Analysis: Hospital Nurse Staffing and Quality of Case Essay

Hospitals with low nurse staffing levels tend to have higher rates of poor patient outcomes such as pneumonia, shock, cardiac arrest, and urinary tract infections, according to research funded by the Agency for Healthcare Research and Quality (AHRQ) and others. Yet increasing staffing levels is not an easy task. Major factors contributing to lower staffing levels include the needs of today’s higher acuity patients for more care and a nationwide gap between the number of available positions and the number of registered nurses (RNs) qualified and willing to fill them. This is evident from an average vacancy rate of 13 percent. This report summarizes the findings of AHRQ-funded and other research on the relationship of nurse staffing levels to adverse patient outcomes. This valuable information can be used by decisionmakers to make more informed choices in terms of adjusting nurse staffing levels and increasing nurse recruitment while optimizing quality of care and improving nurse satisfaction. continue over the next two decades. A Federal Government study predicts that hospital nursing vacancies will reach 800,000, or 29 percent, by 2020.2 The number of nurses is expected to grow by only 6 percent by 2020, while demand for nursing care is expected to grow by 40 percent. The most recent research shows a jump of 100,000 RNs, or 9 percent, in the hospital RN workforce between 2001 and 2002 because of increased demand, higher pay, and a weakening economy. However, since almost all of the Making a Difference Lower levels of hospital nurse staffing are associated with more adverse outcomes†¦Page 3 Patients have higher acuity, yet the skill levels of the nursing staff have declined†¦Page 5 Higher acuity patients and added responsibilities increase nurse workload†¦Page 5 Avoidable adverse outcomes such as pneumonia can raise treatment costs by up to $28,000†¦Page 6 Hiring more RNs does not decrease profits†¦ Page 6 Higher levels of nurse staffing could have positive impact on both quality of care and nurse satisfaction†¦ Background Periods of high vacancy rates for RNs in hospitals have come and gone, but the current shortage is different. According to a 2002 report by the workforce commission of the American Hospital Association, the nursing shortage â€Å"reflects fundamental changes in population demographics, career expectations, work attitudes and worker dissatisfaction.†1 In fact, the present situation may well Author: Mark W. Stanton, M.A. Managing Editor: Margaret Rutherford Design and Production: Frances Eisel Suggested citation: Stanton MW, Rutherford MK. Hospital nurse staffing and quality of care. Rockville (MD): Agency for Healthcare Research and Quality; 2004. Research in Action Issue 14. AHRQ Pub. No. 04-0029. increase came from RNs over age 50 who returned to the workforce and a greater influx of foreign-born RNs, this does not alter the structural features in the long term: the aging of the nurse population and the increasing unwillingness of young women to consider nursing as a profession.3 Today’s difficulties are further complicated by other changes in hospital care, such as new medical technologies and a declining average length of stay, that have led to increases in the amount of care required by patients while they are in the hospital. New medical technologies allow many less seriously ill patients who previously would have received inpatient surgical care to receive care in outpatient settings. Also, patients who in the past would have continued the early stages of their recovery in the hospital, today are discharged to skilled nursing facilities or to home. During the period 1980-2000, the average length of an inpatient hospital stay fell from 7.5 days to 4.9 days.4 An important consequence of these changes is that hospitals have a higher overall concentration of sick people who need more care. Various groups, including the American Hospital Association, the Joint Commission on the Accreditation of Healthcare Organizations, and the Institute of Medicine (IOM), have expressed their concerns about the evolving nursing crisis. The IOM issued a report in 1996 that recognized the importance of determining the appropriate nurse-patient ratios and distribution of skills for ensuring that patients receive quality health care.5 Its report highlighted the fact that research on the relationship between The nurse workforce and nurse staffing levels the level of staffing by nurses in hospitals and patients’ outcomes has been inconclusive. The IOM’s analysis of staffing and quality of care in hospitals concluded by calling for â€Å"a systematic effort †¦ at the national level to collect and analyze current and relevant data and develop a research and evaluation agenda so that informed policy development, implementation and evaluation are undertaken in a timely manner.† To begin to meet that need, AHRQ-funded research and other research have pursued a number of different paths. Hospital nurse staffing and nursing-sensitive outcomes Hospital nurse staffing is a matter of major concern because of the effects it can have on patient safety and quality of care. Nursing-sensitive outcomes are one indicator of quality of care and may be defined as â€Å"variable patient or family caregiver state, condition, or perception responsive to nursing intervention.†6 Some adverse patient outcomes potentially sensitive to nursing care are urinary tract infections (UTIs), pneumonia, shock, upper gastrointestinal bleeding, longer hospital stays, failure to rescue, and 30-day mortality.a Most research has focused on adverse rather than positive patient outcomes for the simple reason that adverse outcomes are much more likely to be documented in the medical record. a â€Å"Failure to rescue† is defined as the death of a patient with a lifethreatening complication for which early identification by nurses and medical and nursing interventions can influence the risk of death. The nurse workforce consists of licensed nurses—registered nurses (RNs) and licensed practical nurses (LPNs)—and nurses’ aides (NAs). Both RNs and LPNs are licensed by the State in which they are employed. RNs assess patient needs, develop patient care plans, and administer medications and treatments; LPNs carry out specified nursing duties under the direction of RNs. Nurses’ aides typically carry out nonspecialized duties and personal care activities. RNs, LPNs, and nurses’ aides all provide direct patient care. RNs have obtained their education through three different routes: 3-year diploma programs, 2-year associate degree programs, and 4year baccalaureate degree programs. Almost a third of all RNs have a baccalaureate degree, and 7.6 percent of hospital nurses have advanced practice credentials (either a master’s or doctoral degree). LPNs receive 12-18-month training programs that emphasize technical nursing tasks. Nurses’ aides are not licensed but many acquire certified nurse aide or nursing assistant (CNA) status after proving they have certain skills related to the requirements of particular positions. Nurse staffing is measured in one of two basic ways: †¢ Nursing hours per patient per day. †¢ The nurse to patient ratio. â€Å"Nursing hours† may refer to RNs only; to RNs and LPNs; or to RNs, LPNs, and nurses’ aides. 2 www.ahrq.gov A broad array of research on this topic has found an association between lower nurse staffing levels and higher rates of some adverse patient outcomes. A new evidence report entitled The Effect of Health Care Working Conditions on Patient Safety, produced by an AHRQfunded Evidence-based Practice Center (EPC), reviewed 26 studies on the relationship between nurse staffing levels and measures of patient safety.b Most of the studies examined nurse staffing levels and adverse occurrences in the hospital setting, including in-hospital deaths and nonfatal adverse outcomes such as nosocomial infections, pressure ulcers, or falls. The EPC’s researchers found that lower nurse-topatient ratios were associated with higher rates of nonfatal adverse outcomes.7 This was true at both the hospital level and the nursing unit level. With regard to in-hospital deaths, however, the evidence does not consistently show that lower nurse staffing levels are associated with higher mortality. The largest of these studies on nurse staffing (jointly funded by AHRQ, the Health Resources and Services Administration, the Centers for Medicare & Medicaid Services, and the National Institute of Nursing Research) examined the records of 5 million medical patients and 1.1 million surgical patients who had been treated at 799 hospitals during 1993.6,8 Among the study’s principal findings: †¢ In hospitals with high RN staffing, medical patients had lower rates of five adverse patient outcomes (UTIs, pneumonia, shock, upper gastrointestinal bleeding, and longer hospital stay) than patients in hospitals with low RN staffing. c †¢ Major surgery patients in hospitals with high RN staffing had lower rates of two patient outcomes (UTIs and failure to rescue). †¢ Higher rates of RN staffing were associated with a 3- to 12-percent reduction in adverse outcomes, depending on the outcome. †¢ Higher staffing at all levels of nursing was associated with a 2- to 25-percent reduction in adverse outcomes, depending on the outcome. Table 1 illustrates some of the major findings. For example, the researchers found that medical patients in hospitals with high RN staffing were 4-12 percent less likely to develop UTIs than medical patients in the comparison group. Lower staffing levels are linked to higher adverse outcome rates The EPC report included five studies funded by AHRQ that examined the relationship between adverse patient outcomes and hospital nurse staffing. All five studies found at least some association between lower nurse staffing levels and one or more types of adverse patient outcomes. How often do such adverse â€Å"nursing-sensitive† patient outcomes occur in hospital care? Different studies report varying adverse event rates, which vary by the type of patient (medical or surgical) as well as other factors. For example, UTIs occur in from 1.9 percent to 6.3 percent of surgical patients and pneumonia in 1.2 percent to 2.6 percent of surgical patients.8-10 b Table 1. Percent reduction in rates of outcomes among medical patients in hospitals with high nurse staffing (75th percentile) compared to the rates in hospitals with low nurse staffing (25th percentile) Amount by which rates are lower for: In order to improve the quality and delivery of health care services, AHRQ has sponsored a series of evidence reports that are based on rigorous, comprehensive reviews of relevant scientific literature. These reports are developed and written by outside research and academic organizations designated as Evidence-based Practice Centers (EPCs). The reports’ emphasis is on explicit and detailed documentation of methods, rationale, and assumptions. The goal of these reports is to provide the scientific foundation that public and private organizations can use to develop their own clinical practice guidelines, quality measures, review criteria, and other tools to improve the quality and delivery of health care services study measured RN staffing as hours per day and as the RN proportion of nursing hours. Hospitals with higher hours of RN staffing (75th percentile) had an average of 9.1 hours of inpatient RN nursing per patient day, while those with lower RN staffing (25th percentile) had an average 6.4 hours of inpatient RN nursing per patient day. Hospitals with a higher proportion of RN staffing (75th percentile) had an average of 75 percent of inpatient nursing hours provided by RNs, while those with lower RN staffing (25th percentile) had an average of 62 percent of nursing hours provided by RNs. Outcome in medical patients Urinary tract infection Upper gastrointestinal bleeding Hospital-acquired pneumonia Shock or cardiac arrest High RN staffing 4-12% 5-7% 6-8% 6-10% High staffing, all levels (RNs, LPNs, aides) 4-25% 3-17% 6-17% 7-13% c This Note: Difference is expressed as a range of values (e.g., 4-12 percent) because several statistical models were used in evaluating the relationship between nurse staffing levels and each adverse event. Source: Needleman J, Buerhaus P, Mattke S, et al. Nurse-staffing levels and patient outcomes in hospitals. Final report for Health Resources and Services Administration. Contract No. 230-99-0021. 2001. Harvard School of Public Health, Boston, MA. www.ahrq.gov 3 Medical patients in hospitals with high levels of total nurse staffing (RNs, LPNs, and aides) were 4-25 percent less likely to develop UTIs than patients in the comparison group. A similar analysis was performed for the smaller group of surgical patients (Table 2). Surgical patients in hospitals with high RN staffing had a 5-6 percent lower rate of UTIs and a 4-6 percent lower rate of failure to rescue than surgical patients in the comparison group.d Pneumonia rates are especially sensitive to staffing levels Three AHRQ-funded studies found a significant correlation between lower nurse staffing levels and higher rates of pneumonia. †¢ The first study found that adding half an hour of RN staffing per patient day could reduce pneumonia in surgical patients by over 4 percent.12 This study covered 589 hospitals in 10 States during 1993. †¢ A second study by the same researchers also found that fewer RN hours per patient day were significantly correlated with a higher incidence of pneumonia.13 The study examined administrative data on post-surgical patients in 11 States during 1990-96. †¢ A study of nurse staffing levels and adverse outcomes in California found that an increase of 1 hour worked by RNs per patient day was associated with an 8.9-percent decrease in the odds of a surgical patient’s contracting pneumonia. 8 †¢ This study also found that a 10-percent increase in RN proportion was associated with a 9.5-percent decrease in the odds of pneumonia. The researchers in the California study believe that the strong relationship between RN staffing and pneumonia can be attributed to the heavy responsibility RNs have for respiratory care in surgical patients. This study examined the effects of nurse staffing on adverse outcomes in 232 acute care hospitals from 1996 to 1999.f Unlike many earlier studies, the California study included only adverse outcomes that were not present at admission.7 Table 2. Percent reduction in rates of outcomes among surgical patients in hospitals with high nurse staffing (75th percentile) compared to the rates in hospitals with low nurse staffing (25th percentile) Amount by which rates re lower for: High staffing, all levels (RNs, LPNs, aides) 3-14% 2-12% 19% Outcome in surgical patients Urinary tract infection Failure to rescue Hospital-acquired pneumonia High RN staffing 5-6% 4-6% 11% Note: Difference is expressed as a range of values (e.g., 2-12 percent) because several statistical models were used in evaluating the relationship between nurse staffing levels and each adverse event. Source: Needleman J, Buerhaus P, Mattke S, et al. Nurse-staffing levels and patient outcomes in hospitals. Final report for Health Resources and Services Administration. Contract No. 230-99-0021. 2001. Harvard School of Public Health, Boston, MA. A second study, funded jointly by AHRQ and the National Science Foundation, examined licensed nurse staffing (RNs and LPNs) and adverse outcomes among both medical and surgical patients in Pennsylvania acute-care hospitals.11 It found a lower incidence of nearly all adverse outcomes it studied in hospitals with more licensed nurses. For example, a 10-percent increase in the number of licensed nurses is estimated to decrease lung collapse by 1.5 percent, pressure ulcers by 2 percent, falls by 3 percent, and UTIs by less than 1 percent. Also, with a 10-percent higher proportion of licensed nurses, there was a 2-percent lower incidence of pressure ulcers.e,11 d Surgical patients overall had lower rates of adverse outcomes than medical patients, perhaps because they are healthier. Also, the smaller number of surgical patients in the study may have made it more difficult to detect associations. Nurse staffing was measured in two ways: (1) the ratio of licensed nurses (RNs + LPNs) to the patient load (with and without adjustments for patient acuity) and (2) the proportion of licensed nurses to the total nursing staff (RNs, LPNs, NAs). The adverse outcomes selected for study were â€Å"either caused by or not prevented by medical management† based on criteria used by the Harvard Medical Practice Study. Nurse staffing was measured in three ways: all hours (the total number of productive hours worked by all nursing personnel per patient day), RN hours (the total number of productive hours worked by registered nurses per patient day), and RN proportion (RN hours divided by all hours).