Limiting Nurse Workloads Good for RNs and Patients

April 21, 2010 — A law passed in California in 2004 limiting the number of patients that can be assigned to a nurse has contributed to lower mortality rates among general surgery patients and increased job satisfaction among the state's nurses, according to the first comprehensive evaluation of the legislation, published online April 9 in Health Services Research.
The California law, the first in the nation, specifies that nurses may care for no more than

  • 5 patients in a medical-surgical unit,
  • 4 pediatric patients,
  • 2 intensive care patients,
  • 6 psychiatric patients, or
  • 3 patients in labor and delivery.
Linda H. Aiken, PhD, RN, director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing, Philadelphia, and colleagues examined general surgery outcomes data and hospital staffing information from California in 2006, 2 years after the law was enacted. The researchers did the same in Pennsylvania and New Jersey — 2 states without mandated nurse staffing requirements — and compared how nurse and patient outcomes are affected by differences in nurse workloads across the hospitals in these 3 states.
The analysis included 22,336 hospital staff nurses working in 604 adult nonfederal acute care hospitals in California (n = 9257 registered nurses [RNs] in 353 hospitals), New Jersey (n = 5818 RNs in 73 hospitals), and Pennsylvania (n = 7261 RNs in 178 hospitals). Small (<100 beds), medium (101 - 250 beds), and large (>251 beds) hospitals were represented.
The authors report that average workloads were significantly lower (P < .05) for RNs in California than in New Jersey and Pennsylvania (mean patients per shift, 4.1 in California vs 5.4 in New Jersey and Pennsylvania). The percentage of California nurses on medical-surgical wards who reported overseeing 5 or fewer patients on their last shift, as mandated under California law, was 88%; the same was true of only 19% and 33% of medical-surgical nurses in New Jersey and Pennsylvania, respectively. On medical-surgical wards, California RNs cared for 2 fewer patients on average than New Jersey RNs and 1.7 fewer patients than Pennsylvania RNs.
"Sizeable" Effects on Surgical Inpatient Mortality
Dr. Aiken's team used logistic regression models to estimate the effects of nurse staffing on 30-day inpatient mortality. The results suggested that there would have been 13.9% fewer deaths among surgery patients in New Jersey and 10.6% fewer in Pennsylvania if hospitals in those states had been staffed at the same average level as California hospitals .
"In these two states alone, 468 lives might have been saved over the 2-year period just among general surgery patients if the California nurse staffing levels were adopted," Dr. Aiken notes in a university-issued statement. "Because all hospitalized patients are likely to benefit from improved nurse staffing, not just general surgery patients, the potential number of lives that could be saved by improving nurse staffing in hospitals nationally is likely to be many thousands a year," she predicted.
Better Work Environment
The survey also found significantly and consistently greater job satisfaction among California RNs. Higher percentages of nurses in California than in New Jersey and Pennsylvania reported that
  • their workloads are reasonable (73% vs 59% and 61% for New Jersey and Pennsylvania, respectively),
  • they receive substantial support in doing their jobs (66% vs 53% and 55%, respectively),
  • there are enough staff RNs to provide quality care (58% vs 41% and 44%, respectively),
  • there are enough staff RNs to get their work done (56% vs 40% and 44%, respectively), and
  • 30-minute breaks are part of their typical workday (74% vs 51% and 45%, respectively).
All of these differences were significant to the P < .01 level.
In addition, a smaller percentage of nurses in California than in New Jersey and Pennsylvania reported that their workloads caused them to miss changes in patient conditions (33% vs 41% and 37%, respectively; P < .01). There was also evidence that a significantly lower proportion of California RNs experience high burnout (29% vs 34% and 36%, respectively).
Dr. Aiken's team notes that although nurse self-reports of workloads may be prone to bias, in previous research they found them to have "considerable predictive validity and better predictive validity than [American Hospital Association] measures of nurse staffing." The researchers also say they rigorously controlled for a variety of nurse characteristics that might affect the data, such as education and experience, as well as patient and hospital characteristics that might affect the results.
"The California experience may inform other states that are currently debating nurse ratio legislation," Dr. Aiken and colleagues conclude, noting that Massachusetts, Minnesota, New Jersey, Illinois, and Oregon are among 18 states currently evaluating nurse staffing issues.
The study was supported by the National Institute of Nursing Research, National Institutes of Health, the Robert Wood Johnson Foundation, and AMN Healthcare Inc. The authors have disclosed no relevant financial relationships.

Better Nurse-Patient Ratios Could Save Thousands of Lives Annually, Says Study

If California's mandatory nurse-patient ratios had been in effect in Pennsylvania and New Jersey hospitals in 2006, those states would have seen 10.6% and 13.9% fewer deaths among general surgical patients, according to a Pennsylvania researcher's analysis.

That equated to 468 lives that might have been saved, says Linda Aiken, director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing and the study's lead author.

Her report was published in the journal Health Services Research, and is considered the first comprehensive evaluation of California's controversial 2004 nurse staffing ratio mandate and may inform decisions in 18 other states that are considering lowering their nurse-staff ratios, such as Massachusetts, Minnesota, and Illinois.
Aiken's study received funding support from the Robert Wood Johnson Foundation and the National Institute of Nursing Research at the National Institutes of Health.

Aiken, a registered nurse and a well-known nursing workforce investigator, says that the difference between staffing at hospitals in California versus New Jersey and Pennsylvania "is very large, about two more patients per nurse [in medical surgical units]. And that's very significant."

To explain the decline in California mortality that she attributes to better nurse-patient ratios, Aiken says, "Nurses are the main surveillance system in hospitals.

"Nurses detect the majority of complications; the majority of medication errors that are detected by anyone are detected by nurses first. And nurses can distinguish between patients who are shivering after surgery because the operating rooms are cold, or who are shivering because they are in shock and are going into multiple organ failure that can't be reversed if it isn't caught early enough."

"All hospitalized patients are likely to benefit from improved nurse staffing, not just general surgery patients," Aiken says, adding that "the potential number of lives that could be saved by improving nurse staffing in hospitals is likely to be many thousands a year."

A spokeswoman for the California Hospital Association, which opposed the patient-nurse ratios and has criticized their effectiveness, said the organization was reviewing the report, but did not yet have a comment.
However, officials for the 155,000-member California Nurses Association were delighted with the report because it sponsored the law that mandated the lower ratios.

"This research documents what California RNs have long known–safe staffing saves lives," says Malinda Markowitz, CNA and National Nurses United co-president. "We see the effects every day at the bedside in improved patient care, an enhanced quality of life for patients, and nurses able to more safely practice the profession to which we have dedicated our lives."

Her study compared patient outcomes data reported by hospitals to state agencies and surveyed 22,236 hospital staff nurses in those three states. The report was long anticipated because California remains the first and only state to implement minimum nurse-patient staff ratios in its acute care hospitals, as of Jan. 1, 2004.
The law says a nurse must care for no more than five patients on a medical-surgical unit, four pediatric patients, two in intensive care, six in a psychiatric unit, and three in labor and delivery.

According to a table in Aiken's report, adjusted 30-day inpatient mortality in California was also significantly lower than in New Jersey or Pennsylvania.

Also, Aiken reported, 88% of nurses surveyed in a medical-surgical unit reported having five patients, but in New Jersey only 19% and in Pennsylvania only 33% reported those ratios. The rest had higher ratios.
Similar disparities were seen for nurses working in intensive care, telemetry, oncology, labor and delivery, and pediatric units, according to Aiken's report.

Aiken's surveys of nurses in those three states revealed that in California, nurses had better job satisfaction, less burnout, and said they provided better quality of care than did nurses who responded in Pennsylvania and New Jersey. "California nurses were more likely to rate quality of care as excellent than nurses in the other two states," she says.

Aiken's report from 2002 found that each patient added to a nurse's workload added 7% to the mortality rate for patients undergoing common surgeries. Also, she reported, higher nurse to patient ratios were also associated with more nurse burnout, job dissatisfaction, and precursors of voluntary turnover.

Since 2004, the state has increased the number of actively licensed RNs by more than 110,000, tripling the average annual increase before 1999 when the law was enacted, and five years before it took effect.
"From a policy perspective, our findings are revealing," Aiken wrote in her conclusion. "The California experience may inform other states that are currently debating nurse ratio legislation."

McAfee antivirus program goes berserk, freezes PCs

NEW YORK – Computers in companies, hospitals and schools around the world got stuck repeatedly rebooting themselves Wednesday after an antivirus program identified a normal Windows file as a virus.
McAfee Inc. confirmed that a software update it posted at 9 a.m. Eastern time caused its antivirus program for corporate customers to misidentify a harmless file. It has posted a replacement update for download.
McAfee could not say how many computers were affected, but judging by online postings, the number was at least in the thousands and possibly in the hundreds of thousands.
McAfee said it did not appear that consumer versions of its software caused similar problems. It is investigating how the error happened "and will take measures" to prevent it from recurring, the company said in a statement.
The computer problem forced about a third of the hospitals in Rhode Island to postpone elective surgeries and stop treating patients without traumas in emergency rooms, said Nancy Jean, a spokeswoman for the Lifespan system of hospitals. The system includes Rhode Island Hospital, the state's largest, and Newport Hospital. Jean said patients who required treatment for gunshot wounds, car accidents, blunt trauma and other potentially fatal injuries were still being admitted to the emergency rooms.
In Kentucky, state police were told to shut down the computers in their patrol cars as technicians tried to fix the problem. The National Science Foundation headquarters in Arlington, Va., also lost computer access.
Intel Corp. appeared to be among the victims, according to employee posts on Twitter. Intel did not immediately return calls for comment.
Peter Juvinall, systems administrator at Illinois State University in Normal, said that when the first computer started rebooting it quickly became evident that it was a major problem, affecting dozens of computers at the College of Business alone.
"I originally thought it was a virus," he said. When the tech support people concluded McAfee's update was to blame, they stopped further downloads of the faulty software update and started shuttling from computer to computer to get the machines working again.
In many offices, personal attention to each PC from a technician appeared to be the only way to fix the problem because the computers weren't receptive to remote software updates when stuck in the reboot cycle. That slowed the recovery.
It's not uncommon for antivirus programs to misidentify legitimate files as viruses. Last month, antivirus software from Bitdefender locked up PCs running several different versions of Windows.
However, the scale of this outage was unusual, said Mike Rothman, president of computer security firm Securosis.
"It looks to be a train wreck," Rothman said.

California hospital plans to use 100 Apple iPad

A California hospital plans to distribute more than 100 Apple iPads among its health care workers to allow them look at X-ray images, EKG results and more on the portable touchscreen device, according to a new report.

Nick Volosin, director of technical services at Kaweah Health Care District in Visalia, Calif., told Network World that he bought three iPads for testing, and plans to implement more than 100 at the facility in the next two months. Various patient monitoring programs will be accessed through Citrix virtual desktop and application delivery software. Using the Citrix Receiver, the hospital will be able to have its workers access desktop applications without writing proprietary software for the iPad.

The iPads will be distributed to home health care and hospice workers, nurses, dietitians and pharmacists. Because tight supply has forced Apple to turn down volume orders, the hospital had to work with Apple directly to make such a large purchase.

Volosin told author Jon Brodkin that the iPad and its 10-hour battery life will replace a laptop for many employees, particularly because it will eliminate the need to charge multiple times throughout the day, and it doesn’t need to be turned on and off. In addition to patient-related services, employees will also be able to use the device to do traditional office tasks like check their e-mail.

Another selling point for the iPad: the price. Starting at $500 for the 16GB Wi-Fi model, Volosin reportedly said that it is a more affordable option when compared to a traditional touchscreen tablet, which can cost as much as $3,000.

In addition to Volosin’s three test units, about 20 doctors have purchased their own iPads to use at the office. One kidney specialist said the device has made him more efficient and also improved patient safety.

Many hospitals have eyed Apple’s iPad since the device was first announced earlier this year. Some health care workers believe tablet computers help doctors and nurses spend more time with patients. One San Francisco program dubbed “Destination Bedside” uses tablet computers to provide X-rays, charts, prescriptions and notes.

In February, one study found that one in five physicians intended to buy an iPad, just days after it was announced. Epocrates Inc.’s survey of more than 350 clinicians found that 9 percent would buy an iPad when it became available, while another 13 percent intend to buy one in the first year. Another 38 percent said they were interested in the iPad, but wanted more information before they would decide whether or not to purchase.

Stress Hormones May Promote Ovarian Cancer Metastasis

FRIDAY, April 23 (HealthDay News) -- In patients with ovarian cancer, focal adhesion kinase (FAK) modulation by stress hormones -- especially norepinephrine and epinephrine -- may contribute to tumor progression, according to research published online April 12 in the Journal of Clinical Investigation.

Anil K. Sood, M.D., of the University of Texas M.D. Anderson Cancer Center in Houston, and colleagues studied human ovarian cancer cells which were exposed to either norepinephrine or epinephrine, and mice with a model of human ovarian cancer which were subjected to restraint stress. They also examined 80 cases of invasive epithelial ovarian cancer to assess the role of stress-induced FAK activity.

The researchers found that cancer cells exposed to the hormones exhibited lower levels of anoikis. In the mice, they found that the associated increases in norepinephrine and epinephrine protected the tumor cells from anoikis and promoted their growth by binding with the β2-adrenergic receptor and activating FAK. In the human cases, they found that 67 percent had increased FAK expression and that 50 percent had heightened levels of phosphorylated FAK. Three-year survival was significantly lower in those with increased FAK expression or heightened levels of phosphorylated FAK (30 and 15 percent, respectively) than in those with low FAK expression (65 percent).

"These findings also imply that the neuroendocrine 'macroenvironment' may play a significant role in shaping cellular activity in the tumor microenvironment in ways that ultimately facilitate cancer progression," the authors write. "Thus, protective interventions targeting the neuroendocrine system might simultaneously modulate multiple molecular pathways involved in tumor metastasis (e.g., anoikis, angiogenesis, and invasion)."

Nursing our way out of a doctor shortage

Give non-physicians more freedom to help patients.

Thanks to health care reform, millions of previously uninsured Americans will have policies enabling them to go to the doctor when necessary without financial fear. But it's a bit like giving everyone a plane ticket to fly tomorrow. If the planes are all full, you won't be going anywhere.

There are not a lot of doctors sitting in their offices like the Maytag repairman, playing solitaire and wishing a patient would drop by. Most of them manage to stay plenty busy. Nor is there a tidal wave of young physicians about to roll in to quench this new thirst for medical care.

On the contrary. The Association of American Medical Colleges says that by 2025, the nation could be 150,000 doctors short of the number we need. Meanwhile, the number of med students entering primary care, the area of greatest need, is on the decline.

It's hard to quickly boost the supply of physicians, since the necessary training usually takes at least seven years beyond college. The result, as an AAMC official told The Wall Street Journal: "It will probably take 10 years to even make a dent into the number of doctors that we need out there."

That, of course, is assuming that the new health insurance system doesn't drive aspiring or existing doctors out of medicine, which is entirely possible. Regardless, there seems to be no doubt that it will get harder to find someone to treat you, it may cost more and you'll spend two hours in the waiting room instead of one.

Or maybe not. What people with medical problems need is medical care, but you don't always need a physician to get treatment. You might also see a different sort of trained professional — say, a nurse practitioner, physician's assistant, nurse or physical therapist.

Not every ailment demands Dr. McDreamy, any more than every car trip requires a Lexus. If you have a sore throat, earache or runny nose, you probably don't absolutely require a board-certified internist to conduct an exam and dispense a remedy.

But it may not be up to you to decide who is suited to provide the care you want. Different states have different rules on what these clinicians may do. In many places, a nurse practitioner has to be under the supervision of a doctor. In others, she may not prescribe medicines or use the title "Dr." even if she has a doctorate (as many do).

Medicare typically reimburses nurse practitioners at a lower rate than physicians. In Chicago, an office visit that would bring $70 to a doctor is worth only $60 to a nurse practitioner.

But the need for more primary care is forcing a welcome reassessment of these policies. So 28 states are reportedly considering loosening the regulations for nurse practitioners, on the novel theory that any competent professional health care is better than none.

Private enterprise is already responding to what consumers want. Walgreens, for example, has established more than 700 retail health clinics staffed by nurses, nurse practitioners and other non-doctor professionals. CVS has its own version. The number of these facilities is expected to soar in the next few years.

You might fear that this sort of treatment is inferior to what you'd get from your personal doctor. Your doctor might agree. The American Medical Association, reports The Associated Press, warns that "a doctor shortage is no reason to put nurses in charge and endanger patients."

But put your mind at ease. A 2000 study published in the Journal of the American Medical Association found that where nurse practitioners have full latitude to do their jobs, their patients did just as well as patients sent to physicians. Other research confirms that finding, while noting that retail clinics provide their services for far less money than doctors' offices and emergency rooms.

Obviously, if you wake up with crushing pain in your chest or fall out of a second-story window, you'd be well-advised to see a specialist. But for common ailments that are mainly a nuisance, a physician may be a superfluous luxury.

Obama's health care reform rests on the assumption that expanding access demands a bigger government role. But even its supporters should be able to see that sometimes, it helps to get the government out of the way.

Steve Chapman is a member of the Tribune's editorial board and blogs at


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Nursing shortage: 1 in 5 quits within first year, study says

MIAMI — Newly minted nurse Katie O'Bryan was determined to stay at her first job at least a year, even if she did leave the hospital every day wanting to quit.
She lasted nine months. The stress of trying to keep her patients from getting much worse as they waited, sometimes for 12 hours, in an overwhelmed Dallas emergency room was just too much. The breaking point came after paramedics brought in a child who'd had seizures. She was told he was stable and to check him in a few minutes, but O'Bryan decided not to wait. She found he had stopped breathing and was turning blue.
"If I hadn't gone right away, he probably would have died," O'Bryan said. "I couldn't do it anymore."
Many novice nurses like O'Bryan are thrown into hospitals with little direct supervision, quickly forced to juggle multiple patients and make critical decisions for the first time in their careers. About 1 in 5 newly licensed nurses quits within a year, according to one national study.

That turnover rate is a major contributor to the nation's growing shortage of nurses. But there are expanding efforts to give new nursing grads better support. Many hospitals are trying to create safety nets with residency training programs.

"It really was, 'Throw them out there and let them learn,"' said University of Portland nursing professor Diane Vines. The university now helps run a year-long program for new nurses.

"This time around, we're a little more humane in our treatment of first-year grads, knowing they might not stay if we don't do better," she said.

The national nursing shortage could reach 500,000 by 2025, as many nurses retire and the demand for nurses balloons with the aging of baby boomers, according to Peter Buerhaus of Vanderbilt University Medical Center. The nursing professor is author of a book about the future of the nursing work force.

Nursing schools have been unable to churn out graduates fast enough to keep up with the demand, which is why hospitals are trying harder to retain them.

Medical school grads get on-the-job training during formal residencies ranging from three to seven years. Many newly licensed nurses do not have a similar protected period as they build their skills and get used to a demanding environment.

Some hospitals have set up their own programs to help new nurses make the transition. Often, they assign novices to more experienced nurses, whom they shadow for a few weeks or months while they learn the ropes. That's what O'Bryan's hospital did, but for her, it wasn't enough.

So more hospitals are investing in longer, more thorough residencies. These can cost roughly $5,000 per resident. But the cost of recruiting and training a replacement for a nurse who washed out is about $50,000, personnel experts estimate.

One national program is the Versant RN Residency, which was developed at Childrens Hospital Los Angeles and since 2004 has spread to 70 other hospitals nationwide. One of those, Baptist Health of South Florida in the Miami area, reports cutting its turnover rate from 22% to 10% in the 18 months since it started its program.

The Versant plan pairs new nurses with more experienced nurses and they share patients. At first, the veterans do the bulk of the work as the rookies watch; by the end of the 18-week training program, those roles are reversed.

The new nurses must complete a 60-item checklist. They must learn how to put in an IV line and urinary catheter; interpret different heart rhythms and know how to treat them; monitor patients on suicide watch and do hourly checkups on very critically ill patients; know how to do a head-to-toe physical assessment on a patient, as well as how to inform families about the condition of their loved one.

For Yaima Milian, who's currently in the program at Baptist, this is markedly different from the preparation she got at her first hospital in New Jersey. She left after a six-week orientation because she didn't feel ready to work solo.

While Milian was paired with a more experienced nurse at the New Jersey hospital, they didn't see patients together; they split the workload. Her first week on the job, Milian was charged with caring for several patients with complicated issues — those on ventilators and with chest tubes — and she felt thoroughly unprepared.

"It just didn't feel right, it felt very unsafe," Milian said.

Besides the residency's professional guidance, which includes classroom instruction, new nurses also get personal support from mentors — people they can call after a bad day or to get career advice. The new nurses also gather with their peers for regular debriefing, or "venting" sessions.

"Here you have this group that is pretty much experiencing the same things you're experiencing," Milian said, "and it makes you feel better."

To be sure, not all the nurses who leave do so because of a rocky transition. But for nurses who do leave because of stress, these programs seem to help.

The American Association of Colleges of Nursing and the University HealthSystem Consortium teamed up in 2002 to create a residency primarily for hospitals affiliated with universities. Fifty-two sites now participate in that year-long program and the average turnover rate for new nurses was about 6% in 2007.

"We believe all new graduates should be given this kind of support system," said Polly Bednash, the nursing association's executive director. "We are facing downstream a horrendous nursing shortage as a large number of nurses retire from the field... So you need to keep the people you get and keep them supported."

The federal government has jumped on the bandwagon. Since 2003, it has awarded $17 million in grants for 75 hospitals to start first-year training programs.

The National Council of State Boards of Nursing is considering a standardized transition program. It cited a study showing a link between residencies and fewer medical errors, but also pointed to the inconsistency among current efforts.

That's something O'Bryan, the Dallas nurse, knows about. Her hospital — which she declined to identify because she didn't want to be seen as complaining about a former employer — had a three-month program, in which she attended weekly classes and was assigned a nurse to shadow. After that period was over, though, O'Bryan was abruptly alone, even as she continued to face new situations that she wasn't sure how to handle.

"When things are going good and I'm not overwhelmed and I'm able to help people, I love it," she said, recalling the gratification of seeing a bedridden patient finally manage to take a few steps.
"There are always those moments," she said, "but they're interrupted pretty quickly."
The 27-year-old is currently looking for a new job. She's not sure it will be in nursing.

Copyright 2009 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.