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Inpatient Mortality Linked to Nurse Understaffing

Cheryl Clark, for HealthLeaders Media, March 17, 2011

"This work is partly intended to answer that question because it's the same unit, the same nurses, same doctors and same equipment," Needleman says. "And it's a great hospital, with mortality lower than you would expect, a magnet hospital that hits target 85% of the time. We asked what happens in the best of circumstances what happens when, as sometimes happens, you don't reach (staffing) target. So these other arguments are substantially put to bed."

A hospital that hits its own nurse staffing targets 85% of the time, he says "is pretty damn good."

The research paper stopped short of recommending nurse-patient ratios such as those in California, saying that the study was not designed to do that for a variety of reasons.

Needleman says that hospitals do not traditionally adjust their RN hours needed or workload to account "for new patients coming on and old patients leaving. They don't adjust for admissions, discharges or internal transfers in or out of the hospital and we felt that was also a potential situation.

"If you had an unusually large number of those, much more than typical number of admissions, discharges or transfers, the workload for the nurses would also be much higher than planned for in the system, and higher workload, would increase the risk of nurses trying to speed things up or (limit) the time or attention given to the individual patient...to observe how they're doing and identify whether something is not quite right."

For hospitals that know what its staffing levels are, the message from this study is to continue to be diligent, and for hospitals that don't know it or fail to hit those targets substantial amount of the time, the message is to do better," Needleman says.

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3 comments on "Inpatient Mortality Linked to Nurse Understaffing"


Mark Stambovsky (3/18/2011 at 4:17 PM)
Re comments from Phyllis Kritek, RN, PhD "Why do we automatically assume that somehow patient/nurse ratios are the preferred solution?" Since when do repeated studies concluding a similar result become an "automatic assumption?" I believe we would better characterize that as statement of fact. All things being equal, it is a matter of eyeballs on patients. The more eyeball time, the better the chances mistakes and/or patient deterioration will be spotted and reported. Ignoring or questioning repeating results in favor of yet further studies smacks of the kind of corporate behavior that serves no one except those who maintain that the bottom line trumps all other promises. I am also surprised and a little sickened, that in 2011 we are still asking, "Who benefits from this world view?" Let's see, how about starting with patients. We can then turn to the nurses who'll feel less like task monkeys and more able to spend actual face time with patients. Hospital nursing, at its core, is highly unpredictable involving fluid variables. Attempts at "nuanced" approaches, or those which hope micromanage what nurses do have always resulted in failure. The old mantra goes something like; "if we could just turn nursing into more of an assembly line, predictable practice we could then precisely staff for exactly what we know will happen." While most Hospital mission statement proclaim safety as job one, too many of them will delay, deny or discredit attempts at improving safety when it means hiring more nurses. After all, their responsibilities can't be all that complex, can they?

Rhonda S. Bell, DBA (3/17/2011 at 12:54 PM)
I respect Phyllis' comments regarding nurse/patient ratio not being the answer in all cases. However, what are some solutions to the nurse staffing challenges that are very real in most hospitals. The IOM reported in 2001, that there are 98,000 deaths due to preventable medical errors, and the 2011 preliminary reports do not show much improvement. This new report on staffing shortages does give merit to why some of these deaths are occurring. Intentional collaboration and communication between administration and nursing staff are essential to identify solutions for reducing preventable deaths. Why does that seem so difficult? True compassionate care does need to go beyond the bedside. Rhonda S. Bell, DBA

Phyllis Kritek, RN, PhD (3/17/2011 at 9:35 AM)
Thank you for posting this information. Two observations, coupled with suggestions: 1. Needleman, Buerhaus, Aiken, and others have amply documented what this study again demonstrates. It would be interesting to see an investigation about the push back their research evokes. It would appear that many want their outcomes to be untrue. What motivates those who challenge these outcomes? 2. When these studies emerge, there seems to be an automatic assumption that their outcomes point to patient/nurse ratios as a solution. Many highly creative nurse executive teams have [INVALID]d [INVALID]native models that provide more nuanced solutions. Patient-nurse ratios are a bit like using a chain saw for surgery. Ratios are an over-simplified solution to a very complex problem. It would be interesting to see investigation of some of the more nuanced responses to nurse staffing. Why do we automatically assume that somehow patient/nurse ratios are the preferred solution? Who benefits from this world view?