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No magic number

January 21, 2006 -- Today the ABC News site posted a useful report by Laura Marquez under the headline "Nursing Shortage: How It May Affect You." The sub-head was "Family Awarded $2.7 million over Alleged Nursing Neglect at Kansas Hospital." The piece tells the story of a hospital patient who was admitted for pneumonia and went seven hours without seeing a nurse, apparently because her nurse had 20 patients. The patient was actually having a heart attack; she became paralyzed and suffered brain damage. This is a powerful illustration of the potential effects of nurse short-staffing. The piece also describes an important new Health Affairs study, conducted by nursing scholar Peter Buerhaus and others, showing that having more registered nurses in hospitals could not only save lives, but save money as well. The piece includes some good points about the nursing shortage. It might have described the lawsuit in a way that did not suggest it was the only successful one ever based on a failure of nursing care, which may imply that nursing is not a very hard or responsible job. And the piece might have explored potential solutions to the shortage and short-staffing in more depth, perhaps describing the various legislative proposals, and the minimum ratios now in effect in California.

See the charts or read more below.

The piece tells the story of Shirley Keck, a 61-year-old whose daughter rushed her to Wesley Hospital in Wichita after she began having trouble breathing. The piece says that "[d]octors" thought Keck had pneumonia and admitted her. For seven hours, Keck's daughter watched her struggle to breathe and repeatedly tried to get help from nurses, to no avail. Keck's "primary nurse" allegedly had 20 patients, "more than the hospital's own guidelines recommend." (The piece might have told us what ratio the guidelines do recommend.) Keck was having a heart attack. Eventually she had to be resuscitated, but she had brain damage and was paralyzed. Her family reportedly won a $2.7 million court judgment. Keck's daughter is quoted as saying that she did not sue for the money: "I wanted them, as I wheeled my mother into that courtroom, to see what their decision to run the hospital shorthanded cost somebody."

The piece describes the suit as "the only successful malpractice lawsuit against a hospital citing inadequate nursing," but notes that given current conditions, it may not be the last one. Perhaps this just means it is the only suit that has specifically alleged that the hospital injured a plaintiff through nurse short-staffing, but it is certainly not the only successful one to cite "inadequate nursing." In fact, there have been numerous major successful nursing malpractice cases against nurses and hospitals over the last decade. Of course, that's not because nurses are unusually sloppy, but because they are serious professionals with independent legal duties doing a difficult life-and-death job, and these days, often doing it without adequate resources. Unfortunately, the way the piece has phrased its statement here may suggest that this is the first successful nursing malpractice suit in history. Given the low level of public understanding, that may suggest to many that nursing is not so difficult that you could make a serious error, as long as you manage to pop your head in once in a while to see if the patient is in distress so obvious even the family can see it. In fact, short-staffing can kill patients even when nurses spend significant time with patients, because nursing--like medicine--requires great skill and judgment.

Fortunately, the piece goes on to make some valuable general points about short-staffing and the shortage. First of all, though the piece does not mention the role of short-staffing in driving the shortage, we commend it for not suggesting that the short-staffing in the Keck case was caused by the hospital's inability to find any nurses, as opposed to budget-driven staffing decisions. It might have been helpful to note that many nurses have fled the bedside over the past decade to avoid confronting the kind of impossible situation seen in the Keck case. But the piece does provide important general information. It cites Buerhaus, an assistant dean at Vanderbilt's School of Nursing, for the idea that this is the worst shortage in 50 years. The piece also explains that hospitals are "under pressure" because of budget constraints, and that nursing is a large part of their budgets. However, it states that the recent Health Affairs study "found hiring more nurses could actually save a hospital money in the long run. The study found 6,700 patient deaths and 4 million days of hospital care could be avoided each year by increasing staff of registered nurses." In fact, the study found that increasing the ratio of RNs to LPNs to the 75th percentile could greatly improve outcomes reducing 1.5 million hospital days, saving 5000 lives, and saving hospitals money even in the short run. It also found that increasing the number of total nurses and increasing the RN to LPN ratio both to the 75th percentile would improve outcomes even more, eliminating 4.1 million inpatient days and saving over 6700 lives. The savings were due to nurses' great influence on patient outcomes, which would mean fewer adverse events and shorter hospital stays. (See study details below.)

The piece goes on to describe some of the barriers to resolving the shortage. The aging population requires more nursing care, and because of budget constraints, the average hospital patient is sicker than ever, and so needs even more care. Yet nursing schools now have limited capacity, and the piece notes that nursing schools last year turned away 125,000 applicants because they lacked faculty to teach them. Many nursing professors are retiring. The piece quotes Buerhaus: "Our current work force will get older and older and retire in large numbers in the next decade just as we see the aging of baby boomers, all 80 million of them, beginning to turn 65 and consuming more health care." In view of this, the piece might have discussed some potential solutions to the faculty shortage.

The piece ends with some suggestions on how patients might try to protect themselves from this "gloomy" picture. These include learning hospitals' nurse-to-patient ratios--an excellent suggestion, assuming you can learn the actual ratios, rather than the kind of hospital "guidelines" mentioned in the Keck case. Currently, as far as we know, U.S. hospitals are not legally required to disclose those ratios, except in California, where they are required to meet specific minimum ratios at all times. The piece also suggests checking the American Nurses Association (ANA) web site's list of magnet hospitals, which are "recognized for excellence in nursing care, including good nurse-to-patient ratios." The piece does not note that only about 3% of U.S. hospitals are now magnet facilities, nor that many nurses at such facilities do not find that the magnet designation has made a significant difference in nursing care. The piece goes on to note that the ANA says "there is no magic number" for nurse-to-patient ratios because "it varies depending on what tasks a particular nursing unit performs and whether they tend to work days or nights, when patients primarily sleep." The piece notes that ICUs need more nurses than general medical wards, that ICU nurses should "[i]deally have no more than two patients," and that the ANA "recommends no more than six patients per nurse in any unit."

The piece might have benefited from some views that differed from the ANA's, and from discussion of existing or proposed legislative solutions. These include the minimum staffing ratios now effect in California, and the staffing bills pending in Congress and some states, notably Massachusetts. Options include set minimum ratios, as well as disclosure of ratios. Some states now have whistleblower protection that may help nurses who object to unsafe staffing. Some unions and other nursing advocates also argue that mandatory minimum ratios can (and the California ones do) account for different types of units. Moreover, while patients may sleep more at night, they do not have fewer health problems then, and nurses have more than enough to do at night, for instance catching up on things for which there was no time earlier. The piece might also have noted that some would probably argue that what happened in the Keck case illustrates the limited effectiveness of "recommended" minimum ratios.

We thank ABC News for reporting on these important issues.

See the report by Laura Marquez "Nursing Shortage: How It May Affect You: Family Awarded $2.7 million over Alleged Nursing Neglect at Kansas Hospital."

See below from 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, no. 1 (2006): 204–211.

Avoided Adverse Outcomes, Hospital Days, Costs, And Deaths If Proportion Of
Registered Nurses (RNs) Or Number Of Licensed Nursing Hours Were Increased To The 75th Percentile Of Hospitals Studied, National Estimates Updated To 2002

Option 1: Raise RN to LPN ratio to 75th percentile without changing number of nursing hours Option 2: Raise number of nursing hours to 75th percentile without changing RN to LPN ratio Option 3: Raise RN to LPN ratio and number of overall nursing hours to 75th percentile
Number of avoided adverse outcomes
Failure to rescue (major surgery pool) 354 597 942
Urinary tract infection 40,770 4,174 44,773
Hospital-acquired pneumonia 11,761 1,372 13,093
Upper GI bleeding 4,145 4,129 8,182
Shock or cardiac arrest 2,908 540 3,426
Total avoided outcomes 59,938 10,813 70,416
Hospital days avoided 1,507,493 2,598,339 4,106,315
Cost impacts (in millions)
Cost savings assuming that 40% of hospital costs are variable
Cost savings of avoided outcomes $73 $17 $89
Cost savings of avoided days 980 1,702 2,683
Total avoided costs 1,053 1,719 2,772
Net cost of increasing nursing -242 5,819 5,716
Net cost as percent of hospital expenses -0.1% 1.50% 1.40%
Cost savings assuming that fixed hospital costs are recovered (in millions)
Cost savings of avoided outcomes $183 $42 $224
Cost savings of avoided days 2,450 4,256 6,707
Total avoided costs 2,633 4,298 6,930
Net cost of increasing nursing -1,821 3,240 1,558
Net cost as % of hospital expenses -0.5% 0.80% 0.40%
Avoided deaths 4997 1,801 6,754

Raising the ratio of RNs to LPNs to the 75th percentile pays for itself 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. See the study here.