Changing how the world thinks about nursing

Join our Facebook group Twitter bird search box

US News hospital rankings undervalue nursing, despite article on shortage; lead statistician tells Center he will consider bigger nursing role

July 28, 2003 -- This week's issue of US News & World Report includes, in its annual "Best Hospitals" section, an article by Jodi Schneider entitled "Getting nurses back on board" which highlights one Houston hospital's efforts to end its need for expensive agency nurses, and also features a sidebar on key factors in quality nursing care.

The article focuses on the decision of one former agency nurse to go on staff at Methodist Hospital as a result of steps the hospital has taken to make the job more appealing, including making nurses part of the hospital "governance process," offering incentives for nurses to further their education, and creating a pool of staff nurses to reduce the need for overtime. The article includes some of the standard information about the nation's nursing shortage and hospital responses to it, but also describes recent studies showing that better nurse staffing ratios improve patient outcomes. It also has good quotes from Methodist's vice president of operations, who is evidently a nurse, on the importance of the image of nurses: "The image of nursing in general is still poor, reinforced by [television]...There's still an image that a nurse is a handmaiden to physicians. And the way nurses are treated by many doctors is, unfortunately, still an issue." Unfortunately, the lengthy article does not explain what nurses actually do that belies this poor media image, or why nursing plays such a key role in patient outcomes.

See "Getting nurses back on board".

The article is accompanied by a sidebar by Ms. Schnieder, "The clues to quality care" which suggests questions patients should ask about nursing in choosing a hospital. This underlines the importance of nursing in good care, though again without any examples of what nurses actually do that makes them so important. The nursing factors Ms. Schneider outlines, apparently based on a report by the Oregon Health and Sciences University for the Agency for Healthcare Research and Quality [summary; full-text], are: adequate staffing levels, experience, shift length, other workplace environmental factors, and the hospital's openness about providing this kind of information.

Ironically, despite this emphasis on nursing as a critical component in good care, it appears to play only a marginal role in US News' annual "best hospital" rankings, which dominate the issue, as they do every year.

To obtain its rankings, the magazine compares hospitals in many specific specialties. The initial analysis is based mainly on objective criteria, such as whether they are teaching hospitals, whether they have certain technology, whether they perform a minimum number of certain procedures, and whether they are affiliated with medical schools, and on one subjective criterion, whether they have been cited by physicians in survey responses. The relatively small number of hospitals that meet these criteria are then assigned a "US News Index," which is comprised of three elements of equal weight: reputation among physicians surveyed, mortality ratios, and "other factors." Assessments in ophthalmology, pediatrics, psychiatry, and rehabilitation appear to be based solely on reputation. The "other factors" seem to consist of 11 additional elements, including the full-time staff "RN's to beds" ratio, discharge figures, technology services offered, availability of hospice or palliative care, the extent to which discharge planning "services" are offered, and other specific measures that appear to apply only to the assessment of certain specialties. Thus, nursing care appears to factor in to only 3% of the analysis of the overall US News' ranking if we exclude the effect that nursing has on overall mortality.

See US News & World Report description of the methodology used to determine the the rankings. Also see the .pdf file describing the full details of the methodology from the National Organization for Research (NORC) at the University of Chicago. Also see the US News glossary of terms used in deciding best hospitals.

It is encouraging that RN-to-bed ratios are at least one of the many elements in the "other factors" category (even though it not indicative of real RN-to-patient ratios), which itself comprises only one third of the final index. However, the US News & World Report rankings do not appear to incorporate any direct measure of nurses' opinions, experience, education or specific skills--in stark contrast to the prominent role accorded to physicians, and despite the fact that nurses play central roles in the work of all of "America's best hospitals."

On July 31, the Center's executive director telephoned statisticians at the National Organization for Research (NORC) at the University of Chicago who create the methodology used to evaluate hospitals for these rankings. The lead researcher was very open to considering changes to the methodology that would include more nursing. Ideas discussed for incorporation into the methodology included: hospital magnet status, RN to patient ratios (as distinct from the current RN to bed ratio that the ratings currently reflect), nursing participation in hospital governance and use of mandatory overtime. We will be following up with NORC with a more specific list of ideas. If you have ideas about how US News & World Report can include nursing in its evaluation of hospitals and how NORC can collect this data, please send your ideas to the Center at