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The impact of California's staffing mandate and the economic recession on registered nurse staffing levels: A longitudinal analysis

  • Author Footnotes
    1 Present address: Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, 3500 Victoria Street, Pittsburgh, PA 15261.
    Andrew Dierkes
    Correspondence
    Corresponding author: Andrew Dierkes, Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, 3500 Victoria Street, Pittsburgh, PA 15261.
    Footnotes
    1 Present address: Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, 3500 Victoria Street, Pittsburgh, PA 15261.
    Affiliations
    Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PA
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  • Author Footnotes
    2 Present address: Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles, Pasadena, CA 91101.
    Duy Do
    Footnotes
    2 Present address: Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles, Pasadena, CA 91101.
    Affiliations
    Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PA
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  • Haley Morin
    Affiliations
    Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PA
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  • Author Footnotes
    3 Present address: School of Nursing, Widener University, One University Pl, Chester, PA 19013.
    Monica Rochman
    Footnotes
    3 Present address: School of Nursing, Widener University, One University Pl, Chester, PA 19013.
    Affiliations
    Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PA
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  • Author Footnotes
    4 Present address: Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, 418 Curie Boulevard, Philadelphia, PA 19104.
    Douglas Sloane
    Footnotes
    4 Present address: Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, 418 Curie Boulevard, Philadelphia, PA 19104.
    Affiliations
    Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PA
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  • Author Footnotes
    4 Present address: Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, 418 Curie Boulevard, Philadelphia, PA 19104.
    Matthew McHugh
    Footnotes
    4 Present address: Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, 418 Curie Boulevard, Philadelphia, PA 19104.
    Affiliations
    Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PA
    Search for articles by this author
  • Author Footnotes
    1 Present address: Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, 3500 Victoria Street, Pittsburgh, PA 15261.
    2 Present address: Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles, Pasadena, CA 91101.
    3 Present address: School of Nursing, Widener University, One University Pl, Chester, PA 19013.
    4 Present address: Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, 418 Curie Boulevard, Philadelphia, PA 19104.
Published:December 15, 2021DOI:https://doi.org/10.1016/j.outlook.2021.09.007

      Highlights

      • California is the only state with a minimum hospital nurse staffing mandate.
      • Postmandate, staffing improved faster in California than in other states.
      • During the Great Recession, nurse staffing was stable in California hospitals.
      • Hospital nurse staffing declined in other states during the Great Recession.
      • Entropy balancing helped account for systematic differences in California hospitals.

      Abstract

      Background

      Despite the importance of adequate hospital nurse staffing, California is the only state with minimum nurse-to-patient ratio mandates. The health care workforce is historically “countercyclical”—exhibiting growth during economic recessions when employment in other sectors is shrinking.

      Purpose

      This study was to examine how staffing mandates impact hospital nurse staffing during economic recessions.

      Method

      We compared hospital nurse staffing in California and in other states over 20 years to examine differences before and after the California mandate and, within the postmandate period, before, during, and after the Great Recession of 2008.

      Findings

      Staffing differences increased during the postmandate period due to faster growth in California staffing compared to other states, except during the Great Recession, when staffing remained stable in California but declined in other states.

      Discussion

      State legislators deliberating staffing mandates should consider the protective factor such policies provide during economic recessions and the implications for the quality and safety of care.

      Keywords

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