October 2, 2007 Celeste Monforton, DrPH, MPH 7Comment

By Liz Borkowski

Hundreds of nurses are on strike in Kentucky and West Virginia after contract negotiations with Appalachian Regional Healthcare failed. The nurses refused to accept a package that reduced their holiday pay and increased their insurance premiums (canceling out the proposed wage increase) and that failed to add staffing that would offset mandatory overtime. (AP) Anyone who might one day be a patient in a U.S. hospital should pay particular attention to that last item, because nurse staffing affects patient care.

Here’s the Lexington Herald-Leader on the nurses’ position:

Anita Jones, a 31-year veteran at the Hazard hospital, said most nurses work 16-hour days and mandatory overtime because of understaffing.

“You work when they want you to work,” said Pat Tanner, a negotiator with the West Virginia and Kentucky nurses associations.

In Hazard, about two dozen nurses stood along the street outside the ARH hospital holding signs that read, “Every patient deserves a nurse!” and “We demand safe staffing.”

A 2006 report on nursing staffing from the Institute for Women’s Policy Research explains the consequences of relying on long days and mandatory overtime (footnotes omitted):

Extended shifts and mandatory overtime can harm quality of patient care. The Institute of Medicine found, for instance, that longer work hours and fatigue reduce nurses’ job functioning. The likelihood of error increases with longer work hours and with any performance of overtime, regardless of the length of the original shift. Error likelihood is three times greater when shifts exceed 12.5 hours. These results are particularly salient given that full-time hospital staff registered nurses work an average of 55 minutes longer than scheduled each day, and 40 percent of registered nursing shifts worked in hospitals exceed 12 hours.

The report notes that staffing issues are cited as the cause of 24% of unexpected negative patient outcomes (up from 16% in 1998), and that more nursing care per patients shortens hospital stays, reduces rates of urinary tract infections and gastrointestinal bleeding in medical patients, and lowers rates of death and occurrence of pneumonia in surgical patients. Of course, the links between nursing staffing levels and quality of care have financial implications:

The costs to hospitals of adding nurses may be at least partially balanced by savings from fewer adverse patient outcomes such as nosocomial pneumonia or other hospital-acquired infections. For instance, pneumonia is associated with more than five additional days spent in the hospital, an increase in the chance of death of approximately 5 percent, and around $25,000 in additional costs; higher nurse staffing levels are associated with lower rates of postsurgical pneumonia.

Because patients receive more care when nurse staffing levels are higher, patient outcomes are better. Kovner and Gergen note that this effect “is good for patients, good for a hospital’s reputation, and—depending on the cost-effectiveness—may be fiscally good for hospitals as well.” Thus, while hospitals’ operating costs increase when the nurse workforce expands, some research suggests that hiring more nurses may not affect hospitals’ profitability.

The financial case for higher nursing staffing levels is even stronger now that Medicare is planning to deny hospitals reimbursement for treatment of conditions the hospital could have prevented.

The question here, and across the country, is whether hospitals will spend the money to improve patient health, and potentially their own overall profitability, or whether their fixation on a single expense line will perpetuate an unhealthy cycle.

Liz Borkowski works for the Project on Scientific Knowledge and Public Policy (SKAPP) at George Washington University’s School of Public Health and Health Services.

7 thoughts on “Nurses Demand Safe Staffing

  1. I hope that some of our public health colleagues, who conduct research on “work organization” issues among nurses, while chime into with comments about the nurses’ strike.

  2. Nurses must evolve different professional practice models whereby the employers no longer dictate the terms and practice of registered nurses.

    A professional practice group model using a self governance structure is one way in which nurses take back ownership and full accountability and responsibility for their professional practice and patient care and outcomes.

    The blog, Universal Health, details the model and processes which would lead to independent and fully professional nursing practice.

  3. I think it was very smart of the nurses to pose the arguments in terms of how staffing levels affect patients and hospitals. That’s a great way to get people to listen to your arguments.

    In terms of how staffing levels affect nurses: Two of the biggest issues in occupational safety and health in the healthcare industry are violence in the workplace and safe patient handling (i.e. musculoskeletal disorders, or MSDs). Nurses are one of the occupational groups that have the most workplace injuries.

    Low staffing levels – among other things – have been linked to higher rates of violence against healthcare staff, usually by a patient.

    Some states have put together laws mandating safe patient lifting, either through mechanical equipment or lifting teams. Without adequate staffing levels, a nurse may be left to do the heavy lifting themselves, making them susceptible to serious injury.

    I’ve written a couple of reports that discuss these factors in the disabling worker’s compensation claims in Oregon:

    Accepted disabling claims in healthcare:

    Violence in the workplace:

  4. Thanks for the links, Tasha. In compiling the weekly occupational health news roundups, I come across a fair number of stories about lifting-related injuries and lifting programs in healthcare settings. The violence angle seems to get less coverage, though.

    This item from your report on violence in the workplace in Oregon is particularly scary:

    “Nursing aides was the occupation with the highest percentage of assault claims (17 percent), followed by police officers (12 percent), guards (6 percent), and teachers (6 percent).”

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