What happens to patients when nurses are short-staffed or work with a high nurse-to-patient ratio?
Quality nursing care saves lives. When nurses are forced to work with high nurse-to-patient ratios, patients die, get infections, get injured, or get sent home too soon without adequate education about how to take care of their illness or injury. So they return right back to the hospital, often sicker than before. When nurses have fewer patients, they can take batter care of them. Then patients are more likely to understand how to manage their diabetes, walk with crutches, watch for signs of infection or brain injury, so they can prevent further illness or deterioration or know when to seek help. When nurses have fewer patients they are more likely to intercept and prevent errors, so fewer patients die or get injured. And when nurses have more time to advocate with physicians, insurance companies or others about the patient's care plan to make sure the patient gets everything s/he needs, patients are more likely to thrive. Please email us for a free bumper sticker that tells the world that nurses save lives at email@example.com. Thank you!
Research on the value of nursing is below. Please let us know if you have a study for us to add to this page.
July 30, 2012 --Jeannie Cimiotti, Linda Aiken and colleagues examined nurse burnout / emotional exhaustion and found that for every extra patient assigned to a nurse, rate of catheter infection increased by 1 infection per 1,000 patients. The nurse researchers found that if hospitals reduced nurse burnout from 30% to 10%, Pennsylvania alone could prevent 4,160 infections. The study appears in the American Journal of Infection Control. see the news article in the Philadelphia Inquirer... and the original study.
April 2010 -- A study by nursing researchers Linda Aiken and colleagues found that 11 to 14% fewer patients would have died in Pennsylvania and New Jersey if those states had patient-to-nurse staffing ratios like those of California. The Health Services Research study "Implications of the California Nurse Staffing Mandate for Other States" (vol. 45, issue 2) also found that California nurses felt 15-20% fewer burnout symptoms compared to NJ and PA nurses respectively. abstract full article and see our analysis of the study.
January - March, 2007 -- This report encourages the health care system to improve nurses' poor working environment. It cites current studies linking fewer registered nurses to poor patient outcomes and danger to patient safety. It encourages improvements to move beyond superficial solutions to increasing the the status of nurses, and "clearer roles and educational reform defining specifically who is a nurse, and what a nurse can and should be able to do, can assist in making nursing a more desirable profession." The study encourages adequate staffing ratios to improve patient safety, " but legal mandates are not enough." "Addressing the satisfaction of nurses through empowerment is essential to attract and retain nurses and improve their working environment. Finally, by empowering nurses and providing them with valuable, practical recurrent skills training and problem solving power, nurses will garner the respect, autonomy, and professional status and skills to lead in the effort to promote patient safety." Published in Laura Lin & Bryan A. Liang, Nursing Forum Volume 42, No. 1...
November 2004 -- This month the International Council of Nurses issued "The Global Shortage of Registered Nurses: An Overview of Issues and Actions." This important report surveys the causes, nature and effects on patient care of nursing shortages throughout the world; discusses the "critical challenges" of HIV/AIDS, internal and international nurse migration, and health sector reform and restructuring; and makes general policy recommendations to address these critical problems. It concludes that "[w]ithout effective and sustained interventions, global shortages will persist, undermining attempts to improve care outcomes and the health of nations." See the report in pdf (419 kb).
November 2004 -- Patricia Stone, Sean Clarke, Jeannie Cimiotti, and Rosaly Correa-de-Araujo report on the effects of nurses working conditions:
March 2004 -- The Agency for Healthcare Research and Quality released its report entitled "Hospital Nurse Staffing and Quality of Care: Hospitals with low nurse staffing levels tend to have higher rates of poor patient outcomes such as pneumonia, shock, cardiac arrest, and urinary tract infections, according to research funded by the Agency for Healthcare Research and Quality (AHRQ) and others." See the comprehensive report in html or pdf format.
November 5, 2003 -- Today Reuters and the New York Times ran passable initial stories about a major report issued by a panel of the National Academy of Science's Institute of Medicine, which advises the federal government on health care, urging reform to protect patients from the proven dangers of excessive nursing overtime and short-staffing. more...
August 7, 2002 -- Today the Joint Commission on Accreditation of Healthcare Organizations issued a huge report on the nursing shortage--focusing on the severity of the current and future nursing shortage and its detrimental effect on patients. more...
October 2013 -- "Hospitals with better registered nurse staffing levels were significantly less likely to be penalized under [The Affordable Care Act’s] CMS Hospital Readmissions Reduction Program than otherwise similar hospitals that were less well staffed," say authors Matthew D. McHugh, Julie Berez and Dylan S. Small. The authors cite a lack of "basic nursing care" such as "such as discharge preparation, care coordination, and patient education" as evidency-based interventions that are lacking in patients who are taken care of by understaffed nurses. "Each additional nurse hour per adjusted patient day was associated with a 10% decrease in the odds of being penalized." "By focusing on a system factor such as nurse staffing, administrators may be able to address multiple quality issues while reducing their likelihood of penalty for excess readmissions." Health Affairs, 32:1740-1747. see the abstract...
April 25, 2011 -- A study1,892 patients out of Marquette University in Milwaukee led by Professor / Sister Rosalie Klein found that when RN staffing was higher (and by non-overtime nurses) that patients were less likely to be readmitted within 30 days because nurses were able to do more effective discharge planning. Increasing staffing cost hospitals nearly $200 but saved insurers (and self-pay patients) over $600 per hospitalization. Decreasing overtime on the other hand only saved hospitals $8 and insurers $10 per patient. See the study...
August 2009 -- Korean nurses Sung-Hyun Choa and Sung-Cheol Yunb found that "hospitals with higher ICU staffing were more likely to fully provide basic care. Better ICU and general staffing tended to be associated with lower in-hospital and 30-day mortality. Compared with in-hospital mortality, 30-day mortality had a more distinct increase as nurse staffing became worse." Published in the International Journal of Nursing Studies, 46, (8), Aug. 2009, pp. 1092-1101. see the abstract...
June 2007 -- Researchers found that hospital units with higher nurse-to-patient staffing ratios had significantly lower incidence of central line IV bloodstream infections, pneumonia associated with ventilators, deaths within 30 days, and bedsores. Increased overtime of nurses was associated with higher rates of catheter-associated urinary tract infections and bedsores, but slightly lower rates of central line IV bloodstream infections. The study was done by Patricia Stone, Cathy Mooney-Kane, Elaine Larson, Teresa Horan, Laurent Glance, Jack Zwanziger, and Andrew Dick, and published in Medical Care. see original article...
October/December 2006 -- When nurses are short-staffed, a research study: "Missed Nursing Care: A Qualitative Study" found that much of necessary patient care was just not being done. Beatrice Kalisch, Past-President of the Center, published her findings in the Journal of Nursing Care Quality. The qualitative, focus group study of RNs, LPNs and nursing assistants found that care was being missed in 9 major areas including surveillance, discharge planning, patient teaching, ambulation, turning, feedings, emotional support, hygiene and intake and output documentation. One RN in the study stated: "People want to give good care and it bothers all of us when we can't do it. You are pulled in 10 directions, and you can't give quality care to your patients. It really bothers me.” And another said: “We don't let ourselves think about [the care not being done]. It is the way we cope. Underneath we don't feel good about it." See the full-text study...
July 20, 2006 -- The IOM issued a massive report called: "Preventing Medication Errors: Quality Chasm Series." It can be read online for free, or purchased in hardcopy or pdf. Some powerful quotes include: "nursing activities are indispensable to patient safety." (p. 80) "[A] study of medication errors found that nurses were responsible for intercepting 86 percent of all errors made by physicians, pharmacists, and others involved in providing medications for patients (Leape et. al, 1995). "Nurses' involvement and vigilance during the preparation process is thus central to accurate medication administration." "High rates of nursing staff turnover have adverse consequences for staffing levels, quality of care, and patient safety. (AHCA, 2002; The HSM Group, 2002). "Although most nursing shifts are 8-12 hours, mandatory overtime and double shifts contribute to nursing-related medication administration errors." (IOM, 2004b). See especially pages 79-83 of the report. Read more...
January/February 2006 -- Raising the ratio of RNs to LPNs to the 75th percentile pays for itself--actually saving money--and avoids 1.5 million hospital days in US hospitals and 5000 deaths. Raising the total number of nurses to the 75th percentile and raising the ratio of RNs to LPNs to the 75th percentile saves over 6700 lives and eliminates over 4.1 million days of patient stays. These reductions would increase hospital net expenses by 0.4%--hardly onerous. The authors suggest that insurers help hospitals pay for this extra expense. Jack Needleman, Peter I. Buerhaus, Maureen Stewart, Katya Zelevinsky, and Soeren Mattke. "Nurse Staffing In Hospitals: Is There A Business Case For Quality?: Costs are only part of the picture; we also need to consider the payoff in cost savings and the value of better patient care." Health Affairs 25, (1) (2006): 204-211. Also see our report on the study.
August 2005 -- Research shows that when nurse staffing is improved from 8 patients per nurse to 4, lives are saved in a cost efficient manner. The adequate nurse staffing intervention cost $136,000 per life saved. Common life saving measures such as the use of thrombolytic therapy for myocardial infarctions and PAP smears for routine cervical cancer screening cost $182,000 and $432,000 respectively per life saved. Rothberg, M., Abraham, I., Lindenauer, P. & Rose, D. (2005). Improving Nurse-to-Patient Staffing Ratios as a Cost-Effective Safety Intervention Medical Care, 43, (8) 795-791.
October 23, 2002 -- In a large research study entitled "Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction" published in the Journal of the American Medical Association, University of Pennsylvania nursing scholar Linda Aiken and her colleagues found that for each additional patient assigned to a nurse, 30-day patient mortality increases by 7%, the odds of nursing job dissatisfaction increase by 15% and the odds of nurse burnout increase by 23%. more...
November 2005 -- From the abstract: "more RN direct care time per resident per day...was associated with fewer pressure ulcers, hospitalizations, and [urinary tract infections]; less weight loss, catheterization, and deterioration in the ability to perform [activites of daily living]; and greater use of oral standard medical nutritional supplements." Susan Horn, Peter Buerhaus, Nancy Bergstrom & Randall Smout (Nov 2005). "RN staffing time and outcomes of long-stay nursing home residents: pressure ulcers and other adverse outcomes are less likely as RNs spend more time on direct patient care," American Journal of Nursing, 105 (11), 58-70; quiz 71. see the article...
May 30, 2002 -- In today's issue of the New England Journal of Medicine (NEJM), researchers Jack Needleman of the Harvard School of Public Health in Boston and Peter Buerhaus of Vanderbilt University's School of Nursing in Nashville, Tennessee found that nurse short-staffing leads to deadly consequences for patients. more... abstract
February 2004 -- Patients were more than twice as likely to report high satisfaction with their care and nurses reported less burnout when nurses worked in conditions with adequate staff, good administrative support for nursing care, and good relations between themselves and physicians. It was a study of 820 nurses and 621 patients from 40 units in 20 US urban hospitals. See: Vahey DC, Aiken LH, Sloane DM, Clarke SP, Vargas D. (2004). Nurse burnout and patient satisfaction. Medical Care 2004; 42(2):II-57-II-66. Abstract.
January 2003 -- Nurse researchers describe how patients deteriorate unnoticed and die when hospitals under-staff nurses. This AJN article shows why the "failure to rescue" rate increases by 7% for each additional patient assigned to a nurse and why this is the best indicator of a hospital's quality. Clarke, Sean and Linda Aiken. (Jan. 2003). Failure to Rescue: Needless deaths are prime examples of the need for more nurses at the bedside. ($) American Journal of Nursing, 103 (1) 42-47.
December 2006 -- Two neonatal ICUs (NICUs) in New York City studied 2,600+ infants over a 2-year period of time. Of these infants, 224 (8.4%) developed a bloodstream infection; and of these, 7% died. In one NICU, higher nurse staffing levels correlated with up to a 79% decrease in the risk of infection. In the other NICU, no association was found between RN hours and infections because consistent understaffing over the course of the study made it impossible to measure any variation. more...
November 17, 2005 -- Quoted from the University of Toronto story:
June 28, 2005 -- Quoted from the University of Toronto/University of Maryland press release:
May 6, 2005 -- Today the Scotsman web site posted a Press Association piece by Lyndsay Moss about a new study finding that intensive care patients were seven times more likely to be infected with the deadly MRSA "superbug" when there was a "shortage of specially trained nurses." The brief piece, "Superbug Peril Higher During Nurse Shortages," does a pretty good job explaining one of the countless hazards of nurse short staffing. But it has expert comment only from physicians, and none from the intensive care nurses whose care is actually at issue--a small but telling example of the kind of attitudes that help make nurse short staffing possible. more...
A Massachusetts survey found that physicians rank understaffing of registered nurses as the biggest hospital problem directly affecting patient care. Over 3/4ths of physicians report nurse staffing too low. One-fifth reported patient deaths from short-staffing, over 8 in 10 found the practice to degrade quality of care and over 6 in 10 reported medication errors. see more...
May-June 2004 -- A Kuwaiti research study split 198 patients into three groups: group I had a ratio of one nurse per two patients, group II had a 1:3 ratio and group III had a 1:4 ratio. As the nurses' workloads increased, patient health suffered. Patients treated under a 1:2 ratio had a HCV prevalence of 26.8% and a HCV seroconversion rate per year of 5.3%. When the nurse-to-patient ratio was 1:3, the rates were 43.6% and 8.7%; and patients subject to a 1:4 nurse-to-patient ratio had rates of 71.8% and 14.4% respectively. See: Saxenaa, A. K. & Panhotrab, B.R. (2004). The Impact of Nurse Understaffing on the Transmission of Hepatitis C Virus in a Hospital-Based Hemodialysis Unit. Medical Principles and Practice, 13, (3), 129-135. Abstract.
Pronovost, P. J., Dang, D., Dorman, T., Lipsett, P.A., Garrett, E., Jenckes, M. & Bass, E.B. (2001). Intensive care unit nurse staffing and the risk for complications after abdominal aortic surgery. Effective Clinical Practice, Sep-Oct; 4(5):199-206. abstract
Dimick, Justin B., Swoboda, Sandra M., Pronovost, Peter J. & Lipsett P.A. (2001). Effect of nurse-to-patient in the intensive care unit on pulmonary complications and resource use after hepatectomy, American Journal of Critical Care, Nov;10 (6), 376-382. abstract
Unruh L. (2003). Licensed nurse staffing and adverse events in hospitals. Medical Care. Jan; 41 (1), 142-152. abstract
More nurses, better preemie oxygenation
June 2007 -- Nurses on the Move: A Global Overview by Mireille Kingma, Health Services Research, 1281-1298.
August 2005 -- Berney B, Needleman J. Trends in nurse overtime, 1995-2002. Policy, politics & nursing practice, 183-190.
February 2004 -- Loeb M, McGeer A, Henry B, Ofner M, Rose D, Hylwka T. SARS among critical care nurses, Toronto. Emerging infectious diseases, 251-255.
2004 -- Rogers A, Hwang W, Scott L, Aiken L, Dinges D. The working hours of hospital staff nurses and patient safety. Health Affairs (Millwood), 202-12.
2004 -- Aiken LH, Buchan J, Sochalski J, Nichols B, Powell M. Trends in international nurse migration. Health Affairs (Millwood), 69-77.
December 2003 -- Alonso-Echanove J, Edwards JR, Richards MJ, Brennan P, Venezia RA, Keen J, et al. Effect of nurse staffing and antimicrobial-impregnated central venous catheters on the risk for bloodstream infections in intensive care units. Infection control and hospital epidemiology, 916-925.
November 2003 -- Institute of Medicine. Keeping patients safe: transforming the work environment of nurses. See especially p. 435.
October 2003 -- Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. The Journal of the American Medical Association, 1868-1874.
August 2003 -- Varia M, Wilson S, Sarwal S, McGeer A, Gournis E, Galanis E, et al. Investigation of a nosocomial outbreak of severe acute respiratory syndrome (SARS) in Toronto, Canada. Canadian Medical Association journal, 285-292.
July 2003 -- Manias E, Aitken R, Peerson A, Parker J, Wong K. Agency nursing work in acute care settings: perceptions of hospital nursing managers and agency nurse providers. Journal of clinical nursing, 457-466.
March 2003 -- Hickman D, Severance S, Feldstein A. The effect of health care working conditions on patient safety. Rep.74. Agency for Healthcare Research and Quality.
2003 -- Stilwell B, Diallo K, Zurn P, Dal Poz M, Adams O, Buchan J. Developing evidence-based ethical policies on the migration of health workers: conceptual and practical challenges. Human resources for health. 2003;1(1):8.
September-October 2002 -- Aiken LH, Clarke SP, Sloane DM. Hospital staffing, organization, and quality of care: Cross-national findings. Nursing Outlook, 187-194.
July 2002 -- Health Resources and Services Administration, Bureau of Health Professions. Projected supply, demand, and shortages of registered nurses: 2000-2020.
June 2002 -- Kovner C, Jones C, Zhan C, Gergen PJ, Basu J. Nurse staffing and postsurgical adverse events: an analysis of administrative data from a sample of U.S. hospitals, 1990-1996. Health services research, 611-629.
June 2002 -- Jackson M, Chairello L, Gaynes RP, Gerberding JL. Nurse staffing and health care-associated infections: proceedings from a working group meeting. American journal of infection control, 199-206.
March 2002 -- Stegenga J, Bell E, Matlow A. The role of nurse understaffing in nosocomial viral gastrointestinal infections on a general pediatrics ward. Infection control and hospital epidemiology, 133-136.
January 2002 -- Andersen BM, Lindemann R, Bergh R, Nesheim B, Syversen G, Solheim N, et al. Spread of methicillin-resistant Staphylococcus aureus in a neonatal intensive unit associated with understaffing, overcrowding and mixing of patients. The Journal of hospital infection, 18-24.
2002 -- Clarke SP, Sloane DM, Aiken LH. Effects of hospital staffing and organizational climate on needlestick injuries to nurses. American journal of public health. 2002;92:1115-1119.
December 2000 -- Amaravadi RK, Jacobson BC, Solomon DH, Fischer MA. ICU nurse-to-patient ratio is associated with complications and resource use after esophagectomy. Intensive Care Medicine, 1857-1862.
January 2000 -- Robert J, Fridkin SK, Blumberg HM, Anderson B, White N, Ray SM, et al. The influence of the composition of the nursing staff on primary bloodstream infection rates in a surgical intensive care unit. Infection control and hospital epidemiology, 12-17.
2000 -- Lichtig LK, Knauf RA, Risen-McCoy R, Wozniak L. Nurse staffing and patient outcomes in the inpatient hospital setting. Washington: American Nurses Association.
November 1999 -- Institute of Medicine. To err is human: building a safer health system. Washington: National Academy Press; 2000.
October 1999 -- Vicca AF. Nursing staff workload as a determinant of methicillin-resistant Staphylococcus aureus spread in an adult intensive therapy unit. The Journal of hospital infection, 109-113.
September 1999 -- Harbarth S, Sudre P, Dharan S, Cadenas M, Pittet D. Outbreak of Enterobacter cloacae related to understaffing, overcrowding, and poor hygiene practices. Infection control and hospital epidemiology, 598-603.
1998 -- Kovner C, Gergen PJ. Nurse staffing levels and adverse events following surgery in U.S. hospitals. Image--the journal of nursing scholarship, 315-321.
November 1997 -- Archibald LK, Manning ML, Bell LM, Banerjee S, Jarvis WR. Patient density, nurse-to-patient ratio and nosocomial infection risk in a pediatric cardiac intensive care unit. The Pediatric infectious disease journal, 1045-1048.
1997 -- Knauf RA, Lichtig LK, Risen-McCoy R, Singer AD, Wozniak L. Implementing nursing's report card: a study of RN staffing, length of stay and patient outcomes.
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May 1990 -- Jones CB. Staff nurse turnover costs: Part II, Measurements and results. The Journal of nursing administration, 27-32.
November 1982 -- Arnow P, Allyn PA, Nichols EM, Hill DL, Pezzlo M, Bartlett RH. Control of methicillin-resistant Staphylococcus aureus in a burn unit: role of nurse staffing. The Journal of trauma, 954-959.
August 2004 -- This month's edition of the American Journal of Nursing summarizes the state of the science on short-staffing. The ANA is preparing a meta-review of data, but the Agency for Healthcare Quality and Research has largely done that in their influential report. There's clearly enough data to take to your hospital administrators to demand higher levels of nurse staffing. See the news item...
February 2, 2004 -- This week Newsweek's "My Turn" column was a powerful piece by Michigan ED nurse Paul Duke about how short-staffing frequently has him "praying like mad that I didn't make any mistakes that hurt anyone." more...
November 2003 -- Economist Anthony Giles Heyes asserts that nurses should be paid less, not more, to solve the global shortage in his piece: The Economics of Vocation or Why is a Badly Paid Nurse a Good Nurse? Julie A. Nelson and Nancy Folbre issue an excellent retort in their article: "Why a Well-Paid Nurse is a Better Nurse".
September 30, 2003 -- Curtin, L. "An Integrated Analysis of Nurse Staffing and Related Variables: Effects on Patient Outcomes." Online Journal of Issues in Nursing. Available: www.nursingworld.org/ojin/topic22/tpc22_5.htm
October 2003 -- This month's issue of Reader's Digest, following up on the September story on the nursing shortage, features an anonymous ICU nurse's powerful account of one short-staffed shift in which the nurse does complex, life-saving work despite facing an array of improper demands and abuse caused by the short-staffing itself. more...
October 2002 -- RN Lorraine Dale paints a vivid picture of the harrowing experience of working at an under-staffed hospital, in an American Journal of Nursing article entitled "Chaos."
November 19, 2002 -- In a New York Times article, physician Abigail Zuger aptly describes the effects of nurse short-staffing on her patients in her article "Prescription, Quite Simply, Was a Nurse."
1997 -- The March Atlantic Monthly published an interview with Suzanne Gordon called "Cutting Down on Care". This nursing advocate journalist is interviewed about her 1996 book Life Support: Three Nurses on the Front Lines, which describes the importance of the work of nurses. National Public Radio's Talk of the Nation also interviewed Ms. Gordon along with Mary Mundinger, Dean of Columbia University School of Nursing and author of Autonomy in Nursing, and Jeannie Chaisson, a Clinical Nurse Specialist. Listen to the Talk of the Nation radio program.
August 2004 -- Health care system changes hurt nurses' health lead to neck, shoulder and back problems in a study by Jane Lipscomb, PhD, RN, Alison Trinkoff, ScD, RN, Barbara Brady, RN, MS and Jeanne Geiger-Brown, PhD, RN. abstract
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