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Best Practices for Nurses are Also Best Practices for Patients

I estimate that hundreds or, perhaps, thousands of deaths each year are due to low staffing... [Nurses are] the eyes and ears of the hospital .... If something is going wrong, they can catch the signs early, before the problem gets worse. ... There were some hospitals, that if I were going to them as a patient, I would be very concerned.292

Thus far, this report has documented the impact of hospital practices on the recruitment and retention of nurses. However, one of the most important conclusions of the literature on hospital employment is that the same practices that create a positive working environment for nurses are also critical to securing standards of quality patient care. The deterioration in patient care is one of the central complaints raised by nurses struggling to remain in the industry. The ANA's recent survey found that an astounding 75 percent of RNs feel that the quality of nursing care at their facility has declined over the past two years, with 68 percent of RNs citing staffing levels as a major contributing factor to this problem. More than 50 percent state that they have experienced a decline in the time available for patient care. Shockingly, more than 40 percent of current nurses report that they would not feel comfortable having a family member taken care of in their hospital.293

Similarly, in Aiken's five-country survey, 44.8 percent of U.S. nurses reported that the quality of care in their hospitals had deteriorated in the past year. Only 33.8 percent of nurses were confident that their patients are able to manage their own care when discharged.294 Moreover, nurses reported signs of stress and patient endangerment at disturbing levels of frequency, as shown in the table below.295

 Overstressed Hospitals: RNs Reporting
Dangerous Conditions Are "Not Infrequent"

 Dangerous Condition

  Nurses Reporting
"Not Infrequent"
Occurrence

 Verbal abuse directed at nurses

 52.7%

 Complaints from patients or families

 49.1% 

 Nosocomial infections

 34.7%

 Patients with injuries from falling

 20.4%

 Patients receiving the wrong
medication or dose

 15.7%

Source: L. H. Aiken, et al. "Nurses' Reports on Hospital Care in Five Countries." Health Affairs, Vol. 20, no. 3. 2001.


 In large part, the roots of these problems can be traced back to the same dynamics that undermined working standards for RNs. In 1999, the American Organization of Nurse Executives identified a troubling increase in the "frequency of nursing practice issues contributing to adverse patient outcomes." An analysis of these incidents determined that the majority of the most common problems resulted from three categories of nursing action:

(1) failure to adequately monitor and assess changing patient status,
(2) failure to properly document findings, and
(3) failure to effectively communicate.296

Based on these findings, analysts conducted a survey of 50 nurse leaders to determine what practices might be causing these rates. Nearly half of the administrators identified "pressure to reduce cost" as the top culprit. The AONE reports:


[O]ver 90 percent of the respondents had participated in a restructuring project in the past five years. In general, restructuring was reported as resulting in the creation of jobs for assistive personnel and in reducing the number of RNs. Respondents expressed concern about the lack of data on clinical outcomes achieved before and after restructuring.297

Thus nurse executives ultimately point to the same "restructuring" strategies used to shrink nursing staffs and intensify nursing work as the root of increased errors in patient care. The analysis by the AONE is widely shared by both nurses and industry observers. Above all, deteriorating patient care has been repeatedly linked to inadequate staffing levels. The Institute of Medicine estimates that more than 7,000 Americans die every year as a result of preventable medication errors. U.S. Pharmacopeia, which tracks such errors, reports that the majority of these errors occur in the administration of medication — i.e. predominantly in nursing work — and that "the primary contributing factors to medication errors were distractions and workload increases."298 JCAHO President O'Leary notes:

The combination of higher acuity plus fewer nurses to care is a formula for patient endangerment. According to Joint Commission data, staffing levels have been a factor in 24 percent of the 1,609 sentinel events — unanticipated events that result in death, injury or permanent loss of function — that have been reported to the Joint Commission since 1996. Several carefully performed studies clearly identify correlations between nurse staffing and complication rates, lengths-of-stay, mortality, and other patient outcomes.299

The most comprehensive study linking staffing levels to patient outcomes was conducted by the Harvard School of Public Health. It was based on data from more than 5 million patient discharge records covering 800 hospitals in 11 states.300 The Harvard study states, "A higher proportion of hours of nursing care provided by registered nurses and a greater number of hours of care by registered nurses per day are associated with better care for hospitalized patients."301 The researchers found a strong and consistent relationship between nurse staffing and five outcomes in medical patients. A higher number of RNs was associated with a 3 to 12 percent reduction in the rates of adverse outcomes, while higher staffing levels for all types of nurses was associated with a decrease of up to 25 percent in adverse outcomes. The study divided hospitals into quarters, according to the proportion of total nursing time performed by RNs. The authors then compared hospitals in the top quarter with those in the bottom quarter:


The medical patients ... in the bottom quarter had stays 3.5 percent longer, 9 percent more urinary infections, 5.1 percent more gastrointestinal bleeding, 6.4 percent more pneumonia and 9.4 percent more shock or cardiac arrest. In addition, the death rate was 2.5 percent higher for "failure to rescue," meaning that the patients died from conditions that might have been reversed if they had been treated in time. Those conditions include pneumonia, shock or cardiac arrest, upper gastrointestinal bleeding, sepsis or a blood clot.302

  • Related table: Rationales for Patient Outcomes Potentially Sensitive to Nursing


Other studies reinforce these findings. Jean Seago, for instance, reports that staffing levels are related to 30-day mortality, unplanned hospital re-admission, failure to rescue, length of stay, nosocomial infection (including urinary tract infection, postoperative infection and pneumonia), and pressure ulcers.303 A separate study likewise concluded, "Higher proportions of RNs were significantly associated with lower length of stay, and lower rates of pressure ulcers, pneumonia, postoperative infection and urinary tract infections."304

 Impact of Nurse Staffing Levels on Medical Patients

Event Relationship Mix or Levels

 Estimated Impact of Shift to

  High RN
Staffing 

  High General
Staffing

Urinary tract infection  strong/consistent RN level and RN mix

 4-12%

 4-25%

Skin pressure ulcers inconsistent      
Pneumonia strong/consistent  RN level and RN mix

 6-8%

 6-17%

Deep vein thrombosis none/inconsistent      
Length of stay strong/consistent RN level and RN mix

 3-6%

 3-12%

Logarithm length of stay same pattern as length of stay, effects smaller   

  1-3%

 3-7%

Mortality none      
Failure to rescue inconsistent         
Upper gastrointestinal bleeding consistent RN level and RN mix 

  5-7%

 3-17%

Central nervous system
complications
none       
Sepsis none        
Shock strong RN mix

 6-10%

  7-13%

Source: J. Needleman, Nurse Staffing and Patient Outcomes in Hospitals, Table 19.

Both the ratio of RNs to patients and the skill mix between RNs and lesser-trained personnel have been shown to affect patient health. One scholar examined the number of nursing hours, skill mix and nursing-related adverse patient outcomes (medication errors, patient falls, skin breakdown, patient and family complaints, respiratory and urinary tract infections, and deaths) controlling for patient acuity, and found that the higher the RN skill mix, the lower the incidence of adverse occurrences in the units.305 Similarly, higher proportions of RNs on a hospital staff were found to be related to lower rates of medication errors and patient falls.306 Another study found that nurses in well-staffed units are more likely to report needlestick problems and less likely to suffer from needlestick injuries.307 After reviewing this extensive body of research, the Institute of Medicine concluded that "literature on RNs' impact on hospital mortality rates is considerable. ...While nursing staffing is not the only factor predictive of mortality outcome, it is an important one affecting the quality of hospital care."308

While staffing levels may be the single most important factor linking nurses' work conditions to patient care, other aspects of the nursing workplace have also been found to affect patients' well-being. One study found that even after controlling for staffing ratios, magnet hospitals provided superior care, resulting in a 4.8 percent lower mortality rate for the patients studied. The authors concluded,

Lower mortality rates were not simply the result of staffing ratios but were related to the degree of nursing autonomy, nursing control over practice, and nurse/physician collaboration.309
Furthermore, research has shown that higher burnout among nurses is "strongly related to patient ratings of quality of nursing care."310 A series of studies by Aiken found that magnet hospitals improve patient outcomes for a combination of reasons that go beyond the impact of staffing ratios alone. Comparing magnets to otherwise similar non-magnet hospitals, the former proved consistently superior:311

  • Patient mortality rates were 4.6 percent lower.
  • AIDS patients were 60 percent more likely to depart the hospital alive.
  • Nurses suffered far fewer needle-stick injuries.
  • Patient satisfaction scores were significantly higher.
  • Nurses enjoyed significantly less job burnout.
  • Nurses believed the care that patients received was better than at non-magnet facilities.


Aiken's research also suggests that better staffing levels and magnet practices may improve the long-term profitability of hospitals. For example, AIDS patients cared for in magnet hospitals stay half as long as patients in non-magnet hospitals. They also had fewer ICU days and lower ancillary expenditures.312

Indeed, some hospitals have found that the adoption of the best practices outlined above not only have improved their ability to recruit and retain nurses but also have proved an economic boon. At Boston's Beth Israel hospital, for instance, the implementation of a primary nursing model has led to improved postoperative follow-up care, increased patient satisfaction and nurse satisfaction, and decreased lengths of stay.313 Thus, where best practices provide superior care to patients, they may also reflect sound financial strategies.