The Impact of Nurses on Patient Morbidity and Mortality - the Need for a Policy Change in Response to the Nursing Shortage

By Twigg, Di; Duffield, Christine et al. | Australian Health Review, August 2010 | Go to article overview

The Impact of Nurses on Patient Morbidity and Mortality - the Need for a Policy Change in Response to the Nursing Shortage


Twigg, Di, Duffield, Christine, Thompson, Peter L., Rapley, Pat, Australian Health Review


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 adverse patient outcomes.

Introduction

By 2012 there will be an estimated shortfall of 61 000 registered nurses (RNs) in Australia.1 One response to this has been an exploration of alternative skill mix models.2 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 that links the role of RNs to patient outcomes, referred to as 'nursing sensitive outcomes'.3 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 classification 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

A seminal study conducted two decades ago4 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 condition deteriorates.5 Nurses are in the best position to initiate actions that minimise adverse events and negative outcomes for patients.6 The effectiveness of nurse surveillance is influenced by the number and mix of nurses available to assess patients on an ongoing basis.6,7 In seminal work Needleman et al. (p. xxiii)7 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. …

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