By David Moberg
In These Times
April 20, 2010

The new health insurance reform package took a few steps toward increasing access to insurance and controlling costs, argues National Nurses United spokesman Chuck Idelson, but it did little to improve quality of care, one of the major challenges facing would-be reformers. 

But research published today in the journal HSR (Health Services Research) concludes that increasing the number of nurses in a hospital can do a lot to boost the chances that patients will survive–and to encourage experienced nurses to stick with the job at a time when many hospitals suffer from nurse shortages and high turnover.

A team of researchers compared nurses’s experience and patient results in California, New Jersey and Pennsylvania.  In 2004 California began implementation of legislation that mandated the maximum ratio of patients to nurses. It’s still the only staffing ratio legislation in the country, although proposals are pending in 18 states and in Congress.

The researchers, led by Linda Aiken, director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing, found that New Jersey and Pennsylvania hospitals would have had, respectively, 14 percent and 11 percent fewer patient deaths in a year if they had the same nurse staffing ratio as California.

“It’s a very important study,” says Dr. Gordon Schiff, associate director of the Center for Patient Research and Practice at Harvard University’s Brigham and Women’s Hospital, because it reinforces other studies that taken together lead to an “unassailable” conclusion that increasing nurse ratios to patients improves health outcomes.

Lower patient loads also made nurses more satisfied with their work and helped hospitals retain them. Aiken and her team report:
The higher the proportion of nurses in hospitals whose patient assignment is in compliance with the benchmark set on California-mandated ratios, the lower the nurse burnout and job dissatisfaction, the less likely nurses are to report the quality of their work environment as only fair or poor, the less likely nurses are to report that their workload causes them to miss changes in patients’ conditions, and the less likely nurses are to intend to leave their jobs.

The superior mortality rates in hospitals with more nurses in relation to patients results from a variety of causes, not just more nurse time with the patient (and family), Schiff suggests. As hospital care has become more fragmented, he says, “nurses are there to pick up all those complications and lack of coordination in our health care system.”

Schiff suspects that nurse staffing ratios may be associated with nurses feeling more powerful and able to act on behalf of patients, although California nurses are highly unionized in addition to having ratios.  “It would be nice to stretch the claim and show that if employees have more power and voice, there will be better outcomes,” Schiff says. “It points to that conclusion.” So does research by University of Massachusetts economist Michael Ash that shows mortality from cardiac failure was 5.7 percent lower in unionized than non-union hospitals.

Schiff cautions that the patient health improvements from staffing ratios are real but modest, and making hospitalized patients safer and more likely to recover will require other measures, such as better use of technology, more primary care and better coordinated care, better listening to patients, and more willingness to learn from mistakes. “It would be tempting to say if we just put more nurses in the hospitals everything will be all right,” Schiff says. “That’s necessary but not sufficient.”

But the new research does underscore how necessary it is to make sure hospitals are adequately staffed by trained nurses, and that management treats them as a key to healthier, surviving patients, not an expendable cost to be cut.