Testimony of Sean Clarke, FAAN, PhD, RN Executive Vice-Dean, NYU Rory Meyers School of Nursing to NYS Department of Health Stakeholder Engagement Session on Staffing Enhancements to Improve Patient Safety | October 24, 2019

As the New York State Department of Health is reviewing staffing enhancements in relation to patient safety and the quality of healthcare service delivery, I write to share my expertise in this subject and highlight relevant research on this topic. I am a nurse researcher and currently serve as Executive Vice-Dean and Professor at the New York University (NYU) Rory Meyers College of Nursing. As of this year, I have been involved in research on nurse workforce and patient safety issues, as well as specifically nurse staffing matters, for two decades. I was the lead data analyst and first coauthor on one of the most influential research papers on staffing in the literature (published in Journal of the American Medical Association in 2002). At this point in my career I have authored and coauthored dozens of articles and given dozens of invited talks on staffing research and policy related to staffing.

Anyone with first-hand experience of health care has always known that nurse staffing matters. When patient loads are excessive, nurses can become unable to deliver high quality care. These perceptions have some backing in research, beginning with the first modern-era study of the associations between outcomes and nurse staffing in US hospitals published by my NYU colleague, Professor Christine Kovner in 1998. No one argues anymore that nurse staffing makes a difference in patient outcomes: much of the daily work of nurse managers and executives in health care organizations across the state goes into ensuring that there are enough of the right nurses in the right places to ensure safe care.

That being said, there are many misunderstandings about the research literature in this area. While all agree that a considerable number of studies have suggested a connection between nurse staffing and outcomes, not all published articles in this area show this link. Furthermore, there is debate and disagreement about how large the effects are, and to what extent the effects found, reflect the importance of ratios per se in the actual work of nurses as opposed to related factors. If other factors linked with staffing explain some of the effects that researchers have seen, it is quite possible that increasing staffing alone won’t improve patient safety. It should also be highlighted that the literature does not speak directly to the question of what levels of staffing from shift to shift are safe, probably because institution, unit and patient variables are so important to making a certain staffing level appropriate, too lean, or wasteful. Finally, as others have stated, evidence to date has been contradictory (and mostly negative) on the question of whether the California initiative has produced benefits for patients in that state.

I would urge the NYS Department of Health and others weighing the question of regulating nurse staffing ratios to be cautious about assuming who within the profession supports and who does not support strict regulation of staffing. Front-line or direct care clinicians are divided, as are academics and scholars, regarding their beliefs on the appropriateness of this policy strategy and whether the benefits outweigh costs. I would similarly urge that any decisions about the regulation of nurse staffing be informed by an understanding of the extensive “grey zones” in the research literature, particularly where the lines between safe and unsafe staffing levels lie. I would further recommend detailed consideration regarding where in the state reimbursement rates are likely insufficient to cover for staffing at proposed levels, as well as what outcomes will actually be improved in relation to potential decreases in availability of services, especially if tight controls are proposed.

I thank the Department for the opportunity to provide feedbackon the research conductedaround nurse staffing issues and would welcome any questions the Department has throughout their review. (Please contact Jennifer Pautz, Senior Director of Government Affairs for NYU, jennifer.pautz@nyu.edu).