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Nursing Shortage Can Have Deadly Consequences

High patient-to-nurse ratio linked to more deaths after surgery

TUESDAY, Oct. 22, 2002 (HealthDayNews) -- Surgery patients whose nurses are overworked are more likely to die of post-operative complications, a new study has found.

The study, published in tomorrow's Journal of the American Medical Association, shows the risk of dying after surgery jumps 14 percent when a patient's nurse has six beds to cover instead of four. It soars by more than 30 percent if the nurse is responsible for eight beds.

If all hospitals had six patients per nurse instead of four, the researchers say, they would expect 2.3 additional deaths per 1,000 patients, and nearly 9 additional complications per 1,000. With a ratio of eight-to-one, there would be 2.6 more deaths and almost 10 more complications for every 1,000 patients, they say.

"You have to have enough nurses around in the hospital to spot complications early and to get appropriate treatment, and those things are put on the line when you don't have enough," says study co-author Sean Clarke, associate director of the center for health outcomes and policy research at the University of Pennsylvania School of Nursing.

U.S. hospital officials estimate that more than 94,000 nursing positions were vacant in 2001.

Compounding the problem, nurses' job satisfaction is far lower than that of workers in other fields, prompting them to flock from hospitals to other industries, such as drug companies. If current nursing school enrollment trends and workplace attrition patterns don't improve, the shortfall is projected to hit 400,000 by 2020 -- or about 20 percent of the nation's total nursing force.

The new study looked at mortality after surgery in 232,342 patients at 168 Pennsylvania hospitals. Of those patients, 53,813, or about one-quarter, had a major complication such as a blood clot or heart attack after surgery. Roughly 4,500, or 2 percent, died within a month of being hospitalized for surgery, but the death rate for patients with complications was four times higher.

After accounting for factors that might increase the risk of complications, including a patient's condition and the size and sophistication of the hospital, nursing staff had a significant impact on the chances of a deadly post-surgery problem, the study found.

For every additional bed a nurse had to tend, a patient's risk of death within 30 days of admission for surgery rose 7 percent. So did patients' odds of not being saved from a complication, a measure called "failure to rescue."

"It was the same relationship if we looked just at the patients who ran into serious problems," Clarke says.

Nurses who worked at hospitals with the largest ratio of patients to nurses reported twice the rate of burnout and low morale as those in hospitals with the smallest ratio, the study also found.

Clarke's group didn't specifically address whether the level of physician staffing was also linked to patient deaths from surgery complications. However, the study did find the effect of high patient-to-nurse ratios held true for all kinds of hospitals, including teaching facilities that tend to have more doctors on duty.

California has mandated that hospitals in the state have at least one licensed nurse for every six medical or surgical patients by July 2003, and one to five in 2004. Current staffing recommendations vary from three to 10 nurses per patient.

"There's no magic ratio," Clarke says. "In some instances, five is a great ratio. In some instances five is too generous, it's not enough work. But we are trying to be a little less coy about what the effect on patients might look like" when staffing levels are too low.

In addition to buttressing staff, Clarke says hospitals could shift some time-consuming duties from nurses to untrained personnel, things like answering telephones and busing meal trays.

Janice Weber, a public policy specialist for the American Association of Critical Care Nurses, calls the new research "great" and says it's "another piece of evidence" tying low staffing to poor patient outcomes.

However, she says correcting patient ratios was only one of several steps necessary to reform America's nursing problem, and it won't solve the issues of attrition and poor morale.

Nurses also want a larger role in setting their schedules and in shaping hospital policy, Weber says, and they want more opportunity for professional advancement.

What To Do

For more on the nursing shortage, try the American Association of Colleges of Nursing or the American Nurses Association.

SOURCES: Sean Clarke, Ph.D., R.N., associate director, center for health outcomes and policy research, University of Pennsylvania School of Nursing, Philadelphia; Janice Weber, R.N., public policy specialist, American Association of Critical Care Nurses, Aliso Viejo, Calif.; Oct. 23/30, 2002, Journal of the American Medical Association
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