The first study found that each additional surgical patient per nurse was associated with a 7-percent higher likelihood of dying within 30 days of admission and a 7-percent higher likelihood of failure to rescue. In the 168 hospitals with a mean patient-to-nurse ratio ranging from 4:1 to 8:1, 4,535 of 232,342 patients died within 30 days of being admitted. If the patient-nurse ratio had been as low as 4:1 in the 168 hospitals, then possibly only 4,000 patients might have died, and had the ratio been as high as 8:1, more than 5,000 might have died. 14 A second study found that 30-day mortality rates among aids patients were lower where there was both a higher nurse-patient ratio and an aids specialty physician service. For example, the study found that an increase.25 nurse per patient day would produce a 20-percent decrease in 30-day mortality. 15 Nurse staffing may be measured by educational level as well as by the number and proportion of RNs in the nursing staff. A third ahrq-funded study found that a 10-percent increase in the proportion of nurses holding a bachelor's degree was associated with a 5-percent decrease in both the likelihood of surgical patients dying within 30 days of admission and the odds of failure to rescue. 16 Return to contents Nurse workload and Job Dissatisfaction The studies discussed have documented the connection between lower levels of nurse staffing and higher rates of adverse events. Complementing those studies are a number of other studies addressing the growing nurse workload and rising rates of burnout the and job dissatisfaction.
13 The study examined administrative data on post-surgical patients in 11 States during 1990-96. A study of nurse staffing levels and adverse outcomes in California found that an increase of 1 hour worked by rns per patient day was associated with.9-percent decrease in the odds of a surgical patient's contracting pneumonia. 8 This study also found that a 10-percent increase in rn proportion was associated with.5-percent decrease in the odds of pneumonia. The researchers in the california study believe that the strong relationship between rn staffing and pneumonia can be attributed to the heavy responsibility rns have for respiratory care in surgical patients. This study examined the effects of nurse staffing on adverse outcomes in 232 dissertation acute care hospitals from 1996 to 1999. F unlike many earlier studies, the california study included only adverse outcomes that were not present at admission. 7 Mortality may be associated with Staffing levels Although studies overall are not consistent in demonstrating that higher nursing workload is associated with higher patient mortality, two recent ahrq-funded studies have found that 30-day mortality and an increase in the likelihood of failure to rescue.
Surgical patients in hospitals with high rn staffing had a 5-6 percent lower rate of utis and a 4-6 percent lower rate of failure to rescue than surgical patients in the comparison group. D a second study, funded jointly by ahrq and the national Science foundation, examined licensed nurse staffing (RNs and lpns) and adverse outcomes among both medical and surgical patients in Pennsylvania acute-care hospitals. 11 It found a lower incidence of nearly all adverse outcomes it studied in hospitals with more licensed nurses. For example, a 10-percent increase in the number of licensed nurses is estimated to decrease lung collapse.5 percent, pressure ulcers by 2 percent, falls by 3 percent, and utis by less than 1 percent. Also, with a 10-percent higher proportion of licensed nurses, there was a 2-percent lower incidence of pressure ulcers. E, 11 Pneumonia rates Are Especially sensitive to Staffing levels Three ahrq-funded studies found a significant correlation between lower nurse staffing levels and higher rates of pneumonia. The first study found that adding half an hour of rn staffing per patient day could reduce pneumonia in surgical patients by over 4 percent. 12 This study covered 589 hospitals in 10 States during 1993. A second study by the same researchers also found that fewer rn hours per patient day were significantly correlated with a higher incidence of pneumonia.
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Different studies report varying adverse event rates, good which vary by the type of patient (medical or surgical) as well as other factors. For example, utis help occur in from.9 percent.3 percent of surgical patients and pneumonia.2 percent.6 percent of surgical patients. 8-10 The largest of these studies on nurse staffing (jointly funded by ahrq, the health Resources and Services Administration, the centers for Medicare medicaid Services, and the national Institute of Nursing Research) examined the records of 5 million medical patients and.1 million surgical patients. 6, 8 Among the study's principal findings: In hospitals with high rn staffing, medical patients had lower rates of five adverse patient outcomes (UTIs, pneumonia, shock, upper gastrointestinal bleeding, and longer hospital stay) than patients in hospitals with low rn staffing. C major surgery patients in hospitals with high rn staffing had lower rates of two patient outcomes (UTIs and failure to rescue). Higher rates of rn staffing were associated with a 3- to 12-percent reduction in adverse outcomes, depending on the outcome.
Higher staffing at all levels of nursing was associated with a 2- to 25-percent reduction in adverse outcomes, depending on the outcome. Table 1 illustrates some of the major findings. For example, the researchers found that medical patients in hospitals with high rn staffing were 4-12 percent less likely to develop utis than medical patients in the comparison group. Medical patients in hospitals with high levels of total nurse staffing (RNs, lpns, and aides) were 4-25 percent less likely to develop utis than patients in the comparison group. A similar analysis was performed for the smaller group of surgical patients ( Table 2 ).
Nursing-sensitive outcomes are one indicator of quality of care and may be defined as "variable patient or family caregiver state, condition, or perception responsive to nursing intervention." 6, some adverse patient outcomes potentially sensitive to nursing care are urinary tract infections (UTIs pneumonia, shock, upper. A, most research has focused on adverse rather than positive patient outcomes for the simple reason that adverse outcomes are much more likely to be documented in the medical record. A broad array of research on this topic has found an association between lower nurse staffing levels and higher rates of some adverse patient outcomes. A new evidence report entitled. The Effect of health Care working Conditions on Patient Safety, produced by an ahrq-funded evidence-based Practice center (epc reviewed 26 studies on the relationship between nurse staffing levels and measures of patient safety. B most of the studies examined nurse staffing levels and adverse occurrences in the hospital setting, including in-hospital deaths and nonfatal adverse outcomes such as nosocomial infections, pressure ulcers, or falls.
The epc's researchers found that lower nurse-to-patient ratios were associated with higher rates of nonfatal adverse outcomes. 7 This was true at both the hospital level and the nursing unit level. With regard to in-hospital deaths, however, the evidence does not consistently show that lower nurse staffing levels are associated with higher mortality. Lower Staffing levels Are linked to higher Adverse outcome rates The epc report included five studies funded by ahrq that examined the relationship between adverse patient outcomes and hospital nurse staffing. All five studies found at least some association between lower nurse staffing levels and one or more types of adverse patient outcomes. How often do such adverse "nursing-sensitive" patient outcomes occur in hospital care?
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RNs have obtained their education through three different routes: 3-year diploma programs, 2-year associate degree programs, and 4-year baccalaureate degree programs. Almost a third of reviews all RNs have a baccalaureate degree, and.6 percent of hospital nurses have advanced practice credentials (either a master's or doctoral degree). Lpns receive 12-18-month training programs that emphasize technical nursing tasks. Nurses' aides are not licensed but many acquire certified nurse aide or nursing assistant (CNA) status after proving they have certain skills related to the requirements of particular positions. Nurse staffing is measured in one of two basic ways: Nursing hours per patient per day. The nurse to patient ratio. "Nursing hours" may refer to rns only; to rns and lpns; or to rns, lpns, and nurses' aides. Return to contents, hospital Nurse Staffing and Nursing-Sensitive outcomes. Hospital nurse staffing is a matter of major concern because of the effects it can have on patient safety and quality of care.
At the national level to collect and analyze current and relevant data and develop a research and evaluation agenda so that informed policy development, implementation and evaluation are undertaken in a timely manner." to begin to meet writing that need, ahrq-funded research and other research have. The nurse workforce and Nurse Staffing levels. The nurse workforce consists of licensed nurses—registered nurses (RNs) and licensed practical nurses (LPNs)—and nurses' aides (NAs). Both RNs and lpns are licensed by the State in which they are employed. RNs assess patient needs, develop patient care plans, and administer medications and treatments; lpns carry out specified nursing duties under the direction of RNs. Nurses' aides typically carry out nonspecialized duties and personal care activities. RNs, lpns, and nurses' aides all provide direct patient care.
nurse population and the increasing. 3, today's difficulties are further complicated by other changes in hospital care, such as new medical technologies and a declining average length of stay, that have led to increases in the amount of care required by patients while they are in the hospital. New medical technologies allow many less seriously ill patients who previously would have received inpatient surgical care to receive care in outpatient settings. Also, patients who in the past would have continued the early stages of their recovery in the hospital, today are discharged to skilled nursing facilities or to home. During the period, the average length of an inpatient hospital stay fell from.5 days.9 days. 4, an important consequence of these changes is that hospitals have a higher overall concentration of sick people who need more care. Various groups, including the American Hospital Association, the joint Commission on the Accreditation of healthcare Organizations, and the Institute of Medicine (iom have expressed their concerns about the evolving nursing crisis. The iom issued a report in 1996 that recognized the importance of determining the appropriate nurse-patient ratios and distribution of skills for ensuring that patients receive quality health care. 5, its report highlighted the fact that research on the relationship between the level of staffing by nurses in hospitals and patients' outcomes has been inconclusive. The iom's analysis of staffing and quality of care in hospitals concluded by calling for "a systematic effort.
This is evident from an average vacancy rate of 13 percent. This report summarizes the findings of ahrq-funded and other research on the relationship of nurse staffing levels to adverse patient outcomes. This valuable information can be used by decisionmakers to make more informed choices in terms of adjusting nurse staffing levels and increasing nurse recruitment while optimizing quality of care and improving nurse satisfaction. Return to contents, background. Periods of high vacancy rates for RNs in hospitals have come and gone, but the current shortage is different. According to a 2002 report by the workforce commission of the American Hospital Association, the nursing shortage "reflects fundamental changes in population demographics, career expectations, work attitudes and worker dissatisfaction." 1, in fact, the present situation may well continue over the next two decades. A federal government study predicts that hospital nursing vacancies will reach 800,000, or 29 percent, by 2020. 2, the number of nurses is expected to grow by only 6 percent by 2020, while demand for nursing care is expected to grow by 40 percent. The most recent research shows a jump of 100,000 RNs, or 9 percent, in the hospital rn workforce between 20 because of increased demand, higher pay, summary and a weakening economy.
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Hospitals with low nurse staffing levels tend to have higher rates of poor patient outcomes such as pneumonia, shock, cardiac arrest, and urinary tract infections, according to research funded by the Agency for healthcare research and quality (ahrq) and others. Select to download print version (. Pdf file, 514 KB). Contents, introduction, background, hospital Nurse Staffing and Nursing-Sensitive outcomes. Nurse workload and Job Dissatisfaction, cost Impacts of Adverse events, strategies for Improvement. The patient Safety Initiative and Hospital Nurse Staffing. Conclusion, references, notes, introduction, although hospitals with low nurse staffing levels tend to have higher rates of poor patient outcomes, increasing staffing levels is not easy. Major for factors contributing to lower staffing levels include the needs of today's higher acuity patients for more care and a nationwide gap between the number of available positions and the number of registered nurses (RNs) qualified and willing to fill them.