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Inpatient Mortality Linked to Nurse Understaffing

Cheryl Clark, for HealthLeaders Media, March 17, 2011

For the California Nurses Association, which successfully lobbied for RN staff-inpatient ratios, the study reinforced "what nurses are seeing throughout the U.S., that safe RN staffing and patient ratios save lives," said Melinda Markowitz, one of CNA's presidents.

However, she says, the study "didn't specify a number," and because of that, it didn't really go far enough."

"What we have found in many hospitals outside of California is that hospitals will use all sorts of pretexts. They'll say staffing is budget-driven and the budget won't allow it. But I believe that kind of thought process really does put the patient at unnecessary risk for death and more adverse events."

Markowitz adds that RN- to-patient ratios save lives and save them money, not just in avoided nurse burnout, which may result in the need for training new staff, but also in avoidance of negative outcomes, which may no longer be reimbursed by federal payers. Sen. Barbara Boxer, D-CA, has introduced a bill that would require even more stringent ratios than the California law requires, Markowitz says.

The American Hospital Association, and its subsidiary, the American Association of Nurse Executives, which in the past expressed objections to mandatory nurse-staff ratios, issued this statement:

The study "highlights what hospitals know: nurses are on the frontline of care and naturally affect the care patients in need receive.  

"To ensure high quality care for patients it is critically important that staffing decisions be the responsibility of nursing leadership at the bedside.  

"Many factors influence a hospital's staffing plan, including the experience and education of its nursing staff, the availability of other caregivers, patients' needs and the severity of their illnesses, and the availability of technology.

"Nurses are striving every day to provide the best care possible – that's not an easy job.  All hospitals are concerned with maintaining safe, quality care and work hard every day to achieve this mission.  The real challenge is how we make sure patients get the care they need and that nurses can provide care in an appropriate setting.  

"We've seen hospitals create a range of innovative solutions from reorganizing care teams to limiting patient admissions. AHA and AONE will continue working within the nursing community to assess their impact and find ways to do even more."


Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.
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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?