Cutting RNs a false economy?

Study: Patients do better with more RNs

A study conducted by the Agency for Health Care Policy and Research in Rockville, MD, recently revealed information that could be useful to you if you are redesigning and restructuring your clinical work force.

Hospitals have been downsizing and downgrading nursing staff for years. Finding the appropriate staffing levels for registered nurses is one of the most contentious issues between hospital managers and their largest group of employees. Over the past five years, many hospitals have tried to save money by using less-skilled workers to perform routine tasks so nurses could supervise those workers and coordinate patient care. Some hospitals laid off RNs and substituted unlicensed caregivers.

Staffing ratios don’t match increased severity

RNs have complained they are unable to provide the quality of care their licenses demand and their patients expect. They also say the heightened severity of inpatient illness in the late 1990s bears no relation to the situation when staffing ratios were set. In response to those concerns, some hospitals have started to boost their staffing levels for RNs, but until this study, no scientific research has been conducted on the effect of such cost-cutting measures on patient outcomes. Now, federally funded researchers have isolated nursing care from other variables and drawn conclusions regarding quality of care as it relates to hospitals’ efforts to reduce costs by replacing RNs with less-skilled workers.

Christine Kovner, RN, PhD, associate professor in the division of nursing at New York University and lead author of the new study, says her study is "one piece of the puzzle." Much more research is needed on the number of RNs associated with levels of quality care, but she says, "the finding of a strong inverse relationship between registered nurse staffing and adverse patient events should be considered when developing strategies to reduce costs."

Surgical patients in hospitals with more RNs per patient are less likely to get infections, pneumonia, and other complications than those with fewer RNs per patient, her study finds.1 The research offers a statistical look at the ongoing debate over how many nurses of what skill levels a hospital needs and how much can be done by other health care workers.

Pneumonia, UTIs decrease in study

Kovner compared the number of hours worked by RNs at a hospital with the health of patients there, focusing on complications that are particularly sensitive to nursing care. The report stated that increasing RN time for half an hour per patient day corresponded to a 4.2% decrease in pneumonia, a 4.5% decrease in urinary tract infections, and a 2.6% decrease in thrombosis. An extra hour of nursing attention per surgical patient each day cut the risk the patient would get a urinary tract infection by nearly 10% and the risk of pneumonia by 8%. The chances of developing other lung-related problems and blood clots also dropped with extra nursing, although not as dramatically.

Earlier research — a 1997 study commissioned by the Washington, DC-based American Nurses Association (ANA) — found a clear relationship between nurse staffing levels and patient deaths, but the recent research looks at the overall quality of care. The authors focused on complications directly related to nursing care. Nurses are responsible for urinary catheter care, for instance, and sloppy or hurried work can lead to urinary tract infections. In addition, nurses can help prevent complications by getting patients out of bed and walking after surgery and monitoring them closely.

The study looked at data from almost 600 hospitals in 10 states — California, Colorado, Connecticut, Florida, Maryland, Massachusetts, New Jersey, New York, Pennsylvania, and Wisconsin — comparing the number of patients who developed certain complications with the number of nurses working in those hospitals. The authors controlled for several factors, including hospital size, ownership, region, and whether it was a teaching institution.

Nursing levels could explain a considerable part of the difference in complication rates, but not all of it, the analysis found. Indeed, the quality of the surgery itself and the size of other staffs at the hospital could also affect patient health.

The study naturally fomented disagreement among parties who are trying to accomplish different goals. Carol Bradley, RN, incoming president of the American Organization of Nurse Executives, says the study did not strongly link the avoidance of complications to RNs. Many different types of employees are involved in patient care besides nurses, she says. The ANA welcomes the research, however, and sees it as support for its campaign to boost nurse staffing levels in hospitals. ANA president Beverly Malone says the results came as no surprise. "Cutting costs by cutting the number of nurses at the bedside is a false economy today," she says.

Neither the American Hospital Association nor nursing organizations track the number of RNs who have been trimmed out of hospitals through cost cutting. And producing hard data that correlate RN care with patient outcomes is extremely difficult, nursing researchers say.

Nurses represent about one-quarter of a typical hospital’s work force and are the single largest labor cost. A hospital typically would have to increase its nurse staffing levels by 17% to add one extra hour of care for each surgical patient.


1. Kovner C, Gergen PJ. Nurse staffing levels and adverse events following surgery in U.S. hospitals. Image: J Nursing Scholarship 1998; 30:315-321.