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The impact of nurses on patient morbidity and mortality - The need for a policy
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DOI: 10.1071/AH08668 · Source: PubMed

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Edith Cowan University
Research Online
ECU Publications

2010

The Impact of Nurses on Patient Morbidity and

Mortality - the Need for a Policy Change in
Response to the Nursing Shortage
Diane Twigg
Edith Cowan University

Christine Duffield

Peter L. Thompson

Pat Rapley

This article was originally published as: Twigg, D. E., Duffield, C. M., Thompson, P., & Rapley, P. (2010). The impact of nurses on patient morbidity
and mortality - the need for a policy change in response to the nursing shortage. Australian Health Review, 34(3), 312 -316. Original article available
here
This Journal Article is posted at Research Online.
http://ro.ecu.edu.au/ecuworks/6241
The impact of nurses on patient morbidity and mortality – the need for a policy change in response to the
nursing shortage
1,2
Di Twigg RN, RM, BHlthSc(Nsg)(Hons), MBA, PhD, FRCNA, FACHSE, Professor, Head of School (School of
Nursing, Midwifery and Postgraduate Medicine)
3,8
Christine Duffield RN, DipNEd, BScN, MHP, PhD, Professor, Associate Dean (Research) (Acting), Director
(Centre for Health Services Management), Deputy Director (WHO CC)
4,5,6
Peter L. Thompson AM, MD, MBBS, FRACP, FACC, FACP, DIPL ABIM, Clinical Professor, Deputy Director
(WAIMR), Cardiologist in Charge of Coronary Care
2,7
Pat Rapley MAppSc, BSc, DipNEd, RN, FRCNA, PhD, Senior Lecturer (School of Nursing and Midwifery),
Nursing Research Consultant (Centre for Nursing Research, Innovation and Quality)
1
School of Nursing, Midwifery and Postgraduate Medicine, Edith Cowan University, Joondalup, WA 6027, Australia.
2
Centre for Nursing Research, Innovation and Quality, Sir Charles Gairdner Hospital, Nedlands, WA 6009, Australia.
3
Centre for Health Services Management, Faculty of Nursing, Midwifery and Health, and World Health Organization
Collaborating Centre for Nursing, Midwifery and Health Development (WHO CC), University of Technology,
Sydney, Ultimo, NSW 2007, Australia.
4
School of Medicine and Pharmacology, The University of Western Australia, Crawley, WA 6009, Australia.
5
West Australian Institute of Medical Research (WAIMR), Nedlands Campus, QEII Medical Centre, Nedlands, WA
6009, Australia.
6
Sir Charles Gairdner Hospital, Nedlands, WA 6009, Australia.
7
School of Nursing and Midwifery, Curtin University of Technology, Bentley, WA 6102, Australia.

Abstract

Context. Workforce projections indicate that by 2012 there will be a shortfall of 61 000 registered nurses in
Australia. There is a growing body of evidence that links registered nurse staffing to better patient outcomes.

Purpose. This article provides a comprehensive review of the research linking nurse staf fing to patient outcomes at
a time of growing shortages, highlighting that a policy response based on substituting registered nurses with lower
skilled workers may have adverse effects on patient outcomes.

Method. An electronic search of articles published in English using the Cumulative Index to Nursing and Allied
Health Literature (CINAHL), Journals @ OVID and Medline was undertaken.

Findings. Robust evidence exists nationally and internationally that links nurse staffing to patient outcomes. Recent
meta-analyses have found that there was a 3–12% reduction in adverse outcomes and a 16% reduction in the risk
of mortality in surgical patients with higher registered nurse staffing. Evidence confirms that improvements in nurse
staffing is a cost-effective investment for the health system but this is not fully appreciated by health policy advisors.

Conclusions. An appropriate policy response demands that the evidence that patient safety is linked to nurse
staffing be recognised. Policy makers must ensure there are suf ficient registered nurses to guarantee patient safety.

What is known about the topic?

Projections indicate that by 2012 there will be an estimated shortfall of 61 000 registered nurses in Australia.
However, research demonstrates the number of registered nurses caring for patients is critically important to
prevent adverse patient outcomes. Evidence also confirms that improvements in nurse staffing is a cost -effective
investment for the health system.

What this paper adds? The paper exposes the lack of an appropriate policy response to the evidence in regard to
nurse staffing and patient outcomes. It argues that patient safety must be recognised as a shared responsibility
between policy makers and the nursing profession.

What are the implications for practitioners? Policy makers, health departments, Chief Executives and Nurse
Leaders need to ensure that adequate nurse staffing includes a high proportion of registered nurses to prevent

Introduction
1
By 2012 there will be an estimated shortfall of 61 000 registered nurses (RNs) in Australia. One response to this
2
has been an exploration of alternative skill mix models. Many healthcare agencies (acute, community and aged
care facilities) have changed the mix of nurses, hiring more enrolled nurses and unregulated workers (assistants in
nursing or healthcare assistants) and less RNs. However, these initiatives conflict with the growing body of evidence
3
that links the role of RNs to patient outcomes, referred to as ‘nursing sensitive outcomes’. This paper will review the
literature in regard to the relationship between the number and mix of nurses and patient outcomes including
mortality. Further, the review will establish the affordability of increases in the RN workforce and discuss the lack of
understanding of this critical evidence by executives and doctors. Lastly, using the outcomes of the review the
authors will expose a lack of a collective policy response in Australia to the evidence in the literature.

Method
For the literature review an electronic search was undertaken of articles published in English using the Cumulative
Index to Nursing and Allied Health Literature (CINAHL), Journals @ OVID and Medline dated from 1982 to 2005. A
search for works by prominent authors in the field was also undertaken. The listed search terms from these
publications also assisted in establishing search terms. Search terms included outcomes (healthcare), hospital
mortality, personnel staffing, skill mix, nurse -patient ratio, workload, workload measurement, educational status,
practice environment, patient classi fication methods and patient dependency. Once the initial search was
undertaken, automatic weekly alerts were established to capture new publications using these search terms and
key authors.

Nurse staffing and patient outcomes

4
A seminal study conducted two decades ago found that interaction and coordination amongst clinicians (medical
and nursing staff) reduced patient deaths in ICU settings, but did not establish a link between nursing activities and
patient outcomes. Since then a growing body of research indicates that RNs provide a continuous (24-h per day, 7
days per week) surveillance system for patients enabling the early detection and prompt intervention when their
5
condition deteriorates. Nurses are in the best position to initiate actions that minimise adverse events and negative
6
fluenced by the number and mix of nurses
outcomes for patients. The effectiveness of nurse surveillance is in
6,7
available to assess patients on an ongoing basis. In seminal work Needleman et al.
7
(p. xxiii) have identified several ‘outcomes potentially sensitive to nursing (OPSN)’, which they defined as:
a group of patient complications that had been established in the literature, which include urinary tract
infections, skin pressure ulcers, hospital acquired pneumonia, and deep vein thrombosis or pulmonary
embolism; a group of exploratory measures, comprised of upper gastrointestinal bleeding, central nervous
system complications, sepsis, and shock or cardiac arrest; complications among surgical patients only, which
included surgical wound infection, pulmonary failure, and metabolic derangement, and a final group consisting
of mortality, two different measures of patient length of stay and failure to rescue, which was constructed as a
death among patients with shock, sepsis, pneumonia, deep vein thrombosis or pulmonary embolism or
gastrointestinal bleeding.
One example of how these outcomes relate to nursing can be found with hospital-acquired pneumonia, where two
key risk factors are prolonged immobility, which leads to inadequate ventilation of parts of the lungs, and
inappropriate or failure to perform pulmonary hygienic techniques. Nursing care influences both risk factors. More
commonly now these patient outcomes are referred to as nursing (or nurse) sensitive outcomes. A great deal of
research has been conducted linking a variety of nursing and staf fing factors related to these outcomes: a summary
follows.

The relationship between nurse staffing and patient outcomes

Early work established that higher levels of RN staffing, measured as RN hours per inpatient-day, were associated
8–15
with improved patient outcomes. These included urinary tract infections and pneumonia after major surgery,
 9 8
thrombosis and pulmonary compromise in surgical patients, pneumonia in elective and emergency patients,
10,11 12 13
medication errors, pressure ulcers and patient complaints, mortality rates and nosocomial infection rates.
Other positive outcomes included better functional health outcomes, pain management and patients’ perceptions of
14
nursing care at discharge.
The results strongly suggested that increased RN-to-patient ratios were inversely related to mortality rates; an
increase in mean length of stay occurred with decreased staffing ratios; and higher staffing by RNs was associated
12,15
with lower rates of unit-specific complications. However, there were several methodological concerns raised
with respect to this early work. Many studies were undertaken at only one hospital or a small number and range of
15
units, resulting in small sample sizes and ambiguity over what constituted patient outcomes.
Two landmark studies involving large administrative datasets provided more robust evidence and addressed many
7
of the concerns identified above. The first study utilised discharge abstracts from 799 hospitals in 11 states of the
5
USA, providing a much larger sample size than any previous study. A second study used discharge data from over
fing levels
200 000 patients at 168 adult general hospitals in Pennsylvania. Both studies found that lower RN staf
5,7
adversely affected patient outcomes. In these studies ‘failure to rescue’ was a term used to describe a death from
the complication of pneumonia, shock or cardiac arrest, upper gastrointestinal bleeding, sepsis or deep vein
7
thrombosis. Needleman et al. found that a higher proportion of hours of care per day and the absolute hours of care
provided by RNs were associated with a shorter length of stay, fewer urinary tract infections, less gastrointestinal
bleeding, lower rates of pneumonia, shock or cardiac arrest and lower rates of failure to rescue in medical patients.
In surgical patients, a higher proportion of care provided by RNs was linked with less urinary tract infections, and a
7
greater number of hours of care per day provided by RNs was linked with lower rates of failure to rescue. Aiken et
5
al. found that each additional patient added to a nurse’s workload was
associated with a 7% increase in the likelihood of dying within 30 days of admission and a 7% increase in the
likelihood of failure to rescue (the results were risk adjusted for patient and hospital characteristics). Both studies
concluded that substantial decreases in mortality rates would occur if there were increased RN staffing.

This growing body of evidence was initially dismissed at a policy level internationally as the work was conducted in
the United States where the care system was different from most other industrialised countries. However, since that
16 17,18 19,20
time, similar large scale studies conducted in England, Canada and Australia have demonstrated similar
relationships.
17
The Canadian study found mortality rates from 18 142 patients in 49 acute care hospitals in Alberta varied
significantly across hospitals. Age and patient co-morbidities explained 44.2% of the variation whereas four nursing
factors explained a further 36.9%. The first of these nursing factors was the level of nurse education. Hospitals with
a higher proportion of baccalaureate-prepared (4 year degree) nurses had lower rates of 30-day mortality, also
6
consistent with Aiken’s findings. The second factor was skill mix: Hospitals with a higher proportion of RNs had
lower rates of 30-day mortality. The third factor was employment status: Hospitals with a higher proportion of casual
and temporary nurses were associated with higher rates of 30-day mortality. The fourth factor was nurse-physician
relationships: Hospitals with higher scores on collaborative nurse-physician relationships had lower rates of 30-day
18
patient mortality. More recently, Tourangeau et al. have found that higher percentages of RNs, higher percentages
of baccalaureate-prepared nurses, more nurses reporting adequacy of staffing and resources were also associated
with lower 30-day mortality rates in medical patients.
16
A UK study that involved 30 acute care trusts, also found consistently better outcomes for patients in hospitals that
had higher nurse-to-patient ratios compared to those with less favour-able staffing. The patients in better staffed
hospitals had lower rates of surgical mortality and failure to rescue. Patients in hospitals with the lowest
nurse-to-patient ratios had a 26% higher mortality. The authors calculated 246 fewer deaths would have occurred in
16
the subset of surgical patients if all patients were treated in hospitals with the most favourable nurse staf fing levels.
19,20
The only Australian studies to examine the relationship between nursing hours of care and the proportion of
hours of care provided by RNs found similar results. Hospitals that had a skill mix with a higher proportion of RN
hours produced statistically significant decreased rates of decubitus ulcers, gastrointestinal bleeding, sepsis, shock,
19
physiologic or metabolic derangement, pulmonary failure, failure to rescue and falls. These same authors found in
20
a parallel study that increasing RN hours by 10% decreased the following adverse events central nervous system
complications (45%), gastrointestinal bleeding (37%), urinary tract infections (34%), failure to rescue (27%),
decubitus ulcers (19%), sepsis (15%) and pneumonia (11%).
In addition to these country specific studies, several systematic reviews of the literature have recently been
21
undertaken, each reporting similarfindings. Stanton concluded that there was a 3–12% reduction in adverse
outcomes (falls, urinary tract infections, upper gastrointestinal bleeding, pressure ulcers, pneumonia, failure to
rescue, and nosocomial infections) with higher RN staf fing levels. A second review concluded that increased patient
mortality, failure to rescue, respiratory tract infection and decreased quality of care were significantly related to high
22
nursing workload. By contrast, increased total hours of nursing time were associated with improvements in patient
outcomes such as lower pressure ulcer rates, lower mortality rates, fewer medication errors, reduced length of stay,
22 3
as well as reductions in the incidence of injuries and falls. Finally, Kane et al. summarised evidence that
concluded that higher RN-to-patient ratios were associated with reduced mortality, failure to rescue and length of
stay. Furthermore, Kane et al. found that every additional RN Full Time Equivalent (FTE) per patient-day was
associated with a 16% reduced risk of mortality in surgical patients. Conversely, every additional patient-to-RN per
shift was associated with a 7% increase in pneumonia, a 53% increase in pulmonary failure and a 17% increase in
medical complications. In contrast, the death rate decreased by 1.98% for every additional nurse-hour per
patient-day.
In summary, as the body of knowledge about nursing sensitive patient outcomes has expanded there can be no
doubt the hours of care and skill mix (hours of care provided by RNs) do affect patient outcomes. Increased nursing
hours and more hours of care provided by RNs have been shown to decrease patient mortality and adverse patient
5–22
outcomes.

Affordability of additional RN staffing

Although the evidence strongly supported the link between an increase in nurse staffing and a higher proportion of
RNs to improvements in the quality of care, questions arose as to whether or not these staffing models were
23
affordable. In response, Needleman et al. utilised data from 799 hospitals to argue a business and social case for
investing in nurse staffing. They analysed the costs of increasing nurse staffing to the 75th percentile for hospitals
below this level to determine cost savings achieved by reduced length of stay and decreased adverse outcomes.
The authors estimated from the data that increased nurse staf fing could avoid 6700 inpatient hospital patient
deaths; three-quarters of those from a richer RN mix, which also resulted in significant cost savings.
24
A second report based on Michigan (USA) data suggested that reducing the number of adverse outcomes by
ficant savings. For example, estimate d savings of US$22.03
increasing nurse to patient ratios resulted in signi
million per year for Michigan hospitals related to prevention of pneumonia and US$5.8 million per year related to
24
nosocomial infections were possible. Data were also used to model the impact of staf fing changes on patient
outcomes. The estimated savings in adverse patient outcomes in a typical 200-bed hospital that moved from a
1-to-5 nurse-topatient ratio over a 10-year period to a 1-to-4 ratio was US$7.5 million in the first year and more than
24 25
US$11 million by year 10. Rothberg, Abraham et al. found increasing the nurse-to-patient ratio to 1-to-4 from
1-to-8 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
26
cervical cancer screening at a cost of US$432 000 per life saved. Similarly, Cho has found the costs of
hospital-acquired pneumonia to be US$22 390–$28 505 per episode. These
23–26
studies clearly support the proposition that to increase RN hours of care is cost effective as it improves patient
outcomes but is also affordable.

Understanding of the evidence by doctors and hospital executives

Although research indicates that employment of an adequate number and mix of RNs achieves better patient
outcomes and is cost effective, the importance of nurse staffing to patient outcomes is not readily understood by
27
medical staff or chief executive officers. In a national US survey of RNs, physicians and hospital executives,
significantly fewer physicians and chief executive officers than RNs believed the nursing shortage had an adverse
impact on patient safety, early detection of patient complications or time for team collaboration. Twice as many RNs
as physicians thought that the shortage of nurses had adversely affected patient safety. The majority of RNs and
chief nursing officers expressed concern about the impact of shortages on the early detection of patient
complications and nurses’ ability to maintain patient safety. The majority of chief executive officers and physicians
did not share this view, suggesting that chief executive officers and medical staff do not associate nurses and their
work with patient safety. In addition, they did not appreciate the impact nurses had in detecting complications or
rescuing the patient before their condition deteriorated and their lives were put at risk. Although similar studies have
not been conducted in Australia, there is no reason to think views would be starkly different to these. The safety of
27
hospital patients remains a shared responsibility amongst the health professions and as the views of senior clinical
staff and chief executive officers influence health policy, it is essential that informed decisions are made, decisions
based on the evidence.

Workforce shortages
A further challenge in providing adequate nurse staf fing and a richer RN mix is the nursing shortage. Workforce
projections in Australia, particularly for nursing, are grim. In 2000 an estimated 170 000 new people entered the
28
workforce per annum but by 2020 this number is expected to drop to 12 500 per annum and there will be an
 1
estimated shortfall of 61 000 nurses. Although demand is growing the current supply is just meeting replacement
29
needs. Of equal concern is that the nursing workforce is aging more rapidly than others with the average age rising
30
from 42.2 in 2001 to 45.1 years in 2005. The proportion of nurses aged 50 years and older increased from 24.4 to
30
35.8%. Consequently, over the next decade more than one third of the Australian nursing workforce is likely to
ficant challenges in se curing adequate
retire. These trends indicate Australian heath care services will face signi
nursing resources (both hours of care and RN skill mix) to provide safe and effective patient care. In part these
shortages have been exacerbated because RNs perceive their workload has increased as the skill mix has
31
changed, leading to a greater likelihood of them leaving.

Policy response
The demonstrated relationship between nurse staffing, and in particular the role of RNs in improving patient
outcomes, requires a collaborative policy response to not only increase the number of nurses in the workforce but
more importantly, to increase the proportion of RNs employed. However, the reality is that the exact opposite is
occurring. Calls for greater workforceflexibility and skill mix changes have resulted in substitution of more highly
6
skilled workers with assistant type roles rather than maximising use of the skills and expertise of the RN workforce
to enhance patient safety. This workforce trend has overlooked the evidence supporting improved patient outcomes
when health services have more hours of care provided by RNs. In addition, the number and diversity of key players
at both state and federal levels involved in workforce planning, education, training and accreditation make it difficult
2
to achieve a coordinated policy response. This diversity of stakeholders results in fragmentation of responsibilities,
ineffective coordination between sectors and inefficiencies in funding and payment arrangements. Effective and
efficient policy responses in this climate are difficult, for example coordination of the number of university places
made available for nurse education.
If governments are serious about reducing the number of patient deaths, then government policy should focus on
32
initiatives aimed at maximising the number of RNs at patients’ bedsides. Current thinking about new models of
care that maximise the use of less skilled workers to assist in patient care is not congruent with evidence to hand.
6
RNs are a critical part of the healthcare team and the number of RNs in the team is directly linked to patient safety.
Policy responses should also support the determination of safe levels of nurse staffing, including the mix of nurses,
by funding studies to empirically examine speci fic nurse staffing methods. Recently in New Zealand a component of
33
the national multi-employer collective agreement was to establish a safe staf fing commission to assess the impact
fing levels, nursing workload, and to create guidelines on safe staffing and healthy
and implications of low staf
workplaces. Addressing the global nursing shortage crisis requires partnerships involving all sectors, actively
engaging stakeholders to implement, monitor and evaluate effective policy interventions and strategies to attract
and retain nurses, especially RNs, into the health workforce. In Australia, the Australian Commission on Safety and
34
Quality in Health Care recently published a proposed list of 58 indicators by which hospital performance would be
assessed. Unlike the United States, nursing skill mix was not one of the indicators.
In conclusion, this paper has highlighted the important role of nurses in providing a continuous surveillance system
5
enabling the early detection and prompt intervention when patients’ conditions deteriorate. The ability of nurses to
6
initiate actions that minimise adverse events and negative outcomes for patients is directly linked to the hours of
23–26
care and the skill mix (proportion of RN hours worked) and has been shown to be cost effective and affordable.
1,28,30
Although Australia is facing significant nursing shortages that are predicted to worsen over the coming decade,
the policy response to the nursing workforce shortages to date have been inadequate. Strategies relying on
2,35
substitution with less skilled workers is in direct contrast to the evidence.

Competing interests
No conflicts of interest exist.

Acknowledgements
Prof D. Twigg was awarded the Western Australian Nurses Memorial patient safety. Centre for Health Services
Management, University of Charitable Trust Grant of AU$19 613.
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