSION: Korea requires a strong regulatory apparatus for nurse staffing in health-care organizations to improve the quality of its health-care services and patient safety.

Effects of Public Reporting Legislation of Nurse Staffing: A Trend Analysis.

Public reporting is a tactic that hospitals and other health care facilities use to provide data such as outcomes to clinicians, patients, and payers. Although inadequate registered nurse (RN) staffing has been linked to poor patient outcomes, only eight states in the United States publicly report staffing ratios-five mandated by legislation and the other three electively. We examine nurse staffing trends after the New Jersey (NJ) legislature and governor enacted P.L.1971, c.136 (C.26:2 H-13) on January 24, 2005, mandating that all health care facilities compile, post, and report staffing information. We conduct a secondary analysis of reported data from the State of NJ Department of Health on 73 hospitals in 2008 to 2009 and 72 hospitals in 2010 to 2015. The first aim was to determine if NJ hospitals complied with legislation, and the second was to identify staffing trends postlegislation. On the reports, staffing was operationalized as the number of patients per RN per quarters. We obtained 30 quarterly reports for 2008 through 2015 and cross-checked these reports for data accuracy on the NJ Department of Health website. From these data, we created a longitudinal data set of 13 inpatient units for each hospital (14,158 observations) and merged these data with American Hospital Association Annual Survey data. The number of patients per RN decreased for 10 specialties, and the American Hospital Association data demonstrate a similar trend. Although the number of patients does not account for patient acuity, the decrease in the patients per RN over 7 years indicated the importance of public reporting in improving patient safety.

Expanding knowledge and roles for authority and practice boundaries of Emergency Department nurses: a grounded theory study.

PURPOSE: While emergency department nurses in Indonesia are critical to quality care, the role lacks recognition and standard practices and regulation of scope of practice are absent. This research explored the role of nurses in Indonesian EDs. METHOD: The conceptual lens applied in the research was grounded theory. The main data source was 51 semi- structured interviews with 43 ED nurses, three directors of nursing, three nurse leaders and two nurse educators. Data were also generated through observations and memos. RESULTS: Two key categories were constructed; shifting work boundaries and lack of authority. Shifting work boundaries was symbolic of a lack of professional authority and legitimized knowledge. Lack of authority reflected the dimension of professional autonomy through the nexus of power and knowledge. The interrelationship of these two concepts constructed a core category, securing legitimate power, which underpinned the positioning of nursing in Indonesia. CONCLUSIONS: The interconnection between political gains, tertiary knowledge, professional regulation and implementation of gender-sensitive policies was critical to the development of the ED role, the positioning of nursing within the health care system and improvement in quality of care.

Massachusetts Voters Reject Nurse Staffing Standards.

Nurses, too, were split on the vote.

Do State Regulations on Nurse Staffing Make a Difference in ICU Outcomes?

A new study questions the effect on patient outcomes but is narrow in scope.

Association of nurse staffing grade and 30-day mortality in intensive care units among cardiovascular disease patients.

After the implementation of a policy differentiating inpatient nursing fees, no study is found in the nursing literature for intensive care unit (ICU) patients admitted with cardiovascular (CV) disease exclusively in Korea. This study investigates the relationship between ICU nurse staffing and 30-day mortality using large representative claim database.National Health Insurance Service-Senior (NHIS-Senior) claim database from 2002 to 2013, which was released by the Korean National Health Insurance Service (KNHIS), was used in this study. We included CV disease inpatients as a primary diagnostic code (I20-I25) who had their ICU utilization records from differentiating inpatient nursing fees code, resulting in 17,081 subjectsAfter adjusting for confounders, the hazard ratio (HR) for 30-day mortality after discharge (HR: 1.177; P: .018) and in-hospital 30-day mortality (HR: 1.145; P: .058) were higher in general hospital (GH) than in tertiary hospital (TH). In GH setting, HR for 30-day mortality after discharge (HR: 1.499; P: .010) and in-hospital 30-day mortality (HR: 1.377; P: .042) were higher in grade 7 to 9 than grade 1 to 2, but not in TH setting.This study shows that ICU nurse staffing related to improved mortality risk in GHs. Therefore, adequate nurse staffing to provide safe and high-quality care can be ensured by continuous monitoring and evaluation of nurse staffing.

Patient Outcomes After the Introduction of Statewide ICU Nurse Staffing Regulations.

OBJECTIVES: To assess whether Massachusetts legislation directed at ICU nurse staffing was associated with improvements in patient outcomes. DESIGN: Retrospective cohort study; difference-in-difference design to compare outcomes in Massachusetts with outcomes of other states (before and after the March 31, 2016, compliance deadline). SETTING: Administrative claims data collected from medical centers across the United States (Vizient). PATIENTS: Adults between 18 and 99 years old who were admitted to ICUs for greater than or equal to 1 day. INTERVENTIONS: Massachusetts General Law c. 111, § 231, which established 1) maximum patient-to-nurse assignments of 2:1 in the ICU and 2) that this determination should be based on a patient acuity tool and by the staff nurses in the unit. MEASUREMENTS AND MAIN RESULTS: Nurse staffing increased similarly in Massachusetts (n = 11 ICUs, Baseline patient-to-nurse ratio 1.38 ± 0.16 to Post-mandate 1.28 ± 0.15; p = 0.006) and other states (n = 88 ICUs, Baseline 1.35 ± 0.19 to Post-mandate 1.31 ± 0.17; p = 0.002; difference-in-difference p = 0.20). Massachusetts ICU nurse staffing regulations were not associated with changes in hospital mortality within Massachusetts (Baseline n = 29,754, standardized mortality ratio 1.20 ± 0.04 to Post-mandate n = 30,058, 1.15 ± 0.04; p = 0.11) or when compared with changes in hospital mortality in other states (Baseline n = 572,952, 1.15 ± 0.01 to Post-mandate n = 567,608, 1.09 ± 0.01; difference-in-difference p = 0.69). Complications (Massachusetts: Baseline 0.68% to Post-mandate 0.67%; other states: Baseline 0.72% to Post-mandate 0.72%; difference-in-difference p = 0.92) and do-not-resuscitate orders (Massachusetts: Baseline 13.5% to Post-mandate 15.4%; other states: Baseline 12.3% to Post-mandate 14.5%; difference-in-difference p = 0.07) also remained unchanged relative to secular trends. Results were similar in interrupted time series analysis, as well as in subgroups of community hospitals and workload intensive patients receiving mechanical ventilation. CONCLUSIONS: State regulation of patient-to-nurse staffing with the aid of patient complexity scores in intensive care was not associated with either increased nurse staffing or changes in patient outcomes.

[Emergency nurse, a speciality whose name says it all?] / Infirmier urgentiste, une spécialité qui dit déjà son nom ?

Proposal no. 10 in French Senate information report no. 685, drawn up by the Social Affairs Commission on hospital emergency departments, opens the debate regarding the creation of an emergency nursing speciality. Does this represent progress for the profession or an inadapted measure? The complex situation of emergency departments raises the need for methodological thinking on this subject.

[The new methods to define the staffing requirements for doctors,nurses and nurses aides: an example of their implementation in an Italian hospital]. / Le nuove metodologie di valutazione del fabbisognodel personale infermieristico, medico e di supporto: un esempio di applicazione.

. The new methods to define the staffing requirements for doctors, nurses and nurses aides: an example of their implementation in an Italian hospital. The Italian government, after the transposition of European Union legislation on working hours, made a declaration of commitment to increase the number of staff of the National Health Service (NHS). The method for assessing the staffing needs innovates the old one that dated back a few decades. AIM: To implement the method proposed by the Ministry of Health to an Italian hospital and assess its impact on staffing and costs. METHODS: The model was implemented on all the wards, multiplying the minutes of care expected in 2016, dividing the result by 60 to obtain the hours of care, and further dividing by the number of yearly hours of work of a nurse (1418). Same was done for nurses aides. The minutes of care were related to mean weight of the Diagnosis Related Groups of the ward and the results obtained compared to the actual staffing of nurses and nurses aides. The costs of the differences were calculated. RESULTS: The implementation of the model produced an excess of 23 nurses and a scarcity of 95 nurses aides compared to the actual staffing, with an increase of the costs of € 1.828.562,00. CONCLUSIONS: The results obtained and the criticisms received so far show the need of major changes. The data from international studies that associate staffing and patients outcomes and the nurse/patient ratio are macro-indicators already available that may orient choices and investments on the health care professions.

Lessons Learned from Litigation: Legal and Ethical Consequences of Social Media.

Editor's note: To the surprise of many, a Canadian nurse's Facebook post complaining about the medical care a family member had received resulted in disciplinary action by the licensing board. We asked our legal and ethical contributing editors to provide some insight on the issues of this case.