In the News
A new study provides support for something nurses have long suspected (and research has borne out): adequate nurse staffing makes for better patient outcomes. The retrospective observational study showed that even in a generally well-staffed hospital, below-target nurse staffing and high patient turnover are independently related to patients' risk of death.
Marcelline Harris, a nurse and research scientist at the Mayo Clinic in Rochester, Minnesota, and her colleagues used data from a large tertiary academic medical center to examine the relationship between patients' risk of dying and their exposure to nursing shifts (on general care, critical care, and step-down units) during which staffing by RNs was at least eight hours below the established staffing target. They also studied the association between mortality and patient turnover. Data on 197,961 admissions and 176,696 eight-hour nursing shifts on 43 hospital units were analyzed. (Many other factors that might increase patient mortality rates were controlled for.)
Although actual staffing was close to target levels on all units, on 15.9% of all shifts, staffing by RNs was eight or more hours below target. Patient turnover was high on 6.9% of shifts. The mortality rate increased significantly with exposure to shifts with below-target RN staffing and high turnover. "The risk of death," according to the authors' estimates, "increased by 2% for each below-target shift and 4% for each high-turnover shift to which a patient was exposed."
Previous studies on this topic have been criticized for flaws in methodology. "In this era of cost containment in hospitals, nurse staffing is going to be under increased scrutiny, and we felt a rigorous study was needed," Harris explained in an interview with AJN. The current study "provides the strongest evidence to date," she said, because the analysis is based on patient-level data that make it possible to show a direct link between nurse staffing and individual patient experiences.
The findings underscore the importance of targeting nurse staffing to patients' needs, and "nurses must be very involved" in discussions of how to do so, Harris said. "Nurses, physicians, and administrators at every hospital have to engage in a common dialog about staffing needs to achieve high-level patient outcomes" at their institutions, she said, adding that efforts are also needed "to find ways to reimburse hospitals, so that they're rewarded for meeting patients' needs for nursing care."
The study "adds a new dimension to our understanding of the relationship between nurse staffing and patient outcomes," said Matthew D. McHugh, assistant professor of nursing at the University of Pennsylvania School of Nursing in Philadelphia, in an e-mail to AJN. "In addition to [showing] the importance of having adequate overall staffing levels," said McHugh, who wasn't involved in the study, "the findings point to the significance of considering management of flow and workload consistently within a given hospital."
Another recent study also found staffing issues to be critical factors in patient outcomes. This study compared U.S. hospitals ranking either in the top or bottom 5% in risk-standardized mortality rates among patients with acute myocardial infarction (AMI). Hospitals with better performance were characterized by shared organizational values and goals, senior management involvement, broad staff presence and expertise in AMI care, communication and coordination among groups, and problem solving and learning. In interviews with hospital staff, nurses at hospitals with better performance were described as "central to improvement efforts" and "empowered to challenge the status quo."—Karen Rosenberg