The Effects of Different Types of State Nurse Staffing Laws on Hospital Staffing in United States

As of 2018, 14 states addressed hospital nurse staffing in laws: California and Massachusetts mandate minimum nurse-to-patient ratios, seven states (Illinois, Washington, Ohio, Oregon, Connecticut, Nevada, and Texas) require establishment of hospital-wide nurse-driven staffing committees to develop nurse staffing plans, and six states (Illinois, New Jersey, New York, Rhode Island, Vermont, and Minnesota) require some form of disclosure and/or public reporting of nurse staffing levels. Most prior research focused on a single state and a single type of law. Studies that evaluate spill-over effects of these laws on other staff are also limited. This study is the first to compare all three types at the national level, and to examine the potential spillover effects on physicians and assistive personnel. Using fifteen years of national data (2002-2016) from the American Hospital Association Annual Survey that documents hospital-wide staffing information, we employed a difference-in-difference approach to compare changes in registered nurse (RN), licensed practical nurse (LPN), nursing assistive personnel (NAP), and physician staffing levels in the state with a mandate, states with required staffing committees, and states with required public reporting to changes in outcomes in states that did not implement any of these laws during the same period. We excluded Illinois and Massachusetts because Illinois’ law requires both staffing committees and public reporting, and Massachusetts’ staffing mandate both because it was limited to ICUs and because while it was enacted in 2014, the deadline for compliance was January 2017. We measured staffing level using productive hours per patient day. We used propensity score weighting to balance hospital characteristics between treatment and comparison groups. Our multivariate linear regression models controlled for hospital characteristics and state level supply of health professionals. We included hospital fixed effects to control for time-invariant characteristics of hospitals and unobserved factors and year fixed effects to account for temporal variation in outcomes that affect all hospitals. The results show that there was a 0.88 increase in RN hours per patient day, a 0.24 increase in NAP hours and a 0.12 decrease in physician hours among California’s hospitals after the mandate was implemented, compared to the change among hospitals in states without laws. States with a staffing committee also saw a decrease of 0.06 physician hours in the post-implementation period compared to states without laws. There were no differences in RN, NAP, or physician staffing in states with staffing committee or public reporting compared to states without laws after the law was implemented. None of the laws was associated with changes in LPN hours. These findings suggest that neither the staffing committee nor the public reporting laws appear to be an effective alternative approach to mandates. States continue to explore ways to ensure adequate staffing levels, most recently in November 2018, when Massachusetts voters defeated a referendum that would have installed a mandate like California. A better understanding of alternative approaches to mandates, as well as the potential spill-over effects of different types of laws, will help inform these policy conversations.