Rising injury rates linked to nursing shortage

JCAHO cites injuries, sick time as key indicators

Employee injury rates are gaining attention as one sign of nurse staffing problems. As concerns rise over a growing nursing shortage, employee health professionals have an unprecedented opportunity to link patient safety with worker safety.

Those links already have been acknowledged by the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL. Staffing has been a factor in about one-quarter of all sentinel events that result in patient death or injury, the Joint Commission revealed in a landmark report. The report cited a poor work environment, including mandatory overtime and difficult physical demands, as contributing to low satisfaction and high turnover among nurses.1

The new Joint Commission staffing effectiveness standard, which became effective in July 2002, puts employee health at the forefront of this issue. Hospitals must collect data on two human resource indicators and two patient outcomes indicators. Staff injuries on the job and sick time are two possible human resource indicators.

"The work environment is the intersection of all things," says Katherine Kany, RN, senior policy fellow at the American Nurses Association in Washington, DC. "When you have a safe work environment, everybody benefits."

Meanwhile, research is emerging that connects low staffing with worker injury. In a study of 22 hospitals, researchers at the University of Pennsyl-vania School of Nursing found that work climate, including staffing, was even more strongly associated with needlestick injuries than safety devices.2 "The take-home message is that staffing impacts worker safety as well as patient safety," says Sean Clarke, RN, PhD, associate director of the university’s Center for Health Outcomes and Policy Research. "If we’re trying to make hospitals better, safer places, we need to look at both [issues]."

Further research is under way on the relationship between staffing, musculoskeletal disorders, and overall injuries. Employee health professionals can look at their own data to uncover links between staffing and injuries, suggests Pat Stone, PhD, RN, assistant professor at the Columbia University School of Nursing in New York City. "This is a unique opportunity to use [employee health] data to demonstrate the effect they’re having on a larger [picture]. Your data are outcome data that we’re using," she says to EHPs. "We’re using your data in a different way."

Stone’s research parallels the new performance data requirements of the Joint Commission. She and her colleagues have enrolled 77 hospitals across the country to look at nursing care per patient day, licensed staff per patient day, nursing satisfaction and perception of the work climate, as well as patient outcomes and employee injury rates. The focus is on the intensive care units of the hospitals.

The Joint Commission staffing effectiveness standard states, "The hospital provides an adequate number of staff members whose qualifications are consistent with job responsibilities." Performance indicators are the method for tracking compliance with that standard.  In a streamlined accreditation process set for 2004, the Joint Commission will track individual patients and interview staff and physicians to determine compliance.

"Over time, [hospitals should] see if there is a relationship between staffing levels and patient outcomes," says Charlene Hill, Joint Commis-sion spokeswoman. "If there is, they should make the necessary corrections and continue to track it and see if they made the correct changes."

Stone’s research will look at the impact of deep cost cutting at hospitals, comparing data from before and after the Balanced Budget Act of 1997. In the three years of her study, concerns have grown about the nursing shortage, mandatory overtime, and understaffing.

This year, California became the first state to set minimum nurse staffing ratios. The ratios vary by unit. For example, in intensive care, the ratio is one nurse for two patients. In general medical/surgical, the ratio will be one nurse for every five patients.

Meanwhile, six states (Maine, Maryland, Minne-sota, Oregon, New Jersey, and Washington) have passed laws that ban or limit mandatory overtime.

The issue isn’t just staffing, Stone says. "It’s organizational climate, leadership, staffing, and overall working conditions. Staffing is an important component but not the only component."

If hospitals are feeling the pinch of a nursing shortage now, they should brace themselves. It’s going to get worse. As fewer young people pursue nursing careers, the overall age of the nursing work force is 43 and rising. There are already 126,000 unfilled nursing positions across the country, according to the American Hospital Association. The retirement of the older nurses and the aging of the U.S. population will coalesce, and by 2020, there will be a projected shortage of 400,000 nurses.3

The consequences already are measurable. Nurse staffing levels are associated with hospital infection rates and patient outcomes, including complication rates and length of stay.4 A recent study of discharge data from almost 800 hospitals in 11 states found that a higher number of hours of care by registered nurses was associated with a shorter length of stay and lower rates of both urinary tract infections and upper gastrointestinal bleeding. A higher proportion of hours of care provided by registered nurses also was associated with lower rates of pneumonia, shock, or cardiac arrest.5 In other words, adequate staffing can be a life-or-death issue.

Those troubling research findings prompted Joint Commission president Dennis S. O’Leary, MD, to issue a "call to action" in August that included a focus on worker safety.

"Dramatic changes must be made now and in the next few years to avoid a full-blown crisis in the care of patients," he said. "This means fostering a workplace that empowers nurses and is respectful of other skills, broad adoption of information and ergonomic technologies to transform the work of nurses, setting staffing levels based on nurse competency and skills relative to patient mix and acuity, and establishing zero-tolerance policies for abusive behaviors by health care practitioners."

A focus on staffing will have a direct impact on employee health. Creating a safe workplace is an important aspect of retention, according to the Joint Commission report, which specifically includes ergonomics among its recommendations for creating "organizational cultures for retention."

Researchers are trying to document the link between staffing and musculoskeletal disorders (MSDs). At the University of Maryland School of Nursing in Baltimore, professor Alison Trinkoff, RN, ScD, FAAN, and her colleagues are studying nursing schedules, the physical demands of the job, and injuries of the neck, back, and shoulder.

"In general, we find that the more atypical your schedule is, the more demanding it is," she says. "The more you get away from 9 to 5, the more likely we were to see people reporting injuries."

At the Mount Sinai School of Medicine in New York City, Paul Landsbergis, PhD, assistant professor, is studying work schedules, overtime, working conditions, and MSDs. "We know that work stress, in general, can increase the risk of hypertension and heart disease as well as have some [increase in] risk of [MSDs]."

The link between needlesticks and work pressures already has been established. In a study of 22 hospitals, Clarke and his colleagues at the University of Pennsylvania surveyed about 2,300 nurses. They found that nurses were 50% more likely to report a needlestick at hospitals where administrative support was rated low and patient loads were the heaviest. In near misses as well as needlesticks, organizational climate and staffing had an even greater impact than the use of safety devices. The study focused on hospitals that had been recognized for high quality or had a reputation for attracting and retaining nurses.

"Creating a safe workplace is one of the most compelling ways that an employer can show the employee that they’re valued," Clarke says. "The easy step is to select equipment that reduces the risk of injury. [Setting a positive organizational climate] is tougher — to think through staffing and make the staffing as fair as possible [and] to set up the impression among employees that administration responds to problems."


1. Joint Commission on Accreditation of Healthcare Organizations. Health Care at the Crossroads. Oakbrook Terrace, IL; 2002.

2. Clarke SP, Rockett JL, Sloane DM, et al. Organizational climate, staffing, and safety equipment as predictors of needlestick injuries and near-misses in hospital nurses. Am J Infect Control 2002; 30:207-216.

3. Buerhaus PI, Staiger DO, Auerbach DI. Implications of an aging registered nurse workforce. JAMA 2000; 283:2,948-2,954.

4. Jackson M, Chiarello LA, Gaynes RP, et al. Nurse staffing and health care associated infections: Proceedings from a working group meeting. Am J Infect Control 2002; 30:199-206.

5. Needleman J, Buerhaus P, Mattke S, et al. Nurse-staffing levels and the quality of care in hospitals. N Engl J Med 2002; 346:1,715-1,722.