Surgical patients in hospitals with higher nurse staffing ratios are less likely to experience such common complications as pneumonia, thrombosis or urinary infections, a study in the nursing journal Image reports.
Hospitals have been downsizing their nursing staffs for years without conducting scientific research on the effect on patient outcomes. Now, for the first time, federally funded researchers have tried to isolate nursing care from other variables and draw conclusions regarding quality of care.
The study analyzed discharge data from 506 hospitals in 10 states during 1993. It found that increasing registered nursing time for a half-hour per patient day corresponded to a 4.2% decrease in pneumonia, a 4.5% decrease in urinary-tract infections and a 2.6% decrease in thrombosis.
The American Nurses Association hailed the report as support for its campaign to boost nurse staffing levels in hospitals. ANA President Beverly Malone said the results came as no surprise. "Cutting costs by cutting the number of nurses at the bedside is a false economy today," she said.
But others said the article is just a beginning. "Hopefully, it's the first of many studies" on this understudied subject, said Lois Kercher, president-elect of the American Organization of Nurse Executives- a subsidiary of the American Hospital Association-and a nurse executive at Virginia Beach (Va.) General Hospital.
It's premature to form conclusions based on one report, she said. And the methodology was seriously flawed and failed to control for many variables, she said.
Finding the appropriate staffing levels for registered nurses is one of the most contentious issues between hospital managers and their largest group of employees. Over the past five years, many hospitals have tried to save money by using less-skilled workers to perform more-routine tasks, so that nurses could supervise those workers and coordinate patient care. Hospitals often laid off registered nurses and substituted unlicensed caregivers.
Nurses have complained they are unable to provide the quality of care their licenses demand and their patients expect. They also say the heightened acuity of inpatients in the late 1990s bears no relation to the situation when staffing ratios were set. In response to those concerns, some hospitals have started to boost their staffing levels for registered nurses.
Neither the American Hospital Association nor nursing organizations track the number of registered nurses who have been trimmed out of hospitals through cost-cutting. And producing hard data that correlates registered-nursing care with patient outcomes is extremely difficult, nursing researchers say.
In 1996 a study by the Institute of Medicine found no evidence of inadequate nurse staffing and did not mandate or even suggest ideal staffing ratios. However, Carolyne Davis, one of the authors of the report, said she was surprised to find that hospitals were not collecting data linking nurse-patient ratios to outcomes.
The Image study, financed by the Agency for Health Care Policy and Research, analyzed a huge national database of hospital discharges to try to isolate complications that could be attributed directly to the quality of nursing care.
Christine Kovner, lead author of the new study and a professor at New York University's division of nursing, said her study is "one piece of the puzzle." Much more research is needed on the number of nurses associated with levels of quality care. One reason so little material exists is that "it's rather expensive research to do," she said. The government and foundations have not directed the funding toward this issue.
Sheila Haas, a teacher at the Loyola University School of Nursing, in Chicago, said such research is technically difficult "because there are so many intervening variables." The patients' progress is affected by all the providers, devices, drugs and procedures with which they have contact.
"So we have not had a lot of outcomes in the hospital setting that are solely the basis of nursing care, because it's delivered by a team," she said. "You can't assign the patients to a blind trial."
Michael Rie, M.D., who studies hospital quality of care at the University of Kentucky, said there weren't enough data to evaluate the scientific basis of the paper.