Nurse staffing: Key to good patient, nurse, and financial outcomes

Nurse staffing: Key to good patient, nurse, and financial outcomes
Nurse Alliance of SEIU Healthcare Train the Trainer Meeting Change that Works: A Prescription for Quality Affordable Healthcare March 12 – 13, 2009 Lynn Unruh, PhD, RN, LHRM

Current healthcare climate
Nursing shortage Tight reimbursements to providers Focus on capital & technology improvements: may be more costly then improving staffing may not improve quality and safety as intended

Presentation topics Conceptual framework
Discuss the evidence on the importance of nurse staffing for: Patient quality and safety Staff satisfaction and health Financial performance Recommendations

Definition of nurse staffing
Number of nurses or nursing hrs/ the number of patients or patient days Skill mix of nurses Little scientific evidence of exact nurse-to-patient-ratios needed Staffing adequacy is related to workload

Definition of workload
The amount and intensity of work a nurse encounters in a given period of time. Affected by all of the following: # of patients patient acuity patient throughput unit design technologies resources amount of administrative tasks skills and education of nurses

Pathways of inadequate nurse staffing
Financial Outcomes: --Unproductive workforce expenditures: Lower productivity Turnover costs Agency costs Absenteeism costs Worker’s comp claims --Unnecessary patient care costs: Longer LOS Higher tx cost Malpractice claims --Lower patient care revenue: Bed closures ER backup/bypass Loss of market share Org. climate & other work environment issues Patient charac-teris-tics Patient outcomes: Dissatisfaction Adverse events Mortality Failure to rescue Education deficits Readmission Inadequate Staffing, Excessive workload Difficult working conditions Poor nursing performance Nursing outcomes: Dissatisfaction Burnout, stress Injury/Illness Absenteeism Turnover Vacancy Nurse skills and characteristics

Pathways of inadequate staffing
Inadequate staffing/heavy workload create a difficult work environment: Time constraints Inadequate knowledge or experience Inadequate supervision of support staff Inadequate communication Generally chaotic or stressful environment

Difficult work environment
A difficult work environment can lead to poor performance Inadequate monitoring Missed care Wrong care

Other factors influencing performance
Degree of control over nursing practice Nurse managers Nurse-physicians relationships Skills, competencies, and reactions of the individual nurses Culture

Hypothesized impacts of understaffing
Negative nursing outcomes dissatisfaction burnout injury or ill-health turnover Negative patient outcomes patient dissatisfaction adverse events failure to rescue (FTR) Mortality Higher costs and lost revenues due to: lower productivity higher turnover use of agency nurses more workers’ compensation claims longer patient lengths of stay higher treatment costs

Evidence base for impact on outcomes
Comprehensive literature review Several article databases : Multiple search terms Articles selected if they were original empirical literature Existing reviews discussed when evaluating the evidence

Impact on patients: studies 1980-2006
>= 45 original studies in the U.S. >= 20 studies outside the U.S. Vast majority of studies find a significant relationship between nurse staffing and patient outcomes such as: Failure to rescue Falls Medication errors Mortality Pneumonia Pulmonary compromise Surgical or treatment complications

RN staffing impact on patients, 2002-2006 (20 studies, 112 findings)
Blood stream infections Compli- cations Falls Failure to rescue RN, LN / pt, pt day, apd 1 = NS 2 = (- ) 3 = (-) 2 = NS 1 = (+) RN, LN skill mix 1 = (-) RN ed level

Med errors Mortal-ity Pneu-monia Post-op infec-tions Pt satis-faction Pulmon- ary compro-mise RN, LN / pt, pt day, apd 1 = (- ) 1 = NS 5 = (- ) 3 = NS 2 = (- ) 1 = (+) 2 = NS RN, LN skill mix RN ed level Nurse/ pt

Restraint use Skin break- down Throm-bosis Urinary tract infec-tions RN, LN / pt, pt day, apd 1 = (- ) 1 =(- ) 3 = NS 1 = NS 2 = (- ) 4 = NS RN, LN skill mix 1 = (1) 2 = NS

Impact on patients: selected studies 2002-2003
Each additional patient in the RN patient load r/t 7% increase in FTR (Aiken et al., 2002)

Higher numbers of RNs/adjusted patient days r/t lower rates of pneumonia (Kovner et al., 2002) Higher ICU RN/patient ratios r/t fewer patient complications (Dang et al., 2002) An increase in RN HPPD or proportion r/t a decrease in the odds of pneumonia (Cho et al., 2003)

In surgical patients: Higher RN proportion r/t fewer UTIs Higher RN HPPD fewer FTR (Needleman et al, 2002)

In medical patients: Higher RNs proportion r/t fewer: UTIs Pneumonia Shock Upper GI bleed FTR Higher RN HPPD r/t fewer Upper GI bleeds (Needleman et al, 2002)

Higher levels of licensed nurses (LNs) r/t fewer: Atelectases Pressure sores Falls UTIs (Unruh, 2003) Higher proportion of LNs r/t fewer Pneumonia

Impact on patients: reviews
Lang et al., 2004, review 43 studies 1981–2003: positive effect of nurse staffing with FTR and mortality Haberfelde et al., 2005: evidence is mixed Lankshear et al.,2005: accumulating evidence of a relationship between nurse staffing & patient outcomes. Lake & Cheung, 2006: studies of falls and pressure sores methodologies vary and the evidence is inconclusive. AHRQ, 2007 (Kane, et al., 2007): large meta-analysis of studies higher nurse staffing is r/t lower pt mortality, FTR

Impact on patients: summary
Most studies find at least one positive relationship between staffing and patient outcomes. Counting the number of statistically significant relationships, the following are related to nurse staffing: Falls FTR Mortality Pneumonia

Impact on patients: research needs
Stronger, consistent methodology Consistent results Stronger clinical significance More valid and reliable unit level data Studies of changes over time Rigorous meta-analysis in which the results are scored on: Statistical significance Methodology Clinical significance (effect size)

Impact on patients: conclusion
Although more research is needed, there appears to be sufficient evidence to indicate that staffing is a key factor in promoting patient quality and safety.

Impact on nurses: methods
Studies assess responses of surveyed nurses regarding adequacy of staffing amount of workload work pressures work demands, stress AND emotional & physical health intent to stay at their job turnover

RN staffing & workload impact on nurses (22 studies, 36 findings)
Burn- out Disengage- ment & intent to quit Exhaus-tion Health status Job dissatis-faction Job satis-faction Under-staffing 1 = (+) 4 = (+) 1 = (-) High workload 2 = (+) 2 = (-) 1 = NS High job demands, stress 1= (+) 1 (-) 1 = (- )

RN staffing & workload impact on nurses (22 studies, 36 findings)
Life satisfac-tion & quality Injury: assault Injury: musculoskeletal Injury: needlestick Stress Turn-over Under-staffing 1 = (+) High workload 1 = (- ) High job demands, stress 2 = (- ) 1= (+)

Impact on nurses: emotional
Emotional exhaustion and/or job dissatisfaction are r/t: insufficient nurse staffing high work or job demands/pressure high patient acuity lack of time to do the job too many things happening at once exhaustion at the end of a shift a sense of poor quality fear of making or actually making a mistake

Impact on nurses: emotional
Burnout and job dissatisfaction reported by surveyed nurses (linked to archival staffing data) r/t lower staffed hospitals (Aiken, et al., 2002)

Impact on nurses: physical
Higher probability of a needle-stick injury r/t understaffing high workloads (Clark, et al. 2002a,b)

Impact on nurses: physical
Physical work demands are r/t neck injuries shoulder injuries back injuries (Trinkoff, et al., 2003) Imbalance between effort & reward is r/t poor self-rated health (Weyers, et al.,2006) Work pressure is r/t the health status of nurses (Landeweerd & Boumans,1994)

Impact on nurses: retention
Reasons for nurse dissatisfaction psychological stress stressful work (Gardulf, et al., 2005) Reasons for intending to quit higher work tempo work-related exhaustion lower quality of care

Impact on nurses: retention
Why nurses left their last job: poor staffing poor work environment work stress (Strachota, et al., 2003)

Impact on nurses: summary
Nearly all studies find that lower staffing or higher workload are related to negative emotional and physical health lower retention (directly or indirectly) More studies of physical impacts need to be conducted 3 out of 4 reviews of the literature have summaries that correspond to these findings

Impact on hospital finances
Small number of studies Difficulty in making the linkage because benefits of better staffing are difficult to monetize Four approaches Efficiencies r/t impact on personnel and operating costs Cost savings r/t impact on patient LOS Cost savings r/t impact on patient adverse events Costs savings of reduced nurse turnover (thought to be affected by staffing)

RN staffing impact on finances (20 studies, 35 findings)
Costs, gen-eral Costs from pt. complic. Costs: operating Costs: personnel Costs: net RN hours 1 = (- ) 1 = (+) RN/pt, pt days 2 = (- ) 2 = (+) RN skill mix 1 = NS RN turnover 3 = (- ) RN other* 2 = ( - ) * actual hrs/recommended hrs, tenure, part-time, temporary, hppd below median

RN staffing impact on finances (20 studies, 35 findings)
LOS Perfor-mance Profits RN hours 3 = (- ) 1 = NS RN/ pt, pt days 2 = (- ) RN skill mix 1 = (- ) RN turnover RN other* * actual hrs/recommended hrs, tenure, part-time, temporary, hppd below median

Impact on finances: costs
Older studies of the impact of RN skill mix on personnel & operating costs have mixed results. A newer study of both personnel and operating costs finds that: Greater RN skill mix is cost-neutral for both types of costs Greater use of temp RNs leads to higher operating costs (Bloom, Alexander, & Nuchols, 1997)

Impact on finances: patient LOS
Lower LOS r/t greater RN hours (Brown, et al., 2002; Shamian, et al., 1994) higher nurse/patient ratios (Provonost, et al., 1999) lower nurse workload (Behner, et al., 1990)

Impact on finances: patient adverse events
An increase in RN hours or proportion is r/t a decrease in the odds of pneumonia significantly lower lengths of stay decreased medical cost (Cho, et al., 2003) An increase in RN hours significantly increases operating expenses but has no significant effect on profits (McCue et al., 2003) An increase in RN skill mix increases operating expenses and lowers profits (McCue et al., 2003)

Impact on finances: patient adverse events
Decreasing patients/nurse lowers mortality and decreases costs but cost savings never completely offset the labor costs. the cost effectiveness declines as the pt/nurse ratio declines is more cost effective than other patient safety interventions (Rothberg et al., 2005) Raising the proportion of RNs without changing licensed hrs is the least costly of several staffing improvement strategies would result in a small average net benefit (negative net cost) (Needleman, et al., 2006)

Impact on finances: nurse turnover
For each nurse replaced, turnover costs include: lower productivity of nurse leaving termination costs training costs lower productivity of nurse hiring on other common expenses

Impact on finances: nurse turnover
Turnover is estimated in 2002 dollars to cost around (Jones, 2005): $62,100 for a medical surgical nurse $67,100 for a specialized nurse This is % of the average 2002 RN salary Depending on the cost categories and other factors other research shows these costs to be: More: $104,089 - $161,139 (Colosi, 2002) Less: $48,258 - $73,538 (Strachota, et al., 2003)

Impact of nurse staffing on outcomes: conclusions
It is becoming clear that adequate nurse staffing and balanced workload are key factors in achieving: Safe, quality patient care Satisfied and healthy nurses Healthy bottom line

Recommendations ensure good staffing levels
maintain reasonable workload make improvements in work environment consider the opportunity costs of choices be careful with innovations evaluate interventions promote staffing research promote adequate supply of nurses

Ensure good staffing levels
As ways are explored to make nursing care safer and better, to recruit and retain nurses, and to maintain healthy financial performance, it should be kept in mind that ensuring reasonable staffing levels and nursing workloads are important interventions.

Maintain reasonable staffing & workload
As technological and workspace changes are made, one of the important goals should be to reduce workload If changes in the workplace can maintain good workloads or reduce heavy workloads they should be implemented If they can’t, they should not.

Maintain reasonable staffing & workload
Mandated ratios California since 2004 Staffing plans/systems RN Staffing Act of 2005 Quality Nursing Care Act of 2005 State laws Public reporting of staffing Recruitment and retention strategies Support staff

Be careful with innovations
Need to understand all effects of innovations Innovations made to improve patient safety, quality, or satisfaction could have a side effect of increased nursing workload may counter-act the intended improvement e.g. going to all private rooms Innovations made in order to increase market share or reduce patient LOS could also increase nursing workload

Be careful with innovations
Innovations that increase patient volume or throughput…. expansions remodeling technology ….should be matched with additional nurses or with other interventions so that workload doesn’t increase computerized ordering and charting increased support staff

Consider the opportunity costs of choices
Capital & technological improvements are expensive remodeling expansion information technology So are increases in nurses Consider the opportunity costs of spending on capital & technology vs. nursing Consider which is most efficacious

Make other improvements in nursing work environment
Scheduling/work hours Leadership and management Organizational culture Professional Practice Staff development & educational support Interdisciplinary collaboration Workspace and work process redesign Nursing process Nurse Competence

Evaluate interventions
How all types of interventions impact important patient, nurse, and organizational outcomes How they interact with each other to do so Rigorous evaluations need to be made of interventions and innovations in bedside patient care Explore the impact of technical and capital changes on workload Define workload Should commercial patient acuity or staffing systems be used?

Promote staffing research on:
The relationship between staffing, workload, & working conditions working conditions & performance performance and medical error situational conditions and working conditions Impact of staffing, working conditions on patients, nurses, finances System barriers to reducing staffing-related errors Rigorous meta-analysis of outcomes studies

Promote adequate supply of nurses
Fund and support nursing education Develop partnerships between educators, employers, payers, consumers and regulatory bodies Improve knowledge of nurses’ contributions to patient safety and quality

Internet Resources Title/ URL Description
AHRQ Patient Safety Network: Patient safety news, literature, tools, and resources complied by the Agency for Healthcare Research and Quality. Health Care at the Crossroads Executive Summary: JCAHO report on the impact of understaffing on patient safety (2002). Keeping Patients Safe: Transforming the Work Environment of Nurses: Book 3 (2003) of Institute of Medicine IOM series on quality. This book focuses on the nursing work environment.

Health Care at the Crossroads Executive Summary: JCAHO report on the impact of understaffing on patient safety (2002). Keeping Patients Safe: Transforming the Work Environment of Nurses: Book 3 (2003) of Institute of Medicine IOM series on quality. This book focuses on the nursing work environment.

Magnet Recognition Program®: Recognizes health care organizations that provide high quality nursing care Transforming Care at the Bedside®: / A Robert Wood Johnson Foundation/Institute for Healthcare Improvement collaboration to create, test and spread prototype hospital nursing unit-level strategies to improve the work environment and quality of care.

Lynn Unruh PhD RN, (2008). Nurse Staffing and Patient, Nurse, and Financial Outcomes, American Journal of Nursing, January 2008 (108)1, 62 - 71. Available at: The AJN article upon which this presentation was based. The on-line version has detailed tables (free) and offers CEUs (for a charge). Value Care, Value Nurses: Postings of articles and blogs regarding nursing care quality and work environment, led by the Nurse Alliance of the Service Employees International Union.

References AFT Healthcare. (2003). Patient-to-nurse staffing ratios: Perspectives from hospital nurses. Peter Hart Research Associates/AFT Healthcare. Aiken, L.H., et al. (2002) Hospital nurse staffing and patient morality, nurse burnout, and job dissatisfaction. American Medical Association, 288(16), Aiken, L.H., Clarke, S.P., Cheung, R.B., Sloane, D.M., & Silber, J.H. (2003). Educational Levels of Hospital Nurses and Surgical Patient Mortality. The Journal of the American Medical Association, 290(12), Bloom, J.R., Alexander, J.A., & Nuchols, B.A. (1997). Nurse staffing patterns and hospital efficiency in the United States. Social Science and Medicine, 44(2), Choi, J., Bakken, S., Larson, E., Du, Y., & Stone, P.W. (2004). Perceived nursing work environment of critical care nurses. Nursing Research, 53, Cho, S., Ketefian, S., Barkauskas, V.H., & Smith, D.G. (2003). The effects of Nurse Staffing on Adverse Events, Morbidity, Mortality, and Medical Costs. Nursing Research, 52(2), Cimiotti, J.P., Quinlan, P.M., Larson, E.L., Pastor, D.K., Lin, S.X., & Stone, P.W. (2005). The magnet process and the perceived work environment of nurses. Nursing Research, 54(6),

References Clarke, S.P., Sloane, D.M., & Aiken, L.H. (2002). Effects of hospital staffing and organizational climate on needlestick injuries to nurses. American Journal of Public Health, 92(7), Clarke, S.P., Rockett, J.L., Sloane, D.M., & Aiken, L.H. (2002). Organizational climate, staffing, and safety equipment as predictors of needlestick injuries and near-misses in hospital nurses. American Journal of Infection Control, 30(4), Colosi ML (2002). Rules for engagement for the nursing shortage. JONA’s Healthcare Law Ethics, and Regulation, 4(3), Dang, D., Johantgen, M.E., Pronovost, P.J., Jenckes, M.W., & Bass, E.B. (2002). Postoperative complications: Does intensive care unit staff nursing make a difference? Heart and Lung, 31(3), Gardulf, A., Soderstrom, I-L., Orton, M-L., Eriksson, L. E., Arnetz, B., & Nordstorm, G. (2005). Why do nurses at a university hospital want to quit their jobs? Journal of Nursing Management, 13(4), Glandon, G. L., Colbert, K. W., & Thomasma, M. (1989). Nursing delivery models and RN mix: cost implications. Nursing Management, 20(5),

References Haberfelde, M., Buffum, M., & Bedecarre, D. (2005). Nurse-sensitive patient outcomes: An annotated bibliography. Journal of Nursing Administration, 35(6), Halloran, E. J. (1983). RN staffing: more care-less cost. Nursing Management, 14(8), Jones, C.J., (2005). The cost of nurse turnover, part 2: application of the nursing turnover cost calculation methodology. Journal of Nursing Administration, 35(1), Kane, R.L., Shamliyan, T., Mueller, C., Duval, S., & Wilt, T.J. (2007). Nurse staffing and quality of patient care. Evidence Report/Technology Assessment No. 151, Rockville MD: AHRQ. Available at Kovner, C., Jones, C., Zhan, C., Gergen, P., & Basu, J. (2002). Nurse staffing and post surgical adverse events: an analysis of administrative data from a sample of U.S. hospitals, Health Services Research, 37(3),

References Lake, E.T., & Cheung, R.B. (2006). Are patient falls and pressure ulcers sensitive to nurse staffing? Western Journal of Nursing Research, 28(6), Landeweerd, J., & Boumans, N. (1994). The effect of work dimensions and need for autonomy on nurses’ work satisfaction and health. Journal of Occupational and Organizational Psychology, 67(3), Lang, T.A., Hodge, M., & Olson, V. (2004). Nurse-patient ratios: A systematic review on the effects of nurse staffing on patient, nurse employee, and hospital outcomes. Journal of Nursing Administration, 34(7/8), Lankshear, A.J., Sheldon, T.A., Maynard, A. (2005) Nurse staffing and healthcare outcomes: a systematic review of the international research evidence. ANS. Advances in Nursing Science. 28(2), McCue, M, Mark, BA & Harless, DW. (2003). Nurse staffing, quality, and financial performance. Journal of Health Care Finance, 29(4),

References Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinsky, K. (2002). Nurse-staffing levels and the quality of care in hospitals. New England Journal of Medicine, 346(22), Needleman, J, Buerhaus, P.I., Stewart, M., Zelevinsky, K. & Mattke, S, (2006). Nurse-staffing in hospitals: is there a business case for quality? Health Affairs, 25(1), Rothberg, M. B., I. Abraham, P. K. Lindenauer, and D. N. Rose. (2005). Improving nurse-to-patient staffing ratios as a cost-effective safety intervention. Medical care 43, no. 8: Shukla, R. K. (1983). All-RN model of nursing care delivery: a cost-benefit evaluation. Inquiry, 20, Strachota, E., Normandin, P., O’Brien, N., Clary, M., Krukow, B. (2003). Reasons registered nurses leave or change employment status. Journal of Nursing Administration, 33(2),

References Titler, M., Dochterman, J., Picone, DM., Everett, L., Xie, X., Kanak, M., Fei, Q. (2005). Cost of hospital care for elderly at risk of falling. Nursing Economics, 23(6), Titler, M., Dochterman, J., Kim, T., Kanak, M., Shever, L., Picone, DM., Everett, L., Budreau, G. (2007). Cost of care for seniors hospitalized for hip fracture and related procedures. Nursing Outlook, 55(1), 5-14. Trinkoff, A. M., Lipscomb, J. A., Geiger-Brown, J., Storr, C. L., Brady, B. A. (2003). Perceived physical demands and reported musculoskeletal problems in registered nurses. American Journal of Preventive Medicine, 24(3), Unruh, L. (2003). Licensed nurse staffing and adverse events in hospitals. Medical Care, 41 (1), Weyers, S., Peter, R., Boggid, H., Jeppesen, H. J., Siegrist, J. (2006). Psychosocial work stress is associated with poor self-rated health in Danish nurses: a test of the effort-reward imbalance model. Scandinavian Journal of Caring Sciences, 20,

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