Patients are safer and less likely to experience serious complications when they are treated in hospitals with more registered nurses on staff, according to a study published last week in the New England Journal of Medicine.
Although the study largely rehashed the findings of a federal government study released last year, it sparked a new wave of publicity in the heated discussion of how to address the nation's growing nurse shortage.
The New England Journal study comes at a time when healthcare staffing is at the top of many executives' worry lists. In its April study on the topic, the American Hospital Association said the national vacancy rate among registered nurses was 13% last fall, and that 84% of hospitals report a nurse shortage. The national turnover rate among registered nurses was a staggering 26% as of late last year, according to the California Nurses Association.
In hospitals where nurses spent more hours each day with patients, the average length of stay was shorter, and the rate of complications-such as urinary tract infections and upper-gastrointestinal bleeding-was lower, the new study said. As registered nurses spent more hours providing patient care, their patients also experienced lower rates of pneumonia, shock, cardiac arrest and death from such complications.
Although the study published in April 2001 by HHS' Health Resources and Services Administration reached many of the same conclusions, sources said the new study that relied on the same data emphasizes the critical role played by registered nurses, as opposed to licensed practical nurses and other nurse aides.
"Education and experience make an enormous difference in whether a patient gets hospital-acquired pneumonia or an upper-GI bleed," said one of the study's authors, Jack Needleman, assistant professor of economics and health policy at Harvard University's department of health policy and management. "As we looked at the numbers again ... we did not see convincing evidence that licensed practical nurses and aide hours were having a consistent or substantial impact on outcomes."
The earlier study looked at staffing in general, paying less attention to how each different type of nurse affects outcomes, Needleman said. Study authors included in their sample 799 hospitals from 11 states, using 1997 discharge data to correlate nursing-care hours to clinical outcomes "potentially sensitive to staffing by nurses." Though the study did not directly tie nursing hours to in-hospital mortality rates, it did find a 3% to 9% higher rate of serious complications in hospitals with fewer registered nurses on staff.
"Patients are less safe and more at risk of adverse outcomes, including death, in hospitals in which nurse staffing is low," Needleman told Modern Healthcare. "Hospitals and nurses are going to have to find ways to establish a working relationship built around the common mission of providing good care."
Nursing groups continue to disagree-with hospitals and even with one another-on how to recruit and retain more nurses. The CNA has been at the center of this debate, having persuaded California legislators to mandate nurse-to-patient ratios in the state's hospital units. As the politically savvy CNA attempts to spread the ratio requirement to other states, however, not everyone is convinced it's the best way to fortify the ranks of registered nurses (May 6, 2002, p. 10).
"Ratios are not the answer because the clinical judgment of the nurse-whether it's the charge nurse or nursing director-has to be a part of figuring out how many patients each nurse can take," said Karen Drenkard, chief nurse executive of five-hospital Inova Health System in Falls Church, Va.
Rather than implementing ratio rules such as those that soon will govern California hospitals, Inova rewards successful nurses to keep them on board. Inova has promoted 138 nurses since June 2001. Had the 138 nurses left, Drenkard estimated, it would have cost from $20,000 to $60,000 to replace each one.
CNA officials said last week's study fuels their argument that the best way to recruit nurses is to minimize the threat of caring for too many patients at once. "Until you can address the systemic problems that created the nursing shortage, you're not going to find a solution to this growing problem," said Charles Idelson, a CNA spokesman.
Despite agreement on the scope of the staffing problem, not all nurses are on the same page as the 40,000-member CNA. The American Nurses Association, which represents some 2.6 million nurses nationally, believes the New England Journal study "bolsters the case for better (registered nurse) staffing" but that ratios, when used, should be flexible enough to account for varying factors such as patient acuity, number of patients and experience of the staff.
Needleman declined to comment on the wisdom of mandated ratios, saying only that an industrywide effort to address staffing would help alleviate shortages and the substandard care they can cause.
"I am convinced that some hospitals have very low staffing that should probably be increased," he said. "How we achieve those increases and decide appropriate ways to ensure those levels are met is going to require the active and creative involvement of hospital executives, nursing staff, accrediting agencies and payers."