iim ORIGINAL CONTRIBUTION Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction Linda H. Aiken, PhD, RN HE PAST DECADE HAS BEEN A TUR bulent time for US hospitalsand practicing nurses. News media have trumpeted urgent con- cers about hospital understalling and 4 growing hospital nurse shortage." Nurses nationwide consistently report that hospital nurse stalling levels in- adequate to provide safe and effective care-** Physicians agree, citing inad- equate nurse salfing asa major impedi- ment to the provision of high-quality hospital care." The shortage of hospital nurses may be linked to unrealistic nurse workloads." Forty percent of hospital nurses have buimout levels that exceed the norms for health care workes.* Job dissatisfaction among hospital nurses is 4 umes greater than the average for all Us workers, and 1 in 5 hospital nurses report that they intend to leave their eur- rent jobs within a year? In 1999, California passed legisla. lion mandating paticnt-to-nurse ra- tios for its hospitals, which goes into effect in July 2003. The California leg- islation was motivated by an inereas- ing hospital nursing shortage and the perception that lower nurse retention in hospital practice was related t bur- For editor I comment see p 2040. (©2002 American Medical Association. All rights reserved. (Reprinted) JAMA, October 2380, Context The worsening hospital nurse shortage and recent California legislation mandating minimum hospital patient-to-nurse ratios demand an understanding of how nurse staffing levels affect patient outcomes and nurse retention in hospital practice Objective To determine the association between the patient-to-nurse ratio and pa- tient mortality, falure-to-rescue (deaths following complications) among surgical pa- tients, and factors related to nurse retention. Design, Setting, and Participants Cross-sectional analyses of linked data from 10184 staff nurses surveyed, 232342 general, orthopedic, and vascular surgery patients discharged from the hospital between April 1, 1998, and November 30, "1999, and administrative data from 168 nonfederal adult general hospitals in Penn” syhvania Main Outcome Measures Risk-adjusted patient mortality and fallure-to-rescue within 30 days of admission, and nurse-reported job dissatisfaction and job-related bumout. Results. After adjusting for patient and hospital characteristics (size, teaching status, and technology), each additional patient per nurse was associated with a 7% (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.03-1.12) increase in the likelihood of dying within 30 days of admission and a 7% (OR, 1.07; 95% Cl, 1.02-1.11) in- crease in the odds of failure-to-rescue. After adjusting for nurse and hospital charac teristics, each addtional patient per nurse was associated with a 23% (OR, 1.23; 95% Cl, 1.13-1.34) increase in the odds of burnout and a 15% (OR, 1.15; 95% Cl, 1.07~ 1.25) increase in the odds of job dissatisfaction. Conclusions In hospitals with high patient-to-nurse ratios, surgical patients expe- rience higher risk-adjusted 30-day mortality and fallure-to-rescue rates, and nurses are more likely to experience burnout and job dissatisfaction, JAMA, 2002288:1987-1993 wu jamacom dense workloads and high eves of Abra: Criath Osid job-related burnout and job dissatis- 207 Resear Scoot Narn (Dr Aken Cae, faction. Stakeholder groups adve- Snsur“stnas’ chtetonme wasaetne Cited widely divergent mininnum rev pst ong fren, Poplin Ss widely drgent minima ss Bn cae ae gt tos. On medical and surgical units, iments of Pediatrics and Anesthesia, School of Medi recommended ratios ranged from 3 Gye se, Urey af fen, Pca we Tov patens for each tasse "yy Sts Creo Otome ees, Cs Pe Hospital of Pade, Phiaclphia, Pa (rSbe. carly 2002, California's governor an- Gop Strands aust as, nounced that hosptals must have at #0. seecentsor estnOaeone Poe Founced that hospitals ust have at och unvesyef eopann 20 Cod least licensed nurse forevery Omedi- Fis Px TStOL ae ear waenorng cal and surgical patente by July 2003, ‘upernad In 6 1987NURSE STAFFING AND HOSPITAL OUTCOMES 4 ratio that will move to 1 to 5 when the mandates are fully implemented. "= This study reports on findings from a comprehensive study of 168 hospitals and clarifies the impact of nurse stall- ing levels on patient outcomes and fac tors that influence nurse retention.” Spe- cifically, we examined whether risk- adjusted surgical mortality and rates of failure-to-rescue (deaths in surgical pa- tients who develop serious complica tions) are lower in hospitals where nurses carry smaller patient loads. In addition, ‘weascertained the extent to which more favorable patient-to-nurse ratios are as- sociated with lower burnout and higher job satisfaction among registered nurses ‘Wealso estimated excess surgical deaths associated with the different nurse staf- ing ratios vigorously debated in Califor nia. Finally, we estimated the impact of nurse stalling levels proposed in Cali- fornia on nurse burnout and dissatisfac- lion, 2 precursors of tirnover.”* Our find ings offer insights into how more {generous registered nurse stalling might affect patient outcomes and inform cur- rent debates in many states regarding the merits of legislative actions to influence stalling levels, METHODS: tients, Data Sources, and Variables ‘Our study combines information about hospital stalling and organization ob- tained from nurse surveys with patient ‘outcomes derived from hospital dis- charge abstracts and hospital character- istics drawn from administrative data- bases." The study protocol for linking anonymized nurse data and handling de- nominalized patient data was ap- proved by the institutional review board of the University of Pennsylvania, Hospitals. Data were collected on all, 210 adult general hospitals in Pennsyl- vvania, Information about hospital char- acteristics was derived [rom the 1099 American Hospital Association (AHA) Annual Survey and the 1999 Pennsyl- vania Department of Health Hospital Survey.'*! Ultimately, 168 of the 210 acute care hospitals had discharge data for surgical patients in the targeted Di- $988 JAMA ccisher 2/30, 2002 Vol 288, No, agnosis Related Groups (DRGs) dur- ing the study period, as well AHA data, and survey data from 10 or more stall nurses, Six of the excluded hospitals were Veterans Affairs hospitals, which do not report discharge data tothe state Twenty-six hospitals were excluded be- cause their administrative or patient out- comes data could not be matched to our surveys because of missing variables, pri- marily because they reported their char- acteristics oF patient data as aggregate rmuluhospital entities, In 10 additional small hospitals, the majority of which hhad fewer than 50 beds, fewer than 10 nurses responded to the survey ‘A nurse stalling measure was caleu- lated asthe mean patient load acrossall stall registered nurses who reported having responsibility for at least 1 but fewer than 20 patients on the last shift, they worked, regardless of the spe- cialty or shift day, evening, night) worked. This measure of stalling is superior to those derived from admin- istrative databases, which generally include registered nurse positions that do not involve inpatient acute care at the bedside. Staffing was measured across entire hospitals because there is no evidence that specialty-specifiestall- ing offers advantages in the study of patient outcome’ and to reflect the fact, that patientsoften receive nursing care in multiple specialty areas of « hospi- tal. Direct measurement also avoided problems with missing data common to the AA's Annual Survey of hospi- tals, which imputed staffing data in 1999 {or 20% of Pennsylvania hospitals. Three hospital characteristics were used as control variables: size, teaching status, and technology. Hospitals were grouped into 3 size categories: small (S100 hospital beds), medium (101- 250 hospital beds), and large (=251 hos- pital beds). Teaching status was mea sured by the ratio of resident physicians and [ellows to hospital beds, which has been suggested as superior to univer sity alfiations and association member- ships as an indicator ofthe intensity of teaching activty."* Hospitals with no postgraduate trainees (nonteaching) were contrasted with those that had 1:4 or smaller trainee-bed ratios (minor teaching hospitals) and those with ra tios that were higher than 1:4 (major teaching hospitals). Finally, hospitals ‘with facilities for open heart surger and/or major transplants were classi- lied as high-technology hospitals and contrasted with other hospital.” Nurses and Nurse Outcomes. Sur vveys were mailed in the spring of 1099 toa 50% random sample of registered nurses who were on the Pennsylvania Board of Nursing rolls and resided inthe state. The response rate was 52%, which ‘compares favorably with rates seen in other voluntary surveys of health pro- fessionals® Roughly one third of the rnurses who responded worked in hos- pitalsand included the sample of 10184 nurses described here. No special re- cruiting methods or inducements were used. Demographic characteristies ofthe respondents matched the profile for Pennsylvania nurses in the National Sample Survey of Registered Nurses.” Nurses employed in hospitals were asked to use a list to identify the hospital in which they worked, and then were q ried about their demographic characte isties, work history, workload, job sat- isfaction, and feelings of job-related burnout. Questionnaires were returned by nurses employed at each of the 210 Pennsylvania hospitals providing adult acute care. To obtain reliable hospital- level estimates of nurse staffing (the ra- tio of patients to nurses in each hospi- tal) attention was restricted o registered, nurses holding stall nurse positions i volving direct patient eare and to hos- pitals from which at least L0'stich nurses returned questionnaires. In 80% of the 168 hospitals in the final sample, 20 or more nurses provided responses to ou ‘questionnaire. There were more than 50 nurse respondents from hal ofthe hos- pitals. We examined 2 nurse job out ‘comes in relation to staffing: job satis- faction (rated on a4-point scale from very dissatisfied to very satisfied) and burn- cout (measured with the Emotional Ex- hhaustion scale of the Maslach Burnout Inventory, a standardized tool) Patients and Patient Outcomes. Di charge abstracts representing ll adm 16 Reprinted (©2002 American Medical Association, All rights reservedsions to nonfederal hospitals in Penn- sylvania rom 1998 0 1999 were obtained from the Pennsylvania Health Care Cost Containment Council. These discharge abstracts were merged with Pennsylva- nia vital statistics records to identify patients who died within 30 days of hos- pial admission to control for timing of discharge as a possible source of varia- tion in hospital outcomes. We exam- ined outcomes for 232342 patients between the ages of 20 nd 85 years who underwent general surgical, orthope- dic, or vascular procedures in the 168 hospitals from April 1, 1998, to Nover- ber 30, 1909, Surgical discharges we selected for study because of the avail- ability of well-validaced risk adjustment models." The numberof patients dis- charged from the study hospitals ranged from 75 to 7746. Only the first hospital admission for any of the DRGs listed in the BOX forany patient during the study period was included in the analyses. In addition to 30-day mortality, we examined failure-to-rescue (deaths within 30 days of admission among patients who experienced complica tions).***" Complications were identi- fied by scanning discharge abstracts for International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes in the secondary di- agnosis and procedure fields that were suggestive of 39 different clinical events. Distinguishing complications from pi viously existing comorbidities in- volved the use of rules developed by ex- pert consensus and previous empirical work, as well as examination of dis- charge records for each patient's hospi- lalizations 90 days before the surgery of interest for overlap in secondary diag- nosis codes.” Examples of complica lions included aspiration pneumonia, and hypotension/shock, Patients who died postoperatively were assumed to hhave developed a complication even if no complication codes were identified in their discharge abstracts Risk adjustment of mortality and fail- ure-to-rescue for patient characteris lies and comorbidities was accom- plished by using 133 variables, including age, sex, surgery types, and dummy vari- NURSE STAFFING AND HOSPITAL OUTCOMES Box. Surgical Patient Diagnosis Related Groups Included in the Analyses of Mortality and Failure-to-Rescue General Surgery 146-155, 157-162, 1o4167, 170, 171, 191-201, 257-268, 285-203, 403, and 404 Orthopedic Surgery 200-211, 213, 216-219, Vascular Surgery 110-114, 119, and 120 234, 471, 401, and 496-503, ables indicating the presence ofchronic of the hospital admission, comorbidi- preexisting health conditions reflected _ties,and relevant interaction terms. For In the ICD-9-CM codes in the dis- analyses of both patient and nurse out charge abstracts (eg, diabetes melli-_ comes, we adjusted for hospital size, tus), as well as a series of interaction teaching status, and technology terms, The final et of control variables Alllogistie regression models were es \was determined by a selection process timated by using Huber-White (ro- that paralleled an approach used and re- bust) procedures to account for the clus- ported previously."”*" The C statistic tering of patients within hospitals and (area under the receiver operating char- adjust the SEs of the parameter esti- acteristic curve) for the mortality riskad- mates appropriately.""*¥ Model ealibra- justment model was 0.89." lion was assesse with the Hosmer- Lemeshow statistic.” We used direct Data Analysis standardization to illustrate the magni- Descriptive datashow how patientsand tude of the effect of staffing by estimat- nurses in our sample were distributed ing the difference in the numbers of across the various categories of hospi- deaths and episodes of failure-to- tals defined by staffing levelsand other rescue under different staffing sce- characteristics. Logistic regression mod-_narios. Usingall patients in the study and. els were used to estimate the fleets of using the final ully-adjusted model, we staffing on the nurse outcomes Gob dis- estimated the probability of death and satisfaction and burnout) and 2 patient failure-to-rescue for each patient un- outcomes (mortality and failure-to- der various patient-to-nurse ratios ( rescue). We computed the odds of 4,6, and 8 patients per nurse) with all, nurses being moderately orvery dissat- other patient characteristics un- isfied with their current positions and changed. We then calculated the differ- reporting a level of emotional exhaus- ences in total deaths under the differ- tion (burnout) above published norms ent scenarios."* Confidence intervals, formedical workersand of patients ex- (CIs) forthese direct standardization es- perieneing mortality and failure-to- mates were derived with the A method rescue under different levels of regis- described by Agrest.” All analyses were tered nurse staffing, before and after performed using STATA version 7.0 contro for individual characteristicsand (STATA Corp, College Station, Tex), and hospital variables. For nurse out- P<.05 was considered statistically sig- comes, we adjusted forsex, years of ex- nificant in all analyses, Threat degree orsbove spon or RESULTS associate degrees highest credential in Characteristics of Hospitals, nursing), and nursing specialty. For Nurses, and Patients analyses of patient outcomes, we con- Distributions of hospitals with various, trolled for the variables in our risk ad- characteristics, distributions of nurses justment model, specifically, demo- surveyed, and patients whose out- graphic characteristiesof patients,nature comes were studied are shown in (©2002 American Medical Association. All rights reserved. (Reprints) JAMA, Oxser 2190, 2002 Vo 288, No. 16 1989NURSE STAFFING AND HOSPITAL OUTCOMES Characteristic ‘Tang pants pornos 5 a Tetinciogy Nene 107627) ‘ner E62, "T Stucy Hospialn Surge! Patents Stached, ana Nurse Respondents Hospiae™ Ne. (08) Nurses (veto 784) anna) 7414173) THT 752 45120 20, 21360 021 TOE TOs 306 (2) 05 (60) 1612369) THOBTOT, 105 700 5 rosaze aa 1288 6. 4706 146.2) BATS 635) 92037 42.8) 4553 48.7 "2, characters of Nurcer 40 184) inthe Study Hospitals” Characterise Te) ma BS LT BSN Jogroe oc higher 2080 (2018) "Yers worked ab a nuree, man ($0) 13:8 1.8) Gina specalty ‘Medics and surgical 3188 0) Intense es 003 (19.8) Gperatrgteconery oom 008 2.8) Ober 4008 29.5) High emotions exhaustion 006 13.) Desatisted with curentjob 4162 (81.8) TALE 1. Fifty percent of the hospitals ‘had patient-to-nurse ratio that were 5:1 or lower, and those hospitals dis- charged 65.9% of the patients in the study and employed 64.4% of the nurses ‘we surveyed, Hospitals with more than 250 beds accounted fora disproportion- ate share of both patients and nurses (45.5% and 43.4%, respectively). Al- though high-technology hospitals ac- counted for only 28.0% of the institt- tions studied, more than half (55.3%) of the patients discharged and 53.8% ‘of nurses surveyed were from high- technology hospitals, A majority of the patients studied and nurses sur- 1990 JAMA oct veyed were drawn from the 61 hospi- tals (36.3%) that reported postgradu- ate medical trainees in 1999, ‘As shown in TABLE 2, 94.19 of the nurses were women and 39.6% held a baccalaureate degree or higher. The mean (SD) work expe Ing was 13.8 years (0.8). Thirty-one pe cent of the nursesin the sample worked fon medical and surgical general units, while 19.6% and 9.8% worked in in- tensive care and perioperative set- tings, respectively. Forty-three pet cent of the nurses had high burnout scores and a similar proportion were dissatisfied with their current jobs. Ofthe 252342 patients studied, 53813, (23.2%) experienced a major complica tion not present on admission and 4535 (2.0%) died within 30 days of admis- sion. The death rateamong patients with complications was 84%. The surgical case types and clinical characteristics of the patient cohortate shown in TABLE 3 Slightly more than half of patients (51.2%) were classified in an orthope- dic surgery DRG, with the next largest, group of patients (36.4%) undergoing di- gestive tract and hepatobiliary surger- tes, Chronic medical conditions, with the exception of hypertension, were rela- tively uncommon among these pa- tients, Patients who experienced com- plications and were included in our analyses of failure-to-rescue were sini- larto the broader group of patients in our mortality analyses with respect to their comorbidities, but orthopedic surgery patients were less prominently repr sented among patients with complica- Lions than in the overall sample. Staffing and Job Satisfaction and Bumout Higheremotional exhaustion and greater jobalissatisfaction in nurses were strongly ‘and significantly associated with patient- lo-nutse ratios. TABLE 4 shows odds ratios (ORs) indicating how much more likely nurses in hospitals with higher palient-lo-nurse ratios were to exhibit ‘burnout scores above published norms and to bedissatisfied with theirjobs. Con- trolling for nurse and hospital charac teristics resulted in a slight increase in these ratios, which in both cases indi cated apronounced ellect ofstaling. The Final adjusted ORs indicated that an increase ofl patient per nurse to a hos- pitalsstalfinglevel increased burnout and job dissatisfaction by factors of 123 (05% C1, 1.13-1.34) and 1.15 (05% C1, Lo7- 1.25), respectively, or by 23% and 15%. This implies that nigsesin hospitals with 8:1 patient-to-nurse ratios would be 2.29 Limesaslikely as nurses with 4:1 patient- to-nurse ratios to show high emotional exhaustion (ie, 1.23 tothe 4th power for 4 additional patients per nurse=2.29) and 1.75 uimesas likely tobe dissatisied with their jobs (ie, 1.15 to the 4th power for 4 additional patients per nurse=1.75), (Our data further indicate that, although 43% of nurses who report high burnout and are dissatisfied with theirjobs intend toleave their current job within the next 12 months, only 11% of the nurses who are not burned out and who remain sat- isfied with their jobs intend to leave Staffing and Patient Mortality and Failure-to-Rescue Among the surgical patients studi there was a pronounced effect of nurse staffing on both mortality and mortal- ity following complications, Table also shows the relationship between nurse staffing and patient mortality and failure- 16 Reprinted (©2002 American Medical Association, All rights reservedNURSE STAFFING AND HOSPITAL OUTCOMES to-reseue (mortality following compli- tients and 8.7 (05% CI, 3.9-13.5) addi-__than 6 patients per nurse, we would ex- cations) when other factors were ig- tional deaths per 1000 patients with pect 2.6 (05% Cl, 1.2-4.0) additional nored, after patient characteristics were complications. Ifthe stalling ratio in all deaths per 1000 patients and 0.5 (05% controlled, and after patient character- hospitals was8 patients per nurse rather Cl,3.8-15.2) additional deaths per 1000 istics and other hospital characteristics (size, teaching status, and technology) ‘were controlled. Although the ORs re- Necting the nurse stafling effect were ‘Table 3. characteris of the Sule! Patents Included In Analyses of Moray an Failre-to-Rescue™ Ne) somewhat diminished by controlling for te patient and hospital characteristics, they peters emt it remained sizable and significant for both Characterete Gave, prenie mortality and failure-to-rescue (1.07; TOT ea ST) 95% Cl, 1.03-1.12 and 1.07; 95% Cl, area) 1.02-1.11, respectively). An OR of L.07 implies thatthe odds of patient mortal- Gesgervahn at caee TSAR ity increased by 7% forevery additional eye Reysene CoE ROC patent in the average nurses workload "Gerad gery inthe hospital and that the difference Deyo ap aaa ois SoS E trom tooandifom tte patents pet levee NBS nurse would be accompanied by 14% and. cca ae patoiary i a 31% increases in mortality respectively Tissases and deorsar ot he a, TTB, (ie, 1L07 tothe 2nd powers 1 Mand 1.07 Saedmoots foam, and oes NOC O} to the 4th power=13)) Ebon ater ace es, These effects imply that, all else being 2rd disorders MOC 10) ‘equal, substantial decreases in mortal. — *nopesiesumgey sec eeald weal immoral sass and dada oh mixcioaaltal EWE GIA WARE ityrates could result from increasing reg. eS istered nurse stalling, especially for pa GS tients who develop complications. Direct Diseases and daorders ofthe crculatory Tee waa standardization echniqes were used to syste MOC) predict excess deaths inall patients and Wedea Fistor comoria inpaientswith complications thatwould — Coraestve hear fi 11705,6.1) be expected ifthe patient-to-nurse ratio forall patients in the study were at vari- ‘ous levels that figure prominently inthe California stalling mandate debates, I'he stalfing ratio in all hospitals was 6 pa- lients per nurse rather than patients per pulronary dea Diabetes alts (reuin and nonnsun Gepance purse wewoulleapeet23(09%CL.L1- patargas a gnecahe oe aS SES OT 3.5) additional deaths per 1000 pa- "sere zones nti carte abso ‘Table 4, Patent to-Nuree Ratios With High Emotional Exmauston and Job Disatsfacton Among Staff Nurses and With Patent Martalty and Failure to-Rescue” ‘Os Fao (05% Confidence awa) “Adjusted for ‘Adjusted for Pp NusoorPatent =p Nurse or Patient and ep Unadjusted Value __Characterisien__—_Value ‘Hospital Characteristics Value Na omconee Hehemotensl exhaustion 1.17 (110-126) oot t7(1.10-426)_<.001 1.23(1.1341.98) 001 Tob cesatetacion TAPROOT OTTO Sor Tasha) =0at Filan outcomes Moray 114(1091.19 —<001_t0a(tottgy 001 107 (1091.12) 001 Fanwetoresaue TAT (LOGT TT) —_ OO .09 0-113) oT Tor Hae. = aT (©2002 American Medical Association. All rights reserved. (Reprints) JAMA, Oxser 2490, 2002 Vo 288, No 161994NURSE STAFFING AND HOSPITAL OUTCOMES patients with complications. Stalling hos- pitals uniformly at 8 vs + patients per nurse would be expected to entail 5.0 (05% Cl, 24.7.6) excess deaths per 1000 patientsand 18.2 (05% Cl, 7.7-28.7).e ccess deaths per 1000 complicated pa- Lents. We were unable to estimate ex cess deaths or failures associated with a ratio of 10 patients per nurse (one of the levels proposed in California) because there were so few hospitalsin our sample stalfed at that level ‘COMMENT Registered nurses constitutean around= the-clock surveillance system in hospi- tals forearly detection and promptinter- vention when patients’ conditions deteriorate. The effectiveness of murse surveillance is influenced by the num ber ofregistered mursesavailable toassess patients on an ongoing basis. Thus, itis hot surprising that we found nurse stall- ing ratios to be important in explaining variation in hospital mortality. Numer= cous studies have reported an associa- tion between more registered nursesand lower hospital mortality, but often as a by-product of analyses focusing directly fon some other aspect of hospital resources such as ownership, teaching status, or anesthesiologist diree- tion." Therefore, asimple search for literature dealing with the relation- ship between nurse staffing and patient outcomes yields only a fraction of the studies that have relevant findings. The relative inaccessibility of this evidence base might account for the influential Audit Commission in England conclud- ingrecentlythat thereisno evidence that more favorable patient-to-nurse ratios result in better patient outcomes.”? (ur results suggest thatthe Califor- nia hospital nurse staffing legislation represents a credible approach to re- ducing mortality and increasing nurse retention in hospital practice, ifitean be successfully implemented. More- over, our findings suggest that Califor- nia officials were Wise to reject ratios favored by hospital stakeholder groups of 10 patients to each nurse on medi- cal and surgical general units in favor of more generous staffing require- 1992 JAMA ccisher 2/30, 2002 Val 288, No, ments of 5 to patients per nurse. Our results do not directly indicate how many nurses are needed to care for pa- dents or whether the ‘mum ratio of patients per nurse above which hospitals should not venture. (Our major point is that there are di tectable differences in risk-adjusted mortality and failure-to-rescue rates across hospitals with different regis- tered nurse staffing ratios, In our sample of 168 Pennsylvania hospitals in which the mean patient-to- nurse ratio ranged from 4:1 10 8:1, 4535, of the 232342 surgical patients with the clinical characteristics we selected died within 30 days of being admitted. Our results imply that had the patient-to- nurse ratio across all Pennsylvania hos- pitalsbeen41, possibly 4000 of these pa- tients may have died, and had it been 8:1, ‘more than 5000 of them may have died, While this dlference of 1000 deaths in Pennsylvania hospitals across the 2stall- ing scenarios is approximate, it repre sents a conservative estimate of prevent- able deaths auributable to nurse stalling fn the state. Our sample of patients rep- resents only about half of all surgical cases in these hospitals, and other pa tients admitted to these hospitals are at risk of dying and similarly subject to the effects of stalling. Moreover, in Califor- nla, which has nearly wiceas many acute care hospitals and discharges and an overall inpatient mortality rate higher than in oursample in Pennsylvania (23% vs 2.0%), it would be reasonable to © pect that the difference of 4 fewer pa tients per nurse might result in 2000 oF more preventable deaths throughout a similar period, ‘Our results further indicate that nurses in hospitals with the highest patient-to- nurse ratiosare more than twiceas likely to experience job-related burnout and almost twice as likely to be dissatisfied with their jobs compared with nursesin the hospitals withthe lowest ratios. This elfect of staffing on job satisfaction and burnout suggests that improvements in nurse staffing in California hospitals resulling from the new legislation could be accompanied by declines in nurse uumover. We found that burnout and dissatisfaction predict nurses’ inten- tions to leave their current jobs within a year. Although we do not know how many ofthe nurses who indicated inten- tions to leave their jobs actually did so, it seems reasonable to assume that the 4-fold difference in intentions across these 2 groups translated to at least a similar difference in nurse resigna- tions. Ifrecently published estimates of the costs of replacing a hospital medi cal and surgical general unit and as cialty nurse of $42000 and $6400, respectively, are correct, improving sall- ing may not only save patient lives and decrease nurse turnover butalso reduce hospital costs.** Additional analyses indicate that our conclusions about the effects of stall- ingand the sizeof these effects are simi- larunder a variety of specifications, We allowed the effect of nurse stalling to be nonlinear (using a quadratic term) and vary in size across stalfing levels (us- ing dummy variables and interaction terms) and found no evidence in this, sample of hospitals that additional reg. istered nurse stalling has different effects atdiffering staling levels. Limiting our analyses to general and orthopedic sur- {gery patients and eliminating vascular surgery patients (who have higher mor- tality and complication rates) did not affect our conclusions and effect-size estimates, Also, our findings were not changed by restricting attention to inpa- tient deaths vs deaths within 30 days of admission. Results were unaffected by restricting analyses to patients who were discharged after our stalling mea- sures were oblained, rather than to the patients who were discharged [rom 9 months before to 9 months following the nurse surveys that produced our staffing measures. They were also unchanged by restricting the sample of nurses from which we derived out stall- ing measures to medical and surgical nurses, as opposed to all staf nurses. Finally, they were neither altered by adjusting for patient-to-licensed prac- ical nurse ratios and patient-to- unlicensed assistive personnel ratios (neither of which were related to patient outcomes) noraffected by excluding the 16 Reprinted (©2002 American Medical Association, All rights reservedhospitals in our sample with smaller numbers of patients of nurses, (One limitation of this study isthe po- tential for response bias, given a 52% re sponse rate. We find no evidence that the nurses in our sample were dispropor- tionately dissatisfied with their work rela- live to Pennsylvania stall nurses from the National Sample Survey of Registered. Nurses (a national probability-based. sample survey performed in 2000) Fur- thermore, with respect to demographic characteristics (sex, age, and educa- tion) included in both surveys, our sample of nursesalso closely resembles those participating in the National ‘Sample Survey of Registered Nurses. We are confident that these resulls are not specific to this particular sample of nurses. Ultimately, longitudinal data sets will be needed to exclude the possibil- lay that low hospital nurse staffing isthe consequence, rather than the cause, of poor patient and nurse ousicomes, (ur findings have important impli- cations for 2 pressing issues: patient safety and the hospital nurse shortage. (Our results document sizable and sig- nificant ellects of registered nurse stall- ing on preventable deaths. The associa lion of nurse staffing levels with the rescue of patients with life-threatening conditions suggests that nurses contib- ute importantly to surveillance, early de- tection, and timely interventions that save lives, The benelits of improved reg- istered nurse stalling also extend to the larger numbers of hospitalized patients who are notat high risk for mortality but nevertheless are vulnerable to a wide range of unfavorable outcomes, Improv ing nurse staffing levels may reduce alarming turnover rates in hospitals by reducing burnout and job dissatisfac- tion, major precursors of job resigna- tion. When taken together, the im- pacts of stalling on patient and nurse ‘outcomes suggest that by investing in registered nurse stalling, hospitals may. avert both preventable mortality and low nurse retention in hospital practice, ‘Author Contibutions: Study concept and desi: ‘Mken late, Sane, Sock, Ser ‘equiston of datz Aen Clarke, Soha ibe ‘oats and interpretation of data Aken, Clarke, Sean, Siber (©2002 American Medical Association, All rights reserved, Downloaded From: https:/ NURSE STAFFING AND HOSPITAL OUTCOMES rating ofthe manuscript: Aiken, Clarke, Sloane, Ser Cts revsin of the manusip for mpartant inte ‘ectual conan Aue, Clarke, Soane Soha, be ‘Sati expertise: Clark, Sloane, ibe. (btainedfunang: Alen, Scan, Soca. ‘Adminstratve tecincal erate support Aken, Cake, ocr Sber ‘Stuy supersin: Aen, Cle, Ibe Funding/Suppert: Ths sua) ws supported by grant OT NAOSa4S trom the Nan Insite of Narsing Reseweh, Natonal estates of Heath. ‘Adpouledgent; WetharkPul Also, PRO, fom {he Universty of Pensivana for statistical cons {ation and Kueme Zhang, MS, Wet Chen MS, er Orit Even shoshan, MS, fom the Cente for Ou ‘ames Research atthe Chile's Hospital of Pi epha for her asistance TaN 4. Soerg SC. Patent deaths edt lack of muss ew Yar ies August 8, 200218 2. Parr Pope T How to lesen impact of rasing Shortage on your hasta stay. Wall Steet uma! March 2, 20078 3, Tlfrd A. Second opiniones cae for patent Washington Post August 20, 2002201. 4 -Aken LH Cathe, ane DM, etal Nurser Pts on host care i ive counties Heath IF Fitiweod? Soot 303 53, 5. Heny Kase arly Fount, Suey of phy Sian and nurses, Avadle at Hips otg Feontet/ 1999/1503 Accessed Maen 22,2002 Shut Rota), Sey D, Long Mito E. ‘ier nave athe nuses gone? final resus of ou Patent Care Suvey. Aer] Nuys, 19969625 39, 17. Comment fara Dadtorn five cunses ee ‘Gecine heath ete quality. Commonwealth Fund (artery. 20005'1-4 nt Conmason on Accretion of Healthcare Organizations Heath care athe cosroads State esi aetng te evching nrg chs, 2008 \Valable a. hi jeto org news oor ‘neues eleatevarchves/heaknscare atthe ‘rosea po ecessd September 17, 2003, 29 Spot: na shoud we exec om Caloris’ miner nurse stain gatien.Nurs Ad. 2001 sis. 40. Seago JA. The Calfornia experiment: ates ‘Bestor imum nue patra. Nurs Adm 700237 48.58 41. Frdman. Nuse raise ohh. San Fan 2:0 Chronic January 30, 200218 ‘2. Covemar Gay Dav announces propose muse {oepaent aos ves lease) Sacramento, Cl OF. tet ne Governor anus 22,2002. 4 Latter Avancern understand preci ingrurse tumover Res Soc Heath Cae 189815 eat 1. kent Cake, Soane DM, Hosta tating ganatond poor and qual oa: cessation png) Ca Heat Cave 2002 183.13, 12. AiA'Annual Survey Database. 1999 ed. Chi 3g, American Hospital ssoition 1298, $e Conmonueatno! Pennsyvaia Moga Ques: tlonar: Reporting Paod uly 7, 1998-lune 30, 1989. Hansburg, Pa: Department of Health, Div Son of Saisie 47 Needleman, ueraus Pl, Mates, Sewart ‘Biewnsty Muse stating and patent outcomes esp Avatable tmp bhp sa gow/nrsing ‘tity him Accessed August 6 2002, 48: Ayan J2, Wersman JS; Chan Taber, Ep Stein AN. Qual of ae fr bo carmon ness in teaching and nonteachinghosplls Health A? (wand, 199: 17198 205, Sp. Mars A, Krakauer H Xun EM e Hostal raters and moray ales Engl Med. 198; Samant 20. Asch DA, Jeiewsti MK. Christakis NA. Re ‘Sorte aes toma surveys pubished in medalou as. J Clin Epidemiol 1997 50:1129-1136. 231 The Reptred Nurse Population Rocke Me {GS Dept of eth and Human series: 1996 22. MelehC, Jao Se Buon heh profes Sons aioe psjenoegeal nays Sanders C8 Sub [es Soaa olay of Heal ands: dae Ni Lawrence Ebaum Acer 1982297-251, 23. Mase GJaccon SE Maia Bum Iver {ary Manual 2b et Pao Ao, Calt-Consuting logs Press 1986, 2a Siber I, Willams 9, Keakauer, Schwa. Fosptal end paint characterises assoated with (eat ater suger ast) of averse occurence and {burt rescue Med Cars, 1992 30615629. 25 Siber 4 Rsenbaum PR, Rose RN. Compasing the conrbuons of ous of predictor: nich ou erves vay wih hospital athe than patent cars. fers? Am Sat Asoc 199590718 26. Sibert Rosenbaur PR Scat 5, Rss RN, ‘ans SV Eslation ofthe completion rte a8 reas of quay of aren coronary ary Bypass (gatsurgery JAA. 1905,274317323, 37, Sa Kena Sk Ever Shshan ©, aA ftneslogs drectn ar patent culcomes. Ane {estoy 200033-152 163, 28, Se Rosenbaum PR rdeau ME ta. Mu {raat mating and bs reduction the surgi outcomes sty. ed Care. 200738 1081068 23, Sber Kenedy SK Eve Shoshana A fsthesologet board creation ana patent ut fees. Avesthesalogy. 2002-36 1048-1052 30, Hanley JA Met Bl. The meaning and ue of Aeateg under ease open arate ROO) five, Racal) 1982°14328 96 SH igber Pl The Behavior of Maximum Like had Estates Under Non sandard Condon Po caigso the Fh Berkley Symposium on ath ‘tial Stasis and Prababiy Bele Uriversty tt cabloma Pres 1967291283 $32. White Maman Kethood etimaon of i ‘pected ade Eeaometca 198230: 535. Hosner DM, Lemesow .Apled LogsicRe gestion New York NY Jo Wey & sors In 1968, 3a hop YON Fenbeg St, Holard PW Dirte ‘Mastvanste Anas Thety and Pachce. Can bide, as: MIT ress 1573 35, Ages A Categoria Data Analysis New Yor, IN Jon Wey & Sons ne 1990, 36. Shotl it, Hughes EPX. The efecto regu fon, competition, and somerhip on moray ats mong hxptl inpatients N ng) Med. 1988 318 ‘00-1107 27. state of Meine. Mursng Stat in Hospital SndNursing Homes Adequate? Washington OC: Natiorat Academy Press 1996. 538. Aken LH Sloane Dl LakeET, Socal We ie AL Grganzatonandautcomes cirpatent AIDS (ae ied Care 1999.37 760-772. 39: Heel Pe, Sorel SM. aves udcomes and ‘aiatorsinovganzaton of care dsvety. Med Care 1387 35(upp!TDNST9.NSS2. 40, Moves Moser sun difeencesin Dostaperave death aes JAMA 196830352 494, 4. Pronovst,Jenees MW, Dorman etal. Or fguizabonal caacesisof tensive care ure fied to utcomes cf abdominal soc sge. MA, sssoaaisio3t7 12. Neeieman ), Buea P, Matte, Stewart M ZeeinseyK Nurse-tatng levels aa the quality of Gare in hospital N Engl J Med. 2002;345:1715 im. 48, fut Commisson Acute Hospital Porto Re ‘eof tional Figs: WardSteting London, and The Aut Comsson: 20013 utsng nective Cornmtee Reversing the Fight Talent Nursing Retention aan Ea of Catherng Srortage Washington, DC: Aavsor Board Co; 200 (Reprints) JAMA, Oxser 2190, 2002 Wo 298, No. 161998