Patient turnover and nursing staff adequacy

Health Services Research, April, 2006 by Lynn Y. Unruh, Myron D. Fottler

Based on this comparison, we believe that the second turnover adjustment (square root of 1/LOS) is a conservative estimate of increases in nursing care intensity, and that it makes a reasonable indicator for changes in intensity in staffing. It could be used alone, or with an appropriate patient severity indicator. The first turnover adjustment (1/LOS) could also be used, but not with a patient severity adjustment.

The most significant limitation of our study is the lack of an empirically derived measure of nursing work intensity, such as that obtained through a time-motion study. Future research needs to better quantify the relationship of ALOS and patient severity to nursing care intensity and to nurse staffing. Consequently, research should focus on developing a more accurate measure of nurse intensity that includes patient severity, patient turnover, and other workplace factors which impact staffing (Seago 2002).

A second limitation of this study is the state-level sample. Future research should replicate this study on a national basis to allow for a stronger generalization. We should note that while the average length of stay in Pennsylvania hospitals declined from 5.96 to 4.87 days between 1995 and 2001 (see Table 1), the decline nationally was 5.4-4.9 days (see CDC 2004). This means that adjusted RN staffing adjustments would have decreased somewhat less nationally than in this study.

A third limitation is the focus on RN staffing ratios to the exclusion of other categories of nursing personnel. Future studies need to assess staffing patterns in all categories of nurses, as staffing patterns could be changing in different directions for different categories of nurses as a result of work reorganization, substitution, and shortages.

The perceptions of nurses, the media, and others concerning increasing nurse workloads/declining staffing ratios are justified and supported by our study. Given the differences between adjusted and unadjusted staffing ratios, and the availability of length of stay and patient severity data necessary to make the adjustments, it is important to begin adjusting staffing measures for these factors. Furthermore, research that uses hospital-level RN staffing data as part of a larger study with other variables, should consider adjusting staffing for patient turnover or including it as an independent variable.

Future research needs to address the pros and cons of our recommended adjustment as well as other possible adjustments. Our study of one state over an 8-year period is suggestive but not definitive. The important point is that nurse staffing and nurse workload studies need to utilize adjusted data. The issue of nurse staffing is too important to continue to disseminate unadjusted results that significantly overstate the level of nurse staffing in hospitals.

REFERENCES

Aiken, L. H., J. Sochalski, and G. F. Anderson. 1996. "Downsizing the Hospital Nursing Workforce." Health Affairs 15 (4): 88-92.

Aiken, L., S. Clark, D. Sloane, J. Sochalski, R. Busse, H. Clarke, P. Giovannetti, J. Hunt, A. Rafferty, and J. Shamian. 2001. "Nurses' Reports on Hospital Care in Five Countries." Health Affairs 20 (3): 43-53.