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2012 HSR&D/QUERI National Conference Abstract

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2012 National Meeting

3006 — Does the Difference Between Regular and Off-Shift Nursing Staffing Affect Patient Outcomes? Longitudinal, Unit-Specific Evidence from VA

de Cordova PB, Columbia University; Phibbs CS, HERC; Bartel AP, and Stone PW, Columbia University;

There is a growing body of evidence that nurse staffing levels and the composition of the nursing staff affect patient outcomes. There is also evidence that more adverse events may occur on nights and weekends (off-shifts). Because activity levels are lower during off-shifts for most units, nurse staffing tends to be lower on off-shifts. There are no existing studies that rigorously examine the relationship between off-shift nurse staffing and patient outcomes.

Monthly data for all VA acute care units from FY 2003-2006 (8,243 unit-month observations) and monthly staffing for each unit, for each type of nurse (RN, LPN, aide, contract), were obtained from DSS. Shift differentials from payroll data were used to identify which shifts each nurse worked. Payroll data also provided education levels and how long each nurse had worked on the unit (unit tenure). Patient characteristics and length of stay (LOS) were obtained from the PTF. Fixed-effects regression was used to control for unobserved heterogeneity (unobserved unit characteristics that affect outcomes). LOS was the dependent variable, and the model controlled for patient age, expected LOS, patient co-morbidities, nurse staffing, nurse skill-mix, unit tenure, and how these nurse variables differed on the night shifts.

Staffing (Hours Per Patient Day (HPPD) 4.26 vs. 3.44) was higher and education levels were marginally higher on day shifts. Unit tenure was higher on the night shifts (5.03 vs. 4.13). Consistent with previous work, higher HPPD, lower share of aides, and higher tenure were associated with shorter LOS. No effects were found for any of the differential weekend staffing variables, but smaller differentials in night HPPD (better staffing at night) were associated with shorter LOS.

These results indicate that there is a limit to the extent that nurse staffing should be reduced on night shifts. Nursing managers need to carefully evaluate workloads in setting off-shift staffing levels.

This study extends the literature on the relationship between nurse staffing and patient outcomes to look at the effects of differential off-shift staffing. We are working with the VA Office of Nursing Services, including the VA Chief Nursing Officer, to develop specific policy recommendations for off-shift staffing.

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