A number of researchers studying hospital staffing levels and patient outcomes have found that evidence does not yet exist to indicate the necessary (minimum) or ideal (optimal) staffing across the various types of hospital inpatient care units (Bolton et al., 2001; Kovner et al., 2002; Spetz et al., 2000). The Agency for Healthcare Research and Quality (AHRQ) evidence report Making Health Care Safer: A Critical Analysis of Patient Safety Practices also finds that, for acute hospital care, “… there is no definitive evidence as to specific thresholds for RN or total nursing staff hours per patient day, or nursing skill mix for various patient populations or nursing unit types” (Seago, 2001:429). The committee agrees that generalizing the results of studies of the effects of hospital-wide staffing on patient safety to specific types of hospital units is inappropriate. We believe nurse staffing regulations should be based on evidence that demonstrates the effect of specific staffing levels (including skill mix) on patient safety within specific patient care units.

Second, federal and state governments already regulate nursing home staffing levels, as described previously. Although a few states regulate hospital nurse staffing levels for specific types of patient care units (e.g., ICUs and labor and delivery units), none currently regulate all the different types of patient care units found in hospitals. California has proposed regulating hospital staffing for all patient care units; the nurse staffing ratios that California hospitals will be required to meet are scheduled to take effect in January 2004. These standards call for certain licensed nurse staffing levels in all hospital patient care units (the state already has hospital staffing requirements for some patient care units, such as ICUs, ORs, and nursery units). However, the regulations do not require the nurses to be RNs as opposed to LPNs/LVNs. California’s regulations allow “sufficient flexibility in the type of nurse to be used … determined by nursing scope of practice and patient acuity” (Office of the Governor, 2002).

Based on the above considerations, the committee makes the following recommendation:

Recommendation 5-1. The U.S. Department of Health and Human Services (DHHS) should update existing regulations established in 1990 that specify minimum standards for registered and licensed nurse staffing in nursing homes. Updated minimum standards should:

  • Require the presence of at least one RN within the facility at all times.

  • Specify staffing levels that increase as the number of patients increase, and that are based on the findings and recommendations of the DHHS report to Congress, Appropriateness of Mini-



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