Not enough nurses in hospitals means more patients die

Intuitively, we all know that an overworked nurse can’t give each patient the care he or she needs; if you stretch nursing staffing too thin, bad things will happen. But do we have any idea what the appropriate staffing level is? There’s a fascinating recent study in the New England Journal of Medicine that tries to get at the answer to this key question. The investigators studied adult patients, deliberately excluding children from their analysis, but I see no reason why the results would be different for children.

The first thing to note about the study is that it took place in a hospital that already had an outstanding safety record, with far less deaths than would have been predicted. Yet even in this outstanding institution, patients who were cared for during shifts when the nurses were overworked and short-staffed had a higher risk of death. The risk was also cumulative: the more such high-risk nursing shifts a patient was exposed to, the higher the risk of death.

Besides looking at simple short-staffed shifts, those for which there were just plain not enough nurses working, the study looked at another variable — patient turnover. This is significant because admitting new patients, dismissing patients from the hospital, and transferring them to another part of the hospital generates an enormous amount of administrative work for the nurses, time that otherwise could go to bedside care.

I find this to be a compelling study. All of us who do hospital medicine know that some shifts are busier than others, and that during such busy shifts the nurses have less time for each patient. This can be irritating to patients and their families. But now we know it can actually be dangerous. I also think the study emphasizes the fact that the administrative burden on the nurse of getting patients into, out of, and around the hospital is huge. I’ve long felt that much of busywork of that process is unnecessary; now we know that it, too, can be dangerous. As the authors point out:

Our finding that below-target nurse staffing and high patient turnover are independently associated with the risk of death among patients suggests that hospitals, payers, and those concerned with the quality of care should pay increased attention to assessing the frequency with which actual staffing matches patients’ needs for nursing care.