Background It is uncertain whether lower levels of staffingby nurses at hospitals are associated with an increased riskthat patients will have complications or die.
Methods We used administrative data from 1997 for 799 hospitalsin 11 states (covering 5,075,969 discharges of medical patientsand 1,104,659 discharges of surgical patients) to examine therelation between the amount of care provided by nurses at thehospital and patients' outcomes. We conducted regression analysesin which we controlled for patients' risk of adverse outcomes,differences in the nursing care needed for each hospital's patients,and other variables.
Results The mean number of hours of nursing care per patient-daywas 11.4, of which 7.8 hours were provided by registered nurses,1.2 hours by licensed practical nurses, and 2.4 hours by nurses'aides. Among medical patients, a higher proportion of hoursof care per day provided by registered nurses and a greaterabsolute number of hours of care per day provided by registerednurses were associated with a shorter length of stay (P=0.01and P<0.001, respectively) and lower rates of both urinarytract infections (P<0.001 and P=0.003, respectively) andupper gastrointestinal bleeding (P=0.03 and P=0.007, respectively).A higher proportion of hours of care provided by registerednurses was also associated with lower rates of pneumonia (P=0.001),shock or cardiac arrest (P=0.007), and "failure to rescue,"which was defined as death from pneumonia, shock or cardiacarrest, upper gastrointestinal bleeding, sepsis, or deep venousthrombosis (P=0.05). Among surgical patients, a higher proportionof care provided by registered nurses was associated with lowerrates of urinary tract infections (P=0.04), and a greater numberof hours of care per day provided by registered nurses was associatedwith lower rates of "failure to rescue" (P=0.008). We foundno associations between increased levels of staffing by registerednurses and the rate of in-hospital death or between increasedstaffing by licensed practical nurses or nurses' aides and therate of adverse outcomes.
Conclusions A higher proportion of hours of nursing care providedby registered nurses and a greater number of hours of care byregistered nurses per day are associated with better care forhospitalized patients.
Hospitals, wrote Lewis Thomas in The Youngest Science, are "heldtogether, glued together, enabled to function . . . by the nurses."1More than 1.3 million registered nurses work in hospitals inthe United States. As hospitals have responded to financialpressure from Medicare, managed care, and other private payers,registered nurses have become increasingly dissatisfied withthe working conditions in hospitals. They report that they arespending less time taking care of increasingly ill patientsand believe that the safety and quality of inpatient care aredeteriorating.2,3,4,5,6,7 Although the number of hours of careper patient-day provided by registered nurses rose through themid-1990s,8,9,10,11,12 some question whether the staffing ofnurses has increased rapidly enough to keep pace with the increasingseverity of illness among hospitalized patients and thus toensure safe and high-quality care.13
Research on the relation between the level of staffing by nursesin hospitals and patients' outcomes has been inconclusive. Whereassome studies have reported an association between higher levelsof staffing by nurses and lower mortality,14,15,16,17,18,19,20as well as lower rates of other adverse outcomes,21,22,23,24,25,26,27,28,29,30others have found no such relations.30,31,32,33,34,35,36,37,38,39Previous studies have assessed only a limited number of outcomesthat are sensitive to the extent or quality of nursing care,such as falls by patients and errors in medication. Many studieshave used small samples of hospitals, controlled only to a limitedextent for the patient's initial risk for the outcomes understudy, failed to include nurses' aides as part of the nursingstaff, and used inconsistent measures of staffing levels. Weexamined the relation between the levels of staffing by nursesin hospitals and the rates of adverse outcomes among patients,using administrative data from a large multistate sample ofhospitals.
Methods
Measures of Adverse Outcomes
The study was approved by the Harvard School of Public HealthHuman Subjects Committee. On the basis of published21,27,28,30,39,40,41,42,43,44,45,46,47and unpublished materials, we identified 14 adverse outcomesduring hospitalization (11 for both medical and surgical patientsand 3 for surgical patients only) that could be coded on thebasis of hospital-discharge abstracts and that are potentiallysensitive to staffing by nurses. Building on previous studies,30,48,49,50we developed coding rules to construct risk groups of patientsand to identify patients with each outcome (listed in the Appendix).
We obtained data on hospital discharges and the staffing bynurses from 11 states that collect both types of data: Arizona,California, Maryland, Massachusetts, Missouri, Nevada, New York,South Carolina, Virginia, West Virginia, and Wisconsin. We estimated1997 staffing as the weighted average of staffing in the hospital'sfiscal years 1997 and 1998, except in Virginia, for which onlyfiscal 1997 data were available. We obtained data on dischargesfor the 1997 calendar year (for Virginia, we obtained data forthe four calendar quarters matching each hospital's fiscal year).The initial sample was 1041 hospitals. We then excluded hospitalswith an average daily census of less than 20, an occupancy ratebelow 20 percent, or missing data on staffing, as well as thosereporting extremely low or high levels of staffing per patient-day(below the 7.5th percentile or above the 92.5th percentile).The final sample included 799 hospitals, which together accountedfor 26 percent of the discharges from nonfederal hospitals inthe United States in 1997.
Measures of Staffing
The levels of staffing by registered nurses, licensed practicalnurses, and nurses' aides were estimated in hours. For statesreporting staffing as full-time equivalents, we used a standardyear of 2080 hours (52 weeks at 40 hours per week). In California,the levels of staffing of nurses for inpatient and outpatientcare are calculated directly from financial data reported bythe California Office of Statewide Health Planning and Development.Using these data, we found that the standard measure, "adjustedpatient-days," that was used to adjust total hours of nursingcare to reflect the number of both inpatients and outpatientstreated at the hospital (hospital volume)51 underestimated staffingfor inpatient care and overestimated staffing for outpatientcare. To adjust for this bias, we constructed a regression model,using data from California, that predicted staffing for inpatientcare per inpatient-day on the basis of the level of staffingper adjusted patient-day and the number of outpatients treated;we used this model to estimate staffing for inpatient care fromthe staffing levels per adjusted patient-day reported in theother 10 states.
For easier comparison of the levels of staffing by nurses indifferent hospitals, we adjusted the hours of nursing care perday for differences in the nursing care needed by the patientsof each hospital. We used estimates of the relative level ofnursing care needed by patients in each diagnosis-related group28,52to construct a nursing case-mix index for each hospital. Wedivided hours of nursing care per inpatient-day by this indexto calculate the adjusted number of hours of nursing care perday.
Risk Adjustment and Characteristics of the Hospitals
To control for differences among hospitals in the relative riskof the outcomes as a result of variations in the mix of patients,we used patient-level logistic-regression analyses to predicteach patient's probability of having each adverse outcome. Patient-levelvariables in these analyses included the rate of the outcomein the patient's diagnosis-related group, the state of residence,age, sex, primary health insurer, whether or not the patientwas admitted on an emergency basis, and the presence or absenceof 13 chronic diseases.48 The regression analyses also includedinteractions between the specific rate of each outcome in eachdiagnosis-related group and all the other variables, as wellas interactions between age and the variables related to chronicdisease. We added the predicted probabilities for patients ineach hospital to obtain the expected number of patients in thathospital who would have each outcome. We used the same variablesin an ordinary least-squares regression analysis to estimatethe expected length of stay. We obtained information on theother characteristics of the hospitals (number of beds, teachingstatus, state, and metropolitan or nonmetropolitan location)from the American Hospital Association's Annual Survey of Hospitalsfor 199751 and 1998.53
Statistical Analysis
The unit of analysis was the hospital. We calculated the lengthof stay, the rates of adverse outcomes, the hours of nursingcare per inpatient-day, and the proportion of hours of nursingcare provided by each category of nursing personnel.
For each outcome, we performed regression analyses with theuse of nurse-staffing and control variables. In all analyses,the control variables included the state, number of beds, teachingstatus, and location of the hospital. We used ordinary least-squaresregression to analyze the difference between the actual andexpected length of stay. We report regression coefficients forthese analyses. For other outcomes, we included the number ofpatients with the adverse outcome as the dependent variablein a negative binomial regression model (the appropriate modelfor this type of data53) and the expected numbers for each adverseoutcome as the measure of exposure required by the model. Wereport incidence-rate ratios from these analyses.
We tested each coefficient for statistical significance usingt-tests in the ordinary least-squares regression analyses andz statistics in the negative binomial regression analyses.54After controlling for other variables, we estimated the differencesin the outcomes between hospitals with staffing levels of registerednurses at the 75th percentile and hospitals with staffing levelsof registered nurses at the 25th percentile (the "decrease"in outcomes with higher levels of staffing). The 95 percentconfidence intervals for the decreases were calculated withthe use of Huber–White standard errors.55 All P valuesare based on two-tailed tests. Statistical analysis was performedwith the use of Stata software.55
To examine whether the mix of skills or the number of hoursof nursing care was more important in influencing patient outcomes,we analyzed 10 models involving nurse-staffing variables andcompared the results. We present results from the two modelsthat most closely match those used in previous published studies.Model 1 examines the mix of skills and includes the proportionof hours of care by licensed nurses (registered-nurse–hoursplus licensed-practical-nurse–hours) that were providedby registered nurses, plus aide-hours and the total hours perday provided by licensed nurses. Model 2 measures all staffingof nurses — by registered nurses, aides, and licensedpractical nurses — in hours per day. Results obtainedwith the other models we analyzed have been reported elsewhere.56
Results
Rates of Adverse Patient Outcomes and Length of Stay
The patient outcomes and characteristics of the hospitals aresummarized in Table 1. Complications that are common in hospitalizedpatients, such as urinary tract infection, pneumonia, and metabolicderangement, were the most frequent. The highest rates werefor "failure to rescue," defined as the death of a patient withone of five life-threatening complications — pneumonia,shock or cardiac arrest, upper gastrointestinal bleeding, sepsis,or deep venous thrombosis — for which early identificationby nurses and medical and nursing interventions can influencethe risk of death. The mean death rates were 18.6 percent amongmedical patients with one of these complications and 19.7 percentamong surgical patients with one of these complications. Ratesfor outcomes were similar in all 11 states. The low rates ofdeep venous thrombosis — 0.4 percent among surgical patientsand 0.5 percent among medical patients — may reflect underreportingof this common complication.
Table 1. Patient Outcomes and Characteristics of the 799 Hospitals.
Variations in Staffing Levels and Mix of Skills
The mean (±SD) numbers of hours of nursing care are shownin Table 2. Hours per inpatient-day averaged 7.8 for registerednurses, 1.2 for licensed practical nurses, and 2.4 for aides.Hours of care by licensed nurses per day averaged 9.0. The meanproportion of total hours of nursing care provided by registerednurses was 68 percent; aides provided 21 percent of total nurse-hours.
Association between Adverse Outcomes and Staffing by Nurses
The relations between adverse outcomes and the levels of staffingby registered nurses are shown in Table 3 for medical patientsand in Table 4 for surgical patients. The ordinary least-squares–regressioncoefficients (for length of stay) or the incidence-rate ratios(for other outcomes) are given for both registered-nurse–hoursas a proportion of total hours of care by licensed nurses andthe number of registered-nurse–hours per patient-day.A negative regression coefficient or an incidence-rate ratioof less than 1.00 indicates that the frequency of the outcomedeclines as the staffing level increases. The estimated percentdecreases in the rates of the outcomes associated with increasingnurse-hours from the 25th to the 75th percentile are also listed.We report results for death and outcomes for which a greaternumber of registered-nurse–hours or a higher proportionof licensed-nurse care provided by registered nurses was associatedwith lower rates of the outcome. Additional results are reportedelsewhere.56
Table 4. Relation between Adverse Outcomes among Surgical Patients and the Levels of Staffing by Registered Nurses (RNs).
Registered Nurses and Adverse Outcomes
Among medical patients, we found an association between registered-nursestaffing and six outcomes. Both a higher proportion of licensed-nursecare provided by registered nurses (model 1) and more registered-nurse–hoursper day (model 2) were associated with a shorter length of stayand lower rates of urinary tract infections and upper gastrointestinalbleeding. A higher proportion of registered-nurse–hours(model 1), but not a greater number of registered-nurse–hoursper day (model 2), was associated with lower rates of threeother adverse outcomes: pneumonia, shock or cardiac arrest,and failure to rescue. The association for failure to rescuewas not as strong as the associations for the other five outcomes,and it was more sensitive to the specifications of the models.56
Among surgical patients, a higher proportion of registered-nurse–hours(model 1) was associated with a lower rate of urinary tractinfection. A greater number of registered-nurse–hoursper day (model 2) was associated with a lower rate of failureto rescue; a greater number of licensed-nurse–hours perday was also associated with a lower rate of failure to rescue(incidence-rate ratio, 0.98; 95 percent confidence interval,0.97 to 1.00; P=0.02). Because most licensed-nurse–hoursare provided by registered nurses, these associations are consistent.Among both medical and surgical patients, we found no evidenceof an association between in-hospital mortality and the proportionof registered-nurse–hours, the number of registered-nurse–hoursper day, or the number of licensed-nurse–hours per day.
Measures of Staffing by Other Nurses
In addition to the association with a lower rate of failureto rescue among surgical patients, a greater number of licensed-nurse–hoursper day was associated with a shorter length of stay among medicalpatients (regression coefficient, –0.08; 95 percent confidenceinterval, –0.12 to –0.05; P<0.001). Measuresof staffing by aides and licensed practical nurses had eithernonsignificant associations with lower rates of the adverseoutcomes we studied or significant associations with higherrates of the adverse outcomes (data not shown). Thus, whereasthere was evidence that greater numbers of registered-nurse–hoursor licensed-nurse–hours were associated with a shorterlength of stay among medical patients and lower rates of failureto rescue among surgical patients, there was no evidence ofan association between lower rates of the outcomes we studiedand a greater number of licensed-practical-nurse–hoursor aide-hours per day or a higher proportion of aide-hours.
Discussion
In a large sample of hospitals from a diverse group of states,after controlling for differences in the nursing case mix andthe patients' levels of risk, we found an association betweenthe proportion of total hours of nursing care provided by registerednurses or the number of registered-nurse–hours per dayand six outcomes among medical patients. These were the lengthof stay and the rates of urinary tract infections, upper gastrointestinalbleeding, hospital-acquired pneumonia, shock or cardiac arrest,and failure to rescue (the death of a patient with one of fivelife-threatening complications — pneumonia, shock or cardiacarrest, upper gastrointestinal bleeding, sepsis, or deep venousthrombosis). The evidence was weaker for failure to rescue thanfor the other five measures. As in other studies,32,57 higherlevels of staffing by registered nurses were associated withlower rates of failure to rescue among surgical patients, amongwhom we also found an association between a higher proportionof registered-nurse–hours and lower rates of urinary tractinfections.
The fact that fewer outcomes among surgical patients than amongmedical patients were found to be associated with the levelof staffing by registered nurses may have several explanations.Surgical patients may be healthier than medical patients andtherefore have a lower risk of adverse outcomes. The smallersize of the samples of surgical patients may also have madeit more difficult to detect associations.
Our findings clarify the relation between the levels of staffingby nurses and the quality of care. We found consistent evidenceof an association between higher levels of staffing by registerednurses and lower rates of adverse outcomes, but no similar evidencerelated to staffing by licensed practical nurses or aides. Ourfindings may reflect the actual contribution of these differentmembers of the nursing staff to patients' outcomes in general,or they may be specific to the outcomes we examined. It is possiblethat the outcomes for which we found significant associationsmay be more sensitive to the contribution that the skills andeducation of registered nurses, in particular, make to patientcare.
A higher proportion of total hours of nursing care providedby registered nurses was more frequently associated with lowerrates of adverse outcomes than was a greater number of registered-nurse–hoursper day. This difference may reflect a real effect, or it maysimply indicate that we could measure differences in the mixof staff among hospitals with greater precision than we couldnurse-hours adjusted for case mix.
We tested the association between staffing levels and 25 outcomesin medical and surgical patients and found an association for8 of these outcomes. With the exception of failure to rescueamong medical patients, these results were consistent acrossalternative regression models. Because of the large number ofcomparisons, however, it is possible that some of the associationswe found may be false positive findings. In addition, differencesamong hospitals may be caused not by the staffing level of nursesper se but by other unmeasured factors associated with higherlevels of staffing by registered nurses or other unmeasuredcharacteristics of the hospitals' nursing work force. The levelof staffing by nurses is an incomplete measure of the qualityof nursing care in hospitals. Other factors, such as effectivecommunication between nurses and physicians and a positive workenvironment, have been found to influence patients' outcomes.58,59
Other limitations of our study arise from weaknesses of currentlyavailable data. Constructing a data base on the staffing levelsof nurses for inpatient care from the diverse data sets of multiplestates required substantial efforts to standardize the dataand to determine what proportion of a hospital's nursing staffwas allocated to inpatient care. Because of the absence of reliablecoding indicating whether secondary problems were present whenthe patient was admitted or developed later, constructing measuresof quality from discharge abstracts involved defining appropriatecoding and exclusion rules for each adverse outcome. These outcomesare likely to be underreported, and the degree of underreportingmay be higher where staffing levels are low. Each of these limitationsweakened our ability to observe associations between outcomesand staffing levels. We studied only adverse outcomes. Furthermore,not all outcomes among patients that are important to examine(for example, falls or medication errors) can be studied onthe basis of discharge data. The outcomes for which we foundassociations with the levels of staffing by nurses should beviewed as indicators of quality rather than as measures of thefull effect of nurses in hospitals.
Further research is needed to refine the measurement of thenursing case mix on the basis of discharge data and to elucidatethe factors influencing the staffing levels of nurses and themix of nursing personnel in hospitals. Given the evidence thatsuch staffing levels are associated with adverse outcomes, aswell as the current and projected shortages of hospital-basedregistered nurses,60,61 systems should be developed for theroutine monitoring, in large numbers of hospitals, of hospitaloutcomes that are sensitive to levels of staffing by nurses.Beyond monitoring, hospital administrators, accrediting agencies,insurers, and regulators should take action to ensure that anadequate nursing staff is available to protect patients andto improve the quality of care.
Supported by a contract (230-99-0021) with the Health Resourcesand Services Administration, Department of Health and HumanServices, with funding from the Health Resources and ServicesAdministration, the Agency for Healthcare Research and Quality,the Centers for Medicare and Medicaid Services, and the NationalInstitute of Nursing Research; by a grant (R01 HS09958) fromthe Agency for Healthcare Research and Quality; and by a Disseminationand Development Grant from Abt Associations (to Dr. Mattke).The views expressed in this article are those of the authorsand not necessarily those of the funding agencies or the organizationsthat provided data.
Presented in part at the annual meeting of the Academy for HealthServices Research and Health Policy, Atlanta, June 10–12,2001.
We are indebted to Carole Gassert, Evelyn Moses, Judy Goldfarb,Tim Cuerdon, Cheryl Jones, Peter Gergen, Carole Hudgings, PamellaMitchell, Donna Diers, Chris Kovner, Mary Blegen, Margaret Sovie,Nancy Donaldson, Ann Minnick, Lisa Iezzoni, Leo Lichtig, RobertKnauf, Alan Zaslavsky, Lucian Leape, Sheila Burke, Barbara Berney,Gabrielle Hermann-Camara, and the Harvard Nursing Research Institutefor advice and recommendations; to the California Office ofStatewide Health Planning and Development and the State of Marylandfor providing data at no cost; and to the staffs of the agenciesin each state from which we obtained data for their assistance.
Source Information
From the Department of Health Policy and Management, Harvard School of Public Health, Boston (J.N., S.M., M.S., K.Z.); the Vanderbilt University School of Nursing, Nashville (P.B.); and Abt Associates, Cambridge, Mass. (S.M.).
Address reprint requests to Dr. Needleman at the Harvard School of Public Health, Department of Health Policy and Management, Rm. 305, 677 Huntington Ave., Boston, MA 02115, or at needlema{at}hsph.harvard.edu.
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