An Examination of Hospital Nurse Staffing and Patient Experience with Care

Differences Between Cross-Sectional and Longitudinal Estimates

Published in: Health Services Research, 2016

Posted on RAND.org on March 02, 2016

by Grant R. Martsolf, Teresa B. Gibson, Richele Benevent, H. Joanna Jiang, Carol Stocks, Emily D. Ehrlich, Ryan Kandrack, David I. Auerbach

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Research Question

  1. How much do nurse staffing levels and skill mix affect hospital patients' care experiences?

OBJECTIVE: To study the association between hospital nurse staffing and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. DATA SOURCES: State hospital financial and utilization reports, Healthcare Cost and Utilization Project State Inpatient Databases, HCAHPS survey, and American Hospital Association Annual Survey of Hospitals. STUDY DESIGN: Retrospective study using cross-sectional and longitudinal models to estimate the effect of nurse staffing levels and skill mix on seven HCAHPS measures. DATA COLLECTION/EXTRACTION METHODS: Hospital-level data measuring nurse staffing, patient experience, and hospital characteristics from 2009 to 2011 for 341 hospitals (977 hospital years) in California, Maryland, and Nevada. PRINCIPAL FINDINGS: Nurse staffing level (i.e., number of licensed practical nurses and registered nurses per 1,000 inpatient days) was significantly and positively associated with all seven HCAHPS measures in cross-sectional models and three of seven measures in longitudinal models. Nursing skill mix (i.e., percentage of all staff who are registered nurses) was significantly and negatively associated with scores on one measure in cross-sectional models and none in longitudinal models. CONCLUSIONS: After controlling for unobserved hospital characteristics, the positive influences of increased nurse staffing levels and skill mix were relatively small in size and limited to a few measures of patients' inpatient experience.

Key Findings

  • In cross-sectional models, nurse staffing levels were positively associated with all HCAPHS (Hospital Consumer Assessment of Healthcare Providers and Systems) measures.
  • When analyzing data over time, however, the effects were smaller, and only the HCAHPS measures on discharge information, communication about medicines, and hospital recommendations were positively associated with staffing levels.
  • Better nurse staffing levels may be a factor in higher scores on some HCAHPS measures but the effect is likely small.

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