When Nurse Staffing Drops, Mortality Rates Rise

When nurse staffing levels fell below target levels in a large hospital, more patients died, a study discovered.

The finding may provide guidance in an era of nursing shortages and cost-cutting, in that the focus should shift from cost to patient safety, said the authors of the research, which was published in The New England Journal of Medicine.

Background

"Hospitals need to know what their nursing needs are for their patients, and they need to bring staffing into line," said study senior author Jack Needleman, PhD, a professor of health services at the School of Public Health of the University of California, Los Angeles.

"Patients are entitled to be safe in the hospital and to have care delivered reliably and to have nurses with enough time to make sure they aren't developing avoidable complications with permanent consequences," Dr. Needleman said.

Previous research has suggested that this might be the case, but many of those studies were dismissed in part because of methodology flaws.

"People had thought maybe (adverse consequences) were due to something else, maybe the quality of the nurses, quality of the doctors, technology, equipment or the hospital doesn't have a commitment to quality," Dr. Needleman explained.

Study Details

For this study, the authors looked at almost 200,000 admissions and about 177,000 nursing shifts at 43 patient units at one hospital that generally had high staffing targets.

Presumably, different areas of the hospital had the same quality of nurses, doctors, technology and equipment, thus eliminating these factors as the source of problems.

Units were considered below target if nursing staffing was lower than the target level for eight hours or longer.

When units were understaffed, patient mortality increased by 2%. On average, a patient stayed in the hospital for three shifts and when they were all understaffed, mortality rose by 6%.

And when nurses had to work harder because of high patient turnover on their unit, the mortality risk increased by 4%.

Expert Commentary

"A telling outcome is that they looked at a hospital that really had pretty good staffing levels and they still found that there was a difference," said Sharon Wilkerson, PhD, RN, dean of the Texas A&M Health Science Center College of Nursing in Bryan. "When I think about the number of hospitals that do not maintain good staffing levels, either because they can't find the nurses or maybe they're rural or they're just aren't as many people they can hire, that's even more frightening."

The authors believe the findings would apply at the very least to other similar hospitals.

"All hospitals need to have a system to identify what their target level of nurse staffing is, based on their patient needs, and this will vary from day to day," Dr. Needleman said.

Hospitals also need to find ways to manage surges, when more admissions and transfers send more patients to a particular unit, said Dr. Needleman, who believes these changes are possible.

"Obviously, we need to figure out how to do this better," Dr. Wilkerson said. "If the workloads and the turnover of patients are causing problems in terms of negative outcomes for patients, then we need to do a better job of handling that."

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