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Shortage of Nurses Hurts Patient Care, Study Finds
By DENISE GRADY
In hospitals with low numbers of registered nurses, patients are more likely
to suffer complications like urinary infections and pneumonia, to stay in
the hospital longer and to die from treatable conditions like shock or
gastrointestinal bleeding, researchers report today.
"I estimate that hundreds or, perhaps, thousands of deaths each year are due
to low staffing," said Dr. Jack Needleman, an economist at the Harvard
School of Public Health and the lead author of a study on staffing published
today in The New England Journal of Medicine.
The nation has a serious nursing shortage, with 126,000 jobs unfilled, 12
percent of capacity, says the American Hospital Association. The shortage is
a result of hospital mergers, layoffs and heavy workloads. Many hospital
nurses shifted to other work. The average salary, $46,000 a year, has not
increased much in a decade. Even though hospitals are trying to hire again,
nurses are no longer available.
The new study, paid mostly by the government, is one of the largest to look
at care in relation to staffing. The findings were based on a computer
analysis of the discharge records of more than six million patients at 799
hospitals in 11 states in 1997. Five million had medical problems. One
million had surgery.
The research sought to find out whether there was a correlation between how
patients fared and the levels of registered nurses and two other types of
workers with less training, licensed practical nurses and aides.
Registered nurses receive several years of training and usually hold
associate's or bachelor's degrees. Practical nurses usually have high school
diplomas and a year of training. Aides have less training.
The researchers found that for certain aspects of care just nurses made a
difference. In hospitals with higher nurse staffing, stays were 3 to 5
percent shorter, and complication rates 2 to 9 percent lower than in
hospitals with lower staffing. No relation was found between patients'
well-being or length of stay and the levels of aides or practical nurses.
Registered nurses, Dr. Needleman said, are "the eyes and ears of the
hospital" for judging whether a patient is recovering normally.
"If something is going wrong," he said, "they can catch the signs early,
before the problem gets worse."
But problems cannot be spotted early, he added, if nurses do not have time
to observe their patients.
The president of the American Nurses Association, Mary E. Foley, said,
"We're very pleased that another large set of research data has validated
what the American Nurses Association has been saying since the mid-90's,
that there is a direct effect on the outcome of patient care when you have
enough nurses."
As an example, Ms. Foley said, pneumonia and blood clots in hospitalized
patients often result from immobility, and nurses help prevent such
complications by turning and repositioning bedridden patients, encouraging
them to exercise and cough and helping others to get up and walk around.
Even if nurses themselves do not do those things for patients, they have the
training and experience to know when such help is needed and to ensure it is
provided.
A senior vice president for policy at the American Hospital Association,
Carmela Coyle, said: "The study suggests that registered nurses are key and
critical to insuring good patient care. This is something that hospitals and
patients have known for some time."
Ms. Coyle said she feared that the study would lead some people to assume
that health care problems could be solved by laws that require specific
staffing ratios, a move that hospital trade groups have long resisted. She
called such a reaction overly simplistic.
"What you really need to look at," Ms. Coyle said, "is much more than the
number of nurses and the number of patients. How many of the nurses have 20
years of experience or more, and how many are right out of school? What
technology is there to support them? How sick are the patients?"
Dr. Needleman said his group made its study because the government sought to
fill a large research gap on the connection between nurse staffing and
quality of care. In the early 1990's, nurses testified to Congress that
patients in some hospitals were endangered by managed-care companies that
were trying to save money by replacing registered nurses with less skilled
and lower paid workers. Congress asked the Institute of Medicine to study
the issue. In a report in 1996, the institute said there was not enough data
to draw conclusions and called on the government to finance studies.
Dr. Needleman's is one of those. It measured staffing two ways, by the
proportion of nursing hours provided by each type of worker and by the
number of hours a day the types of workers devoted to each patient.
For registered nurses, the average number of hours a day per patient worked
out to eight. The hours included not only time spent at the bedside, but
also time spent preparing medication, writing chart reports and consulting
colleagues or family members.
The averages include intensive care units, with one nurse for every one or
two patients around the clock.
"There were some hospitals, that if I were going to them as a patient, I
would be very concerned," Dr. Needleman said. "The hospitals at the very low
end of our sample had as little as two hours, and some at the high end had
16 hours."
When the study compared the hospitals in the top quarter with those in the
bottom quarter on the proportion of nursing time from registered nurses, it
found that the medical patients, as opposed to surgical patients, in the
bottom quarter had stays 3.5 percent longer, 9 percent more urinary
infections, 5.1 percent more gastrointestinal bleeding, 6.4 percent more
pneumonia and 9.4 percent more shock or cardiac arrest.
In addition, the death rate was 2.5 percent higher for "failure to rescue,"
meaning that the patients died from conditions that might have been reversed
if they had been treated in time. Those conditions include pneumonia, shock
or cardiac arrest, upper gastrointestinal bleeding, sepsis or a blood clot.