Grantee Profiles
Arylss Anderson Rothman
The nationwide nursing shortage, a deepening recession and other factors have left many hospital units with fewer registered nurses.
Experts worry that short-staffing can lead to complications or even medical errors. Research done so far adds to that concern: Studies from the Agency for Healthcare Research and Quality have found links between short-staffed hospital units and a greater risk of bad outcomes like pneumonia, gastrointestinal bleeding or longer hospital stays.
But do hospitals that have higher RN staffing levels (RN hours per patient day) find that quality measures go up? A research team led by Interdisciplinary Nursing Quality Research Initiative (INQRI) researcher Arlyss Anderson Rothman says the answer to that question is yes.
Dr. Anderson Rothman, an assistant professor of nursing at the University of California, San Francisco, and her team gathered information from a large survey of patients who had recently been discharged from the hospital. The Consumer Assessment of Health Care Providers and Systems Hospital Survey contains a series of questions that relate to quality of care and patient satisfaction. Patients complete the 27 question survey at home.
The survey asks patients to rate their experience in the hospital, and thus, is somewhat subjective. However, some of the questions directly relate to important quality markers. For example, one question asks whether patients got enough information about a new prescription to take a medication as directed. Other studies have indicated that patients who don't get such information, which is often provided by a nurse, can run into trouble when they leave the hospital.
The team then looked at a measure of nurse staffing, one collected by the California Nursing Outcomes Coalition, or CalNOC for short. This group collects information on the number of nurses and aids on a hospital floor as well as the number of patients who need direct nursing care. Anderson Rothman and her team got snapshots of both the number of registered nurses and less qualified nurses or aids on a given unit, like a surgical ward. They also factored in estimates of the amount of nursing care delivered to patients.
Data collected by CalNOC have been used by hospitals internally as a measure of performance but generally are not made public. The team got permission from 137 California hospitals to use the RN staffing level data and then paired that information with the survey results to do this study, which was funded by the Robert Wood Johnson Foundation INQRI program.
The preliminary findings suggest that patients report being happier with the care they receive when hospitals staff medical and surgical units with more registered nurses. The findings also indicate that hospitals that staffed medical units with more registered nurses seemed to deliver a higher caliber of care. For example, patients in these units were more likely to say that the staff told them about the danger signs of a possible complication on discharge. Other studies suggest that patients that don't get such information are more likely to miss the danger signs of a complication or an adverse event, and may need to be re-admitted.
In addition, data from the Joint Commission show that more registered nurses means that patients are more likely to receive necessary medications, such as beta blockers for patients who have had a heart attack, or to receive pneumonia vaccines to prevent complications.
Hospital units with higher levels of nursing staff can dedicate more time to educating patients about complications that often surface in the risky weeks after a hospital stay, Anderson Rothman adds. On a short-staffed unit, nurses might be too busy to sit down with patients for a pre-discharge chat that includes this safety information, she says.
The findings from medical and surgical units of the hospitals surveyed found similar results: units with more registered nurses were more likely to give patients crucial information about many aspects of their care that can have a direct effect on patient safety. In addition to the examples above, units with more registered nurses were more likely to give patients information about new medications, such as possible side effects and the purpose of the medication. Patients who don't understand the dosing or the purpose of a drug might skip a dose or make some other mistake that could lead to an adverse drug event—and another trip to the hospital.
The study also shows that patients are happier with the courtesy and respect they receive from nurses, their communication with nurses, and the help that was provided when they were in pain when there are more RNs available on the unit.
Such performance measures will increasingly become important in an era of health reform. Right now, policymakers are trying to craft reforms that would both reduce medical spending and at the same time boost quality of care.
What do patients know about quality? Plenty, says Anderson Rothman. And, in fact, patients may be the best source of information to understand what information was actually delivered to and understood by patients.
This study suggests that patients know the value of the extra attention they get when hospitals staff medical and surgical units with experienced nurses. The investment in nursing staff will likely pay off for hospitals in the form of better performance ratings—and consumers that are more likely to recommend the facility to a friend who needs hospital care.
That's a pay off that hospitals can't afford to ignore in the lean times ahead.