Nurse Staffing and Quality of Care: What Does Current Research Tell Us?

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Nurse Staffing and Quality of Care What Does
Current Research Tell Us?

• Michigan Health and Safety Coalition
• April 14, 2004
• Peter I. Buerhaus, PhD, RN, FAAN

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Agenda

• Overview of research on nurse staffing and
  quality of care
• Is there a business case for nursing?
• Important developments in improving quality and
  safety related to nursing
• Research on nurse staffing Serious threats
  facing the nursing profession and the quality
  and safety of care
• Recommendations

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Overview of research on nurse staffing and
quality of care
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Evidence Linking Nurse Staffing Patient
Outcomes Comes from

• Many small sample studies of nursing units
• About 15 published, hospital-level, large sample
  studies

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Large Sample Studies

• L. Aiken, H. Smith, E. Lake, Lower Medicare
  mortality among a set of hospitals known for good
  nursing care, Medical Care (1994) Vol. 32, No.
  8. pp 60-772
• L. Aiken, S. Clarke, D. Sloane, J. Sochalski, J.
  Silber, Hospital Nurse Staffing and Patient
  Mortality, Nurse Burnout, and Job
  Dissatisfaction JAMA (2002) 2881987-1993.

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Large Sample Studies

• C. Kovner and P. Gergen, Nurse Staffing Levels
  and Adverse Events Following Surgery in US
  Hospitals, IMAGE Journal of nursing scholarship
  (1998), Vol. 30, No. 4, pp. 315-321
• L. Lichtig, et al. Some Impacts of Nursing on
  Acute Care Hospital Outcomes, Journal of Nursing
  Administration (1999), vol. 29, No. 2, pp 25-33

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Large Sample Studies

• N. Donaldson, et al. Nurse staffing in
  California hospitals 1928-200 Findings from the
  California nursing outcomes coalition database
  project, Policy, Politics, Nursing Practice
  (February 2001)
• Network, Inc., Nurse Staffing and Patient
  Outcomes in the Inpatient Hospital Setting,
  (Washington, DC American Nurses Association,
  2000).

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Large Sample Studies

• J. Needleman, P. Buerhaus, S. Mattke, M. Stewart,
  K. Zelevinsky, Nurse Staffing and Patient
  Outcomes in Hospitals. Final Report US
  Department of Health and Human Services, Health
  Resources and Services Administration Contract
  (2001)
• J. Needleman, P. Buerhaus, S. Mattke, M. Stewart,
  K. Zelevinsky, Nurse Staffing and Quality of
  Care in Hospitals in the United States, The New
  England Journal of Medicine (May 30, 2002)

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Large Sample Studies

• Ulrich, L. Licensed nurse staffing and adverse
  events in hospitals Medical Care, 41(1),
  142-152.
• Person, S. et al. Nurse staffing and mortality
  for Medicare patients with acute myocardial
  infarction Medical Care 42(1) 4-12.
• Kovner, C, Jones, C. et al. Nurse staffing and
  postsurgical adverse events An analysis of
  administrated data from a sample of US
  hospitals. Health Services Research 2002 37
  611-629.

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HRSA Study

• Co-sponsored by HRSA, NINR, HCFA, AHRQ (Needleman
  Buerhaus)
• Purpose of Study Develop the evidence base on
  the relationship between patient outcomes
  potentially sensitive to nurse staffing in
  inpatient units in acute care hospitals
• Three analyses based on hospital discharge
  abstracts, testing 14 patient outcomes

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1. All-patient Analysis (HRSA)

• Questions
• Is there an association between nurse staffing
  and outcomes?
• What is impact of different nursing staff (RNs,
  LPNs, and Aides)?

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1. Summary of All-Patient Analysis

• Sample 799 hospitals in 11 states, gt 5 million
• Discharges
• Medical patients
• Length of stay, pneumonia, UGI bleeding,
• shock/cardiac arrest, failure to rescue
• Major surgery patients
• Urinary tract infection, failure to rescue,
• Pneumonia (weak)
• Relationships strongest for RNs shift from low
  to high RN staffing results in
• 3-12 reduction in risk of adverse outcome

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2. Analysis of Unit Level Versus Hospital Level
Staffing

• Questions
• Is hospital nursing unit level more precise?
• Does unit level Identify more outcomes related to
  nursing?
• Sample 256 California Hospitals
• Conclusion No to both questions

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3. Medicare Only vs. All-Patients

• Question Can Medicare only data (MedPAR)
  substitute for all-patient data?
• Sample gt 12 million Medicare discharges
• Conclusions
• For medical patients, similar results using
  national MedPAR and 11 state all-patient data
• For surgical patients, MedPAR and 11 state
  all-patient identify additional outcomes
• UGI, Shock, Sepsis, Pneumonia stronger
• See J. Needleman, J., Buerhaus, P. Stewart, M.,
  Zelevinsky, K. Measuring Hospital Quality Can
  Medicare Data Substitute for All-Payer Data?
  Health Services Research 2003 38(6)1487-1508.

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Trends in adverse hospital inpatient outcomes
associated with nurse staffing (1988-1997)

• Purpose Determine whether quality of hospital
  care related to nursing has improved or worsened
  over time
• Data Approximately 50 million discharge
  abstracts
• Funded by Agency for HealthCare Research and
  Quality

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Trends in Outcomes Using Hospital Discharge Data

• States
• California
• Florida
• Massachusetts
• New York
• Washington
• Wisconsin

• Outcomes Examined
• UTI
• Pneumonia
• Sepsis
• Shock/cardiac arrest
• UGI bleeding
• DVT

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Tentative Conclusions

• At this point in our analysis, we see no evidence
  of across the board improvement in these outcomes
  over this time period
• Work remaining
• Control for changes in market conditions
• Determine year by year associations with nurse
  staffing

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Other Current Work Impact of Nursing on Outcomes
in Nursing Home Residents

• Susan Horn, Peter Buerhaus, Nancy Bergstrom,
  Randall Smout
• 1,376 residents (mean age 81.5, mostly women) at
  risk for developing pressure ulcers in 109
  nursing homes in 23 states
• Controls for diagnosis, severity, and patient
  characteristics

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Preliminary Results(Under Journal Review)

• More RN time associated with
• Fewer UTIs, catheterizations, pressure ulcers,
  hospitalizations, and deaths
• More nutritional supplements
• Less weight loss

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Agenda

1. Overview of research on nurse staffing and
   quality of care
2. Is there a business case for nursing?
3. Important developments and improving quality and
   safety related to nursing care
4. Research on nurse staffing Serious threats to
   the nursing profession
5. Recommendations

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Is there a business case for nursing?

• Jack Needleman, PhD, UCLA School of Public Health
• Peter Buerhaus, RN, PhD, Vanderbilt University
  School of Nursing
• Maureen Stewart, BA, Heller School, Brandeis
  University
• Katya Zelevinsky, BA, Harvard School of Public
  Health

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Approach

• Determine cost of increasing RN and LPN staffing
  in US hospitals staffed below 75th percentile
• Estimate national cost savings associated with
  decreased number of adverse outcomes, avoided
  deaths, and avoided hospital days
• Based on NEJM analysis (799 hospitals, gt 5
  million discharges)
• Funded by The Commonwealth Fund

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Agenda

1. Overview of research on nurse staffing and
   quality of care
2. Is there a business case for nursing?
3. Important developments in improving quality and
   safety related to nursing care
4. Research on nurse staffing Serious threats
   facing the nursing profession
5. Recommendations

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Important Nursing Quality-Related Developments

• JCAHO shortage task force, nurse sensitive
  outcomes, Nursing Advisory Council, conference in
  Sept
• IOM Committee on Work Environment for Nurses
  and Patient Safety
• National Quality Forum Steering Committee on
  Nursing Care Performance Measures

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National Quality Forum

• Identify and endorse a set of performance
  measures for evaluating the quality of nursing
  care in acute care hospitals
• Identify a framework for measuring nursing care
  performance attention to nurses contribution to
  effective care teams
• Identify and prioritize unresolved issues and
  develop research agenda

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Screening, Evaluation, and Recommendation

• Initially more than 100 measures identified and
  screened for relevance to the purpose, framework,
  scope, and priorities
• Steering committee selected 57 for detailed
  evaluation
• Evaluations based on NQF criteria importance,
  scientific, acceptability, usability, and
  feasibility

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19 NQF Voluntary Nursing Performance Measures

• Ventilator associated pneumonia
• Smoking cessation for AMI
• Smoking cessation counseling for heart failure
• Smoking cessation for pneumonia
• Skill mix (RN, LPN, UAP and contract)
• Nursing care hours per patient day (RN, LPN, UAP)
• Practice environment (Nursing Work Index)
• Voluntary turnover
• Nurses education preparation

• Failure to rescue (surgical patients)
• Pressure ulcer prevalence
• Pneumonia prevalence
• Falls prevalence
• Falls with injury
• Restraint prevalence
• Restraint prevalence (vest and limb only)
• Urinary tract infection
• UTI catheter associated
• Central line associated blood stream infection

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NQF Steps

• October NQF member and public comment period
• November distribution of consensus report and
  ballots to NQF members
• December voting period ends
• January 26, 2004 Final ballots due
• Spring release of set of initial voluntary
  measures of nursing performance

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Other Important Developments

• IHI/AHA IMPACT on Workforce
• California Nurse staffing ratios
• Johnson Johnson Campaign for Nursings Future
  private sector leadership, others getting
  involved
• Congress has done NOTHING!

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Agenda

1. Overview of research on nurse staffing and
   quality of care
2. Is there a business case for nursing?
3. Important developments and improving quality and
   safety related to nursing care
4. Research on Nurse Staffing Serious threats
   facing the nursing profession
5. Recommendations

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Key Facts

• Average age of RN workforce is increasing more
  than twice as fast as all other occupations in US
  workforce
• Between 1983-1998, number of RNs under 30 years
  decreased 41 percent the number of working
  people in the US workforce under 30 years of age
  dropped by only 1 percent
• Source Buerhaus, Staiger, Auerbach.
  Implications of a rapidly aging RN workforce.
  JAMA 2000 283 (22) 2948-2954.

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HRSA Health Resources and Services
Administration, 2002 B/S/A Buerhaus, Staiger,
Auerbach, 2002, updated forecasts originally
published in JAMA, June 2000
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Physicians and Nurses Perceptions of Nurse
Shortage
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Impact of Shortage on Nursing Practice
Inpatient RN vs. Other RNs
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C5. How would you rate the quality of your
current work setting in each of the
following areas?
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C5. How would you rate the quality of your
current work setting in each of the
following areas?
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C5. How would you rate the quality of your
current work setting in each of the
following areas?
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Agenda

• Overview of research on nurse staffing and
  quality of care
• Is there a business case for nursing?
• Important developments in improving quality and
  safety related to nursing care
• Research on nurse staffing Serious threats
  facing the nursing profession
• Recommendations
• Quality and safety
• RN Workforce

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Improving Quality and Safety

• The evidence establishes that low RN staffing
  increases the risk of adverse outcomes
• This information is meaningless unless nurses
  apply it in their daily nursing practice to
  improve nursing care and inform their practice

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Actions to Improve Quality and Safety

• Develop team (physicians, nurses, HR,
  administration, pharmacy, medical records) to
  select patient outcomes related to nursing (e.g.,
  consider National Quality Forum measures)
• Determine capability to measure outcomes

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Actions to Improve Quality and Safety

• Determine and test changes in nursing practice or
  system that are likely to improve outcomes
• Implement changes and record results
• Collect data over time
• Report results to constituents nurses,
  physicians, administration, HR, medical records,
  pharmacy, others

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But Without Enough RNsin the Future

• Access to care will be compromised
• Delays in admissions, discharges
• Inability to staff current programs, let alone
  open new ones
• Quality of care will be jeopardized
• Increased adverse outcomes, deaths, longer
  hospitals stays
• Safety will be threatened
• From falls, medication errors, oversight and
  coordination, etc.

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To Ensure Enough RNs

• Get tough on Congress, election coming up, and
  this is an issue that looms very large and
  negative for the hospital industry, nursing
  profession, and those concerned with quality and
  safety of care
• Focus government relations team on getting
  Congress to
• Immediately increase capacity of nursing
  education programs through faculty raises, loans
  and scholarships, capitation programs
• Set state and national goals
• Establish and maintain relationships with local
  schools and nursing programs

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To Ensure Enough RNs

• Prepare for an older RN workforce (economics and
  ergonomics)
• Survey ergonomic environment and make
  improvements
• Engage suppliers, pharmaceuticals, and medical
  device manufactures

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To Ensure Enough RNs

• Improve workplace climate quickly and decisively,
  act on AHA Workplace Commission report (April
  2002), JCAHO white paper (July 2002), RWJF report
  (August 2000), AONE/NurseWeek National Survey of
  RNs, and IOM report
• Find ways to decrease/smooth demand on RNs via
  patient scheduling, good management

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To Ensure Enough RNs

• Avoid legislation regulating nurse staffing
• CMS must help hospitals with resources, but tie
  to developing better data on nurse staffing and
  patient outcomes, monitoring, and actual
  improvements in workplace
• Stimulate greater private sector involvement
  Johnson Johnson Campaign cant do it alone