Peter I. Buerhaus

Nurse Staffing and Inpatient Hospital Mortality

BACKGROUNDnCross-sectional studies of hospital-level administrative data have shown an association between lower levels of staffing of registered nurses (RNs) and increased patient mortality. However, such studies have been criticized because they have not shown a direct link between the level of staffing and individual patient experiences and have not included sufficient statistical controls.nnnMETHODSnWe used data from a large tertiary academic medical center involving 197,961 admissions and 176,696 nursing shifts of 8 hours each in 43 hospital units to examine the association between mortality and patient exposure to nursing shifts during which staffing by RNs was 8 hours or more below the staffing target. We also examined the association between mortality and high patient turnover owing to admissions, transfers, and discharges. We used Cox proportional-hazards models in the analyses with adjustment for characteristics of patients and hospital units.nnnRESULTSnStaffing by RNs was within 8 hours of the target level for 84% of shifts, and patient turnover was within 1 SD of the day-shift mean for 93% of shifts. Overall mortality was 61% of the expected rate for similar patients on the basis of modified diagnosis-related groups. There was a significant association between increased mortality and increased exposure to unit shifts during which staffing by RNs was 8 hours or more below the target level (hazard ratio per shift 8 hours or more below target, 1.02; 95% confidence interval [CI], 1.01 to 1.03; P<0.001). The association between increased mortality and high patient turnover was also significant (hazard ratio per high-turnover shift, 1.04; 95% CI, 1.02 to 1.06; P<0.001).nnnCONCLUSIONSnIn this retrospective observational study, staffing of RNs below target levels was associated with increased mortality, which reinforces the need to match staffing with patients needs for nursing care. (Funded by the Agency for Healthcare Research and Quality.).

The Recent Surge In Nurse Employment: Causes And Implications

Registered nurse (RN) employment has increased during the current recession, and we may soon see an end to the decade-long nurse shortage. This would give hospitals welcome relief and an opportunity to strengthen the nurse workforce by addressing issues associated with an increasingly older and foreign-born workforce. The recent increase in employment is also improving projections of the future supply of RNs, yet large shortages are still expected in the next decade. Until nursing education capacity is increased, future imbalances in the nurse labor market will be unavoidable.

Managing Unnecessary Variability in Patient Demand to Reduce Nursing Stress and Improve Patient Safety

BACKGROUNDnIncreases in adverse clinical outcomes have been documented when hospital nurse staffing is inadequate. Since most hospitals limit nurse staffing to levels for average rather than peak patient census, substantial census increases create serious potential stresses for both patients and nurses. By reducing unnecessary variability, hospitals can reduce many of these stresses and thereby improve patient safety and quality of care.nnnTHE SOURCE AND NATURE OF VARIABILITY IN DEMANDnThe variability in the daily patient census is a combination of the natural (uncontrollable) variability contributed by the emergency department and the artificial (potentially controllable) peaks and valleys of patient flow into the hospital fromelective admissions. Once artificial variability in demand is significantly reduced, a substantial portion of the peaks and valleys in census disappears; the remaining censsus variability is largely patient and disease driven. When artificial variability has been minimized, a hospital must have sufficient resources for the remaining patient-driven peaks in demand, over which it has no control, if it is to deliver an optimal level of care.nnnDISCUSSIONnStudy of operational issues in health care delivery, and acting on what is learned, is critical. Al forms of artificial variation in the demand and supply of health care services should be identified, and pilot programs to test operational changes should be conducted.

Resident Work Hour Limits and Patient Safety

Objective:This study evaluates the effect of resident physician work hour limits on surgical patient safety. Background:Resident work hour limits have been enforced in New York State since 1998 and nationwide from 2003. A primary assumption of these limits is that these changes will improve patient safety. We examined effects of this policy in New York on standardized surgical Patient Safety Indicators (PSIs). Methods:An interrupted time series analysis was performed using 1995 to 2001 Nationwide Inpatient Sample data. The intervention studied was resident work hour limit enforcement in New York teaching hospitals. PSIs included rates of accidental puncture or laceration (APL), postoperative pulmonary embolus or deep venous thrombosis (PEDVT), foreign body left during procedure (FB), iatrogenic pneumothorax (PTX), and postoperative wound dehiscence (WD). PSI trends were compared pre- versus postintervention in New York teaching hospitals and in 2 control groups: New York nonteaching hospitals and California teaching hospitals. Results:A mean of 2.6 million New York discharges per year wereanalyzed with cumulative events of 33,756 (APL), 36,970 (PEDVT), 1,447 (FB), 10,727 (PTX), and 2,520 (WD). Increased rates over time (expressed per 1000 discharges each quarter) were observed in both APL (0.15, 95% confidence interval, 0.09–0.20, P<0.05) and PEDVT (0.43, 95% confidence interval, 0.03–0.83, P<0.05) after policy enforcement in New York teaching hospitals. No changes were observed in either control group for these events or New York teaching hospital rates of FB, PTX, or WD. Conclusions:Resident work hour limits in New York teaching hospitals were not associated with improvements in surgical patient safety measures, with worsening trends observed in APL and PEDVT corresponding with enforcement.

Perspectives of Physicians and Nurse Practitioners on Primary Care Practice

BACKGROUNDnThe U.S. health care system is at a critical juncture in health care workforce planning. The nation has a shortage of primary care physicians. Policy analysts have proposed expanding the supply and scope of practice of nurse practitioners to address increased demand for primary care providers. These proposals are controversial.nnnMETHODSnFrom November 23, 2011, to April 9, 2012, we conducted a national postal-mail survey of 972 clinicians (505 physicians and 467 nurse practitioners) in primary care practice. Questionnaire domains included scope of work, practice characteristics, and attitudes about the effect of expanding the role of nurse practitioners in primary care. The response rate was 61.2%.nnnRESULTSnPhysicians reported working longer hours, seeing more patients, and earning higher incomes than did nurse practitioners. A total of 80.9% of nurse practitioners reported working in a practice with a physician, as compared with 41.4% of physicians who reported working with a nurse practitioner. Nurse practitioners were more likely than physicians to believe that they should lead medical homes, be allowed hospital admitting privileges, and be paid equally for the same clinical services. When asked whether they agreed with the statement that physicians provide a higher-quality examination and consultation than do nurse practitioners during the same type of primary care visit, 66.1% of physicians agreed and 75.3% of nurse practitioners disagreed.nnnCONCLUSIONSnCurrent policy recommendations that are aimed at expanding the supply and scope of practice of primary care nurse practitioners are controversial. Physicians and nurse practitioners do not agree about their respective roles in the delivery of primary care. (Funded by the Gordon and Betty Moore Foundation and others.).

How Rns View the Work Environment: Results of a National Survey of Registered Nurses

Objective To determine registered nurses (RNs) views of the workplace environment. Background Numerous studies have shown relationships between work environment, RN satisfaction and retention, and patient safety and outcomes. In 2002, NurseWeek Publishing and the American Organization of Nurse Executives completed a national survey on the views of RNs on the nursing shortage, workplace environments, and their future career intentions, which revealed areas needing improvement. Results from the follow-up survey conducted in 2004 provide new information on RNs views of the work environment and a comparison of results to the previous survey. Methods A nationally representative random sample of 3500 RNs licensed to practice in the United States was surveyed. Results In the views of RNs, there have been improvements in a number of aspects of the work environment of nurses. While there are no areas of decline, there are areas in which little or no progress is apparent. Conclusions/Implications Some strategies designed to improve the work environment have resulted in positive outcomes, but creative solutions must be continuously developed and implemented to build on recent successes. Results of this survey help identify areas for continued improvement efforts.

Trends in the Work Hours of Physicians in the United States

CONTEXTnRecent trends in hours worked by physicians may affect workforce needs but have not been thoroughly analyzed.nnnOBJECTIVESnTo estimate trends in hours worked by US physicians and assess for association with physician fees.nnnDESIGN, SETTING, AND PARTICIPANTSnA retrospective analysis of trends in hours worked among US physicians using nationally representative workforce information from the US Census Bureau Current Population Survey between 1976 and 2008 (N = 116,733). Trends were estimated among all US physicians and by residency status, sex, age, and work setting. Trends in hours were compared with national trends in physician fees, and estimated separately for physicians located in metropolitan areas with high and low fees in 2001.nnnMAIN OUTCOME MEASUREnSelf-reported hours worked in the week before the survey.nnnRESULTSnAfter remaining stable through the early 1990s, mean hours worked per week decreased by 7.2% between 1996 and 2008 among all physicians (from 54.9 hours per week in 1996-1998 to 51.0 hours per week in 2006-2008; 95% confidence interval [CI], 5.3%-9.0%; P < .001). Excluding resident physicians, whose hours decreased by 9.8% (95% CI, 5.8%-13.7%; P < .001) in the last decade due to duty hour limits imposed in 2003, nonresident physician hours decreased by 5.7% (95% CI, 3.8%-7.7%; P < .001). The decrease in hours was largest for nonresident physicians younger than 45 years (7.4%; 95% CI, 4.7%-10.2%; P < .001) and working outside of the hospital (6.4%; 95% CI, 4.1%-8.7%; P < .001), and the decrease was smallest for those aged 45 years or older (3.7%; 95% CI, 1.0%-6.5%; P = .008) and working in the hospital (4.0%; 95% CI, 0.4%-7.6%; P = .03). After adjusting for inflation, mean physician fees decreased nationwide by 25% between 1995 and 2006, coincident with the decrease in physician hours. In 2001, mean physician hours were less than 49 hours per week in metropolitan areas with the lowest physician fees, whereas physician hours remained more than 52 hours per week elsewhere (P < .001 for difference).nnnCONCLUSIONnA steady decrease in hours worked per week during the last decade was observed for all physicians, which was temporally and geographically associated with lower physician fees.

Registered Nurse Supply Grows Faster Than Projected Amid Surge In New Entrants Ages 23–26

The vast preponderance of the nations registered nurses are women. In the 1980s and 1990 s, a decline in the number of women ages 23-26 who were choosing nursing as a career led to concerns that there would be future nurse shortages unless the trend was reversed. Between 2002 and 2009, however, the number of full-time-equivalent registered nurses ages 23-26 increased by 62 percent. If these young nurses follow the same life-cycle employment patterns as those who preceded them--as they appear to be thus far--then they will be the largest cohort of registered nurses ever observed. Because of this surge in the number of young people entering nursing during the past decade, the nurse workforce is projected to grow faster during the next two decades than previously anticipated. However, it is uncertain whether interest in nursing will continue to grow in the future.

Magnet status and registered nurse views of the work environment and nursing as a career.

OBJECTIVESnTo compare how registered nurses view the work environment and the nursing shortage based on the Magnet status of their organizations.nnnBACKGROUNDnThe upsurge in organizations pursuing and obtaining Magnet recognition provides increased opportunities to investigate whether and how registered nurses who are employed in Magnet organizations and organizations pursuing Magnet status perceive differences in the nursing shortage, hospitals responses to the shortage, characteristics of the work environment, and professional relationships.nnnMETHODSnA nationally representative sample of registered nurses licensed to practice in the United States was surveyed. The views of registered nurses who worked in Magnet organizations, organizations in the process of applying for Magnet status, and non-Magnet organizations were analyzed as independent groups.nnnRESULTSnSignificant differences were found. Although there is a clear Magnet difference, there are also identifiable differences that occur during the pursuit of Magnet recognition.nnnCONCLUSIONnMany organizations in the process of applying for Magnet status rated higher than Magnet organizations, indicating that there is much to do to maintain the comparative advantages for Magnet hospitals.

Nurse-managed health centers and patient-centered medical homes could mitigate expected primary care physician shortage.

Numerous forecasts have predicted shortages of primary care providers, particularly in light of an expected increase in patient demand resulting from the Affordable Care Act. Yet these forecasts could be inaccurate because they generally do not allow for changes in the way primary care is delivered. We analyzed the impact of two emerging models of care--the patient-centered medical home and the nurse-managed health center--both of which use a provider mix that is richer in nurse practitioners and physician assistants than todays predominant models of care delivery. We found that projected physician shortages were substantially reduced in plausible scenarios that envisioned greater reliance on these new models, even without increases in the supply of physicians. Some less plausible scenarios even eliminated the shortage. All of these scenarios, however, may require additional changes, such as liberalized scope-of-practice laws; a larger supply of medical assistants, licensed practical nurses, and aides; and payment changes that reward providers for population health management.