Nurses: Staffing study falls short on stress, injuries

Injury-staffing link ignored, critics claim

A national report on nurse staffing has drawn sharp criticism from nursing organizations that object to the document's failure to conclusively link occupational injuries to staffing levels in hospitals and nursing homes.

The 256-page study by the Institute of Medicine (IOM) in Washington, DC, is due out this month. It examines a range of issues related to the adequacy of nurse staffing in hospitals and nursing homes.1 One of those issues focuses on the relationship of staffing to work-related injuries and stress.

An IOM committee undertook the two-year project in response to a congressional mandate. In 1970, the National Academy of Sciences chartered the IOM as a private, nonprofit adviser to the federal government on public health and medical care issues. Elected members representative of various health professions serve on committees as volunteers.

The report -- which was compiled from information gathered from the scientific literature, written and oral testimony, and hospital/ nursing home site visits -- establishes only one clear link between staffing and injuries. The IOM Committee on the Adequacy of Nurse Staffing in Hospitals and Nursing Homes, which compiled the study, was "struck by the high rates of injuries to nursing personnel in both the hospital and the nursing home setting but it only found conclusive evidence of a strong link between nurse staffing per se and injuries for the category of back injuries," the report states.

While acknowledging that nursing personnel "encounter a remarkable range of work-related hazards," including "infectious, biologic, chemical, environmental, physical, and psychosocial," the report notes that "except for back injuries, the committee is unable to substantiate conclusively the linkages among staffing numbers, skill mix, and work-related problems."

One section of the study makes some general observations and recommendations based on a review of the literature and anecdotal reports on back injuries, needlestick injuries, violence, and stress. (See related story, p. 46.)

Hospitals are becoming increasingly hazardous workplaces, the study notes. While injury and illness rates for private industry as a whole have remained steady or declined slightly since 1980, rates for hospitals during the same period have increased by about 52%. During that period, hospitals reported about 338,000 cases, an incidence rate of nearly 12 per 100 full-time workers, well above the 8.5 per 100 rate found for private industry as a whole. (See Table 1, inserted in this issue.)

In 1993, hospitals ranked second highest in injuries among nine industries in which at least 100,000 injuries occurred annually.2 (See related story in Hospital Employee Health, April 1995, pp. 53-54.)

Nurse assistants ranked second only to truck drivers and laborers in the incidence of injuries and illnesses that involved lost work days.3 For persons in all occupations who had worked less than one year, nurse assistants had the most injuries and illnesses, mainly sprains and strains involving the back. Overexertion related to patient care was cited as the primary cause. The major source of injury reported was the patient whom the aide was trying to lift or assist. (See Table 2, inserted in this issue.)

'Assembly line' woes

These and other injuries will only increase if hospitals continue to downsize and ignore resulting worker safety issues, says Susan Wilburn, RN, occupational safety and health specialist for the American Nurses Association (ANA) in Washington, DC, which represents some 2.2 million registered nurses.

"The fact is that when people work under short-staffed conditions, the risk of illness and injury is increased, just like if you work in a factory and they speed up the assembly line," Wilburn says.

ANA officials are "disappointed" with the portion of the IOM report that addresses workplace injuries because it does not go far enough in linking injuries with short staffing, nor does it offer recommendations for adequate staffing to help prevent injuries, Wilburn states.

At issue in the controversy is a pioneering study by the Minnesota Nurses Association (MNA) in St. Paul, which established an extensive database of information that revealed a definite correlation between staffing levels and numbers of injuries. (See related story in HEH, November 1995, pp. 140-142.) The MNA study will be published later this year in the American Journal of Nursing.

Study data -- taken from U.S. Occupational Safety and Health Administration "200 logs" on workplace injuries correlated with state department of health information on lengths of patient stays, as well as with information related to downsizing and unit re-engineering -- showed that hospital restructurings tended to produce higher worker injury rates.

Nursing organization officials claim the IOM disregarded the Minnesota study when compiling its report, despite the fact that the IOM had asked the MNA to gather and submit data for consideration.

"The Minnesota data from four years showed a 65% increase in injuries and illnesses to RNs. The IOM must have ignored the data or else they would have mentioned it because it is so striking," says Wilburn. "If they didn't pay attention [to the Minnesota data] because it was only one study, or if they felt there wasn't enough evidence, then why didn't they call for NIOSH or OSHA to request more research on the issue? It was the charge of the IOM committee to look at the relationship between staffing and illness and injuries, and they said there was no relationship that they could determine, but they didn't say as a result we need more research."

ANA officials expected the IOM report to cite the Minnesota data, to suggest that the research be replicated, and to state "the evidence from Minnesota was so striking and alarming that it needs immediate action," she adds.

Even without a formal recommendation, five state nurses' associations are moving forward with plans to replicate the Minnesota study data this year, she notes.

Need to monitor injury rates

MNA study director Elizabeth Shogren, RN, a staff specialist in labor relations, says motivating other organizations to conduct similar studies is some consolation for being omitted from the IOM report.

"I understand when you're the first person to have done a study like this, and it's the only one that's out there, the best you can hope to do is to entice others into trying to duplicate the study to see if it holds true," she tells HEH. "The study will be duplicated on a small scale at one hospital in Michigan. Some other state nurses' associations are talking to me about getting the software we developed in order to duplicate the study. We expect to see more of that."

Despite the IOM's findings, Shogren maintains the MNA study has revealed significant data showing that in hospitals where staffing rates are adequate and stable, injury rates are stable and somewhat lower. When hospitals restructure and lay off nursing personnel, injury rates often skyrocket. The study also shows that increased injuries do not have to be a "foregone conclusion" of hospital restructuring.

"There are some situations in which management has been intuitive enough to know that when you change a lot of conditions in a workplace, the potential for injury increases, and they have monitored it closely," she says. "One value of the study is certainly not to say you can't do workplace redesign because people get hurt, but to say if you're going to do it, you have to monitor very carefully whether you have an increased injury rate. If you do, you have to take steps to find out why that is happening. Generally, restructuring involves trying to produce a product less expensively, and if you've got a hidden cost of increased work injuries, it's just money coming out of another pocket."

The IOM apparently "didn't think [the Minnesota study] demonstrates a pattern they could point to and say, 'Based on this one study that was done in Minnesota, this is what we think is happening in health care across the nation.' We did [the study] because the institute asked us if we could generate the data to support our concerns about staffing levels, and we were able to do that," Shogren states. "We were able to use the data to improve actually and potentially the working environment for all the nurses we represent in Minnesota. We've had a tremendous payback from doing that study without the IOM doing anything with it."

Expectations too high?

IOM study directors have somewhat different explanations for why the Minnesota research was not included in their report.

Gooloo S. Wunderlich, PhD, study director in the IOM's division of health care services, says she read the Minnesota study, and "it's good, but I can't cite every study."

In compiling the report, "our job was not just to show whether injuries have gone up or down," she says. "We had a mandate that asked if [injuries are] related to staffing levels, and we do say that there is enough information to show there is a relationship between back injuries and staffing, but we couldn't find much evidence for other things."

Nursing groups have criticized the report because they were unrealistic about its potential, Wunderlich states.

"The expectations of nursing groups were so high that they thought we were going to solve all their problems, but there's no way we can do that," she says. "We have to base our findings on empirical solid evidence, not just on pure anecdote. Anecdotes are important, and we did listen to a lot of them. We have referred to them in many of our statements in the report; they raise a red flag. But an academy study does not make policy recommendations solely on anecdotes."

Nursing organizations need to wait for additional studies to provide more evidence, she says. "Their position is, 'We can't wait for data; we have enough anecdotes.' But the trouble is, if you keep doing that you will not have data. It's about time that we bite the bullet and say, 'Let's see how we can get out good quality, well-designed studies to get the right kind of information.'"

While Wunderlich indicates that she carefully reviewed the Minnesota research, Carolyne K. Davis, PhD, RN, IOM study chair, says committee members became aware of the MNA report "very late" last fall, when the IOM report already was near completion.

In addition, "it was only one study and didn't take precedence over the other research that we had. It would be true that we would use something like that only with great caution if we were to use it at all," she says. "It's only one study; there needs to be more done to determine if this [connection] is true. Clearly one study alone wouldn't be enough for us to make recommendations."


1. Wunderlich GS, Sloan FA, Davis CK, eds. Committee on the Adequacy of Nurse Staffing in Hospitals and Nursing Homes, Division of Health Care Services, Institute of Medicine. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate? Washington, DC: National Academy Press; 1996.

2. Bureau of Labor Statistics. Shifting workplace spawns new set of hazardous occupations. Issues in Labor Statistics. Summary 94-8. Washington, DC: U.S. Department of Labor; 1994.

3. Bureau of Labor Statistics. Survey of Occupational Health and Injuries. Summary 95-5. Washington, DC: U.S. Department of Labor; 1995. *