Registered Nurses’ Perceptions of Nurse Staffing Ratios and New Hospital Payment Regulations

Introduction

While U.S. Policy discussions are dominated by reforming the health care delivery system, restoring the nation’s financial system, and revitalizing the economy, two regulatory initiatives weigh heavily on the nursing workforce: (a) establishing minimum patient-to-nurse staffing ratios in hospitals and (b) eliminating payments to hospitals for negative consequences of care. Although the mechanisms are different, both of these regulatory initiatives carry a strong potential to change the organization and delivery of nursing care provided in hospitals.

Currently, only California has implemented mandatory nurse staffing ratios in hospitals. However, at least 13 states have introduced legislation that would mandate nurse staffing ratios (Washington, Arizona, Minnesota, Missouri, Illinois, Michigan, Kentucky, West Virginia, Florida, Pennsylvania, New York, New Jersey, and Texas). In addition, seven states have enacted laws affecting hospital staffing plans, including public reporting (Oregon, Illinois, New Jersey, Vermont, Rhode Island, Maine, Texas), and ten states have introduced legislation on staffing plans (Washington, Nevada, Colorado, Missouri, Michigan, Ohio, Maryland, Connecticut, Maine, and Florida) (Thrall, 2008).

On October 1, 2008, the Centers for Medicare and Medicaid Services (CMS) implemented new regulations that link Medicare hospital payment to patient outcomes. In effect, CMS no longer pays hospitals for the additional costs incurred by caring for patients who experience any of eight conditions that CMS has determined should never occur: pressure ulcers, falls with injury, catheter-associated urinary tract infections, vascular catheter associated infections, certain surgical site infections, objects mistakenly left inside surgical patients, air emboli, and blood incompatibility reactions (Kurtzman & Buerhaus, 2008). Research has established evidence that the first four of these "never conditions" are associated with nurse staffing (Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002; Kane, Shamlivan, Mueller, Duval, & Wilt, 2007). Because these conditions are relatively infrequent and because the regulations have only been in effect for a short period of time, the impacts of this payment change are unknown.

Although both of these regulatory initiatives will affect the nursing profession, no information exists about the views RNs’ themselves hold about either staffing or payment regulations on a national basis. Without such information, actions by policymakers and hospital decision makers could be undertaken without understanding nurse’s views about the desirability of and expected impact of either regulatory initiative. The purpose of the study described in this article is to determine RNs’ perceptions of nurse staffing ratios and of payment policy that eliminates payment to hospitals for negative consequences of care associated with nursing care.

Data and Methods

Data for the study were obtained from the 2008 National Survey of RNs (NSRN). The procedures used to conduct this survey and the characteristics of the RNs who responded to it are described in detail elsewhere (Buerhaus, Donelan, DesRoches, & Hess 2009). Briefly, the 2008 NSRN was conducted by mail from March 4 to June 3, 2008. The survey was funded by the Johnson & Johnson Campaign for Nursing’s Future and by the Gannett Healthcare Group, and its administration was conducted by the survey research firm Harris Interactive. The eightpage questionnaire was mailed to a random sample of 3,500 RNs drawn from the Gannett Healthcare Group national database of RNs. This database is frequently updated with data from boards of registration in all states. Up to five mailings were sent to non-responders to encourage participation. Response enhancement incentives included 2 hours of continuing nursing education courses valued at $35 and the opportunity to be entered into a lottery drawing for a voucher redeemable for travel to professional conferences.

The 2008 NSRN contained sections assessing RNs’ perceptions of health policy issues and the Presidential election (see Buerhaus, Ulrich, Donelan, & DesRoches, 2008), the nursing shortage, quality of the hospital environment, quality of patient care, awareness of the J&J Campaign, and other topics (see Buerhaus et al., 2009). In total, 1,284 RNs provided responses to the 2008 NSRN. In this article we limit our analysis to the 468 RNs who reported that they work in hospital settings and provide direct patient care in that setting. We compared differences between groups of RNs using a two-tailed t test for differences in proportions.

All surveys are subject to sampling and non-sampling error and thus results may differ from what would be obtained had the entire population of RNs been surveyed. Possible sources of non-sampling error include non-response bias, question wording, and ordering effects. Efforts to minimize nonsampling error included pretesting, checks for internal consistency and reliability, review of the instrument by multiple experts, and use of instruments and questions tested previously for other studies.

Results Staffing Ratios

Hospital-employed RNs were asked to indicate their agreement to three statements which most closely described their attitude about whether ratios should be mandated or not, and whether they should be mandated by either the federal or state government. Overall, six in ten RNs (62%) reported that minimum RN staffing ratios should be mandated. However, RNs were nearly evenly split between whether they thought ratios should be mandated by the federal government (34%) or by the states (29%). Approximately one in four (26%) RNs reported that minimum RN staffing ratios should not be mandated and approximately one in ten (12%) did not provide a response.

RNs’ perceptions of mandatory nurse staffing ratios could be influenced by whether a nursing shortage exists in the hospital where the RN worked, RNs’ job satisfaction, and whether there is legislative activity to implement staffing ratios in the state where the RN is employed. With respect to the presence of a nursing shortage, no statistically significant difference in RNs’ perceptions of staffing ratios were found between RNs who reported they worked in hospitals with nursing shortages and those who worked in hospitals without shortages. Job satisfaction, however, was significantly associated with attitudes about staffing ratios. RNs who reported low levels of satisfaction with their current job were significantly more likely to support mandates at the federal level (61% among very or somewhat dissatisfied RNs) than were RNs who reported they were satisfied with their jobs (35% among very or somewhat satisfied RNs) (p<0.001). Similarly, RNs who reported low levels of job satisfaction were more likely to support state-level staffing ratio mandates (34% among very or somewhat dissatisfied RNs versus 22% among very or somewhat satisfied RNs) (p<0.001).

With respect to the views of RNs who are employed in the 20 states that have been active in pursuing nurse staffing legislation, RNs in those states are significantly more likely to agree that ratios should be mandated at the federal or state level compared to RNs in states that were not engaged in nurse staffing legislation. RNs employed in California, which has enacted mandatory nurse staffing ratios, are significantly more likely to say that ratios should be mandated at the federal or state level compared to RNs in all other states (p<0.05).

To obtain information on the perceived effects of staffing ratios, the survey included a question that asked: "In general, what effect do you think minimum RN staffing rations have on the quality of care provided for patients?" A little more than half (54%) of RNs felt that the effect of staffing ratios was "very or somewhat positive," 24% "very or somewhat negative," and 11% "neither positive nor negative." Additional analysis was conducted to assess whether responses varied according to RNs’ perceptions of the presence of a nursing shortage in the hospital where they worked, and to whether RNs’ perceived that during the past 2 years the quality of nursing care provided to patients in their hospitals had improved or not. RNs who reported a very or somewhat serious nursing shortage in their hospital of employment were significantly more likely than RNs who did not perceive a shortage to perceive that staffing ratios would have a positive effect on the quality of patient care (p<0.001). There were no statistically significant differences in RNs’ perceptions of the impact of staffing ratios on quality associated with RNs views about whether quality of nursing care over the past 2 years had improved or not.

CMS Hospital Payment Regulations

The 2008 NSRN was conducted prior to the implementation of the CMS payment change to eliminate payment to hospitals for negative consequences of care, sometimes referred to as "never conditions." Therefore, to explain this impending policy change, the survey provided the following summary before asking respondents two questions about the expected impact of the change: "On October 1, 2008, the Centers for Medicare and Medicaid Services (CMS) will eliminate additional payments for eight preventable, hospital-acquired conditions (e.g., pressure ulcers, urinary tract infections, blood stream infections, etc.). Researchers have found that several of these conditions are associated with hospital nurse staffing."

The first question asked RNs to indicate their agreement to a list of possible consequences of the policy change shown in Table 1. RNs’ reported the one most likely result of the policy change will be an increase in nurses’ focus on prevention and surveillance, which was selected by 37% of RNs. Hospitals blaming nurses for these conditions was the next most likely expected result chosen by 34% of RNs. Twice as many RNs (14%) agreed that hospitals would decrease resources for patient care versus those (6%) who indicated that hospitals would increase resources.

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Table 1. RN Perceptions of the Most Likely Effects of the CMS Policy Change in 2008

NOTE: Based on responses of 468 hospital-employed RNs providing direct patient care.

The second question asked: "Recognizing that nursing care is closely associated with some of the conditions for which additional payments to hospitals will be eliminated, do you think this policy change will result in any of the following responses" (see Table 2). A majority of RNs (65%) reported that the principal result will be more work for nurses, and nearly half (47%) indicated that this policy change will result in additional education and training. Very few RNs felt that the CMS payment change will result in positive outcomes for nurses, including higher pay, more respect, or more staffing.

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Table 2. RN Perceptions of the Results of the CMS Policy Change in 2008

Discussion

To the authors’ knowledge, the 2008 NSRN is the first national assessment of RNs’ perceptions of two regulatory initiatives that are affecting RNs employed in U.S. hospitals. Staffing ratios have been on the policy agenda for many years and thus it is very likely that most RNs have formed their opinions about their desirability and expected impact. In contrast, the CMS regulations had not yet been implemented at the time the survey was conducted and, therefore, it is likely that many and perhaps most RNs had not heard about this initiative, let alone formed an opinion toward this initiative that is intended to give hospitals an economic incentive to reduce the occurrence of certain adverse patient conditions.

Staffing Ratios

Study findings provide information from the perspective of RNs who provide patent care in hospitals. That the majority of RNs favor ratios gives support to unions and others who advocate a regulatory approach to hospital nurse staffing. Support was particularly strong among RNs who reported low job satisfaction. On the other hand, results also indicate that a good number of RNs either do not support ratios or are unsure, which suggests that while many RNs support ratios, the support is not universal. For hospitals and others who are opposed to nurse staffing ratios, the results make clear that half of RNs think that ratios are likely to have a positive impact on the quality of hospital care. RNs who reported working in a hospital with a nursing shortage were significantly more likely to report ratios would positively impact quality of care.

One implication of these findings is that opponents of nurse staffing ratios should do more than oppose ratios but act to address the underlying factors that are at the root of RNs’ support for ratios. However, it is not clear where such efforts should be directed. On the one hand, biennial national surveys of RNs conducted by the authors since 2002 consistently show that more than 80% of RNs agree that improving the quality of the workplace environment is the most important way to resolve nursing shortages; presumably, support for regulations is driven in part by RNs’ belief that nurse staffing ratios would increase nurse staffing levels. Yet, studies of California hospitals that sought to assess the impact of nurse staffing ratios found, if anything, wages increased (Mark, Harless, & Spetz, 2009) but ratios have not increased job satisfaction, improved patient outcomes, and that the increase in nurse staffing that resulted was supplied to a meaningful degree by temporary or traveling nurses (Burnes Bolton et al., 2008; Donaldson et al., 2005; Sochalski, Konetzka, Zhu, & Volpp, 2008; Spetz, 2008). Given this disconnect between nurses’ emphasis on improving their work environment and the evidence indicating that ratios have not delivered this change in the one state that has implemented ratios, hospitals might be better off initiating a dialogue with their nursing workforce aimed at identifying the problems in nurse staffing in their organization. Then, together with nurses, hospital leaders could followup with actions designed to correct the underlying problems and evaluate their effectiveness (Buerhaus, 2009).

Currently, states seem to be hesitant to enact legislation to mandate hospital staffing ratios; instead, most are requiring greater transparency of staffing plans and greater involvement of nurses in staffing decisions. This hesitancy gives hospitals an opportunity to fix underlying problems that may be at the heart of nurses’ support for a regulatory approach to staffing. If this opportunity is not taken, then hospitals can anticipate that the favorable sentiments toward staffing ratios held by nearly two in three RNs are likely to eventually result in more states beefing up their regulations and some may even follow California’s lead. With the economic recession resulting in record increases in hospital RN employment and the substantial easing of the nursing shortage which started over 10 years ago, now is a particularly good time for hospitals to make needed improvements that benefit nurses, address the adequacy of staffing, and support RNs’ ability to provide patient care (Buerhaus, Auerbach, & Staiger, 2009).

Payment Policy

With regard to the CMS hospital payment regulations, the results of the 2008 NSRN provide a mixed picture. While many RNs expect that this policy change will increase the emphasis on prevention and additional education and training, RNs also believe they will be blamed if adverse patient conditions occur. A clear majority think that their work will increase, and only a small percentage of RNs think the regulations will lead to added respect, more staffing, higher pay, or raise their status.

These findings should be taken in context. Because the regulations were not in effect at the time the survey was conducted, RNs’ perceptions could be quite different if the survey had been conducted after implementation of the regulations when RNs would have had direct experience with them. Thus, these results can be viewed as a baseline assessment prior to policy implementation. Hopefully, future studies will assess RNs’ experiences and their perceptions of the regulations’ impact and, by comparing results to our survey, discern whether and how RN views have changed. Because CMS intends to add additional conditions to their list of conditions for which they will eliminate payment, it is important to assess the views of RNs as they experience these changes and take actions to support them.

Nursing educators can anticipate that nurses will need to know more about payment policy and how it impacts the practice of the profession. Reducing the cost of health care is a major goal of health care and thus, in the future, nurses will be expected to play a more visible role in modifying their practice to reduce costs without harming the quality and safety of patient care. Nurses’ ability to thrive in the future will be increased if they receive a stronger education in health care economics, particularly in the areas of productivity, efficiency, and equity. Educators need to ensure that the profession has the necessary knowledge base so that RNs can align their clinical practice with the economic performance of hospitals and other health care delivery organizations. A more wellrounded education can help to ensure that the payment policy changes that have already been enacted (and those to come) do not fulfill the negative expectations held by many RNs as suggested by the 2008 NSRN. A more detailed explanation of the CMS payment change, implications for nurses, and strategies to help RNs adjust successfully are reported elsewhere (Kurtzman & Buerhaus, 2008).

Concluding Comments

Regardless of their intended or actual effects, government rules and regulations are a fact of life in general, in health care, and in the lives of nurses who provide patient care. Because the regulations described in this article are changing the organization and delivery of nursing care in hospital settings, and because it is difficult to "take back" regulations once they are in effect, RNs and policymakers should carefully think through the implications of hospital staffing ratios and payment regulations. Beyond affecting the clinical environment, both regulations will impact RNs’ economic value in the eyes of the hospitals that employ them, with the impact varying according to a hospital’s financial health and the priority given to providing high-quality care. Finally, these regulations are likely to affect how society views RNs and, here again, RNs should factor in how the image of the nursing profession may be improved or weakened by its responses to either regulatory initiative. $

Sidebar Executive Summary

• Two regulatory initiatives weigh heavily on the nursing workforce: establishing minimum patient-tonurse staffing ratios in hospitals and payment policy that eliminates payment to hospitals for negative consequences of care.
• Although the majority of RNs favor ratios, results also indicate that a good number of RNs either do not support ratios or are unsure, which suggests that while strong support for ratios exists, the support is not universal.
• With regard to the Centers for Medicare and Medicaid Services hospital payment regulations, while many RNs expect that this policy change will increase the emphasis on prevention and additional education and training, RNs also believe they will be blamed if adverse patient conditions occur.
• A clear majority think that their work will increase, and only a small percentage of RNs think the regulations will lead to added respect, more staffing, higher pay, or raise their status.
• Beyond affecting the clinical environment, both regulations will impact RNs’ economic value in the eyes of the hospitals that employ them.

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References

• Buerhaus, P. (2009). Avoiding mandatory hospital nurse staffing ratios: An economic commentary. Nursing Outlook,57(2), 107–112.
• Buerhaus, P., Auerbach, D., Staiger, D. (2009). The recent surge in nurse employment: Causes and implications (Web Exclusive, June 12, 2009). Health Affairs, w657–668.
• Buerhaus, P., Donelan, K., DesRoches, & Hess, R. (2009). Still making progress to improve the hospital workplace environment? Results from the 2008 national survey of registered nurses. Nursing Economic$, 27(5), 289–301.
• Buerhaus, P., Ulrich, B., Donelan, K., & DesRoches, C. (2008). Registered nurses’ perspectives on health care and the 2008 presidential election. Nursing Economic$, 26(4), 227–235, 257.
• Burnes Bolton, L., Aydin C., Donaldson N., Brown D., Sandhu M., Fridman, M., et al. (2007). Mandated nurse staffing ratios in California: A comparison of staffing and nursing-sensitive outcomes pre-and postregulation. Policy,Politics, & Nursing Practice, 8(4), 238–250.
• Donaldson, N., Bolton, L., Aydin C., Brown, D., Elashoff, J., & Sandhu, M. (2005). Impact of California’s licensed nurse patient ratios on unit-level nurse staffing and patient outcomes. Policy, Politics, & Nursing Practice,6(3), 198–210.
• Kane, R., Shamlivan, T., Mueller, C., Duval, S., & Wilt, T. (2007). The association of registered nurse staffing levels and patient outcomes. Systematic review and meta-analysis. Medical Care,45(12), 1195–1204.
• Kurtzman, E., & Buerhaus, P. (2008). New Medicare payment rules: Danger or opportunity for nursing. AmericanJournal of Nursing, 108(6), 30–35.
• Mark, B., Harless, D., & Spetz, J. (2009). California’s minimum-nurse-staffing legislation and nurses’ wages. HealthAffairs, 28(2), (Web Exclusive, February 10, 2009) W326–334.
• Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinsky, K. (2002). Nurse staffing and quality of care in hospitals in the United States. TheNew England Journal of Medicine,346(22), 1715–1722.
• Sochalski, J., Konetzka, R., Zhu, J., & Volpp, K. (2008). Will mandated minimum nurse staffing ratios lead to better patient outcomes? Medical Care,46(6), 606–613.
• Spetz, J. (2008). Nurse satisfaction and the implementation of minimum nurse staffing regulations. Politics, Policy & Nursing Practice, 9(1), 15–21.
• Thrall, T. (2008). Nurse staffing laws: Should you worry? Hospitals & Health Networks, 82(4), 36–39.

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Authors and Disclosures

Peter I. Buerhaus, Karen Donelan, Catherine DesRoches and Robert Hess

PETER I. BUERHAUS, PhD, RN, FAAN, is Valere Potter Professor of Nursing; Director, Center for Interdisciplinary Health Workforce Studies, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN; and a member of the Nursing Economic$ Editorial Board.

KAREN DONELAN, ScD, is Senior Scientist in Health Policy, Massachusetts General Hospital, Boston, MA.

CATHERINE DesROCHES, DrPH, is an Instructor, Institute for Health Policy, Massachusetts General Hospital, Boston, MA.

ROBERT HESS, PhD, RN, FAAN, is Executive Vice President, Continuing Education Programming, Gannett Healthcare Group, Falls Church, VA.

Acknowledgment

The study was funded by a major grant from the Johnson & Johnson National Campaign for Nursing’s Future — a national initiative aimed at increasing the number of people becoming nurses in the United States, retaining nurses in clinical practice, and expanding the capacity of the nation’s nursing education system, including increasing the supply of faculty. Johnson & Johnson played no role in the design and conduct of the study, analysis and interpretation of results, and preparation or approval of this manuscript. Financial support for the study was also received from the Gannett Healthcare Group. The authors appreciate the efforts and dedication to our program of survey research on the nursing workforce provided by Sandra Applebaum who led the fieldwork team from Harris Interactive and provided assistance in survey design throughout this project. Finally, we acknowledge Beth T. Ulrich, EdD, RN, FACHE, FAAN, for her substantial contributions to this survey.

Nurs Econ. 2009;27(6):372-376. © 2009 Jannetti Publications, Inc.

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