Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction FREE

ABSTRACT | METHODS | RESULTS | COMMENT | REFERENCES| METHODS | RESULTS | COMMENT | REFERENCES Context The worsening hospital nurse shortage and recent California legislation mandating minimum hospital patient-tonurse ratios demand an understanding of how nurse staffing levels affect patient outcomes and nurse retention in hospital practice. Objective To determine the association between the patient-to-nurse ratio and patient mortality, failure-to-rescue (deaths following complications) among surgical patients, and factors related to nurse retention. Design, Setting, and Participants Cross-sectional analyses of linked data from 10 184 staff nurses surveyed, 232 342 general, orthopedic, and vascular surgery patients discharged from the hospital between April 1, 1998, and November 30, 1999, and administrative data from 168 nonfederal adult general hospitals in Pennsylvania. Main Outcome Measures Risk-adjusted patient mortality and failure-to-rescue within 30 days of admission, and nursereported job dissatisfaction and job-related burnout. Results After adjusting for patient and hospital characteristics (size, teaching status, and technology), each additional patient per nurse was associated with a 7% (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.03-1.12) increase in the likelihood of dying within 30 days of admission and a 7% (OR, 1.07; 95% CI, 1.02-1.11) increase in the odds of failure-to-rescue. After adjusting for nurse and hospital characteristics, each additional patient per nurse was associated with a 23% (OR, 1.23; 95% CI, 1.13-1.34) increase in the odds of burnout and a 15% (OR, 1.15; 95% CI, 1.07-1.25) increase in the odds of job dissatisfaction. Conclusions In hospitals with high patient-to-nurse ratios, surgical patients experience higher risk-adjusted 30-day mortality and failure-to-rescue rates, and nurses are more likely to experience burnout and job dissatisfaction. The past decade has been a turbulent time for US hospitals and practicing nurses. News media have trumpeted urgent concerns about hospital understaffing and a growing hospital nurse shortage.1 3Nurses nationwide consistently report that hospital nurse staffing levels are inadequate to provide safe and effective care.4 6 Physicians agree, citing inadequate nurse staffing as a major impediment to the provision of high-quality hospital care.7 The shortage of hospital nurses may be linked to unrealistic nurse workloads.8 Forty percent of hospital nurses have burnout levels that exceed the norms for health care workers.4 Job dissatisfaction among hospital nurses is 4 times greater than the average for all US workers, and 1 in 5 hospital nurses report that they intend to leave their current jobs within a year.4 In 1999, California passed legislation mandating patient-to-nurse ratios for its hospitals, which goes into effect in July 2003. The California legislation was motivated by an increasing hospital nursing shortage and the perception that lower nurse retention in hospital practice was related to burdensome workloads and high levels of job-related burnout and job dissatisfaction. Stakeholder groups advocated widely divergent minimum ratios. On medical and surgical units, recommended ratios ranged from 3 to 10 patients for each nurse.9 11 In early 2002, California's governor announced that hospitals must have at least 1 licensed nurse for every 6 medical and surgical patients by July 2003, a ratio that will move to 1 to 5 when the mandates are fully implemented.12 This study reports on findings from a comprehensive study of 168 hospitals and clarifies the impact of nurse staffing levels on patient outcomes and factors that influence nurse retention.13Specifically, we examined whether risk-adjusted surgical mortality and rates of failure-to-rescue (deaths in surgical patients who develop serious complications) are lower in hospitals where nurses carry smaller patient loads. In addition, we ascertained the extent to which more favorable patient-to-nurse ratios are associated with lower burnout and higher job satisfaction among registered nurses. We also estimated excess surgical deaths associated with the different nurse staffing ratios vigorously debated in California. Finally, we estimated the impact of nurse staffing levels proposed in California on nurse burnout and dissatisfaction, 2 precursors of turnover.13 Our findings offer insights into how more generous registered nurse staffing might affect patient outcomes and inform current debates in many states regarding the merits of legislative actions to influence staffing levels.