Changing Tides
Nurses are buoyed by new evidence that shows more RN vigilance, knowledge
and training play an important part in saving lives–and hospital
costs
By
Cathryn Domrose
August 6, 2002
Nurses and Patients at University Medical Center in Tucson, Ariz., know firsthand what happens when a hospital hires more RNs. Since April, nurses on the medical/surgical and telemetry units there have cared for no more than four patients on a shift as part of a new hospital policy. The hospital has hired 25 new nurses and is filling another 30 new positions.
As a result, Erin Brown, RN, clinical leader at University Medical Center, said that nurses now have time to sit and talk with patients. They have time to educate families and patients about their conditions. They have time to help less experienced colleagues. They have time to look at lab results earlier and catch potential problems. They have time to notice things like whether a patient has difficulty breathing or possible cardiac difficulties.
"Are less mistakes being made?" Brown asked. "Absolutely. Are we seeing less incident reports? Absolutely. This has allowed us to go beyond the minimum. You can do those extra things that make a difference for the patient and give fulfillment to the nurse."
After years of studies, experts now are saying what most hospital nurses have known for years-more care by RNs means better care for patients in hospitals. The difference is now there is scientific evidence to prove it. >>
A study recently published in the New England Journal of Medicine, "Nurse Staffing Levels and the Quality of Care in Hospitals," reprised a government study released last year showing that lower levels of RN staffing in hospitals is associated with an increased risk of potentially fatal complications in patients.
That article sparked stories in the national press and ricocheted through the health care community, but research since the 1970s has indicated a significant relationship between amount of nursing care and better outcomes for patients.
A number of studies have shown a relationship between RN staffing and health-care associated infections, pressure ulcers and falls. Studies by researcher Linda Aiken, Ph.D., RN, have focused on better patient outcomes in designated nursing Magnet hospitals, where RNs generally have more autonomy and better communication with physicians than in non-Magnet hospitals. Aiken's work suggests the importance of nursing organization, as well as adequate staffing.
The challenge now, researchers say, is to develop a model that will show how having more RNs and deploying them correctly not only improves patient care, but also makes good economic sense. Researchers also need to look more carefully at the mix of RNs, LVNs and aides to determine how various nurse-to-patient ratios affect patient populations.
Regardless of what future research shows, the growing body of evidence is beginning to persuade hospital administrators and government health analysts that nursing is an important part of the health care picture. And given the nursing shortage, nurse executives say, it becomes more important than ever to attract and keep people in nursing.
Nursing matters
"Hopefully, the debate is over about whether nursing matters," said Peter Buerhaus, Ph.D., RN, FAAN, professor of nursing and senior associate dean for research at the Vanderbilt University School of Nursing in Nashville, Tenn. "I think people now think the government spent a lot of money just to prove what everybody knows."
Buerhaus is co-director of the most recent and perhaps best-publicized studies on the relationship between nurse-staffing levels and quality of care in hospitals. The Department of Health and Human Services originally released that study in 2001, led by Jack Needleman, Ph.D., of the Harvard School of Public Health. It was published in the May 30 edition of the New England Journal of Medicine.
Needleman and Buerhaus analyzed outcomes for more than 6 million medical and surgical patients in 799 hospitals across the country, using administrative data from 1997. They determined that patients in hospitals with the greatest proportion of RN care-as opposed to care by aides or LVNs-were less likely to develop pneumonia, shock or cardiac arrest, upper gastrointestinal bleeding, blood poisoning or a blood clot.
These complications-called "outcomes potentially sensitive to nursing" or OPSNs because they can be prevented by good nursing care-occurred 3 percent to 9 percent more often in hospitals with lower RN staffing. "Those are all nasty complications," Buerhaus said. "If a patient gets one of those, they are at an increased risk of death."
He offered two explanations for the apparent relationship between RN care and better outcomes. The first, strongly suggested by his and Needleman's work, he said, is that in hospitals with a higher proportion of RN care, nurses simply have more time to spend with patients, and can catch possible complications.
"The chances are better that the nurses will have more contact with the patients, go on rounds, maybe help out with feeding and taking in trays and maybe even personal issues," he said. In lower-staffed hospitals, nurses who must rush from room to room and spend time trying catch up on paperwork may not be able to spend much time with each patient, he said.
A second possibility-suggested by some of Aiken's work, he said-is that close communication between nurses and physicians may mean nurses are able to alert physicians quickly to any changes in the patient's condition and prevent potential complications.
Buerhaus suspects both explanations are correct. In either case, he added, RN vigilance, training and knowledge play important roles in saving lives. "We don't want to convey the suggestion that aides or LVNs aren't important," he said. "I know aides and LVNs are important." But if a hospital administrator is deciding how to improve quality of care and has a choice of hiring more aides, LVNs or RNs, Buerhaus said, "my clinical and research experience says it would be the RNs."
Several studies by the American Nurses Association have shown that increased percentages of RN care were associated with lower infection rates, showing a 0.3 percent to 0.7 percent reduction in infection rates with a 1 percent increase in percentage of RN hours of care.
The ANA also has looked at relationships between RN care and nursing-related outcomes such as pressure ulcers and falls, said Patricia Rowell, Ph.D., RN, senior policy fellow in nursing practice and policy at the American Nurses Association. The association would like to do a full analysis of all the nursing care and outcomes studies to see where the gaps in the research lie and show what further work needs to be done, she said.
Julie Sochalski, Ph.D., RN, FAAN, associate professor at the University of Pennsylvania, research faculty member at the Center for Health Services and Policy Research and co-investigator with Aiken on nursing workforce studies, has spent more than six years researching the correlation between patient outcomes and staffing.
"There has been a fair amount of evidence out there," she said. "Better-staffed hospitals have better outcomes."
The Needleman-Buerhaus study is important because it looks at a large number of hospitals in 11 states, she said. Like Buerhaus, she believes that the expertise that RNs bring to hospital work is invaluable and unique.
"You're looking at a group of people that train at a higher level," she said. "They have a greater education. The knowledge base they have is much broader. It's a deeper, richer education."
Sochalski's work with Aiken has shown that hospitals that are known for respecting, trusting and supporting that RN training-those designated as nursing Magnet hospitals by the American Nurses Credentialing Center program-have shown better patient outcomes than non-Magnet hospitals. Magnet hospitals are committed to RN staffing, Sochalski said. But they also organize nursing care in a way that lets nurses be autonomous and take more responsibility for patient care. "It's not enough to have enough people," she said. "You have to deploy them correctly."
Other work by Aiken has found that two-thirds of nurses surveyed in Pennsylvania hospitals believe they do not have enough staff to get their work done, and about 40 percent said they had no time to comfort or talk with patients. One-third reported that hospital infections had occurred regularly in the year preceding the survey.
A recent national study of RNs by NURSEWEEK and the American Organization of Nurse Executives supports Aiken's work.
About half the nurse respondents said their jobs involve so many non-nursing tasks that little time remains for nursing. Nearly 90 percent said the nursing shortage was a major problem that prevented them from spending time with patients, two-thirds said the shortage was a major problem that affected the quality of nursing care, and 64 percent said it was a major problem in maintaining patient safety.
Only 40 percent thought opportunities to influence decisions about workplace organizations were good, very good or excellent. About half said the opportunities to influence decisions about patient care were good, very good or excellent.
Nursing is not cheap
Most researchers agree that the next step is to develop economic models that show how hiring more nurses will save hospitals money in the long run. "Nursing is not cheap," Buerhaus said. "People are going to have to be making some very tough decisions."
Researchers now must study the actual cost benefits of increasing low RN staffs, he said. That means figuring out what it costs to increase staffing from, say 55 percent to 75 percent RNs, and how much that cost would be offset by fewer adverse outcomes, happier patients and shorter patient stays. "We think there's a potential economic case to make that hospitals will get an economic gain by bringing in more RNs and patients would be better off," Buerhaus said.
The cost benefits of retention also need further study, Sochalski said. She cited one report that showed that if an average hospital with an average mix of nursing staff reduced vacancies from 13 percent to 10 percent, it could reduce costs by about $800,000.
"Talk about a win-win situation," she said. "Save money, make better patients." Such studies would be valuable to the head of a hospital that is trying to persuade a board of trustees to invest in staff, she said. But right now, those studies are hard to find.
Researchers also need to look further at the mix of RNs, LVNs and aides to determine what works best. Most studies avoid discussing specific nurse-patient ratios, said Ada Sue Hinshaw, Ph.D., RN, FAAN, dean and professor at the University of Michigan School of Nursing in Ann Arbor, and author of a book on Magnet hospitals. "Because conditions vary so much. Having magic ratios is not really helpful."
Nurse executives need the freedom to make staffing decisions based on the needs of their hospital and their patients, said Lisa Sams, MSN, RN, president of Clinical Linkages Inc., a Virginia-based company that works with hospitals to improve outcomes.
"We can't say, 'Somebody, tell me what to do,' " Sams said. The recent patient-outcome studies have given nursing great evidence to help make good decisions, she said. But nurses no longer can say, "We've always used team models" or "Everyone must use an all-RN model."
On the other hand, if evidence shows that having a certain percentage of RNs on staff saves lives, ratios should at least be considered, Sochalski said. "I'm not big on legislated numbers, but I think that if you have good evidence that says you're going to save lives by increasing staff, you certainly to have that discussion on the table, as a number of states are."
Win-win situation
Some hospital administrators are acting without government prompting. Applications for Magnet hospital status have increased tremendously in the past year, Rowell said. "In some states, it's becoming almost a way of marketing yourself."
Marty Enriquez, MS, RN, vice president of patient care services at University Medical Center in Tucson called the Needleman-Buerhaus study "probably the most helpful of anything we've ever seen" for persuading hospitals to hire more nurses.
When the study appeared in the New England Journal of Medicine, nurses at University Medical Center were thrilled to see their hospital's increased commitment to nursing justified in the pages of a prestigious medical journal. "It was great to have a factual study that supports what we are doing," Brown said. "It lends us credibility. I am really grateful for the insight of our hospital. It's a great, great thing and I hope it spreads."
Although that study was published after University Medical Center changed its policy, Enriquez used some of Aiken's work on outcomes to persuade the hospital board to invest in hiring more nurses and commit to a 1-to-4 nurse-patient ratio. She also focused on studies showing how much money the hospital would save in training, recruitment and retention.
"We have been reading everything that's been coming out in the press, and everything indicates that work environment is very important," she said.
At least one nurse who planned to retire has changed her mind because of the increased staffing, Enriquez said. She believes that when nurses understand the hospital is serious about its commitment to nursing-it has applied for Magnet status-the remaining vacancies will be filled and, eventually, the hospital will save money because nurses won't want to leave. She hopes the hospital will set an example for others in the area.
Many hospital administrators believe the question of whether to hire more nurses is moot because they already are struggling to hire staff in the face of a nursing shortage.
"I think they're convinced that nurses are important and that they're important in certain numbers," Hinshaw said. "But it's one thing to understand that intellectually and another thing to put money into it." She is concerned that hospitals are throwing money into bonuses and other short-term solutions instead of focusing on creating good work environments for the nurses they have.
She hopes that as the evidence mounts, the government and the health care industry will see good nursing care as a worthy investment, like good technology or good physicians.
Before the studies on nurse staffing, Hinshaw said, "we all knew inherently that nursing made a difference, but it was considered part of the hotel bill. People never could provide evidence of how we made a difference. We had no data on that."
The Needleman-Buerhaus study and others have finally provided that data, nurse researchers say. "We get paid for the knowledge we bring," Rowell said. "I think the evidence is there if people will open their eyes and look at it."
Positive ratios
Some recent studies show an association between nurse staffing and patient outcomes:
A study published in the May 30 edition of the New England Journal of Medicine found that a higher proportion of care provided by registered nurses was associated with lower rates of pneumonia, shock or cardiac arrest, urinary tract infections, upper gastrointestinal bleeding and "failure to rescue"-death from those complications, blood poisoning or blood clots. The study looked at discharge information from more than 6 million patients in 799 hospitals in 1997. It was funded by the Department of Health and Human Services and originally released in April 2001. Researchers concluded that more hours of care and a higher proportion of hours of care provided by RNs were "associated with better care for hospitalized patients."
Researchers from Johns Hopkins University in Baltimore found that fewer RNs in the intensive care unit at night resulted in more patient complications and increased costs. Researchers used data from 569 patients in the ICU after undergoing hepatic resection. Patients with fewer RNs had increased risk for reintubation and incurred a 14 percent increase in hospital costs, according to the study published in the American Journal of Critical Care, November 2001.
A study of hospital nurses in five countries found that nearly two-thirds of American nurses believed their hospitals did not have enough nurses to provide high-quality care or to do the work that needed to be done. More than 80 percent reported an increase in the number of patients assigned to them between 1998 and 1999. Nearly half said they believed the quality of care in their hospital had deteriorated in the past year. Between one-third and two-thirds of responding nurses said they spent time performing non-nursing tasks such as housekeeping and transporting patients while important nursing tasks such as updating care plans or skin care frequently were left undone. The study, headed by Linda Aiken, Ph.D., RN, was published in the May/June 2001 issue of Health Affairs.
Studies by the American Nurses Association in 1997 and 2000 found that increased percentages of RNs in the workforce were associated with lower infection rates and pressure ulcers. The 1997 study used data from 462 hospitals in New York and California in 1992 and 1994. The 2000 study used Medicare data from 1,500 hospitals in nine states and all patient data from 1,000 hospitals in six states.
Aiken and other researchers found that nursing presence, whether measured as RN hours to some patient ratio or as RN hours relative to other nursing personnel hours, is significantly correlated to mortality. The 1994 study, published in Medical Care, concluded that hospitals that deliver good nursing care and have positive mortality outcomes also may have specific organizational assets for nurses, including greater autonomy, more control and better relationships with doctors.
~Cathryn Domrose