Analysis: Hospital Nurse Staffing and Quality of Case Essay

Hospitals with low shield staffing levels tend to have high range of poor enduring outcomes such as pneumonia, shock, cardiac arrest, and urinary tract infections, agree to search funded by the Agency for healthc atomic number 18 Research and Quality (AHRQ) and others. Yet increasing staffing levels is not an easy task. Major factors contributing to begin staffing levels include the inevitably of to solar days higher alertness forbearings for more fright and a nationwide gap between the number of available positions and the number of registered have gots (RNs) qualified and will to fill them. This is evident from an average va drive outcy rate of 13 per centum.This report summarizes the findings of AHRQ-funded and other inquiry on the relationship of blow staffing levels to ominous patient outcomes. This precious information can be used by decisionmakers to make more informed choices in terms of adjusting nurse staffing levels and increasing nurse recruitment tranc e optimizing part of cargon and improving nurse satisfaction. continue over the next two decades. A Federal Government adopt predicts that hospital breast feeding vacancies will r for each one 800,000, or 29 percent, by 2020.2 The number of nurses is expected to grow by tho 6 percent by 2020, while demand for care for compassionate 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 2001 and 2002 because of increased demand, higher pay, and a weakening economy. However, since almost all of theMaking a DifferenceLower levels of hospital nurse staffing are pertaind with more ominous outcomesPage 3 Patients have higher acuity, yet the skill levels of the nursing staff have declinedPage 5 Higher acuity patients and added responsibilities increase nurse workloadPage 5 Avoidable unfortunate outcomes such as pneumonia can raise treatment costs by up to $28,000Page 6 Hiring more RNs does not dec rease profits Page 6 Higher levels of nurse staffing could have positive impact on two quality of care and nurse satisfactionBackgroundPeriods of high vacancy rank for RNs in hospitals have come and gone, but the current shortage is different. check 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 prole dissatisfaction.1 In fact, the present situation may wellAuthor Mark W. Stanton, M.A. Managing Editor Margaret Rutherford Design and Production Frances Eisel Suggested citation Stanton MW, Rutherford MK. Hospital nurse staffing and quality of care. Rockville (MD) Agency for Healthcare Research and Quality 2004. Research in Action Issue 14. AHRQ Pub. No. 04-0029.increase came from RNs over age 50 who returned to the workforce and a greater influx of foreign-born RNs, this does not alter the structural features in the long term the aging of the nurse population and the increasing unwillingness of preadolescent women to consider nursing as a profession.3 Todays surdies are further complicated by other changes in hospital care, such as new health check 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 functional 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 layover 1980-2000, the average length of an inpatient hospital stay fell from 7.5 days to 4.9 days.4 An important consequence of these changes is that hospitals have a higher overall concentration of toot 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 associates somewhat 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 nurse workforce and nurse staffing levelsthe level of staffing by nurses in hospitals and patients outcomes has been inconclusive. The IOMs analysis of staffing and quality of care in hospitals reason by calling for a systematic effort 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 that need, AHRQ-funded research and other res earch have pursued a number of different paths.Hospital nurse staffing and nursing- beautiful outcomesHospital nurse staffing is a matter of major concern because of the effects it can have on patient safety and quality of care. Nursing-sensitive outcomes are one indicator of quality of care and may be specify as variable patient or family caregiver state, condition, or perception responsive to nursing intervention.6 Some indecent patient outcomes potentially sensitive to nursing care are urinary tract infections (UTIs), pneumonia, shock, upper gastrointestinal bleeding, longer hospital stays, failure to rescue, and 30-day mortality.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. aFailure to rescue is defined as the death of a patient with a lifethreatening complication for which early identification by nurses and medical and nursing interventions c an influence the risk of death.The nurse workforce consists of clear nursesregistered nurses (RNs) and license 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 andtreatments LPNs protract 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. RNs have obtained their education through three different routes 3-year diploma programs, 2-year associate degree programs, and 4year baccalaureate degree programs.Almost a third of all RNs have a baccalaureate degree, and 7.6 percent of hospital nurses have advanced utilisation credentials (either a masters or doctoral degree). LPNs receive 12-18-month training programs that emphasize technical nursing tasks. Nurses aides are not licensed but man y acquire certified nurse aide or nursing assistant (CNA) status after proving they have certain skills related to the requirements of busy 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.2www.ahrq.govA 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 AHRQfunded 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 EPCs researchers found that lower nurse-topatient ratios were associated with higher rates of nonfatal adverse outcomes.7 This was true at both(prenominal) 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.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 1.1 million working(a) patients who had been treated at 799 hospitals during 1993.6,8 Among the studys 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 M ajor 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.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 nu rsing-sensitive patient outcomes occur in hospital care? Different studies report change adverse event rates, which vary by the type of patient (medical or surgical) as well as other factors. For example, UTIs occur in from 1.9 percent to 6.3 percent of surgical patients and pneumonia in 1.2 percent to 2.6 percent of surgical patients.8-10 bTable 1. Percent reduction in rates of outcomes among medical patients in hospitals with high nurse staffing (75th percentile) compared to the rates in hospitals with low nurse staffing (25th percentile) Amount by which rates are lower forIn order to improve the quality and delivery of health care operate, AHRQ has sponsored a series of evidence reports that are based on rigorous, comprehensive reviews of relevant scientific literature. These reports are developed and written by after-school(prenominal) research and academic organizations designated as Evidence-based Practice Centers (EPCs). The reports emphasis is on explicit and detailed do cumentation of methods, rationale, and assumptions.The goal of these reports is to provide the scientific foundation that public and cloistered organizations can use to develop their own clinical practice guidelines, quality measures, review criteria, and other tools to improve the quality and delivery of health care services study measured RN staffing as hours per day and as the RN proportion of nursing hours. Hospitals with higher hours of RN staffing (75th percentile) had an average of 9.1 hours of inpatient RN nursing per patient day, while those with lower RN staffing (25th percentile) had an average 6.4 hours of inpatient RN nursing per patient day. Hospitals with a higher proportion of RN staffing (75th percentile) had an average of 75 percent of inpatient nursing hours provided by RNs, while those with lower RN staffing (25th percentile) had an average of 62 percent of nursing hours provided by RNs.Outcome in medical patients Urinary tract infection Upper gastrointestinal b leeding Hospital-acquired pneumonia Shock or cardiac arrestHigh RN staffing 4-12% 5-7% 6-8% 6-10%High staffing, all levels (RNs, LPNs, aides) 4-25% 3-17% 6-17% 7-13%c ThisNote Difference is expressed as a range of set (e.g., 4-12 percent) because several statistical models were used in evaluating the relationship between nurse staffing levels and each adverse event. Source Needleman J, Buerhaus P, Mattke S, et al. Nurse-staffing levels and patient outcomes in hospitals. Final report for Health Resources and Services Administration. Contract No. 230-99-0021. 2001. Harvard School of Public Health, Boston, MA.www.ahrq.gov3 medical exam 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). 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.dPneumonia rates are especially sensitive to staffing levelsThree 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.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 an 8.9-percent decrease in the odds of a surgical patients contracting pneumonia.8 This study also found that a 10 -percent increase in RN proportion was associated with a 9.5-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 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.7Table 2. Percent reduction in rates of outcomes among surgical patients in hospitals with high nurse staffing (75th percentile) compared to the rates in hospitals with low nurse staffing (25th percentile) Amount by which ratesre lower for High staffing, all levels (RNs, LPNs, aides) 3-14% 2-12% 19%Outcome in surgical patients Urinary tract infection Failure to rescue Hospital-acquired pneumoniaHigh RN staffing 5-6% 4-6% 11%Note Difference is exp ressed as a range of values (e.g., 2-12 percent) because several statistical models were used in evaluating the relationship between nurse staffing levels and each adverse event. Source Needleman J, Buerhaus P, Mattke S, et al. Nurse-staffing levels and patient outcomes in hospitals. Final report for Health Resources and Services Administration. Contract No. 230-99-0021. 2001. Harvard School of Public Health, Boston, MA.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 by 1.5 percent, pressure ulcers by 2 percent, falls by 3 percent, and UTIs by less than 1 percent. Also, with a 10-percent higher p roportion of licensed nurses, there was a 2-percent lower incidence of pressure ulcers.e,11dSurgical patients overall had lower rates of adverse outcomes than medical patients, perhaps because they are healthier. Also, the smaller number of surgical patients in the study may have made it more difficult to detect associations. Nurse staffing was measured in two ways (1) the ratio of licensed nurses (RNs + LPNs) to the patient load (with and without adjustments for patient acuity) and (2) the proportion of licensed nurses to the total nursing staff (RNs, LPNs, NAs). The adverse outcomes selected for study were either caused by or not prevented by medical management based on criteria used by the Harvard Medical Practice Study. Nurse staffing was measured in three ways all hours (the total number of productive hours worked by all nursing personnel per patient day), RN hours (the total number of productive hours worked by registered nurses per patient day), and RN proportion (RN hours di vided by all hours).