3067 — The Associations of Nurse, Patient and Organizational Characteristics with Nursing Workload

Li YF (Seattle COE), Liu CF (Seattle COE), Sharp ND (Seattle COE), Lowy E (Seattle COE), Maciejewski ML (Durham COE), Sales AE (University of Alberta), Needleman J (UCLA)

Objectives:
The optimal level and mix of nursing staff is essential for meeting VA patient care goals. The success of staffing methodologies relies on environment-specific factors as well as available resources to deliver care. We examined the impact of patient, nurse, and organizational characteristics on patient-to-registered nurse (RN) ratio per shift.

Methods:
We used data from 2/03-6/03 to examine the associations of nurse staffing with patient health and cost outcomes. This sub-analysis included data from 1069 RNs from 249 acute medical/surgical units at 121 VAMCs who responded to a nursing staff survey. We obtained nurse characteristics, nursing activities and RNs’ patient loads (patient-to-RN ratio) during the last worked shift from survey responses, and patient and organizational characteristics from VA and non-VA national databases. Multilevel mixed-effects linear regressions were used to examine the associations of patient, nurse, inpatient unit and facility characteristics with patient-to-RN ratio.

Results:
RNs reported caring for an average of 6.79, 7.48, and 7.52 patients (p=.002) for the day, evening, and night shifts, respectively. The corresponding RN to total nursing staff ratios were 58.3%, 56.7%, and 61.5% (p=.008). Observed RN patient loads were lower if their patients required close monitoring (b=-1.11, p=.003), full nursing assessment (b=-.81, p=.001), or intravenous medications (b=-.28, p=.026). RNs’ patient loads were higher when there were fewer RNs relative to other nursing personnel on a shift (b=-4.03, p < .001), if a unit had more patients over age 85 (b=19.66, p=.045) or fewer patients admitted from urgent care (b=-37.70, p=.040). Patient-to-RN ratios varied by facility complexity grouping, with the highest ratio at facilities of median complexity (ratio=7.96), followed by low (ratio=7.29) and high (ratio=6.26) complexity facilities (p < .001). Patient-to-RN ratios were not associated with RN demographics, unexpected changes in patient conditions, or simultaneous demands for admitting/transferring/discharging patients.

Implications:
Observed RN patient loads appeared associated with patient complexity, unit characteristics, and facility complexity. However, nurse staffing decisions were less responsive to RN qualifications and unexpected increases in nursing workload.

Impacts:
Policy makers and healthcare administrators should consider the whole scope of factors influencing nursing workload to assist in staff allocation and budget planning decisions.