the level of individual hospitals illustrates this point. This study of nurse staffing in all general, acute care Pennsylvania hospitals from 1991 to 1997 found that, although the statewide ratio of all nursing staff (RNs, LPNs, and NAs) to patient days of care increased from 3.86 to 4.04 between 1991 and 1997, examination of staffing at each hospital individually revealed that 32 percent of hospitals reduced the ratio of all nurses (RNs, LPNs, and NAs) to patients by more than 10 percent; and, with adjustments for the increased acuity of patients, more than 50 percent of hospitals decreased their ratio of nursing staff to patient days by more than 10 percent (Unruh, 2002a). Such declines are worrisome because health services research continues to produce strong evidence that nurse staffing in the aggregate is an important factor in the prevention of adverse events in both acute hospitals (Kovner et al., 2002; Needleman et al., 2002; Seago, 2001) and nursing homes (CMS, 2002).

Frequent Patient Turnover

High patient turnover rates contribute to increased workload for hospital nurses. Patient turnover refers to the phenomenon in which a given hospital bed may be occupied by more than one patient in a 24-hour period. For example, a patient may be discharged at 10:00 in the morning and a new patient admitted to the same bed during the same nursing shift. The number of patients in need of care is typically counted at a point in time during a 24-hour period (e.g., midnight). However, this patient census does not indicate the true number of patients in need of care because it does not reflect the actual number of patients cared for or the admissions and discharges taking place on a given day. Assessment and stabilization of patients upon admission and patient education and planning upon discharge are time- and personnel-intensive.

The patient turnover rate has increased as the numbers of available hospital beds and lengths of stay have declined. In one study of 20 medical–surgical units in five hospitals, the number of admissions, discharges, and transfers averaged between 25 and 70 percent of the midnight census (Lawrenz, 1992). Patient turnover rates as high as 40–50 percent also have been reported during an 8- to 12-hour period (Norrish and Rundall, 2001).

High Staff Turnover

High rates of turnover characterize the nursing staff of both hospitals and nursing homes. Such high turnover can have adverse consequences for patient safety. Evidence from non–health care industries shows that new or substitute staff are less familiar with work processes, and that the potential for errors thereby increases (Rousseau and Libuser, 1997). In nursing



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