More Patients + Fewer Nurses = More Deaths

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Illustration by Julia Vakser

There’s a grim, obvious logic to the findings of a recent study by Penn researchers: More surgical patients per hospital nurse means those patients run a higher risk of dying. According to the study—led by Dr. Linda Aiken, the Leadership Professor of Nursing who serves as director of the Center for Health Outcomes and Policy Research at the School of Nursing—each patient added to the workload of the average hospital nurse increases the risk of death in surgical patients by seven percent. Patients who have common surgeries in hospitals with the poorest ratio of nurses to patients increase their risks of dying by up to 31 percent.

“Our findings suggest that thousands of deaths each year following common surgical procedures could be prevented by improved registered-nurse staffing in U.S. hospitals,” says Aiken, adding that “nurses report greater job dissatisfaction and emotional exhaustion when they’re responsible for more patients than they can safely care for.” 

However, she notes, “On the positive side, there is ample evidence that hospitals could dramatically increase the retention of nurses in hospital practice, thus going a long way to solving the existing nurse shortage, by improving working conditions.”

The study, “Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction,” which was published in the October 23 Journal of the American Medical Association, examined data 
collected from 168 hospitals, 232,342 surgical patients, and 10,184 nurses in Pennsylvania from 1998 to 1999. The researchers focused on such relatively common general surgeries as gall-bladder, orthopedic (hip-replacement or knee), and vascular (but not bypass), as well as some routine but emergency surgeries such as appendectomies. Roughly four million surgeries in those categories are performed each year.

The researchers concluded that adding two patients to a nurse already caring for four increases the risk of death by 14 percent, while adding four increases the risk by 31 percent. Although hospitals are trying to contain costs, the study concludes that having too few nurses may actually cost more because of the higher costs of caring for patients with poor outcomes, not to mention the cost of replacing burnt-out nurses.

The study was prompted by “previous research we had conducted on a smaller scale showing that hospitals with reputations for being good places for nurses to practice—and where nurses had smaller case loads—had better patient outcomes,” Aiken notes. Nurses with too many patients “are sometimes delayed in recognizing early warning signs of potentially life-threatening events,” and that “timing is often critical to rescuing patients experiencing complications.” 

While “inadequate staffing of hospitals is the single biggest factor in the flight of nurses from hospital practice,” she warns, “there has been little, if any, national response to these hazardous hospital conditions.”

The researchers’ hope was that their findings would “serve as a catalyst for action to protect the health of the public,” Aiken says—and to a considerable degree, that has happened. “The widespread media coverage of our findings, complete with editorials and cartoons in leading newspapers, suggest the public is quite alarmed by our findings, as well they should be,” she says.

“We advise consumers to inquire at their hospital about how many other patients they can expect their nurse to be caring for,” she adds. “Every patient should expect to have a primary nurse who is accessible to them and to their families throughout their hospital stay, just as their physician is.” She further suggests that potential patients “find out if their hospital has been awarded Magnet Status by the American Nurses Credentialing Center.”

For administrators, her advice is blunt: “Stop throwing money at stop-gap measures and focus instead on fostering a culture of retention that reduces high levels of dissatisfaction, burnout, and turnover among the most qualified nurses. Devolve authority to nurses to make needed changes and support their decisions.”

On the whole, she says, the study “documents that the majority of nurses are satisfied with their choice of nursing as a career,” and are “searching for opportunities” to practice their chosen profession. But for hospitals to keep the nurses they have now, “they need to create the conditions for safe practice and rewarding careers.”

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