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Crit Care Nurse 2003 Feb; 23(1): 14-15
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Editorial

Nurse Staffing and Patient Outcomes

This Is News?

Listening to the evening newscasts is usually an opportune time each day to hear about what’s going on in the world and to keep up on important world, national, and local events. Webster’s1 defines newsworthy as "sufficiently interesting to the general public to warrant reporting" and news as "a report of recent events" and as "matter that is newsworthy." Every now and then, I hear a news report that rings in my ears as the oxymoron of "old news." Such was the case a few months ago, when Tom Brokaw introduced the nightly "News for Your Health" segment with the steely eyed and slowly paced revelation that research just published in the Journal of the American Medical Association found that burdening registered nurses (RNs) with increasingly heavier patient workloads can be dangerous to a patient’s health. The newscaster referred to a research study reported by Aiken et al in a late October 2002 issue of the Journal of the American Medical Association,2 in which data from a cross-sectional analysis of 232342 general, orthopedic, and vascular surgery patients, aged 20 to 85 years, discharged from 168 nonfederal hospitals in Pennsylvania over an 18-month period, were examined to determine the association between patient:nurse ratio and patient mortality within 30 days of admission, as well as patient:nurse ratio and patient mortality following complications ("failure to rescue"). The findings indicated that after adjusting for patient and hospital features (such as size and teaching status), each patient added to an RN’s average workload was associated with a 7% greater likelihood of patient death subsequent to complications and a 7% greater likelihood of patient death within 30 days of admission to the hospital. As a result, increasing an RN’s patient assignment by 2 patients (eg, from 4 patients to 6 patients) was associated with a 14 % increase in mortality and increasing it by 4 (ie, from 4 to 8 patients) was associated with a 31% increase in patient mortality. As preliminary as these findings may be, they clearly support the contention that inadequate RN staffing has a direct and positive correlation with higher patient mortality. Finding statistical evidence that patients can die in proportion to the weight of a nurse’s patient assignment is surely notable and newsworthy, but is it news?

Earlier in the year, the New England Journal of Medicine published results from another study of similar genre reported by a different group of nurse researchers. In that paper, Needleman et al3 examined whether different levels of nurse staffing are related to a patient’s risk of developing complications or of dying. Data from more than 5 million medical patient discharges and more than 1.1 million surgical patient discharges from 799 hospitals in 11 different states revealed that patients receiving more care from RNs (compared to licensed practical nurses and nurses’ aides) and those receiving the most hours of care per day from RNs experienced fewer complications and lower mortality rates than those who received more of their care from licensed practical nurses and/or aides. Specifically for medical patients, those who received more hours per day of care from an RN and/or those who had a greater proportions of their care provided by RNs experienced statistically significant shorter length of stay and lower complication rates (urinary tract infections, gastrointestinal bleeding, pneumonia, cardiac arrest, or shock), as well as fewer deaths from these and other (sepsis, deep vein thrombosis) complications. Findings among surgical patients were consistent in the incidence of urinary tract infections and mortality attributable to complications. Finding statistical evidence that hospitalized patients experience fewer serious complications and die less often from their complications is—once again—both striking and newsworthy to the public, but does it constitute news?

Perhaps these findings constitute news in a hospital’s medical and surgical units, but is there any evidence of comparable findings within critical care areas? Unfortunately, there is. Dimick et al4 at The Johns Hopkins School of Medicine recently examined hospital discharge data on 569 adults admitted to the intensive care unit (ICU) following high-risk surgery (hepatic resection) over a 4-year period. Findings revealed that ICU nurse:patient ratios of 1:3 or higher on night shift are associated with increased risks of pulmonary failure and reintubation on high-risk surgery (hepatectomy) patients compared with nurse:patient ratios of 1:1 or 1:2 at night. Similarly, studies reported by both the department of nursing5 at Hopkins as well as by the departments of medicine, hygiene, and public health6 found that having fewer ICU nurses per patient is associated with a significantly increased risk of respiratory complications in patients undergoing abdominal aortic surgery.

No doubt it would be an understatement to characterize these findings as newsworthy for the general public. But if news truly refers to "a report of recent events," I can’t name one nurse, with a pulse—particularly any critical care nurse—who has not known these things pretty much since the ink dried on their first RN license. The due recognition awarded to magnet hospitals offers evidence that at least a few healthcare facilities get it—that is, they not only acknowledge but voluntarily and intentionally design patient care delivery systems that recognize the pivotal contributions that RNs make to patient outcomes. In so many other instances, however, healthcare facilities must be dragged kicking and screaming into legislatively mandated minimum staffing ratios. Evidence that findings such as these were wholeheartedly and nationally translated into improved RN staffing of healthcare facilities—now that would be news!

References

  1. Webster’s New Collegiate Dictionary. Springfield, Mass: G & C Merriam Co; 1973.
  2. Aiken LH, Clarke SP, Douglas MS, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288:1987–1993.[Abstract/Free Full Text]
  3. Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K. Nurse-staffing levels and the quality of care in hospitals. N Engl J Med. 2002;346:1715–1722.[Abstract/Free Full Text]
  4. Dimick JB, Swoboda SM, Pronovost PJ, Lipsett PA. Effect of nurse-to-patient ratio in the intensive care unit on pulmonary complications and resource use after hepatectomy. Am J Crit Care. 2001;10:376–382.
  5. Dang D, Johantgen ME, Pronovost PJ, Jenckes MW, Bass EB. Postoperative complications: does intensive care unit staff nursing make a difference? Heart Lung. 2002;31:219–228.[Medline]
  6. Pronovost PJ, Dang D, Dorman T, et al. Intensive care unit nurse staffing and the risk for complications after abdominal aortic surgery. Eff Clin Pract. 2001;4:223–225.[Medline]
Grif Alspach, RN, MSN, EdD
Editor





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