Paper
Thursday, 20 July 2006
This presentation is part of : Acute Care Models and Strategies
Association Between Nurse Staffing and Education and Inpatient Mortality in VHA
Yu-Fang Li, PhD, RN1, Anne E. Sales, MSN, PhD, RN2, Nancy D. Sharp, PhD1, Elliott Lowy, PhD1, and Gwendolyn Greiner, MSW, MPH1. (1) HSR&D, VA Puget Sound Health Care System, Seattle, WA, USA, (2) Health Services Research and Development, VA Puget Sound Health Care System, Seattle, WA, USA
Learning Objective #1: State how findings from unit level analysis of the association between nurse staffing and mortality differ from facility level analysis.
Learning Objective #2: Discuss reasons for differences between analysis at the facility and unit level in the association between nurse staffing and mortality.
Objectives: Several large scale studies have found associations between nurse staffing and mortality outcomes for hospitalized patients, aggregated to the facility level. In the largest study yet conducted with unit level staffing and patient data, we examined the association between nurse staffing, skill mix, educational factors, and patient in-hospital mortality. Methods: Data came from several Veterans Affairs databases. We used risk adjusted, hierarchical modeling to examine the association between nurse staffing, skill mix, and mortality. Results: The analyses included 126,382 patients from 463 nursing units in 119 VAMCs. 184 were intensive care, and 279 non-intensive acute care units. In all cases, patient risk was the most significant factor associated with mortality (OR 1.18 in ICU, 1.35 in non-intensive acute care). Skill mix and staffing had a non-linear, U-shaped association with mortality risk in both ICU and non-intensive care patients, and there was no significant relationship between non-RN staffing and mortality. RN educational level was not significantly associated with mortality in either type of unit. Conclusions: Some of the relationships that have been shown between patient mortality and nursing factors at the facility level do not appear to hold in unit level analyses. Multi-level modeling, adequate patient risk adjustment, and careful modeling of non-linear relationships are critical. Aggregating both patients and nurse staffing to the facility level may result in biased estimates through mixing very heterogeneous groups. Implications: Staffing variables are modifiable by managers, but their relationship to outcomes is more complex than previously reported. It may be possible to optimize the mix between costly RN and less costly staff without an adverse impact on patient mortality.

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