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
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
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
Nursing Care Intensity

Indicators of nursing care intensity:

Patient acuity
• Patient turnover
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 patient’s
stay
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.
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?
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
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
Results
Average Patient Length of Stay in
Pennsylvania Hospitals, 1991-2000
9
8
7
6
5
4
00
20
99
19
98
19
97
19
96
19
95
19
94
19
93
19
92
19
91
19
Results
2
Average Patient Turnover in
Pennsylvania Hospitals 1991-2000
1.5
1
0.5
0
00
20
99
19
98
19
97
19
96
19
95
19
94
19
93
19
92
19
91
19
Results
RN/1,000 APDC in
Pennsylvania Hospitals 1991-2000
RN/1000APDC
1991
1995
2000
Before Adjustment
2.68
2.88
2.87
After Adjustment
2.69
2.45
2.04
Mean Difference
0
-0.44
-0.83
---
-10.53***
-25.05***
t Value
p<.01=*, p<.001=**, p<.0001=***
Results
LPN/1,000 APDC in
Pennsylvania Hospitals 1991-2000
LPN/1000APDC
1991
1995
2000
Before Adjustment
0.60
0.52
0.43
After Adjustment
0.61
0.44
0.30
Mean Difference
0
-0.08
-0.13
t Value
p<.01=*, p<.001=**, p<.0001=***
---
-8.04*** -14.10***
Results
NA/1,000 APDC in
Pennsylvania Hospitals 1991-2000
NA/1000APDC
1991
1995
2000
Before Adjustment
0.58
0.60
0.65
After Adjustment
0.58
0.50
0.45
Mean Difference
0
-0.08
-0.19
---
-3.92**
-13.29***
t Value
p<.01=*, p<.001=**, p<.0001=***
Results
Percentage Change in RN/1,000
APDC in Pennsylvania Hospitals
RN/1000APDC
1991-2
1995-6 1999-00
Before Adjustment
4.19
2.32
-0.73
After Adjustment
5.50
-2.82
-4.23
Mean Difference
0.85
-5.29
-2.20
t Value
0.45
-8.71***
-4.40***
p<.01=*, p<.001=**, p<.0001=***
Results
Percentage Change in LPN/1,000
APDC in Pennsylvania Hospitals
LPN/1000APDC
1991-2
Before Adjustment
5.13
-1.17
-4.35
After Adjustment
5.66
-7.63
-7.13
Mean Difference
0.26
-5.30
-2.11
t Value
0.18 -10.08***
-4.07***
p<.01=*, p<.001=**, p<.0001=***
1995-6 1999-00
Results
Percentage Change in NA/1,000
APDC in Pennsylvania Hospitals
NA/1000APDC
1991-2
1995-6 1999-00
Before Adjustment
13.61
8.40
9.73
After Adjustment
16.14
3.12
13.33
Mean Difference
1.94
-5.47
-2.26
t Value
1.01
-7.69***
-4.30***
p<.01=*, p<.001=**, p<.0001=***
Results
Percentage Change in Nursing Staff/1,000
APDC in Pennsylvania Hospitals 1991-2000
RN/1000 LPN/1000 NA/1000
Before
Adjustment
After Adjustment
7.24
-18.70
32.95
-25.88
-43.61
-9.34
Mean Difference
-32.25
-24.55
-37.48
-24.75***
-10.16***
-12.00***
t Value
p<.01=*, p<.001=**, p<.0001=***
Results
RNs
2
LPNs
NAs
1
% Change
1991-2000:
0
RNs -44%
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
3
Nursing Staff/1,000 Adjusted APDC* in
Pennsylvania Hospitals 1991-2000
LPNs -65%
*APDC adjusted for patient acuity and turnover
NAs -48%
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