This article provides a comprehensive overview of nursing workforce studies, examines current efforts to investigate the relationship between hospital nurse staffing and patient outcomes that are sensitive to nursing, and discusses the implications for public and private policy making. Although the impact of hospital restructuring on nurses is generally well known, public policy making in this area has not resulted in significant changes. The lack of substantial policy is attributed to insufficient empirical evidence linking changes in hospital nurse staffing to adverse patient outcomes. Even though new studies are providing a rapidly expanding body of knowledge, readers are urged to use caution when using these findings to support mandated hospital nurse staffing levels. The level of sophistication that would allow precise estimates of minimal acceptable staffing levels and ratios will not be achieved. The authors suggest areas for future research that would further knowledge and policy development in this area.
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References
1.
Aiken, L. , & Fagin, C. (1997). Evaluating the consequences of hospital restructuring. Medical Care, 35(Suppl. 10), OS1-OS4.
2.
Aiken, L. , Smith, H., & Lake, E. (1994). Lower Medicare mortality among a set of hospitals known for good nursing care. Medical Care, 32(8), 771-787.
3.
Aiken, L. , Sochalski, J., & Anderson, G. (1996). Downsizing the hospital nursing workforce. Health Affairs, 4, 88-92.
4.
Al-Haider, A. , & Wan, T. (1991). Modeling organizational determinants of hospital mortality. Health Services Research, 26, 303.
5.
Allman, R. , Laprade, C., Noel, L., Walker, J., Moorer, C., Dear, M., & Mith, C. (1986). Pressure sores among hospitalized patients. Internal Medicine, 105(3), 337-342.
6.
American Nurses Association . (1996). Nursing quality indicators. Washington, DC: Author.
7.
Anderson, G. , & Kohn, L. (1996a). Employment trends in hospitals, 1981-1993. Inquiry, 33(1), 79-84.
8.
Anderson, G. , & Kohn, L. (1996b). Hospital employment trends in California, 1982-1994. Health Affairs, 15, 153-158.
9.
Appleby, J. (1999, November 19). Cost cutting changes how nurses operate. As workloads increase and staff levels fall, many worry that patients could suffer. USA Today, pp. 1B-2B.
10.
Bates, D. W. , Spell, N., Cullen, D. J., Burdick, E., Laird, N., Petersen, L. A., Small, S. D., Sweitzer, B. J., & Leape, L. L. (1997). The costs of adverse drug events in hospitalized patients. Journal of the American Medical Association, 227, 307-311.
11.
Bates, D. W. , Spell, N., Laird, N., Cullen, D. J., Petersen, L. A., Small, S. D., Servi, D., Laffel, G., Sweitzer, B. J., Shea, B. F., Hallisey, R., Vliet, M. V., Nemeskal, R., & Leape, L. L. (1995). Incidence of adverse drug events and potential adverse drug events. Journal of the American Medical Association, 274, 29-34.
12.
Blegen, M. , Good, C., & Reed, L. (1998). Nurse staffing and patient outcomes. Nursing Research, 47(1), 43-49.
13.
Blegen, M. , & Vaughn, T. (1998). A multisite study of nurse staffing and patient outcomes. Nursing Economic$, 16(4), 196-203.
14.
Brennan, T. A. , Leape, L. L., Laird, N., Hebert, L., Localio, A. R., Lawthers, A. G., Newhouse, J. P., Weiler, P. C., & Hiatt, H. H. (1991). Incidence of adverse events and negligence in hospitalized patients. New England Journal of Medicine, 324, 370-376.
15.
Brider, P. (1996a). Enrollment boom ends as job hunt lengthens. American Journal of Nursing, 96(2), 61, 65.
16.
Brider, P. (1996b). Morale skidding with restructuring. American Journal of Nursing, 96(2), 62-64.
17.
Brown, G. (1979). Medication errors: A case study. Hospitals, 53, 61-62, 65.
18.
Bryan, Y. , Hitchings, K., Fuss, M., Fox, M., Kinneman, M., & Young, M. (1998a). Measuring and evaluating hospital restructuring efforts: 18-month follow-up and extension to critical care, part 1. Journal of Nursing Administration, 28(9), 21-27.
19.
Bryan, Y. , Hitchings, K., Fuss, M., Fox, M., Kinneman, M., & Young, M. (1998b). Measuring and evaluating hospital restructuring efforts: 18-month follow-up and extension to critical care, part 2. Journal of Nursing Administration, 28(10), 13-19.
20.
Buerhaus, P. (1999). Lucian Leape on the causes and prevention of errors and adverse events in health care. IMAGE: Journal of Nursing Scholarship, 31(3), 281-286.
21.
Buerhaus, P. , & Staiger, D. (1996). Managed care and the nurse labor market. Journal of the American Medical Association, 276(18), 1487-1493.
22.
Buerhaus, P. , & Staiger, D. (1999). Trouble in the nurse labor market? Recent trends and future outlook. Health Affairs, 18(1), 214-222.
23.
Buerhaus, P. , Staiger, D., & Auerbach, D. (1999). Employment and earnings trends, 1998. Unpublished manuscript, Harvard University.
24.
Buerhaus, P. , Staiger, D., & Auerbach, D. (2000). Implications of a rapidly aging registered nurse workforce. Unpublished manuscript.
25.
Cheng, Y. , Buerhaus, P., Colditz, G., & Kawachi, I. (1999). Nurses’ job insecurity and diminished health functioning. Manuscript submitted for publication.
26.
Classen, D. , Pestotonik, N., Evans, R., & Burke, J. (1991). Computerized surveillance of adverse drug events in hospital patients. Journal of the American Medical Association, 266, 847-851.
27.
Flood, S. , & Diers, D. (1998). Nurse staffing, patient outcome and cost. Nursing Management, 19(5), 34-43.
28.
Gaebler, S. (1993). Predicting which patient will fall again... and again. Journal of Advanced Nursing, 18(12), 1895-1902.
Ginsburg, P. (1999, November). Tracking health care costs: Long-predicted upturn appears (Issue Brief, Number 23). Washington, DC: Center for Studying Health System Change.
31.
Greiner, A. (1995). Cost and quality matters: Workplace innovations in the health care industry. Washington, DC: Economic Policy Institute.
32.
Hartz, A. J. , Krakauer, H., Kuhn, E. M., Young, M., Jacobsen, S. J., Gay, G., Muenz, L., Katzoff, M., Bailey, R., & Rimm, A. (1989). Hospital characteristics and mortality rates. New England Journal of Medicine, 321(25), 1720-1725.
33.
Iezzoni, L. , Daley, J., Heeren, T., Foley, S., Hughes, J., Fisher, E., Duncan, C., & Coffman, G. (1994). Using administrative data to screen hospitals for high complication rates. Inquiry, 31, 40.
34.
Kaiser Family Foundation and Harvard School of Public Health . (1999). 1999 survey of physicians and nurses. Retrieved July 28, 1999, from the World Wide Web: www.kff.org
35.
Knaus, W. , Draper, E., Wagner, D., & Zimmerman, J. (1986). An evaluation of outcomes from intensive care in major medical centers. Annals of Internal Medicine, 104, 410.
36.
Kohn, L. , Corrigan, J., & Donaldson, M. (1999). To err is human. Building a safer health system. Washington, DC: National Academy Press, Committee on Quality of Health Care in America, Institute of Medicine.
37.
Kovner, C. , & Gergen, P. (1998). The relationship between nurse staffing level and adverse events following surgery in acute care hospitals. IMAGE: The Journal of Nursing Scholarship, 30(4), 315-321.
38.
Krakauer, J. , Bailey, R., Skellan, K., Stewart, J., Hartz, A., Kuhn, E., & Rimm, A. (1992). Evaluation of the HCFA model for the analysis of mortality following hospitalization. Health Services Research, 27(3), 317-335.
39.
Kuhn, B. , & Coulter, S. (1992). Balancing the pressure ulcer cost and quality equation. Nursing Economic$, 10(5), 352-359.
40.
Lazarou, J. , Pomeranz, B., & Corey, P. (1998). Incidence of adverse drug reactions in hospitalized patients. Journal of the American Medical Association, 279, 1200-1205.
41.
Leape, L. (1994). Error in medicine. Journal of the American Medical Association, 272, 1851-1857.
42.
Leape, L. , Lawthers, A., Brennan, T., & Johson, W. (1993). Preventing medical injury. Quality Review Bulletin, 19, 144-149.
43.
Leape, L. L. , Bates, D. W., Cullen, D. J., Cooper, J., Demonaco, H. J., Gallivan, T., Hallisey, R., Ives, J., Laird, N., Laffel, G., Nemeskal, R., Petersen, L. A., Porter, K., Servi, D., Shea, B. F., Small, S. D., Sweitzer, B. J., Thompson, T., & Vliet, M. V. (1995). Systems analysis of adverse drug events. Journal of the American Medical Association, 274, 35-43.
44.
Leape, L. L. , Brennan, T. A., Laird, N. M., Lawthers, A. G., Localio, A. R., Barnes, B. A., Hebert, L., Newhouse, J. P., Weiler, P. C., & Hiatt, H. H. (1991). The nature of adverse events in hospitalized patients. New England Journal of Medicine, 324, 377-384.
45.
Lewellyn, J. , Martin, B., & Shekleton, M. (1998). Analysis of falls in the acute surgical and cardiovascular surgical patient. Applied Nursing Research, 1(3), 116-121.
46.
Lichtig, L. , Knauf, R., & Milholland, K. (1999). Some impacts of nursing on acute care hospital outcomes. Journal of Nursing Administration, 29(2), 25-33.
47.
Maas, M. , Johnson, M., & Moorhead, S. (1996). Classifying nursing-sensitive patient outcomes. IMAGE: Journal of Nursing Scholarship, 28(4), 295-301.
48.
Manheim, L. , Feinglass, J., Shortell, S., & Hughes, E. (1992). Regional variation in Medicare hospital mortality. Inquiry, 29, 55-66.
Mitchell, P. , Armstrong, S., Simpson, T., & Leutz, M. (1989). AACN demonstration project: Profile of excellence in critical care nursing. Heart and Lung, 18(3), 219-236.
51.
Mitchell, P. , & Shortell, S. (1997). Adverse outcomes and variations in organization of care delivery. Medical Care, 35(Suppl. 11), NS19-NS32.
52.
Moore, S. , & Wise, L. (1997). Reducing nosocomial pressure ulcers. Journal of Nursing Administration, 27(10), 28-34.
53.
Morgan, V. , Mathison, J., & Rice, J. (1985). Hospital falls: A persistent problem. American Journal of Public Health, 75(7), 775-777.
54.
Neidlinger, S. , Bostrum, J., Stricker, A., Hild, J., & Zhang, J. (1993). Incorporating nursing assistive personnel into a nursing professional practice model. Journal of Nursing Administration, 23(3), 29-37.
55.
Pang, S. , & Wong, T. (1998). Predicting pressure sore risk with the Norton, Braden, and Waterlow Scales in a Hong Kong rehabilitation hospital. Nursing Research, 47(3), 147-153.
56.
Peter D. Hart Research Associates, Inc. (1998, January 17). Health profession’s view of quality: A national survey presented to the President’s Advisory Commission on Consumer Protection and Quality. Washington, DC: Author.
57.
Rawsky, E. (1998). Review of the literature on falls among the elderly. IMAGE: Journal of Nursing Scholarship, 30(1), 47-52.
58.
Reed, L. , Blegen, M., & Goode, C. (1998). Adverse patient occurrences as a measure of nursing care quality. Journal of Nursing Administration, 28(5), 62-69.
59.
Scott, W. , Forrest, W., & Brown, B. (1976). Hospital structure and postoperative mortality and morbidity. In S. M. Shortell & M. Brown (Eds.), Organizational research in hospitals (pp. 72-89). Chicago: Blue Cross Association.
60.
Shaprio, S. , Slone, D., Lewis, G. P., & Herhsel, J. (1971). Fatal drug reactions among medical inpatients. Journal of the American Medical Association, 216, 467-472.
61.
Shortell, S. , & Hughes, E. (1988). The effects of regulation, competition, and ownership on mortality rates among hospital inpatients. New England Journal of Medicine, 318(17), 1100-1107.
62.
Shortell, S. , Zimmerman, M., Rousseau, D., Gillies, R., Wagner, D., Draper, E., Knaus, W., & Duffy, J. (1994). The performance of intensive care units: Does good management make a difference?Medical Care, 32(5), 508-525.
63.
Silber, J. , Rosenbaum, P., Schwartz, J., Ross, R., & Williams, S. (1995). Evaluation of the complication rate as a measure of quality of care in coronary artery bypass graft surgery. Journal of the American Medical Association, 274, 317.
64.
Silber, J. , Williams, S., Krakauer, H., & Schwartz, J. (1992). Hospital and patient characteristics associated with death after surgery: A study of adverse occurrence and failure to rescue. Medical Care, 30(7), 615-627.
65.
Spetz, J. (1998). Hospital employment of nursing personnel. Journal of Nursing Administration, 28(3), 20-27.
66.
Synderman, N. (Producer). (1999, November 26). Disappearing nurses (20/20). New York: ABC.
67.
Wan, T. , & Shukla, R. (1987). Contextual and organizational correlates of the quality of hospital nursing care. Quality Review Bulletin, 13, 61.
68.
Wunderlich, G. , Sloan, F., & Davis, C. (Eds.). (1996). Nursing staff in hospitals and nursing homes. Is it adequate?Washington, DC: National Academy Press, Committee on the Adequacy of Nurse Staffing in Hospitals and Nursing Homes, Institute of Medicine.
69.
Young, S. , & Brown, H. (1994). Effects of hospital downsizing on surviving staff. Nursing Economics$, 16(5), 258-262.
