UCLA

Background: Surveys of nurses indicate that persistent and pervasive staffing deficits affect care delivery. A systematic review of longitudinal observational studies demonstrates that staffing levels impact patient outcomes, including mortality and length of stay. Studies of California’s mandated patient-level ratios show mixed results in improving patient outcomes, though the policy is linked to higher nurse staffing levels and greater nurse satisfaction. A quasi-experimental study conducted in Australia showed that a unit level nurse-to-patient ratio policy in medical-surgical units led to improved staffing, reduced patient mortality, and shorter length of stay. Objectives: The aim of this project is to leverage diverse perspective in an analysis of a policy that requires minimum unit-level nurse-to-patient ratios in acute care medical-surgical settings in the United States. Specifically, the project examines policy impact on staffing levels, patient length of stay and nurse attrition, and gathers input on potential unintended consequences, such as increasing healthcare costs or decreasing innovation. Methods: The Delphi Policy analysis involves inviting a diverse panel of participants to share their perspectives through a series of iterative surveys. For this project, 28 panelists including direct care nurses and health care leaders, were enrolled. Prior to completing the first survey, participants viewed a short presentation on the evidence related to ratio-based nurse staffing policy. Panelists completed the second and third surveys after reviewing the results of the prior survey. This process creates a virtual, anonymous dialogue between panel members. Results: In survey 1, participants demonstrated moderate agreement that the proposed policy would have a positive impact on staffing levels and patient length of stay, and less agreement regarding the effect on nurse attrition. Survey 1 also elicited a wide range of unintended consequences of the policy. In Survey 2, participants ranked the likelihood that these consequences would occur. In Survey 3, participants further examined the unintended consequences and the policy impact on different stakeholder groups. Results indicated an expectation that the policy will create positive change for nurses and patients, and conflicting views about the policy’s effect on healthcare costs and care delivery innovation. Conclusion: This project demonstrates that a unit-level ratio policy may benefit nurses and patients and will also have unintended consequences. Inclusion of direct-care nurses and healthcare leaders in policy development is crucial to identifying and mitigating the untended consequences that staffing policy will generate. This project also demonstrates that the Delphi policy analysis process is an effective tool for studying the divisive topic of staffing policy.