Texas Nurse Staffing Trends Before and After Implementation of Nurse Staffing Regulations

Purpose:
Texas is the first and largest states to adopt regulations mandating nurse staffing committees; however, the empirical benefit of nurse staffing committees has not been documented. The purpose of this study is to evaluate the effects of the Texas Nurse Staffing Legislation on nurse staffing levels.

Background/Significance:
The requirement for nurse staffing committees in Texas hospitals was introduced through the rulemaking process of the state hospital licensing agent in 2004 and placed in statute in 2009. The effects of this staffing policy have not been formally evaluated. Therefore, the aims of this study include: to examine nurse staffing trends before and after adoption of the Safe Nurse Staffing Rules and SB 476, and to examine variations in nurse staffing trends based on hospital contextual factors.

Methods:
This study was a secondary analysis of cross-sectional hospital administration survey data from the American Hospital Association over 13 years (2000 to 2012). Criteria for inclusion were hospitals: located in Texas; identified as a medical-surgical hospital; with complete nurse staffing data for at least 11 of the 13 years examined. Federally owned and operated hospitals were excluded; however, no blanket exclusions were made based on bed size or average daily census. Study variables included: geographic location, size, control/ownership, adjusted patient day, and nurse staffing. No adjustments were made for the potential confounding effects of acuity or utilization of registry staff.

Results:
The 313 hospitals were diverse in size (44% small, 42% medium, and 14% large), ownership (40% non-federal government, 35% not-for- profit, and 25% for-profit), and location (54% metropolitan, 46% non-metropolitan and 8% on the Mexico border). The pre-regulation decline in median total nurse staffing reached a nadir of 7.00 HPPD in 2002; total nurse staffing peaked in 2010 at a median of 7.63 HPPD. Most hospitals (59%) experienced an increase in total staffing (5% change) post implementation. RN HPPD increased in 69% of hospitals (median change of .96) but LVN HPPD decreased in 81% of hospitals (median change of-.51). RN skill mix increased in 80% of hospitals (median change of .07).

Conclusions and Implications for Practice:
The modest increase in total staffing is insufficient to support widespread adoption of mandated nurse staffing committees. More research is needed to determine how nurse staffing committees, patient acuity, and workforce shortages may have contributed to the observed patterns.