Better staffing saves lives

Improvements in nurse staffing will save both lives and money, says one of Australia’s leading nursing researchers and administrators.

Professor Di Twigg, head of the School of Nursing and Midwifery at Edith Cowan University, Perth, says there is mounting evidence that governments will improve patient outcomes and reduce health care costs by increasing nurse hours of care and using more skilled nurses.

However, policy makers are ignoring evidence by seeking to maximise the use of less skilled nurses, she told the NSWNMA annual conference in August.

Prof. Twigg is a former President of the Royal College of Nursing Australia and was Executive Director of Nursing Services of Sir Charles Gairdner Hospital for 13 years – the first hospital in Western Australia to be recognised as a centre for nursing excellence under the American Nurses Credentialing Center’s prestigious, Magnet program.

“Improvements in nurse staffing are cost effective and policy needs to start reflecting the evidence,” Prof. Twigg said. “The evidence in regard to nurse staffing is greater than for many health care practices and certainly more than any other health care workforce group.

“Yet it is a constant battle to secure adequate resources so nurses can practice professionally to deliver high quality care.

“The policy response has been woefully inadequate and we really do need to influence it now.

“Nurses, in partnership with consumers, must unite to lead the required changes.”

She said international evidence showed that higher registered nurse staffing levels led to fewer deaths in hospital, fewer incidents of failure to rescue (deaths due to treatable complications) and reduced length of stay.

She said nurses in Victoria and WA took industrial action that resulted in improved staffing formulas from 2000 onward. A subsequent study at three WA teaching hospitals revealed a 25 % decrease in the overall mortality rate due to the improved staffing method and skill mix.

Among surgical patients there was a 54% decrease in the rate of central nervous system complications, a 17% decrease in the pneumonia rate and a 37% decrease in the ulcer/ gastritis/UGI bleed rate.

The improved staffing levels at the three hospitals prevented 155 “failure to rescue” events.

This yielded a gain of 1240 life years and a cost per life year of $8907 – a “highly cost effective” result.

Prof. Twigg said a 2005 study in the United States found that increasing the proportion of hours worked by RNs, without changing the total hours of nursing care, would result in significant cost savings.

“The US studies also found that increasing the nurse-to-patient ratio from 1-to-8 to 1-to-4 would save additional lives at a cost of US$136,000 per life saved.

“This constituted a considerable saving compared to the cost of thrombolytic therapy in acute myocardial infarction at US$182,000 per life saved, or routine cervical cancer screening at a cost of US$432,000 per life saved.”

Prof. Twigg said hours of care and skill mix were important determinants of patient safety, along with nurses’ educational preparation and the practice environment.

She said further research was needed on workforce requirements for particular patient groups.

“Nursing is a scarce resource – we cannot staff every ward as 1-to-3 or 1-to-4 just because we’d like to. We do need to get the evidence that these particular patient groups need this workforce model to give the best patient outcomes in the most efficient way for the community.

“We need to develop an understanding of when it is appropriate and safe to use less skilled workers. They should not be seen as substitutes for RNs.”

Focus on keeping nurses at work

Prof. Twigg said Australia’s nurse shortage was projected to increase to 110,000 in 2025, or 130,000 nurses if governments relied less on migration.

Governments were responding to the shortage by calling for “greater workforce flexibility” and substitution of more highly skilled workers with assistant-type roles.

She said training more nurses was only part of the answer; policy makers should focus on keeping nurses in the workforce by improving the practice environment.

“In 2009 the exit rate of Australians leaving nursing was 2%. Five years before it was 5% – the change is primarily attributable to economic factors associated with the global financial crisis.

“If we can keep the exit rate at 2% that 130,000 gap falls to 25,000 which is far more manageable.”

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Lives at risk when nurses overworked

Each additional patient added to a nurse’s workload results in a 7% increase in the risk of patients dying within 30 days of admission. This was one of the findings of pioneering research in the USA a decade ago.

Professor Linda Aiken, an authority on the impact of nursing on patient outcomes, also found a 10% increase in the number of degree educated nurses was associated with a 5% decrease in the chance of patients dying within 30 days of admission.

Later research in Canada and the UK found:

•Hospitals with a higher proportion of registered nurses, compared to non-registered nurses, were associated with lower rates of 30-day mortality.

•Hospitals that had the highest nurse-to-patient ratios had consistently better outcomes than those with less favourable staffing.

•The patients in favourably staffed hospitals had lower surgical mortality and lower failure to rescue rates.

Patients in the hospitals with the poorest nurse-to-patient ratios had 26% higher mortality.

In New Zealand, “health re-engineering”, which cut nursing hours by 36%, led to significant increases in complications for patients, including:

•Central nervous system complications

•Wound infection

•Pulmonary failure

•Physiological and metabolic derangement

•Urinary tract infections

•Sepsis

•Decubitus ulcers

New South Wales research by Professor Christine Duffield showed that using a higher proportion of RNs produced significant decreases in:

•Decubitus ulcers

•Gastrointestinal bleeding

•Sepsis

•Shock

•Physiologic/metabolic derangement

•Pulmonary failure

•Failure to rescue