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JAMA Study Shows When RNs Have More Than 4 Patients, Patients’ Risk of Death and Complications Increases—Study Supports MNA Call for Safe Staffing Bill

MNA Cites Report as Evidence of Positive Impact Nurses Have on Patient Care and the Need for Policies to Increase RN Staffing and Regulate Registered Nurse-to-Patient Ratios

CANTON, Mass. —
A new study in the October 23/30 issue of JAMA finds that the higher the patient-to-nurse ratio in the hospital, the more likely there will be patient deaths or complications after surgeries that can lead to death. The study also finds that a high patient-to-nurse ratio is linked with nurses being more likely to report dissatisfaction with their jobs.

The study, one of the largest studies to examine the relationship between nurses patient load and patient mortality, provides a strong scientific underpinning to efforts of nurses and patient advocates to pass legislation regulating RN-to-patient ratios in hospitals, according to the Massachusetts Nurses Association which has been pushing such a bill for a number of years and is currently in the process of drafting legislation to be introduced in the next legislative session on Beacon Hill.

The study finds that with each additional patient a nurse is responsible for, the patients’ risk of dying increases. The researchers found that "after adjusting for patient and hospital characteristics (size, teaching status, and technology), each additional patient per nurse was associated with a 7% increase in the likelihood of dying within 30 days and a 7% increase in the odds of failure to rescue." For instance, "the difference from 4 to 6 and from 4 to 8 patients per nurse would be accompanied by 14% and 31% increases in mortality, respectively." The researchers also found that each additional patient per nurse was associated with a 23% increase in the odds of burnout and a 15% increase in the odds of job dissatisfaction.

The researchers point out that California has passed a law that goes into effect July 2003 mandating hospitals to have at least 1 licensed nurse for every 6 medical and surgical patients. When fully implemented, the ratio will lower to 1 in 5. The California legislation was motivated by an increasing hospital nursing shortage and the perception that lower nurse retention in hospital practice was related to burdensome workloads and high levels of job-related burnout and job dissatisfaction," the authors write.

Linda H. Aiken, PhD, RN, of the University of Pennsylvania School of Nursing, Philadelphia, and colleagues report findings from a study of 168 adult, general hospitals in Pennsylvania. The data analyzed came from surveys of 10,184 staff registered nurses and the outcomes for 232-342 patients between the ages of 20 and 85 years who underwent general surgical, orthopedic, or vascular procedures and were discharged from the hospital between April 1, 1998 and November 30, 1999. The researchers looked at death rates among the patients and "failure to rescue" complications resulting in death within 30 days of admission. The nurses completed questionnaires on job satisfaction and burn-out.

In conclusion the authors state, "our results document sizable and significant effects of registered nurse staffing on preventable deaths. The association of nurse staffing levels with the rescue of patients suggests that nurses contribute importantly to surveillance, early detection, and timely interventions that save lives. Improving nurse staffing levels may reduce alarming turnover rates in hospitals by reducing burnout and job dissatisfaction, major precursors of job resignation."

"This report validates what the Massachusetts Nurses Association and thousands of nurses across the Commonwealth have been saying for more than seven years–nurses are the key to quality care in our hospitals and chronic understaffing conditions are harming patients and driving thousands of nurses away from the hospital bedside," said Karen Higgins, president of the MNA. "We intend to re-introduce our safe staffing legislation in December and will base the registered nurse-to-patient ratios we recommend on the research presented in this study, as well as on the experience of the state of California.

Authors Conclusions Supported by Previous Research
The JAMA study follows on the heels of a number of recent studies and reports that show registered nurse staffing levels cause a number of patient complications and may cause thousands of patient deaths each year. In August, the Joint Commission on the Accreditation of hospitals issues a report stating that that inadequate staffing levels have been a factor in nearly a quarter of most serious life-threatening events that have been reported to the Commission in the last five years.

The JCAHO report analyzed more than 1,600 serious incidents from 1996 through March 2002 and found that nurse staffing levels were deemed a contributing factor in 50% of ventilator-related incidents, 42% of surgery-related incidents, 25% of transfusion incidents, 25% of delays in treatment, 25% of infant abductions, 19% of medication errors, 14% of inpatient suicides, and 14% of patient falls.

In May, the New England Journal of Medicine published a study that found a strong and consistent relationship between nurse staffing and five outcomes in medical patients urinary tract infection, pneumonia, shock, upper gastrointestinal bleeding, and length-of-stay. A higher number of registered nurses was associated with a 3 percent to 12 percent reduction in the rates of adverse outcomes, while higher staffing levels for all types of nurses was associated with a decrease in adverse outcomes from 2 percent to 25 percent. Similar to the JAMA study, the New England Journal researchers found a correlation between a poor nurse staffing levels and a failure to rescue patients suffering cardiac arrest after surgery.

Staffing Conditions Caused and Now Drive the Nursing Shortage

In addition to shedding light on the devastating impact poor staffing has on patients, the JAMA study s findings support the MNA s position that poor nurse staffing conditions have driven and continue to drive nurses away from the hospital bedside.

According to Julie Pinkham, executive director of the MNA, The current shortage of nurses was created by the bad policies of the health care industry and made worse by consistent mistreatment of its nursing staff over last 15 years. Nurses are just plain tired of being taken advantage of.

While Massachusetts has the highest population of nurses in the nation (over 82,000 RNs licensed by the state), we are experiencing a serious shortage of nurses willing to work at the hospital bedside. A recent survey of Massachusetts nurses found that while 81% were working in nursing, only 46% (an estimated 37,000) are working at the hospital bedside, and more than half of those nurses are working part time.

Throughout the 1990s, hospitals laid off thousands of nurses and/or replaced them with unlicensed personnel in an attempt to cut costs under managed care. Also, under managed care, only the sickest patients made it into the hospital. Nurses at the bedside saw their patient assignments increase while their patients were sicker, requiring more intensive nursing care. At many hospitals, managers compensated for inadequate staffing levels by using mandatory overtime as a mechanism for staffing their facilities.

Supporting the JAMA study s findings regarding nurse burnout, a recent national survey of nurses by the federal government found that nurses have the lowest job satisfaction of any employee group surveyed by the government. Staff nurses in hospitals and in nursing homes have the lowest job satisfaction of all, which is due to poor working conditions and low pay. The same survey found nursing salaries have been stagnant since 1993.

"What policymakers need to understand is that we don t have a shortage of nurses in Massachusetts. What we have is a shortage of nurses willing to practice with the current staffing ratios. If we give nurses a safe number of patients to care for, nurses will stay, and more importantly, more nurses will come back to the bedside," Pinkham said.