T H E I S S U ERegistered nurses (RNs) are in high demandand short supply. After a steady decline innursing school enrollment from 1995-2001,interest in the field has begun to rebound.H o w e v e r, today’s nursing schools lack thecapacity to meet demand due to shortages offaculty (many of whom are retiring), classroomspace, and clinical space in health care facilitieswhere nursing students gain first handexperience with patients. The capacityconstraints are not trivial, as an estimated125,000 qualified applicants were turned awayfrom U.S. nursing education programs in 2004.The United States can anticipate further declinein available registered nurses as the babyboomer generation reaches retirement age –increasing the net population seeking healthcare and decreasing those available to provide it.So, even with renewed interest in the field, it isunlikely there will be enough registered nurses tomeet projected future needs. As a result, U.S.health care providers increasingly turn torecruitment of nurses from other parts of theworld. Complicating the issue, research hasshown an association between low hospitalnurse staffing and quality of care.

Findings of a study publishedin the May 30, 2002 N e wEngland Journal of Medicineestablished a relationshipbetween hospital nurse staffingand patient outcomes. Theinvestigation, led by JackNeedleman, Ph.D., associateprofessor in the Department of

Health Services in the UCLA School of Public Health andPeter Buerhaus, Ph.D., R.N., FAAN, Valere Potter Professorand senior associate dean for research, Va n d e r b i l tUniversity School of Nursing, found that patients inhospitals with fewer registered nurses stay longer and aremore likely to suffer complications, such as urinary tractinfections and upper gastrointestinal bleeding, thanpatients in hospitals with more RNs.

In the initial investigation, researchers analyzed morethan six million patient discharge records from 799hospitals in 11 states during 1997. The investigatorsexamined the relationship between the amount of careprovided by nurses—including RNs, licensed practicalnurses (LPNs), and nurses’ aides—and patientoutcomes, taking into account differences in the patients’level of risk and the mix of patients being treated. Patientsat hospitals with a lower proportion of RNs hadsignificantly higher rates of six complications (longerhospital stays, higher rates of urinary tract infections,pneumonia, shock/cardiac arrest, upper gastrointestinalbleeding, and failure to rescue) when compared withpatients in hospitals that had more RNs. Among surgicalpatients, low RN staffing correlated with increased ratesof failure to rescue and urinary tract infections.

Overall, hospitals with high RN staffing had lengths ofstay that were 3 to 5 percent shorter, and complicationrates 2 to 9 percent lower, than hospitals with low RNstaffing. RN staffing appeared to have a greater impacton quality of care than did staffing by LPNs or aides,positions that require less training and education. Thestudy found no consistent association between outcomesand staffing by LPNs or aides.

In a recent follow-up investigation, Needleman, Buerhaus,et al simulated the effect of three different options toincrease nurse staffing to determine if increased nursestaffing costs might be offset by savings from improvedq u a l i t y. These options were:

1. Increase the proportion of hours of care provided by RNs

2. Increase the number of licensed (RNs or LPNs) nursinghours per day

3. Increase both the proportion of registered nurses andnursing hours per day

Costs of increased nursing hours were estimated from theoriginal sample. Estimates of avoided adverse events andhospitals days were simulated from the original sampleand avoided costs and deaths were estimated usingadditional regression analysis.

The second analysis found that all three scenarios forincreased nurse staffing reduced adverse outcomes,hospitals days and deaths to varying degrees. However,increasing the proportion of care hours provided byRNs offered the greatest potential costs savings,because the costs of changing the RN/LPN mix withoutchanging total nursing hours is relatively low. While thesecond two options were also associated with reducedcosts, these savings were offset by a significant increasein staffing expenses. The authors contend there is astrong business case for the first option, and a strongcase-based on value-for spending more on nursing torealize higher quality, a case that should be subject towidespread discussion and debate.

The researchers initial report placed the nursing shortageprominently in the public’s eye—and on policymakers’agendas. The findings were widely reported in newspapers,magazines, and radio programs across the country,including a “60 Minutes” episode reporting the results andhighlighting multi-national nurse recruiting by hospitals.

The Business Case forNurse StaffingSNAPSHOT OF SUCCESSMore Registered Nurses Mean Improved Quality of Care, Potential Cost Savings

2006 HSR Impact Aw a r d e e

Continued on back page

The AcademyHealth Health ServicesResearch Impact Award (HSR ImpactAward) recognizes outstanding examples of the positive impact of health servicesresearch on health policy or practice. HSR Impact Awards are evaluated based on the quality of research presented, successof the translation to policy or practice, andbenefit to the target population. The award is presented annually.

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2006 HSR Impact Aw a r d e e The Business Case for Nurse Staffing

About half of the RN work force will reachretirement age in the next 15 years. Nurses for a Healthier Tomorrow

Registered nurses make up the largest health careoccupation with more than 2 million jobs. B u r e a uof Labor Statistics

Nominal earnings for registered nurses increasedsteadily from 1983 until 2000, yet after adjusting forinflation, that growth proved relatively flat after 1991.H o w e v e r, as reported by Buerhaus, Staiter, andAurebach (Health Affairs, 2004), inflation adjustedearnings increased 5.0% in 2003 and 1.8% in 2004. Health Resources and Services Administration

In August 2002, Congress passed the NurseReinvestment Act—a bill that authorizes theDepartment of Health and Human Services to createpublic service announcements promoting the nursingprofession, award grants to nursing schools to helpincrease enrollment, and create a fast-track nursingfaculty training program. The bill also providesscholarships for those who agree to work in nursingshortage areas after graduation, and increases thematching rate for Medicaid nurses’ aide training andcompetency evaluation programs.

“One of our goals was to help move the policydiscussion from the question of whether nursingmakes a difference to patients—which we and otherresearchers have now clearly established—to an

examination of what should be done about it,” saysNeedleman. “Our study and the visibility it receivedhelped do this.”

Organizations accrediting, regulating, andmonitoring quality of care also took notice. TheJoint Commission on Accreditation of HealthcareOrganizations adopted a new standard on staffingperformance that incorporated two outcomes fromthe original study. And, in 2004, the failure-to-rescuemeasure was adopted by the National QualityForum’s National Voluntary Consensus Standardsfor Nursing-Sensitive Care and adapted by theAgency for Healthcare Research and Quality’s(AHRQ) revised HCUP Patient Safety Indicators.

What is health servicesresearch?Health services research examineshow people get access to health care,how much care costs, and whathappens to patients as a result ofthis care. The main goals of healthservices research are to identify themost effective ways to organize,manage, finance, and deliver high-quality care; reduce medical errors;and improve patient safety.

— Agency for Healthcare Research and Quality

FACTS

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American Association of Managed Ca r eNurses, Inc.w w w. a a m c n . o r g

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American Association of Managed Ca r eNurses, Inc.w w w. a a m c n . o r g

American Association of Critical Care Nursesw w w. a a c n . o r g

WEBSITES

D r. Needleman’s follow-up analysis waspublished in the January/February 2006 editionof Health Affairs. w w w. h e a l t h a f f a i r s . o r g

D r. Needleman and colleagues also published anarticle outlining strategies to address the nursingworkforce in hospitals. See: Buerhaus, P. et al.“Strengthening Hospital Nursing,” H e a l t hA f f a i r s, Vol. 21, No. 5, September/October, 2002,pp. 123-32.

D r. Buerhaus and colleagues published the firststudy to describe the aging of the RN workforce and to assess its implications for the future.See: Buerhaus, P., et al. “Implications of arapidly aging registered nurse workforce,” The Journal of the American Medical Association, Vol 283 , No. 22, 2000, pp. 2948-54.

The Department of Health and Human Servicesawarded more than $22 million in grantsthrough the Health Resources and ServicesAdministration for colleges, universities, andother groups working to increase the number ofqualified nurses in the United States. Another $8 million has been set aside to repay studentloans for critical care nurses who work innursing shortage areas after graduation. Formore information, visit www.bhpr.hrsa.gov/g r a n t s / # n u r s i n g.

The National League for Nursing (NLN)sponsors grants that research nursing education,particularly in one of their six nursing educationresearch priorities. Information on thesubmission process and past grant recipients isavailable at w w w. n l n . o r g / a b o u t n l n / g r a n t s . h t m.

The September/October 2002 issue of H e a l t hA f f a i r s focuses on the nursing shortage in thiscountry and its impact on patient care. Some ofthe articles in the issue are available online atw w w. p r o j e c t h o p e . o r g.

Linda Aiken and others at the University ofPennsylvania found that, in hospitals with highpatient-to-nurse ratios, each additional patientper nurse translated into a 7 percent increase inthe possibility of a patient death within 30 daysof admission. The research, published in theJournal of the American Medical Association(J A M A ), looked at surveys from more than10,000 nurses and more than 230,000 general,orthopedic, and vascular surgery patients at 168 hospitals in Pennsylvania during 1998 and1999. The study appears in the Oct. 23/30, 2002,issue of JAMA, and is also available ath t t p : / / j a m a . a m a a s s n . o r g /i s s u e s / v 2 8 8 n 1 6 / r f u l l / j o c 2 0 5 4 7 . h t m l.

RELATED INFORMATION

N u r s e s (continued)

AcademyHealth is the professionalhome for health services researchers,policy analysts, and practitioners, anda leading, non-partisan resource for

the best in health research and policy.AcademyHealth promotes the use

of objective research and analysis toinform health policy and practice.

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