This paper examines the relationship between nursing shortages and patient outcomes in hospital settings, drawing primarily on two peer-reviewed studies published in 2003. The first, published in Nursing Economics by Potter, Barr, McSweeney, and Sledge, analyzes RN staffing levels against measurable patient outcomes such as pain, self-care, and satisfaction in acute care units. The second, published in JONA by Sasichay-Akkadachanunt, Scalzi, and Jawad, investigates nurse-to-patient ratios and in-hospital mortality in Thailand. Together, these studies provide compelling evidence that reductions in professional nursing staff negatively affect patient care, raise ethical concerns, and may ultimately undermine the cost-saving rationale that drives staffing cuts in the first place.
In today's environment of rising costs in the healthcare industry, one of the first casualties in many hospitals is the level of RN staffing. 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 phenomenon is 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 RNs are acutely aware of the negative repercussions they experience personally as a result of understaffing — particularly in acute healthcare units. Most also realize that this understaffing results from 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 necessarily increase costs in the short term, this raises the question of whether, given the detrimental effect that reductions in RN staffing have on patient outcomes, the current definition of "cost" is one-dimensional.
Although it is tempting to weigh financial considerations too heavily 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 to defending the quality of healthcare offered to patients, but it is also ultimately more cost-effective in reducing the very real financial repercussions that arise from negative patient outcomes. These include "measures of patient falls, medication errors, self-reported symptom management, self-care and health status, and post-discharge patient satisfaction" (Potter, Barr, McSweeney, & Sledge, 2003). After all, if one factors in the higher costs associated with medication errors, medical complications resulting from inadequate care (such as pressure ulcers and falls), and possible legal action by affected patients — to say nothing of the moral and ethical implications — the actual financial benefit of reduced RN staffing may look very different indeed.
It is tempting to question whether the so-called "negative patient outcomes" described in the Nursing Economics article are even related to the ratio of RNs to patients in any particular unit. Many might argue that most negative patient outcomes result more from individual patients' medical conditions than from levels of nursing care. For example, a study referenced in the Nursing Economics article (Reed, Blegen, and Goode, 1998) concluded that "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, 2003). While it is true that establishing a causal relationship between any two variables in a multi-variable situation is particularly difficult, the strength of the Reed, Blegen, and Goode study appears to put this question to rest.
Understanding that the causal relationship between nurse staffing and patient outcomes 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, & Sledge, 2003).
The study authors defined the term "outcome" as follows:
"Outcomes 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 a three-tier model that includes 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 patterns)" (Potter, Barr, McSweeney, & Sledge, 2003).
This definition of patient outcome is particularly important because it can be interpreted in any number of ways. In response to this issue, the study authors specifically defined "patient outcome" as above while selecting those outcome indicators that most lend themselves to statistical analysis. They found that adverse events — measured by the "fall index" and the "medication errors" index — along with inpatient self-reports (in which patients reported symptom management, self-care, and health status) collected by means of the Eight Visual Analog Scale (VAS), as well as an "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, advocacy, and patient compassionate care" (Potter, Barr, McSweeney, & Sledge, 2003). Researchers also measured staffing data and levels of patient acuity, adjusting the data distribution according to float percentages and acuity. The outcome was striking and definitive.
Overall, the study found that "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 the level of pain perceived by patients, the better the patient's perception of self-care ability and health status, and the greater patients' satisfaction post-discharge.
Furthermore, although the study did not find a correlation between RN staffing and the medication and fall indices, it 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, larger amounts of nursing hours provided by all categories of nursing personnel are associated with less patient distress, fewer problems with symptom management, fewer falls, and more successful self-care.
Interestingly, the findings of this study closely mirror those of 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 Sasichay-Akkadachanunt, Scalzi, and Jawad, the question was similarly raised, examining patient outcomes — in this case, specifically mortality — alongside nurse staffing variables such as the ratio of nursing staff to patients, the proportion of RNs in the nursing staff, the level of RN experience in mean years, and the overall percentage of nursing staff holding a bachelor's degree in nursing.
"Thailand study links staffing ratios to mortality"
"Administrative rationale behind continued staffing cuts"
"Research findings translated into healthcare policy"
It is also important to note that once the correlation between reductions in nursing staff and poor patient outcomes is established — or at the very least strongly indicated — it not only becomes unethical to implement further reductive changes, but it also has the very real potential to eliminate any cost-effectiveness gained by those cuts. Errors resulting from overwork, oversight, or understaffing cost hospitals money in terms of more intensive nursing care required as a corrective response. They also open the possibility of extremely costly legal action, judgments, and litigation. Once an administration has reason to know of the negative correlation between nursing reductions and patient care, it may be found negligent for ignoring that fact.
Regardless of its financial implications — although the bottom line remains ever-present in today's healthcare discourse — it is clear that the current nursing shortage is more than just a nuisance for nurses and patients. Reducing the number of nurses in any given unit can have very serious repercussions on patient outcomes. In an industry where the best possible patient outcome is of paramount importance, there can be no greater concern, dollar sign or no.
Potter, P., Barr, N., McSweeney, M., & Sledge, J. (2003). Identifying nurse staffing and patient outcome relationships: A guide for change in care delivery. Nursing Economics, 21(4).
Sasichay-Akkadachanunt, T., Scalzi, C., & Jawad, A. (2003). The relationship between nurse staffing and patient outcomes. JONA, 33(9).
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