Registered nurses are vital to patient safety

Decades of national and international research consistently demonstrate a link between inadequate registered nurse staffing and poor patient outcomes, including increases in death rates, hospital-acquired infections, pneumonia, sepsis, pressure ulcers, gastrointestinal bleeding, shock, cardiac arrest, medication errors and falls, as well as, longer than expected lengths of hospital stays.

 

RN Staffing

 McGregor, M.J., Murphy, J.M., Poss, J.W., McGrail, K.M., Kuramoto, L., Huang, H. & Stirling, B. (2015). 24/7 registered nurse staffing coverage in Saskatchewan nursing homes and acute hospital use. Canadian Journal on Aging, 34(4), 492-505.

 Long term care facilities (LTC) in Saskatchewan with 24/7 RN coverage were compared to those with non 24/7 RN coverage. That is, facilities that utilized LPNs or Care Aides to cover night shifts instead of having a RN present. The study found that risks associated with less-than-24/7 RN coverage and substituting with LPNs or care aides for night shifts were associated with significantly higher incidence of transfer to emergency departments and increased inpatient hospital admissions.  Findings suggest that acute care services utilization may be negatively influenced by the absence of 24/7 RN coverage. Findings also suggest there may be empirical evidence to support 24/7 RN on-site presence in LTC facilities.

 Aiken, L., Sloane, D., Bruyneel, L., Van den Heede, K., Griffiths, P., Busse, R., Diomidous, M., Kinnunen, J., et al. (2014). Nurse staffing and education and hospital mortality in nine European countries: A restrospective observational study. The Lancet, 383(9931), 1824-1830.

 Current human resource planning models in nursing are unreliable and ineffective as they consider volumes of patients rather than quality in the delivery of care. The RN4CAST study was designed to inform decision making about nurse staff and quality care. Findings of this study identify that an increase in nurses’ workload by 1 patient increased the likelihood of an inpatient dying within 30 days of admission by 7%. In addition, ever 10% increase in bachelor’s degree nurses was associated with a decrease in this likelihood by 7%. These associations imply that patients in hospital in which 60% of nurses had bachelor’s degrees and where nurses care for an average of 6 patients would have almost 30% lower mortality than patients in hospitals in which only 30% of nurses had bachelor’s degrees and nurses cared for an average of 8 patients.  These findings are interpreted to mean that nurse staffing cuts to save money might adversely affect patient outcomes and an increased emphasis on bachelor’s education for nurses could reduce preventable hospital deaths.

 

Medication Errors

 Vogelsmeier, A., Anbari, A., Ganong, L., Anderson, R., Oderda, L., Farag, A., & Madsen, R. (2015). Detecting medication order discrepancies in nursing homes: How RNs and LPNs differ. Journal of Nursing Regulation, 6(3), 48-56.

 Medication order discrepancies pose safety risks when nursing home residents transition between health care settings. In nursing homes both RNs and LPNs frequently are assigned to detect medication discrepancies, using the process of medication reconciliation. This study was undertaken to examine the extent which licensure (RN, LPN), and years of experience performing medication reconciliation were related to difference in the detection of medication order discrepancies. The study found that years of experience were not related to reports of discrepancies. However, RNs detected discrepancies involving orders for high-risk medications significantly more often than LPNs. These findings regarding the discrepancies detected in order for high-risk medications have implications for resident safety.

 

Mortality

 Aiken, L., Cimiotti, J., Sloane, D., Smith, H., Flynn, L., & Neff, D. (2011). Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Medical Care, 49(12), 1047-1053.

 This study was conducted to determine the conditions under which the impact of hospital nurse staffing , nurse education, and work environment are associated with patient outcomes. Evidence suggests that lower patient-to-nurse ratios, higher proportion of nurses with a baccalaureate level education, and better nurse work environments are associated individually and additively with lower mortality and failure-to-rescue. This study reveals the conditional circumstances under which particular nursing investments yield the best outcomes. Results suggest that nursing characteristics sometimes need to be considered in combination to improve quality and safety. Higher patient-to-nurse ratios increase the odds on patient deaths and failures to rescue, whereas better work environments and higher percentages of BSN nurses decrease those odds.

 McHugh, M., Kelly, L., Smith, H., Wu, E., Vanak, J., & Aiken, L. (2013). Lower mortality in magnet hospitals. Medical Care, 51(5), 382-388.

 This study aimed to determine whether magnet hospitals have lower mortality and failure-to-rescue compared with non-magnet hospitals and to determine the most likely explanations. Findings suggest that magnet hospital had signficiantly better work environments and higher proportions of nurses with bachelor’s degress and specialty certification. These nursing factors explained much of the magnet hospital effect on patient outcomes including decreased mortality and failure to rescue.

 

Infections

 Esparza, S.J., Zoller, J.S., Weatherby White, A. & Highfield, E.F. (2012). Nurse staffing and skill mix patterns: Are there differences in outcomes?

 An examination of the impact on patient outcomes of nurse staffing and registered nurse skill mix on medical surgical units was conducted. The researchers focused on determining the differences in patient outcomes for conditions that are considered sensitive to nursing care – specifically urinary tract infections and length of stay. The findings show a strong association between the proportion of RN care provided and a lower length of stay and lower odds of patients developing UTI. These finding are significant in addressing rising health care costs due to preventable adverse events.

 Kane, R.L., Shamliyan, T.A., Mueller, C., Duval, S. & Wilt, T.J. (2007). The association of registered nurse staffing levels and patient outcomes.

 The purpose of this study was to examine the association between RN staffing and patient outcomes in acute care hospitals. These included nurse-sensitive factors such as hospital acquired pneumonia, urinary tract infection, respiratory failure, blood stream infection, cardiac arrest, etc. Study findings identify increased RN staffing as being associated with lower hospital related mortality in ICU, surgical and medical patients. The available evidence indicates that there is a statistically and clinically significant association between RN staffing and hospital related mortality, failure to rescue and other patient outcomes. These findings are significant in associating positive patient outcomes with RN staffing, thus decreasing health care costs and patient adverse events.