26 Years of Research demonstrates more nursing equals better outcomes

8/10/2019 26 Years of Research demonstrates more nursing equals better outcomes.

1/7

26 years of research: A mounting volume of evidence clearlydemonstrates the strong relationship between RN staffing and betterpatient outcomes particularly in reducing complications and death.Also, enhancing nurse staffing does not pose a significant cost forhospitals and in fact may result in cost savings:

As early as 1988, researchers found associations between nurse staffing anddevelopment of hospital-acquired infections. (Flood & Diers 1988).

In "one of the clearest demonstrations to date of the impact of nursing staffing onoutcomes for both patients and nurses in acute care hospitals," (Clarke & Aiken2003), a study in the Journal of the American Medical Association, analyzed datafrom 168 Pennsylvania hospitals. After adjusting for patient and hospitalcharacteristics, each additional patient beyond four per nurse resulted in a 7%greater likelihood of dying within 30 days of admission and a 7% increase in thelikelihood of failure to rescue. (Aiken, Clarke, Sloane, Sochalski & Silber, 2001).

In a study published in the New England Journal of Medicine, data from 799hospitals in 11 states, including 5,075,969 medical discharges and 1,104,659surgical discharges revealed that among medical patients, a higher proportion ofhours of nursing care per day provided by RNs and a greater total number of hoursof nursing care per day provided by RNs were associated with a shorter length ofstay, lower rates of urinary tract infections and upper gastrointestinal bleeding. Ahigher proportion of hours of care provided by RNs was also associated with lowerrates of pneumonia, shock or cardiac arrest and failure to rescue. Among surgicalpatients, a higher proportion of nursing care provided by RNs was associated withlower rates of urinary tract infections. A greater number of RN hours of care perday was associated with lower rates of failure to rescue. The authors summarizetheir findings, in part, by noting their estimate that patients treated in whosestaffing placed them in the upper quarter of hospitals studied)have lengths of stay3-5% shorter and rates of complication 2-9% lower than those with RN staffing inthe lower quarter of hospitals in the study. (Needleman, Buerhaus, Mattke,Stewart & Zelevinsky, 2002a, 2002b).

A study of 1609 hospital reports of sentinel events (unanticipated events thatresult in death, injury or permanent loss of function), found that 24% of suchevents were attributed to nurse staffing levels (Joint Commission on Accreditationof Healthcare Organizations, 2002).

Discharge data from 589 acute-care hospitals in 10 states, finding a large and

significant inverse relationship between full-time equivalent RNs per adjustedinpatient day (RNAPD) and two post-surgical complications urinary tractinfections and pneumonia. (Kovner & Green, 1988).

Data from 42 units in a large university hospital found that a higher proportion ofRN hours of care was associated with hospital unit rates of medication errors,pressure ulcers and patient complaints. Total nursing hours of care were


2/7

associated with lower rates of pressure ulcers, patient complaints and mortality.(Blegen, Goode & Reed, 1998).

A study of 3763 U.S. hospitals found a decrease in mortality rates as staffingincreased for registered nurses (Bond, Raehl, Petterle & Franke 1999).

Hospital data from New York and California showed significant relationshipsbetween RNs per adjusted patient days and incidence of urinary tract infections,pneumonia, pressure ulcers and a weaker but significant relationship to thrombosisand pulmonary complications. (Lichtig, Knauf & Milholland, 1999)

A study of 28 university hospitals that had undergone restructuring found anincrease in the rate of patient falls as patient-to-nurse ratios increased. (Sovie andJawad, 2001).

Patients undergoing abdominal aortic surgery who were cared for in ICUs withnurse:patient ratios of 1:3 or more averaged 49% greater lengths of stay in theICU.. (Pronovost, Jenckes, Dorman, Garrett, Breslow, Rosenfeld, et al.1999).

Data for 118,940 patients hospitalized with acute myocardial infarction showedlower likelihood of in-hospital mortality for patients treated in hospitals withhigher RN staffing levels. (Person, Allison, Kiefe, Weaver, Williams, Centor, et al.,2004).

Data from hospitals in states participating in the National Inpatient Sample (NIS)maintained by the federal Agency for Healthcare Research and Quality showedthat higher levels of nurse staffing were associated with lower rates of pneumonia.(Kovner, Jones, Zhan, Gergen & Basu (2002).

An increase of 1 hour of RN care per patient day in California hospitals wasassociated with an 8.9% decrease in the odds of pneumonia. A 10% increase in

proportion of RNs was associated with a 9.5% decrease in the odds of pneumonia.(Cho, Ketefian, Barkauskas & Smith 2003). Rates of bloodstream infections related to central venous catheter use in eight

intensive care units were significantly associated with the use of float nurses(Alonso-Echanove, Edwards, Richards, Brennan, Venezia, Keen, et al., 2003).

Data from 1751 units in hospitals participating in the National Database of NursingQuality Indicators found that higher rates of patient falls were associated bothwith fewer nursing hours per patient day and a lower percentage of RNs. (Dunton,Gajewski, Taunton & Moore, 2004).

In a study of 19 teaching hospitals in Ontario, Canada, a lower proportion of RNsemployed on a hospital nursing unit was associated with higher numbers ofmedication errors and wound infections. (McGillis Hall, Doran & Pink 2004).

A nurse-patient ratio of 1:2 was associated with a higher incidence of unplannedextubation relative to a nurse-to-patient ratio of 1:1. (Marcin, Rutan, Rapetti,Brown, Rahnamayi & Pretzlaff).

Analyzing data from two large hospital studies compared nurse staffing levelsranging from four to eight patients per nurse, mortality among medical and


3/7

surgical patients decreased as staffing increased. (Rothberg, Abraham, Lindenauer& Rose, 2005).

Other important factors that have been examined include level of education(Aiken, Clarke, Cheung, Sloane & Silber, 2003; Estabrooks, Midodzi, Cummings,Ricker & Giovanetti, 2005) and experience level (Tourangeau, Giovanetti, Tu &Wood, 2002; Blegen, Vaughn & Goode 2001).

Additional research has pointed to the association between the use of floatnurses (nurses assigned to units outside of their usual specialty areas) and greaterincidence of bloodstream infections among intensive care unit (ICU) patients withcentral venous catheters (Alonso-Echanove, Edwards, Richards, Brennan, Venezia,Keen, et al., 2003).

An analysis of outcomes data for 18,142 patients discharged from 49 acute carehospitals in Alberta, Canada, found an association between higher proportion ofcasual or temporary (such as agency) nurses and 30-day mortality rates(Estabrooks, Midodzi, Cummings, Ricker & Giovanetti, 2005).

A study evaluating nurse staffing for every nursing shift in 43 hospital units at onehospital found that staffing of RNs below target levels was associated withincreased mortality. High patient turnover -- admissions, discharges and transfers -- during a shift also was linked with greater risk of patient deaths. (Needleman,Jack, Buerhaus, Peter, Pankratz, et al., 2011).

Evidence suggests that improving nurse work environments in hospitals could resultin improved patient outcomes, including better patient experiences and highersatisfaction ratings. Patient-to-nurse ratios in hospitals do affect patientsatisfaction ratings and recommendation of the hospital to others. (Kutney-Lee,McHugh, Sloane, Cimiotti, et al., 2009).

This systematic review and meta-analysis revealed consistent evidence that anincrease in Registered Nurse (RN) to patient ratios was associated with a reductionin hospital-related mortality, failure to rescue, and other nurse-sensitiveoutcomes, as well as reduced length of stay. An increase in total nurse hours perpatient day was associated with reduced hospital mortality, failure to rescue, andother adverse events. (Kane, Shamliyan, Mueller, Duval, & Wilt, 2007).

Research suggests that improved registered nurse staffing has a beneficial effecton patient outcomes. Conversely, research shows that the likelihood of bothoverall patient mortality (i.e., in-hospital death) and mortality following acomplication (failure to rescue) increases by 7% for each additional patient addedto the average registered nurse workload.(Aiken, Clark, Sloan, Sochalski & Silber,2002).

Results from a sample of Pennsylvania hospitals indicates that increased nursestaffing is associated with reductions in atelectasis (lung collapse), decubitusulcers, falls, and urinary tract infections. (Unruh, 2003).


4/7

Hospital nurses reporting higher workloads in a survey were more likely to reportmore frequent medical errors and patient falls occurring in their units. (Sochalski,

2004). The number of hours worked by RNs is an important factor in the rate of medical

errors. Odds of making an error during a shift of 12.5 hours or longer is over threetimes as great as during a shift of 8.5 hours or less.Rogers, Hwang, Scott, Aiken,Dinges, 2004).

The Institute of Medicine, in a study of the nursing work environment,recommends that the length of nursing shifts be limited to 12 hours in any 24 hourperiod, whether mandatory or voluntary. (Institute of Medicine (2004).

Lichtig, Knauf & Milholland (1999) suggested that by decreasing adverse outcomes(particularly those that are likely to result in increased length of stay), increasedRN staffing could result in modestly decreased hospital costs.

Earlier, Flood & Diers (1988) had similarly suggested an association betweenstaffing levels and lower hospital costs resulting from decreased rates ofnosocomial infections.

More recently, Needleman and his colleagues (2006) examined the data used intheir 2002 study in order to determine the impact on hospital costs of differentadjustments in nurse staffing. Under different potential staffing scenarios, theyfound that increasing overall hours of nursing care (irrespective of overall skillmix) would lead to a significant reduction in length of stay, patient deaths andother adverse outcomes, at net increase of hospital costs of 1.5% percent or less.Increasing RN hours as a proportion of nursing hours without increasing overallnursing hours (i.e., increasing skill mix while holding nurse staffing hours steady)was associated with a small net reduction in costs.

A study of patient mortality and length of stay data from two large hospital studiescompared staffing ratios ranging from 8:1 to 4:1 and noted the cost-effectivenessof increased nurse staffing. Savings from shortened length of stay improved thecost-effectiveness of increased staffing, although the savings only offset half ofthe increased labor costs. Savings resulting from decreased length of stay would

largely accrue to payers, such as health insurers, while hospitals would incur thecosts of additional staffing. (Rothberg, Abraham, Lindenauer & Rose, 2005).


5/7

1. Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J., & Silber, J.H. (2002). Hospital nurse staffingand patient mortality, nurse burnout and job dissatisfaction. Journal of the American MedicalAssociation, 288, 1987-1993.

2. Amaravadi, R.K., Dimick, J.B., Pronovost, P.J., & Lipsett, P.A. (2000). ICU nurse-to-patient ratio isassociated with complications and resource use after esophagectomy. Intensive Care Medi cine,

26, 1857-1862.3. Barkell, N.P., Killinger, K.A., & Schultz, S.D. (2002). The relationship between nurse staffing

models and patient outcomes: A descriptive study. Outcomes Manage ment, 6, 27-33.4. Behner, K.G., Fogg, L.F., Fournier, L.C., Frankenbach, J., & Robertson, S.B. (1990). Nursing

resource management: Analyzing the relationship between costs and quality in staffingdecisions. Healthcare Management Review, 15, 63-71.

5. Bloom, J.R., Alexander, J.A., & Nuchols, B.A. (1997). Nurse staffing patterns and hospitalefficiency in the United States. Social Science & Medicine, 44, 145-155.

6. Cho, S.H., Ketefian, S., Barkauskas, V.H., & Smith, D.G. (2003). The effects of nurse staffing onadverse events, morbidity, mortality, and medical costs. Nursing Research, 52, 71-79.

7. Cummings, G., & Estabrooks, C. (2003). The effects of hospital restructuring that included layoffson individual nurses who remained employed: A systematic review of impact. InternationalJournal of Sociology and Social Policy, 8/9, 8-53.

8. Dimick J.B., Swoboda, S.M., Pronovost, P.J., & Lipsett, P.A. (2001). Effect of nurse-to-patientratio in the intensive care unit on pulmonary complications and resource use after hepatectomy.American Journal of Critical Care, 10, 376-382.

9. Dimick J.B., Swoboda, S.M., Pronovost, P.J., & Lipsett, P.A. (2001). Effect of nurse-to-patientratio in the intensive care unit on pulmonary complications and resource use after hepatectomy.American Journal of Critical Care, 10, 376-382.

10. Edbrooke, D., Stevens, G.V., Hibbert, C., Mann, A., & Wilson, A. (1997). A new method ofaccurately identifying costs of individual patients in intensive care: The initial results. IntensiveCare Medicine, 23, 645-650.

11. Estabrooks, C.A., Goel, V., Thiel, E., Pinfold, P., Sawka, C., & Williams, I. (2001). Decision aids: Arethey worth it? A systematic review. Journal of Health Services Research Policy, 6, 170-182.

12. Estabrooks, C.A., Midodzi, W.K., Cummings, G.G. Ricker, K.L., & Giovannetti, P. (2005).Determining the impact of hospital nursing characteristics on 30-day mortality among patientsin Alberta acute care hospitals. Nursing Research, 54(2), 74-84.

13. Flood, S., & Diers, D. (1988). Nurse staffing, patient outcome, and cost. Nursing Management,19, 34-43.

14. Gyldmark, M. (1995). A review of cost studies of intensive care units: Problem with the costconcept. Critical Care Medicine, 23, 964-972.

15. Hannan, E.L, Racz, M.J., Jollis, J.G., & Peterson, E.D., (1997). Using Medicare claims data toassess provider quality for CABG surgery: Does it work well enough? Health Services Research,31, 659-678.

16. Heinz, D. (2004). Hospital nurse staffing and patient outcomes: A review of current literature.Dimensions of Critical Care Nursing, 23, 44-50.


6/7

17. Institute of Medicine (2004) Keeping Patients Safe: Transforming the Work Environment ofNurses. Washington, D.C., National Academies Press, p.237.

18. Kane, R.L., Shamliyan, T., Mueller, C., Duval, S., and Wilt, T.J. (2007). Nurse Staffing and Qualityof Patient Care. Agency for Healthcare Research and Quality. AHRQ Publication 07-E005.

19. Kovner, C.T., Mezey, M., & Harrington, C. (2002). Who cares for older adults? Workforceimplications of an aging society. Health Affairs, 21, 78-89.

20. Kunen, J. (1996). The new hands-off nursing. Time, 148, 56-57.21. Kutney-Lee, A, McHugh, M.D., Sloane, D.M., Cimiotti, J.P., Flynn, L., Felber Neff, D., and Aiken,

L.H. (2009). Nursing: A Key to Patient Satisfaction. Health Affairs 28 (4), 669-677.22. Lange, T.A., Hodge, M., Olson, V., Romano, P.S., & Kravitz, R.L. (2004). Nurse-patient ratios: A

systematic review on the effects of nurse staffing on patient, nurse employee, and hospitaloutcomes. Journal of Nursing Admin istra tion, 34, 326-337.

23. Lassnigg, A., Hiesmayr, M.J., Bauer, P., & Haisjackl, M. (2002). Effect of centre-, patient- andprocedure-related factors on intensive care resource utilization after cardiac surgery. IntensiveCare Medicine, 28, 1453-1461.

24. Lawthers, A.G., McCarthy, E.P., Davis, R.B., Peterson, L.E., Palmer, R.H., & Iezzoni, L.I. (2000).Identification of in-hospital complications from claims data. Is it valid? Medical Care, 38, 785-795.

25. Lee, T.Y., Yeh, M.L., Chen, H.H., & Lien, G.H. (2004). The skill mix practice model for nursing:Measuring outcome. Journal of Advanced Nursing, 51, 406-413.

26. Lichtig, L.K., Knauf, R.A., & Milholland, D.K. (1999). Some impacts of nursing on acute carehospital outcomes. Journal of Nursing Administration, 29, 25-33.

27. Marik, E.P., & Hedman, L. (2000). What is a day? Determining intensive care unit length ofstay.Critical Care Medicine, 28, 2090-2093.

28. Mark, B.A., Harless, D.W., McCue, M., & Xu, Y. (2004). A longitudinal examination of hospitalregistered nurse staffing and quality of care. Health Services Research, 39, 279-300.

29. McCue, M., Mark, B.A., & Harless, D. (2003). Nurse staffing, quality, and financial performance.Journal of Healthcare Finance, 29(4), 54-76.

30. McGillis Hall, L., Doran, D., & Pink, G.H. (2004). Nurse staffing models, nursing hours, and patientsafety outcomes. Journal of Nursing Administration, 34, 41-45.

31. Meijers, J., Janssen, M., Cummings, G.G., Wallin, L., Estabrooks, C., & Halfens, R. (2006).Assessing the relationships between contextual factors and research utilization in nursing: Asystematic literature review. Journal of Advanced Nursing, 55(5), 623-635.

32. Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinsky, K. (2002). Nurse-staffinglevels and the quality of care in hospitals. New England Journal of Medicine, 346, 1715-1722.

33. Needleman, J., Buerhaus, P.I., Mattke, S., Stewart, M., & Zelevinsky, K. (2003). Measuringhospital quality: Can Medi care data substitute for all-payer data? Health Services Research, 38,1487-508.

34. Needleman, J., Buerhaus, P., Stewart, M., Zelevinsky, K., & Mattke, S. (2006). Nurse-staffing inhospital: Is there a business case for quality. Health Affairs, 25, 204-211.


7/7

35. Needleman, Jack, Buerhaus, Peter, Pankratz, V. Shane, Leibson, Cynthia L., Stevens, Susanna R.,Harris, Marcelline (2011). Nurse Staffing and Inpatient Hospital Mortality. New England Journalof Medicine (364:11), 1037-1045.

36. Newhouse, P.R., Johantgen, M., Pronovost, J.P., & Johnson, E. (2005). Perioperative nurses andpatient outcomes Mortality, complications, and length of stay. AORN Journal, 81(3), 513-522,525-528.

37. Norrish, B.R., & Rundall, T.G. (2001). Hospital restructuring and the work of registered nurses.The Milbank Quarterly, 79, 55-79.

38. Pratt, R., Burr, G., Leelarthaepin, B., Blizard, P., & Walsh, S. (1993). The effects of All-RN and RN-EN staffing on the quality and cost of patient care. The Australian Journal of Advanced Nurs ing,10, 27-39.

39. Pronovost, P.J., Jenckes, M.W., Dorman, T., Garrett, E., Breslow, M.J., Rosenfeld, B.A., et al.(1999). Organizational characteristics of intensive care units related to outcomes of abdominalaortic surgery. Journal of the American Medical Association, 281, 1310-1317.

40. Rogers, A.E., Hwang, W., Scott, L.D., Aiken, L.H., Dinges, D.F. (2004). The Working Hours ofHospital Staff Nurses and Patient Safety. Health Affairs, 23(4), 202-12.

41. Rothberg, M.B., Abraham, I., Lindenauer, P.K.& Rose, D.N. (2005). Improving Nurse to PatientStaffing Ratios as a Cost Effective Safety Intervention. Medical Care, 43(8), 785-91.

42. Schultz, M.A., Van Servellen, G., Chang, B.L., McNeese-Smith, D., & Waxenberg, E. (1998). Therelationship of hospital structural and financial characteristics to mortality and length of stay inacute myocardial infarction patients. Outcomes Management Nurse Practice, 2, 130-136.

43. Sochalski, J. (2004). Is More Better? The Relationship Between Hospital Staffing and the Qualityof Nursing Care in Hospitals. Medical Care, 42(2 Suppl.) 1167-73.

44. Tourangeau, A.E., Giovannetti, P., Tu, J.V., & Wood, M. (2002). Nursing-related determinants of30- day mortality for hospitalized patients. Canadian Journal of Nursing Research, 33(4), 71-88.

45. Unruh, L. (2003). Licensed Nurse Staffing and Adverse Events in Hospitals. Medical Care, 41(1),142-52.

46. Woods, N.F., & Catanzaro, M. (1988). Nursing research: Theory and practice. St. Louis:Mosby

Documents

26 Years of Research demonstrates more nursing equals better outcomes