Increasing Both Nurse and Doctor Staffing Levels Can Reduce Patient Mortality in ICUs – but Nurses Are Key

A new study in the International Journal of Nursing Studies finds that higher staffing levels for doctors and nurses in intensive care units (ICUs) are associated with higher survival rates for patients at high risk for death. The report, titled “Nurse staffing, medical staffing and mortality in Intensive Care: an observational study,” examines whether the number of nurses, doctors, and support staff affected the survival chances of critically ill patients in both the ICU and the hospital, HealthCanal reports.

Researchers reviewed information on nearly 40,000 patients from 65 ICUs in the United Kingdom. Among the findings, higher numbers of nurses per bed were associated with higher survival rates, and the number of nurses had the greatest impact on patients at a high risk of death when compared to other medical staffing levels.

An INQRI-funded study on the impact of nursing staffing on hospital performance revealed that increasing the number of registered nurse (RN) hours per patient day increased the quality of patient care. The study looked in particular at patients who were being treated for acute myocardial infarction, pneumonia or heart failure.) For all three conditions, increasing the number of RN hours increased the quality of care. This did not hold true for increasing the number of licensed practical nurse or nursing assistant hours.

The study's authors—Gestur Davidson, Ira Moscovice, and Kathy Belk—posited that RNs are involved in and directly affect procedures, practices and processes that directly influence patient outcomes. This was the first study into how nurse staffing affects hospital performance on quality metrics used in the Premier Hospital Quality Demonstration project. It is reviewed in a research brief on the Robert Wood Johnson Foundation website.

Research Brief: Quality of Nursing Care on Acute Inpatient Units

Does the composition of hospital nurse staffing levels matter when it comes to preventing costly complications and death following those complications? A team at the University of California, led by Mary Blegen, Tom Vaughn (from the University of Iowa) and Colleen Goode (from the University of Colorado), examined the extent to which nurse staffing levels affected the incidence of complications and the failure to rescue from those complications, (i.e. death following complications). Their examination showed that nursing hours per patient day were strongly associated with lower rates of pressure ulcers and hospital acquired infections, and fewer deaths from complications. Further, more RN hours in the mix had additional benefit with still lower rates of failure to rescue and hospital acquired infections. Their work shows that higher levels of nursing hours per patient day and RN skill mix in intensive care units and in general units will lead to better patient outcomes, information that can guide states considering regulation of nurse-patient staffing ratios to address patient safety gaps.

Access the research brief.

This post is part of a series to provide the public with research briefs on INQRI-funded projects across a range of interests.

Research Brief: Supplemental Nurse Staffing

A team of researchers at the University of Rochester, led by Ying Xue and Deborah Freund, conducted a study to better understand one hospital's use of supplemental registered nurses (SRNs) and examine its impact on patient and nurse outcomes and cost. Using focus groups, interviews, mail surveys, chart reviews and reviewing hospital administration data, the team found that use of SRNs varied greatly by unit and that typically permanent RNs have similar experience and more education (BSN or higher degree). Although, the use of supplemental nurses occurred more frequently in units that were rated as having poor working environments, the team did not find that their use had any negative impact on patient or nurse outcomes. The findings of this project will further understanding of the impact of SRNs on quality and cost outcomes and help hospital administrators make evidence-based strategic plan for nurse staffing.
Access the research brief.

This post is part of a series to provide the public with research briefs on INQRI-funded projects across a range of interests.

Research Brief: Impact of Nurse Characteristics and Practices on Patient Outcomes

An INQRI team led by Nancy Donaldson and Carolyn Aydin examined individual and collective effects of unit level nurse workload, staff nurse characteristics and selected risk assessment and preventive intervention processes of care on variance in nursing sensitive outcomes of acute care medical-surgical units. The team found that patient outcomes were predicted by combinations of all elements in their model, including: unit/patient characteristics, nursing workload, registered nurse expertise and clinical processes. Interestingly, they found that falls and falls with injury were predicted by patient characteristics and clinical process variables, but not by nurse expertise. However, hospital acquired pressure ulcer prevalence was predicted by a combination of all elements in the model. Finally, the team also found that unit and patient characteristics and workload could predict medication practice errors and that workload and practice errors predicted medication outcome errors. These findings can guide hospitals in efforts to improve staffing effectiveness and patient safety, reducing medication administration errors and understanding prevalence of facility acquired pressure ulcers.

Access the research brief.

This post is part of a series to provide the public with research briefs on INQRI-funded projects across a range of interests.

Staffing, Quality, and Costs

The New York State Nurses Association is supporting a bill currently under discussion in the New York state legislature that would establish required nurse staffing ratios in the state's 185 acute care hospitals.  The hospitals oppose the bill, noting that the suggested ratios would cost their institutions and nursing homes about $3 billion a year and would affect their ability to shift staff use as needed.

This is an important conversation, given that research is demonstrating that nurse staffing levels have a definite impact on the quality of patient care.

INQRI researchers Mary Blegen and Tom Vaughn examined the extent to which nurse staffing levels affected the incidence of complications and the failure to rescue from those complications, (i.e. death following complications). Their examination showed that nursing hours per patient day were strongly associated with lower rates of pressure ulcers and hospital acquired infections, and fewer deaths from complications. Further, more RN hours in the mix had additional benefit with still lower rates of failure to rescue and hospital acquired infections. Their work shows that higher levels of nursing hours per patient day and RN skill mix in intensive care units and in general units will lead to better patient outcomes, information that can guide states considering regulation of nurse-patient staffing ratios to address patient safety gaps.

Findings from the first study to look at the link between nursing and very low birthweight infants in the neonatal intensive care unit (NICU) indicate that nurse staffing and practice environment do matter. INQRI researchers Eileen Lake and Jeannette Rogowski examined care in more than 100 NICUs around the U.S. and found that when babies are treated in units where nurses have less support and less frontline experience they are at higher risk of developing infections. Babies in hospitals where nurses are supported and have more experience are less likely to have medical complications such as bleeding in the brain, which leads to costly complications. The study results could guide decisions related to setting standards for all hospitals to follow when creating and staffing a neonatal intensive care unit where infants thrive.

Click here to read an article about the New York legislation in the Wall Street Journal.
Click here to learn more about the Blegen-Vaughn study.
Click here to learn more about the Lake-Rogowski study.

Minimum Nurse Staffing Ratios, Mentoring Programs Are Part of New Senate Bill

Earlier this week, U.S. Senator Barbara Boxer (D-CA) introduced the National Nursing Shortage Reform and Patient Advocacy Act, aimed at improving patient care and addressing the nursing shortage. 

The bill would:

• establish minimum nurse-to-patient staffing ratios;
• invest in nursing mentorship demonstration programs; and
• provide for whistleblower protections to allow nurses to report violations of minimum standards of care without fear of reprisal.

 In a statement, Boxer said, “I am proud to introduce legislation that will help save the lives of countless patients by improving the quality of care in our nation’s hospitals. We must support the nurses who work tirelessly every day to provide the best possible care to their patients.”

Several INQRI studies (as well as numerous other studies) have established that higher nurse staffing levels improve patient outcomes, including research led by Mary Blegen and Tom Vaughn, and Linda Flynn and Dong-Churl Suh.

INQRI Goes International

INQRI grantee Patti Hamilton recently had the opportunity to present on missed care and off-peak work environments to the Australian Nurse and Midwifery Federation. The findings are the result of a joint study with Midwestern State University and Flinders University. It is an international extension of Dr. Hamilton's INQRI study, "The Effect of Off-peak Hospital Environments on Nurses' Work: an Institutional Ethnography."

The research team interviewed 354 nurses and midwives in Australia using Kalisch's MISSCARE instrument to determine which items of care were commonly missed and to understand why.  Respondents noted a wide range of "missed care" items, including: bathing patients, providing adequate discharge information, handwashing, patient education, and much more.  Perceived reasons for these omissions included: communications challenges, inadequate hand-offs and number of staff, heavy admission and discharge needs, and more.

Similar to the results of Hamilton's original INQRI study with Dr. Gretchen Gemeinhardt, more issues occurred during "off-peak" shifts.

The MSU-Flinders team also found results similar to those identified in another INQRI study, conducted by Dr. Sue Letvak and Christopher Ruhm, "The Effects of Nurse Presenteeism on Quality of Care and Patient Safety." Letvak and Ruhm found that nurse "presenteeism" (nurses working when sick) was significantly associated with patient falls, medication errors and the perceived quality of care.  Hamilton and her colleagues at Flinders found that the number of shifts worked by nurses who were sick or fatigued related to the total number of missed care items reported.

Congratulations to Dr. Hamilton and her colleagues, Eileen Willis (principal investigator), Julie Henderson, Claire Verrall, Clare Harvey, Liz Abery, Luisa Toffoli, and Ian Blackman on this important work!

Longer Shifts for Nurses Lead to Burnout & Patient Dissatisfaction

A new study published in Health Affairs has found that longer shifts for nurses not only cause job dissatisfaction, but also make patients more likely to be unhappy with the care they have received from nurses.

A team from the University of Pennsylvania has demonstrated that nurses working 10 hour shifts (or longer) were up to 2.5 times more likely than nurses with shorter shifts to experience job dissatisfaction and burnout.

Click here to read about the study on Nurse.com.
Click here to access the abstract on the Health Affairs website.

Bringing Nurses to the Table to Address Staffing Concerns

The Pennsylvania State Nurses Association (PSNA) believes that nurses should be responsible for setting staffing plans that prevent medical errors caused by fatigue and inadequate staffing levels.  The PSNA has engaged hospital administrators and lawmakers in the negotiations around passing the Safe Staffing Law.

Click here to read an editorial in support of the bill on PennLive.com.

Click here to read about INQRI's work in regards to nurse staffing.

Massachusetts' Governor Signs Bill Banning Mandatory Overtime

Earlier this week, Governor Deval Patrick's signed new health care cost containment legislation that included a ban on mandatory overtime at acute care hospitals. Since the Institute of Medicine's focus on preventable deaths related to mandatory overtime on patient care in their 2004 report: "Keeping Patients Safe: Transforming the Work Environment of Nurses", many states have enacted similar legislation to ban the practice of mandatory overtime.

To read more about the passage of this integral piece of patient safety legislation, click here.

New Study Examines Link Between Nurse Burnout and Care

Researchers at the University of Pennsylvania (INQRI's home) examined the relationship between nurse-burnout and potential harm to patients. The study, which was published on Monday in the American Journal of Infection Control, utilized 2006 infection data linked with two separate surveys examining hospital work environments and nurse burnout. The research team found that by adding a single patient to a nurse's workload, there was an increase of nearly one infection per 1,000 patient. Additionally, the authors also found that a 10 percent increase in a hospital's proportion of burned-out nurses raised urinary tract infections about the same amount but surgical site infections more than 50 percent, from 4.2 per 1,000 patients to more than six.

To read more about the study, click here.

To read the research article, click here (subscription required).

Did You Miss Monday's Webinar?

If so, you can catch it right here.  We were joined by INQRI grantees, Linda Flynn and Suzanne Gordon for the seventh session in our series on the Institute of Medicine report, "The Future of Nursing: Leading Change, Advancing Health."

This webinar focused on Recommendation 2: "Expand opportunities for nurses to lead and diffuse collaborative improvement efforts."

"Expanding Opportunities for Nurses to Lead: Impact of a Nurse Manager Development Program" - Presented by Linda Flynn, PhD, RN, FAAN & Suzanne Gordon, Journalist & Advocate.

Don't Forget... Webinar Today!

As we mentioned last week, Versant Holdings, LLC is holding a webinar today at 11amET featuring Peter I. Buerhaus, PhD, RN, FAAN, an expert in nurse and physician workforces in the United States.

Click here to register for the webinar, "The Supply of Registered Nurses - Are We in an Employment Bubble?"

No Jobs for 43% of Newly Licensed Nurses Responding to California Statewide Survey

A recent survey conducted by the California Institute for Nursing & Health Care (CINHC) has found that forty-three percent of nurses who obtained their RN license within 18 months. With conflicting reports stating that there is a nursing shortage in the United States, this latest poll is rather troubling for new nursing graduates attempting to break into the field. The CINHC survey found that 92% of nurses polled cited that their lack of experience was the primary reason they were unable to obtain a job. This is a rather complex issue with new nursing graduates unable to obtain a job due to lack of experience, and unable to gain experience due to the lack of entry level positions.

Click here to read the full press release.

Nurse Staffing Mandates Debated at Hospitals

Over the weekend, Ben Sutherly, staff writer for the Dayton Daily News, reported on the different viewpoints hospital administrators and nurses have on nurse staffing mandates in the state of Ohio and around the country. Mr. Sutherly cites the work of renowned nursing workforce scholar and INQRI NAC member, Linda Aiken, to support the argument that nurse staffing levels should be mandated at the state level. Dr. Aiken's research found that there would be 14% fewer surgical deaths in Pennsylvania if the state were to adopt nurse staffing mandates that are similar to those in California, the only state that has mandated nurse-to-patient ratios. However, Mr. Sutherly also presents the case for hospitals as they argue that the quality of the health care workforce is much more important than having a minimum nurse-to-patient ratio in order to provide the highest quality of care.

Click here to read the whole article.

Click here to read more blogposts relating to nurse staffing.

Minimum Nurse Staffing Level Legislation Introduced In Minnesota

Last week, Renee Passal, of local ABC affiliate WDIO, reported that the Minnesota House and Senate has introduced legislation aiming to establish minimum nurse staffing levels at hospitals. The article also features a video snippet further detailing the proposed bills.

Click here to read the article and watch the video.

Click here to read other blogposts relating to nurse staffing.

Philadelphia Hospital Boosts Use Of Registered Nurses In Bid To Improve care

Yesterday, Stacey Burling, reporting for the Philadelphia Inquirer, detailed how Hahnemann University Hospital plans to utilize more registered nurses (RNs) and reduce the amount of nurse assistants. This decision was spurred by a pilot study conducted in one nursing unit that found that using all registered nurses to care for patients instead of a combination of nurses and nursing assistants led to higher-quality care, and greater patient and nurse satisfaction. The hospital cites changing payment models that emphasize the importance of quality of care as a catalyst for this initiative. The hospital's decision also relates to INQRI studies that have found having higher levels of RN skill mix leads to better patient outcomes.

It should also be noted that the union representing the certified nursing assistants protested outside of the hospital yesterday in response to the new care model announcement?

What are your thoughts on this issue?

Click here to read the full story.

Why The Florida Nursing Shortage Matters

Earlier today, Kathleen Long, Dean of the University of Florida College of Nursing, was featured as a guest columnist in The Gainesville Sun. Dr. Long discussed the future implications of the nursing shortage in Florida, citing the work of University of Pennsylvania's nurse staffing expert, Dr. Linda Aiken, as well as the IOM's Future of Nursing: Leading Change, Advancing Health report.

Click here to read the full article.

Click here to read other blogposts relating to the IOM's report.

Non-Profit Nursing Home Staff Happier Than Their For-Profit Counterparts

Last week, Paula Span, of the New York Times, detailed the findings of a recently published study that found nursing home ownership status was significantly related to job satisfaction. The study, published in the September 2011 issue of The Gerontologist, was conducted by a research team that included INQRI grantee, Linda Flynn, PhD, RN, FAAN, as well as INQRI NAC member, Linda H. Aiken, PhD, RN, FAAN. While this study may not have been published in 2012, Ms. Span's discussion of the study's findings in last week's New York Times demonstrates that this issue will be of great importance as the baby boomer generation continues to age and more adult children are faced with the task of finding the best care facilities for their loved ones.

Click here to read Ms. Span's article.

Click here to read the study as published in The Gerontologist (subscription required).

New York Bill Would Require Four Year Registered Nursing Degrees

We hope that everyone had a safe and happy holiday season!

Last week, The Washington Post reported on a new bill being considered by the New York State Senate that will require all registerd nurses to obtain bachelor’s degrees within 10 years in order to keep working in the state. This intiative, “BSN in 10”, is supported by major nursing and health policy organizations across the country. The proposed legislation also directly addresses recommendation #4 made in the IOM's Future of Nursing: Leading Change, Advancing Health report.

Click here to read the article.

Click here to read all blogposts relating to the IOM's report.