1. Patient Turnover and Nursing Staff Adequacy Lynn Unruh, PhD, RN, LHRM Myron D. Fottler, PhD AcademyHealth Annual Research Meeting San Diego, June 6-8, 2004

2. Research Problem Common hospital nurse staffing measures: nurses or hours of nursing care patients or patient days of care Need to also consider intensity of nursing care Staffing needs vary with the amount and type of care provided for each of those patients

3. Research Problem An ideal measure of nursing staff adequacy should indicate the volume of nurses of a certain skill level that is necessary for the given volume of patients given the intensity of nursing care required for those patients during their stay: # of RNs # of patient days X intensity of RN care for those patient days

4. Nursing Care Intensity Indicators of nursing care intensity: Patient turnover Patient acuity

5. Patient Turnover As patient turnover increases Nursing care must be delivered in a shorter period of time Holding patient acuity and total nursing care requirements for the patient stay constant Admission, transfer, and discharge procedures take up an increasing proportion of the patients stay

6. Patient Turnover An available measure for patient turnover is patient length of stay The number of days a patient is an inpatient in the hospital. The inverse of patient length of stay produces a fraction that ranges between 0 and 1 Lower amounts indicate lower turnover, and vice versa.

7. Research Questions Does adjusting nurse staffing data for patient turnover, as measured by the inverse of patient LOS, significantly alter the measurement of nurse staffing and changes in nurse staffing? What is the trend in nurse staffing when measures adjust for both patient turnover and patient acuity?

8. Sample and Data Sources All general, acute-care Pennsylvania hospitals 1991-2000 (N= 166-213) Data obtained from: Pennsylvania Department of Health Yearly filled RN, LPN and Nursing Assistant FTEs American Hospital Association APDC* and LOS Patient days of care include outpatient care Atlas MediQual System Patient acuity

9. Design Assess the trend in the average patient LOS and turnover (inverse of length of stay). Create a patient turnover index using 1991 as the base year, and adjust nurse staffing measures for patient turnover using this index Compare the standard and new measures using paired sample t-tests Assess whether the trend over time in nurse staffing utilizing the new measure is significantly different than the old measure using paired sample t-tests Analyze the trend in nurse staffing adjusted for both patient turnover and acuity

10. Results Average Patient Length of Stay in Pennsylvania Hospitals, 1991-2000

11. Results Average Patient Turnover in Pennsylvania Hospitals 1991-2000

12. Results RN/1000APDC199119952000 Before Adjustment2.682.882.87 After Adjustment2.692.452.04 Mean Difference0-0.44-0.83 t Value----10.53***-25.05*** p<.01=*, p<.001=**, p<.0001=*** RN/1,000 APDC in Pennsylvania Hospitals 1991-2000

13. Results LPN/1000APDC199119952000 Before Adjustment0.600.520.43 After Adjustment0.610.440.30 Mean Difference0-0.08-0.13 t Value----8.04***-14.10*** p<.01=*, p<.001=**, p<.0001=*** LPN/1,000 APDC in Pennsylvania Hospitals 1991-2000

14. Results NA/1000APDC199119952000 Before Adjustment0.580.600.65 After Adjustment0.580.500.45 Mean Difference0-0.08-0.19 t Value----3.92**-13.29*** p<.01=*, p<.001=**, p<.0001=*** NA/1,000 APDC in Pennsylvania Hospitals 1991-2000

15. Results RN/1000APDC1991-21995-61999-00 Before Adjustment4.192.32-0.73 After Adjustment5.50-2.82-4.23 Mean Difference0.85-5.29-2.20 t Value0.45-8.71***-4.40*** p<.01=*, p<.001=**, p<.0001=*** Percentage Change in RN/1,000 APDC in Pennsylvania Hospitals

16. Results LPN/1000APDC1991-21995-61999-00 Before Adjustment5.13-1.17-4.35 After Adjustment5.66-7.63-7.13 Mean Difference0.26-5.30-2.11 t Value0.18-10.08***-4.07*** p<.01=*, p<.001=**, p<.0001=*** Percentage Change in LPN/1,000 APDC in Pennsylvania Hospitals

17. Results NA/1000APDC1991-21995-61999-00 Before Adjustment13.618.409.73 After Adjustment16.143.1213.33 Mean Difference1.94-5.47-2.26 t Value1.01-7.69***-4.30*** p<.01=*, p<.001=**, p<.0001=*** Percentage Change in NA/1,000 APDC in Pennsylvania Hospitals

18. Results RN/1000LPN/1000NA/1000 Before Adjustment 7.24-18.7032.95 After Adjustment-25.88-43.61-9.34 Mean Difference-32.25-24.55-37.48 t Value-24.75***-10.16***-12.00*** p<.01=*, p<.001=**, p<.0001=*** Percentage Change in Nursing Staff/1,000 APDC in Pennsylvania Hospitals 1991-2000

19. Results Nursing Staff/1,000 Adjusted APDC* in Pennsylvania Hospitals 1991-2000 *APDC adjusted for patient acuity and turnover % Change 1991-2000: RNs -44% LPNs -65% NAs -48%

20. Conclusions Unadjusted nurse workload measures fail to adequately address the work intensity issue and, consequently, significantly underestimate nurse workloads Perceptions of nurses themselves, the media, and others concerning increasing nurse workloads/declining staffing ratios are justified and supported by our results Future research on nurse staffing or nurse workload issues should adjust for both patient acuity and patient turnover