Nursing Shortage: Its Effect on Patient Outcome In today's environment of rising costs in the health care industry, one of the first casualties in many hospitals is the level of RN staffing. In fact, across the country, hospital RNs are increasingly forced to work in an atmosphere in which they are understaffed, overworked, and charged with responsibilities wholly unrelated to direct patient care. This is a phenomenon illustrated in alarming detail in the article "Identifying Nurse Staffing and Patient Outcome Relationships: A Guide for Change in Care Delivery," published in the July-August, 2003 issue of Nursing Economics, in which a solid connection between inadequate RN staffing and negative patient outcomes is presented.

Most RN's are acutely aware of the negative repercussions they experience personally as a result of understaffing -- particularly in acute health care units. Most also realize that this understaffing is the result of the popular administrative notion that the higher the RN percentage in any given facility, the higher hospital costs rise (Potter, Barr, McSweeney, Sledge, 2003). Although, it is true that higher RN concentrations in any given facility must necessarily increase cost in the short-term, there remains the question of whether, in consideration of the detrimental effect reductions in RN staffing has on patient outcome, the current definition of "cost" is one-dimensional.

Although it is tempting to fall into the trap of weighing, perhaps, too heavily on financial considerations in hospital policy decisions, particularly concerning RN staffing, the nature of the hospital as a "caring" institution must be upheld. Not only is this absolutely essential in defending the quality of health care offered to patients, but it is also ultimately more cost effective in reducing the very real financial repercussions that arise out of negative patient outcomes -- which include factors such as "measures of patient falls, medication errors, self-reported symptom management, self-care and health status, and post-discharge patient satisfaction ((Potter, Barr, McSweeney, Sledge)." After all, were one to factor in the higher costs associated with medication errors, medical complications resulting from inadequate care (pressure ulcers, falls), as well as possible legal action leveled by disgruntled patients (again, to say nothing of the moral and ethical implications), the actual financial benefit of reduced RN staffing may be very different, indeed.

However, it is tempting to question whether these so called "negative patient outcomes," described in the Nursing Economics article previously mentioned, are even related to the ratio of RN to patient in any particular unit. After all, many might argue that it is highly possible that most negative patient outcomes are more a result of the individual patient's medical condition than levels of nursing care. For example, a study referenced in the Nursing Economics article (Reed, Blegen, and Goode, 1998), came to the conclusion that the "adverse occurrences typically measured as clinical outcomes (for example, medication errors, pressure ulcer rates, and falls) may reflect the severity of patients' conditions rather than the quality of nursing care (Potter, Barr, McSweeney, Sledge)." While it is true that it is particularly difficult to attribute a cause and effect relationship between any two variables in a multi-variable situation, the strength of the Reed, Blegen and Good study seems to put this question to rest.

Understanding that a causal relationship between nurse staffing and patient outcome was under question, Potter, Barr, McSweeney, and Sledge sought to clarify the relationship between the two variables in their study. According to the authors:

The purposes of the main study were to determine baseline values of patient outcome measures and the relationship of nurse staffing at the unit level to patient outcomes in the acute care, inpatient setting, while adjusting for acuity level and percentage of float nurses on the unit. The findings regarding outcome measures would serve as a baseline for evaluating changes in care delivery to be undertaken within the hospital (Potter, Barr, McSweeney, and Sledge).

Further, the study authors defined the term "outcome" specifically as follows:

Outcome are what happens to the patient [including] the patient's health status, functional status, quality of life or the presence or absence of disease (Mitchell, 1993) The American Nurses Association (ANA) (1995) defines quality with three-tier model that include patient-focused outcome indicators (for example, how patients' conditions are affected by their interactions with nursing staff), process of care indicators (for example, nursing satisfaction), and structure of care indicators (for example, staffing patters) (Potter, Barr, McSweeney, and Sledge).

This definition of patient outcome is particularly important in that it can be interpreted as a concept in any number of ways. Therefore, in response to this issue, the study authors specifically defined "patient...

In short, they found that adverse events, measured by the "fall index" and the "medication errors" index, inpatient self-reports (in which patients reported symptom management, self-care, and health status), collected by means of the Eight Visual Analog Scale, or VAS, as well as a "excellent to poor" five point scaled question regarding the patient's perception of overall health would be the most "data friendly" aspects to consider.
In all, the study included a total of 3,418 patients. They were questioned concerning their overall "satisfaction," based on "communication, respect, coordination of care, nursing care, discharge process, advocation, and patient compassionate care (Potter, Barr, McSweeney, and Sledge). They also measured staffing data, as well as levels of patient acuity (and adjusted the data distribution according to float percentages and acuity). The outcome was striking and definitive.

Overall, the study found:

The percentage of RN hours negatively correlated with patient pain and self-care ability...in other words, the higher the percentage of hours of nursing care provided by RNs, the lower level of pain perceived by patients, the better the patient's perception of self-care ability and health status, and the greater the patients' satisfaction post-discharge.

Further, although the study did not find that there was a correlation between RN staffing and the medication and fall indices, the study did find that, "Total hours of nursing care per patient day were negatively correlated with patient distress, willingness and ability to care for self, the indexes of symptom management and self-care, and the fall index," therefore, the larger the amount of nursing hours "by all categories of nursing personnel are associated with less patient distress, fewer problems with symptom management," falls, and successful self-care.

Interestingly, the findings of this study closely mirror another study focusing on virtually the same topic, described in the JONA article, "The Relationship Between Nurse Staffing and Patient Outcomes." (2003) In this study, conducted by Sacichay-Akkadachanunt, Scalzi, and Jawad, the question was similarly raised, considering patient outcome (in this case, specifically morality), and nurse staffing variables (ratio of nursing staff to patient, proportion of RNs in the nursing staff, the level of RN experience in mean years, and the overall percentage of BS in nursing degrees).

The reason that this article is interesting is not only because the outcome seems to closely relate to the previous study, but that it seems to indicate the universality of the negative relationship between high patient to nurse ratios and patient outcomes (represented by mortality) across cultural and national lines (the study was conducted in Thailand). Specifically, the study found that, based on the nursing staff variables used in the study:

the ratio of total nurse staffing to patients was significantly related to in- hospital mortality in both partial and marginal analyses, controlling for patient characteristics. In addition, the ratio of total nursing staff to patients was found to be the best predictor of in-hospital mortality among the four nurse staffing variables

Not only did the above study's conclusions, "add to our understanding of the importance of nurse staffing and its relationship to the patient outcome of hospital mortality," (perhaps the most "extreme" embodiment of negative patient outcome) but it also gives significant support to the idea that reductions in nurse and RN staffing may reduce cost, yet have significant negative effects on patient outcome -- all the way up to the level of increased incidence of hospital mortality (recall, also adjusted for patient characteristics).

If, then, this is the case, and the reduction in nursing staff results in negative patient outcomes (even if adjusted for compounding variables), why are nursing staffs continually downsized and padded with relatively unskilled "unlicensed assistive personnel," or UAPs? After all, according to the Thailand study, which cited the logic of the American Nurses Association:

When there is adequate staff, nurses can spend more time with each patient in every aspect of patient care, while time constraints can increase the probability of mistakes my creating a busy, stressful environment with distractions and interruptions that adversely affect quality of care (Sacichay-Akkadachanunt, Scalzi, and Jawad).

Although, previous to these studies, many would assert that such a statement made by the American Nurses Association might be imbibed with significant amounts of self-interest, the outcomes of both "Identifying Nurse Staffing and Patient Outcome Relationships: A Guide for Change in Care Delivery," as well as "The Relationship Between Nurse Staffing and Patient Outcomes," seems to support the American Nurses Association's hypothesis -- (one that should…