Evidence mounts for safe staffing

Members and supporters at Montefiore New Rochelle Hospital.

For several decades, one nurse has distinguished herself in the discipline of safe staffing for hospital nurses. Since the 1990s, Linda Aiken, PhD, RN, and colleagues have produced numerous studies on RN staffing. These studies are considered the gold standard for the nursing profession.

Aiken is the founding director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing. The Center has received the top research awards from the National Academy of Medicine and the Joint Commission that accredits hospitals, among others.

Since the early 1990s, RNs reported that there were not enough nurses in hospitals to provide high-quality, safe care to patients. These studies, discussed below, validate the hospital RN experience, including Aikens’ most recent findings in New York.

This past year Linda Aiken and her team released two “peer reviewed” studies. Both drew upon survey data. The first surveyed nurses and patients in New York and Illinois from December 2019 to February 2020 and was published in Open Access under the title, “Chronic hospital nurse understaffing: an observational study” (August 8, 2020). The second survey results ran in the American Journal of Infection Control, titled “Evaluation of hospital nurse-to-patient staffing ratios and sepsis bundles on patient outcomes.” (December 9, 2020) The latter contained this result: “Each additional patient per nurse is associated with 12% higher odds of in-hospital mortality, 7% higher odds of 60-day mortality [and] 7% higher odds of 60-day readmission….” (p.1)

NYSNA, like other unions, associations and organizations whose members’ work is in a scientific field, often refers to “peer-reviewed” studies in the process of upholding the legitimacy and accuracy of data and conclusions in a study. Peer reviewed has the force of law and may be introduced in a court as irrefutable evidence.

Before New York: Aiken’s peer reviewed studies

Previous Aiken research demonstrated the validity of nurse reports, including hospital mortality outcomes. In California in 2010, looking back at nurse-to-patient ratios six years after the implementation of its ratio law, the conclusion was that hospital nurse staffing ratios led to lower patient mortality and better nurse retention.

Reflecting on the California law, Aiken said, “One of the best natural experiments occurred when California enacted mandated nurse-to-patient ratios. When implemented on January 1, 2004, the hospitals that were not in compliance with the staffing ratios had to change on that day and they did it. Our research has shown that staffing did change — even in safety net hospitals, which have been very difficult to get to change on hospital nurse staffing…. Almost 15 years later, California still has the best nursing-staffed hospitals in the country. The state has seen steeper declines in mortality and improvements in other indicators than other states.” (National Nurses United, “Learning from the California Experience,” 2018)

Aiken’s study of California RN ratios found that when the ratios were applied to other states results were dramatic. New Jersey hospitals, for example, would have 14% fewer deaths and Pennsylvania 11% fewer if they matched California 1:5 ratios in surgical units. This lead to some revisions in New Jersey’s staffing laws.

In August 2020, a paper co-authored by Aiken was the basis of a report in the American Journal of Infection Control. It looked at staffing ratios and incidence of sepsis between December 2019 and February 2020 in 116 hospitals (including in New York). The data show an average MedSurg patient-to-nurse ratio to be 6.3:1. The study found: “[T]he average hospital provides appropriate sepsis care only to a little more than half of patients. … In this study, we find that every additional patient in a nurses’ workload is associated with higher odds of death, as well as higher odds of readmission and longer lengths of stay….” (AJIC, August 2020, p. 5)

Staffing in the time of COVID

At the onset of the pandemic, Aiken and her colleagues proved prescient about hospital conditions in Illinois and New York. They began gathering data on staffing in January and February 2020, surveying all registered nurses licensed in the two states. In New York, the result was an aggregation of average staffing in 116 hospitals across the state, where Aiken linked nurse reports to outcome records of 418,000 Medicare patients treated in these same hospitals.

The conclusions appeared in a published paper, “Chronic hospital nurse understaffing meets COVID-19: an observational study.” (August, 2020) The main purpose of the study, the authors state, was “to provide relevant evidence to inform hospital nurse staffing legislation… in the two states.” (Open Access, p. 1; also reported in LDI Research, August, 2020)

The paper’s discussion of New York conforms to experiences NYSNA nurses have had and shared at meetings. “In the weeks before the surge, … hospital nurses in NY and IL were already struggling with high patient workloads and frequent operational failures including missing supplies and missing or broken equipment,” the study found. “Patient-to-nurse ratios ranged considerably across hospitals in both states from means of 3.3 to 9.7 in adult medical-surgical units. Half of nurses were experiencing high burnout, and one in four planned to leave their job within a year.” (Open Access, p. 5)

Aiken and her co-authors concluded: “Hospital nurses were burned out and working in understaffed conditions in the weeks prior to the first wave of COVID-19, posing risks to the public’s health.” They added, “[C]hronic nurse understaffing has persisted in a significant share of US hospitals for decades, and poses significant risk to patients even without the presence of a pandemic.” (Open Access, pp. 1, 7)

The New York Study

In her most recent publication, Aiken looks squarely at New York and nursing practices in the state. The article in the journal, Medical Care, is entitled, “Is Hospital Nurse Staffing Legislation in the Public’s Interest?” and was released in February, 2021. In it, Aiken utilizes hospital Medicare data gathered from the years 2017-2018.

The article lays out a history of New York’s Safe Staffing for Quality Care Act and explains the sources of her data, from a total of 417,861 MedSurg patient claims from all parts of the state submitted to Medicare. (“It is likely,” she notes, “that the staffing data collected in 2019-2020 closely resembles staffing in 2017-2018.”)

Aiken’s testimony at the New York Joint Legislative Budget Hearing on February 25 included these remarks: “We found that each patient reduction in nurses’ workloads was associated with a 13% decrease in patient deaths for elderly patients hospitalized with common surgical and medi-cal conditions.” (p. 2, emphasis in original)

Aiken findings showed that, on average, hospital nurse staffing ratios in hospitals across NY state were 6.3:1 patients per nurse. In NYC, that average was 6.9:1 patients per nurse. These ratios were brought out in previous studies in other states where poor patient care and high mortality were observed.

Saving lives and costs

Among the most significant conclusion in Aikens’ recent paper is this startling fact: If NY hospitals had staffed medical-surgical nurses at the 1:4 ratio as proposed in the current legislation, “We project there would have been 4,370 fewer in-hospital deaths in the 2-year period among Medicare patients,” writes Aiken. With regard to costs, Aiken provides, “With roughly 388,160 fewer hospital days annually, we project $658 million in cost savings to hospitals annually from shortened lengths of stay.” She concludes: “These estimates are produced by only about 25% of the Medicare hospitalizations in NY, so the actual savings when applied to all inpatients — both Medicare and non-Medicare — would likely be many-fold higher.” (p. 5)

Safe Staffing Saves Lives!

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