Patient Turnover and Nursing Staff Adequacy

Lynn Unruh, PhD, RN, LHRM

Myron D. Fottler, PhD

AcademyHealth Annual Research MeetingSan Diego, June 6-8, 2004

Research Problem

Common hospital nurse staffing measures:

nurses or hours of nursing care

patients or patient days of care

Need to also consider intensity of nursing care Staffing needs vary with the amount and type of care

provided for each of those patients

Research Problem

An ideal measure of nursing staff adequacy should indicate the volume of nurses of a certain skill level that is necessary for the given volume of patients given the intensity of nursing care required for those patients during their stay:

# of RNs

# of patient days X intensity of RN care for those patient days

Nursing Care Intensity

Indicators of nursing care intensity:

• Patient turnover Patient acuity

Patient Turnover

As patient turnover increases Nursing care must be delivered in a shorter period

of time Holding patient acuity and total nursing care

requirements for the patient stay constant Admission, transfer, and discharge procedures

take up an increasing proportion of the patient’s stay

Patient Turnover

An available measure for patient turnover is patient length of stay The number of days a patient is an inpatient in the

hospital. The inverse of patient length of stay produces a

fraction that ranges between 0 and 1 Lower amounts indicate lower turnover, and vice

versa.

Research Questions

Does adjusting nurse staffing data for patient turnover, as measured by the inverse of patient LOS, significantly alter the measurement of nurse staffing and changes in nurse staffing?

What is the trend in nurse staffing when measures adjust for both patient turnover and patient acuity?

Sample and Data Sources

All general, acute-care Pennsylvania hospitals 1991-2000 (N= 166-213)

Data obtained from:• Pennsylvania Department of Health

• Yearly filled RN, LPN and Nursing Assistant FTEs

• American Hospital Association• APDC* and LOS

Patient days of care include outpatient care

• Atlas MediQual System• Patient acuity

Design Assess the trend in the average patient LOS and

turnover (inverse of length of stay). Create a patient turnover index using 1991 as the

base year, and adjust nurse staffing measures for patient turnover using this index

Compare the standard and new measures using paired sample t-tests

Assess whether the trend over time in nurse staffing utilizing the new measure is significantly different than the old measure using paired sample t-tests

Analyze the trend in nurse staffing adjusted for both patient turnover and acuity

Results

4

5

6

7

8

9

Average Patient Length of Stay in Pennsylvania Hospitals, 1991-2000

Results

0

0.5

1

1.5

2Average Patient Turnover in

Pennsylvania Hospitals 1991-2000

Results

RN/1000APDC 1991 1995 2000

Before Adjustment 2.68 2.88 2.87

After Adjustment 2.69 2.45 2.04

Mean Difference 0 -0.44 -0.83

t Value --- -10.53*** -25.05***

p<.01=*, p<.001=**, p<.0001=***

RN/1,000 APDC in

Pennsylvania Hospitals 1991-2000

Results

LPN/1000APDC 1991 1995 2000

Before Adjustment 0.60 0.52 0.43

After Adjustment 0.61 0.44 0.30

Mean Difference 0 -0.08 -0.13

t Value --- -8.04*** -14.10***

p<.01=*, p<.001=**, p<.0001=***

LPN/1,000 APDC in Pennsylvania Hospitals 1991-2000

Results

NA/1000APDC 1991 1995 2000

Before Adjustment 0.58 0.60 0.65

After Adjustment 0.58 0.50 0.45

Mean Difference 0 -0.08 -0.19

t Value --- -3.92** -13.29***

p<.01=*, p<.001=**, p<.0001=***

NA/1,000 APDC in Pennsylvania Hospitals 1991-2000

Results

RN/1000APDC 1991-2 1995-6 1999-00

Before Adjustment 4.19 2.32 -0.73

After Adjustment 5.50 -2.82 -4.23

Mean Difference 0.85 -5.29 -2.20

t Value 0.45 -8.71*** -4.40***

p<.01=*, p<.001=**, p<.0001=***

Percentage Change in RN/1,000 APDC in Pennsylvania Hospitals

Results

LPN/1000APDC 1991-2 1995-6 1999-00

Before Adjustment 5.13 -1.17 -4.35

After Adjustment 5.66 -7.63 -7.13

Mean Difference 0.26 -5.30 -2.11

t Value 0.18 -10.08*** -4.07***

p<.01=*, p<.001=**, p<.0001=***

Percentage Change in LPN/1,000 APDC in Pennsylvania Hospitals

Results

NA/1000APDC 1991-2 1995-6 1999-00

Before Adjustment 13.61 8.40 9.73

After Adjustment 16.14 3.12 13.33

Mean Difference 1.94 -5.47 -2.26

t Value 1.01 -7.69*** -4.30***

p<.01=*, p<.001=**, p<.0001=***

Percentage Change in NA/1,000 APDC in Pennsylvania Hospitals

Results

RN/1000 LPN/1000 NA/1000Before Adjustment

7.24 -18.70 32.95

After Adjustment -25.88 -43.61 -9.34

Mean Difference -32.25 -24.55 -37.48

t Value -24.75*** -10.16*** -12.00***

p<.01=*, p<.001=**, p<.0001=***

Percentage Change in Nursing Staff/1,000 APDC in Pennsylvania Hospitals 1991-2000

Results

0

1

2

3RNs

LPNs

NAs

Nursing Staff/1,000 Adjusted APDC* in Pennsylvania Hospitals 1991-2000

*APDC adjusted for patient acuity and turnover

% Change 1991-2000:

RNs -44%

LPNs -65%

NAs -48%

Conclusions

Unadjusted nurse workload measures fail to adequately address the work intensity issue and, consequently, significantly underestimate nurse workloads

Perceptions of nurses themselves, the media, and others concerning increasing nurse workloads/declining staffing ratios are justified and supported by our results

Future research on nurse staffing or nurse workload issues should adjust for both patient acuity and patient turnover