Wide variation across hospitals in nurse staffing is threat to public's health

According to a new study published today in BMJ Quality & Safety, many hospitals in New York and Illinois were understaffed right before the first surge of critically ill COVID-19 patients. The study, "Chronic Hospital Nurse Understaffing Meets COVID-19," documented staffing ratios that varied from 3 to 10 patients for each nurse on general adult medical and surgical units. ICU nurse staffing was better but also varied significantly across hospitals.

New York City, an international gateway to the US with three major international airports and the early epicenter of the COVID-19 surge in the US, had the poorest average hospital nurse staffing on the eve of the COVID-19 medical emergency.

Researchers at the University of Pennsylvania found that the workload had adverse consequences on nurses and on patient care. One third of patients in New York state and Illinois hospitals did not give their hospitals excellent ratings and would not definitely recommend their hospital to family and friends needing care.

"Half of nurses right before the COVID-19 emergency scored in the high burnout range due to high workloads, and one in five nurses said they planned to leave their jobs within a year," said lead author Karen Lasater, Ph.D., RN, an assistant professor and researcher at the Center for Health Outcomes and Policy Research (CHOPR) at the University of Pennsylvania School of Nursing (Penn Nursing). "It is an immense credit to nurses that in such an exhausted and depleted state before the pandemic they were able to reach deep within themselves to stay at the hospital bedside very long hours and save lives during the emergency," continued Lasater.

"It is very important for the public to take note that in this large study of nurses practicing in New York and Illinois hospitals, half of nurses gave their hospitals unfavorable grades on patient safety and two-thirds would not definitely recommend their hospital to family and friends," said CHOPR Director Linda Aiken, Ph.D., RN, a senior researcher and professor at the University of Pennsylvania. She noted that nurses have been rated in the Gallup poll as the profession most trusted by the American public for past 18 consecutive years.

The researchers surveyed all registered nurses (RNs) holding active licenses to practice in New York state and Illinois during the period December 16, 2019 to February 24, 2020, immediately prior to the COVID-19 medical emergency. Hospital nurses reported on the number of patients assigned to them to care for at one time. These nurse reports were linked to Medicare patient-reported outcomes for the same hospitals. They studied 254 hospitals throughout New York state and Illinois, including 47 hospitals in the metropolitan New York area (the five NYC boroughs plus Nassau and Westchester counties).

Policy debate on safe nurse staffing standards

Both New York state and Illinois have pending legislation requiring hospitals to meet minimum safe nurse staffing standards—no more than four patients per nurse on adult general medical and surgical units. The study found that most hospitals in both states currently do not meet these proposed standards, nor do they even meet the safe nurse staffing standard of five patients per nurse set by legislation in California 20 years ago.

"This study provides an important public service by documenting in real time and in states debating current nurse staffing legislation actual hospital nurse staffing levels—information not now easily accessible to the public—and the adverse consequences of such great variation in an essential component of hospital care—nursing," said Maryann Alexander, Ph.D., RN, coauthor and Chief Officer, Nursing Regulation at the National Council of State Boards of Nursing.

The study's authors conclude:

• there is no standardization in nurse staffing in NY and IL hospitals;
• the majority of hospital nurses in these states were burned out and working in understaffed conditions immediately prior to the surge in critically ill COVID-19 patients;
• understaffed hospitals pose a public health risk;
• pending legislation in NY and IL may result in hospital staffing more aligned with the public's interest;
• the Nurse Licensure Compact also offers a solution and may ease the strain on hospitals.

More study findings...

• Mean staffing in adult medical and surgical units in NY and IL hospitals varied from 3.36 patients-per-nurse to 9.7 patients per nurse and in ICUs from 1.5 to 4 patients per nurse.
• Each additional patient per nurse significantly increased the proportion of both patients and nurses giving unfavorable hospital quality and safety ratings, after differences in hospital characteristics such as teaching status, size, and technology availability were taken into account.
• Half of nurses were burned out, 31 percent were dissatisfied with their jobs, and 22 percent intended to leave their jobs within a year.
• Half of nurses gave their hospitals an unfavorable grade on patient safety, a third gave unfavorable ratings on prevention of infections, and 70 percent would not definitely recommend the hospital where they worked to a family member or friend.
• 65 percent of nurses reported delays in care were common because of insufficient staff and 40 percent reported frequent delays in care due to missing supplies including medications and missing or broken equipment.

The study was carried out by the Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing in partnership with the National Council of State Boards of Nursing. Funding for the study was from the National Council of State Boards of Nursing, the National Institute of Nursing Research/NIH, and the Leonard Davis Institute of Health Economics at the University of Pennsylvania.