Nurse Staffing and Inpatient Hospital Mortality: Special Article

T h e NE W ENGL A ND JOUR NA L o f MEDICINE
SPECIAL ARTICLE
Nurse Staffing and Inpatient

Hospital Mortality
Jack Needleman, Ph.D., Peter Buerhaus, Ph.D., R.N., V. Shane Pankratz,
Ph.D., Cynthia L. Leibson, Ph.D., Susanna R. Stevens, M.S., and
Marcelline Harris, Ph.D., R.N.
A B S T R AC T
BACKGROUND
Cross-sectional studies of hospital-level administrative data have shown an associa- From the Department of Health Services,
University of California, Los Angeles, School
tion between lower levels of staffing of registered nurses (RNs) and increased pa-
of Public Health, Los Angeles (J.N.);
tient mortality. However, such studies have been criticized because they have not Vanderbilt University, Nashville (P.B.); Mayo
shown a direct link between the level of staffing and individual patient experiences Clinic Department of Health Sciences
Research, Rochester, MN (V.S.P., C.L.L.,
and have not included sufficient statistical controls.
M.H.); and Duke Clinical Research Institute,
Duke University Medical Cen-ter, Durham,
METHODS NC (S.R.S.). Address reprint requests to Dr.
We used data from a large tertiary academic medical center involving 197,961 ad- Harris at the Mayo Clinic, Department of
Health Sciences Research, 200 First St.
missions and 176,696 nursing shifts of 8 hours each in 43 hospital units to examine SW, Rochester, MN 55905, or at
the association between mortality and patient exposure to nursing shifts during harris.marcelline@mayo.edu.
which staffing by RNs was 8 hours or more below the staffing target. We also ex-
N Engl J Med 2011;364:1037-45.
amined the association between mortality and high patient turnover owing to ad- Copyright © 2011 Massachusetts Medical Society.
missions, transfers, and discharges. We used Cox proportional-hazards models in
the analyses with adjustment for characteristics of patients and hospital units.
RESULTS
Staffing by RNs was within 8 hours of the target level for 84% of shifts, and patient
turnover was within 1 SD of the day-shift mean for 93% of shifts. Overall mortality
was 61% of the expected rate for similar patients on the basis of modified
diagnosis-related groups. There was a significant association between increased
mortality and increased exposure to unit shifts during which staffing by RNs was 8
hours or more below the target level (hazard ratio per shift 8 hours or more below
target, 1.02; 95% confidence interval [CI], 1.01 to 1.03; P<0.001). The association
between increased mortality and high patient turnover was also significant (hazard
ratio per high-turnover shift, 1.04; 95% CI, 1.02 to 1.06; P<0.001).
CONCLUSIONS
In this retrospective observational study, staffing of RNs below target levels was
associated with increased mortality, which reinforces the need to match staffing
with patients’ needs for nursing care. (Funded by the Agency for Healthcare
Research and Quality.)
N ENGL J MED 364;11 NEJM.ORG MARCH 17, 2011 1037

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E VIDENCE FROM AN INCREASING

NUMBER of studies has shown an association
DATA AND POPULATION
We retrieved data for 2003 through 2006 from
electronic data systems of the medical center. We
be-tween the level of in-hospital staffing by
registered nurses (RNs) and patient mortality,1-5 excluded pediatric, labor and delivery, behavioral
adverse patient outcomes,1,5-12 and other quality health, and inpatient rehabilitation units. We clas-
measures.13-16 Quality measures that are related to sified the remaining 43 hospital units according to
nurse staffing have been adopted by the Na-tional unit type (intensive care, step-down care [i.e., with
Quality Forum,17 the Agency for Health-care
monitored beds but not intensive care], and general
Research and Quality (AHRQ),18 and the Joint
Commission.19 Some private payers have followed care) and service type (medical or surgi-cal). For
the lead of the Centers for Medicare and Medicaid each unit, we obtained data on patient census,
Services in no longer paying hospitals for the costs admissions, transfers, and discharges and on
associated with certain nursing-sensitive, hospital-
acquired “never” events, such as pressure staffing levels for each nursing shift.
20
ulcers and catheter-associated infections. We excluded data for patients who declined to
The strength of the evidence underpinning the authorize the use of their data for research pur-
association between nurse staffing and patient poses (3.1% of patients). The final sample
outcomes has been challenged because studies are includ-ed 197,961 admissions. We obtained data
typically cross-sectional in design, use hospi-tal- about patients from electronic discharge
level administrative data that imprecisely allo-cate abstracts. On a shift-by-shift basis, we identified
staffing to individual patients, and do not account the unit on which each patient was located and
for differences in patients’ requirements for nursing then merged unit characteristics and staffing data
care.21,22 Other observers have asked whether for the shift with the patient data. This process
differences in mortality are linked not to nursing resulted in 3,227,457 separate records with
but to unmeasured variables correlated with nurse information for each patient for each shift during
staffing.23 In this study, we address these concerns which they were hospitalized (which we have
by examining the association be-tween mortality called patient unit-shifts); these records included
and day-to-day, shift-to-shift vari-ations in staffing measures of patient-level and unit-level
at the unit level in a single in-stitution that has characteristics, nurse staffing, and other shift-
lower-than-expected mortality and high average specific measures. When we considered only the
nurse staffing levels and has been recognized for first admission of pos-sibly multiple admissions
high quality by the Dart-mouth Atlas, rankings in for any specific patient during the study period,
U.S. News and World Re-port, and Magnet hospital there were 1,897,424 unit-shifts for patients.
designation. In addi-tion, our analysis includes
extensive controls for potential sources of an MEASURES
increased risk of death other than nurse staffing. Inpatient Mortality
Death at hospital discharge was coded on patient
discharge abstracts. Data for each hospitalization
were retrieved from the hospital’s administrative
data support system.
M E T HOD S
RN Staffing per Unit-Shift
STUDY OVERSIGHT Studies involving RN staffing have shown that
The study, which was funded by the AHRQ, was when the nursing workload is high, nurses’ sur-
designed by the research team and approved by veillance of patients is impaired, and the risk of
the institutional review board at each collaborat- adverse events increases. To measure patients’
ing institution. Data were obtained from a ter- exposure to high-workload shifts, we construct-
tiary academic medical center with trained local ed measures of below-target staffing and high
data specialists who constructed the analytic data turnover, each of which increases the workload
set. Members of the research team jointly for nurses.
provided direction and oversight of the analysis, RN staffing was normalized to 8-hour blocks
wrote the manuscript, and made the decision to of time that correspond to common notions of
submit the manuscript for publication. shifts. We obtained target RN hours for each
1038 N ENGL J MED 364;11 NEJM.ORG MARCH 17, 2011

NURSE STAFFING AND INPATIENT HOSPITAL MORTALITY
unit and shift, which were generated by a well- addition, each patient was assigned a predicted in-
calibrated and audited commercial patient-classi- hospital mortality value on the basis of the patient’s
fication system. Patients may be reassessed mul- diagnosis-related group (DRG). This val-ue was
tiple times during a shift and target staffing may constructed for each DRG for each year from the
be revised, so we used the last estimate of target 2003–2006 AHRQ Hospital Cost and Utilization
staffing for each shift. We adjusted the target Project National Inpatient Samples by estimating
hours for each shift to account for the time that the average annual in-hospital rate of death for each
patients spent away from the unit for anesthesia- AHRQ-modified DRG, with a sin-gle pooled value
related procedures (but not for procedures, such for low-volume modified DRGs. AHRQ-modified
as dialysis, that do not require anesthesia). We DRGs are used in AHRQ risk-adjustment models to
calculated the difference between target RN decrease the possibility that hospital-acquired
hours for the shift and actual hours worked on complications influence esti-mates of risk
the unit in direct patient care, and we set a flag adjustment.27 To adjust for possible confounding
for below-target staffing when actual staffing from measures of staffing and hos-pitalization in an
was 8 hours or more below the adjusted target. intensive care unit (ICU), we included as a time-
varying covariate the cumula-tive number of shifts
Patient Turnover during which the patient had been in an ICU.
Because demands on nursing staff increase as the
numbers of admissions, transfers, or dis-charges
24,25 STATISTICAL ANALYSIS
increase, we constructed a measure of
patient turnover for each shift that was equal to To assess the association between mortality and
the sum of unit admissions, transfers, and dis- nurse staffing, we conducted a survival analysis
charges (excluding deaths) and the adjusted or using Cox proportional-hazards regression mod-
start-of-shift census so that complete patient els with the time from hospital admission as the
turn-over would equal 100%. A shift was defined time scale and in-hospital death as the outcome.
as having a high turnover if the rate was greater We summarized the characteristics of patients,
than or equal to the mean plus 1 SD for the day- units, and shifts with the use of means and stan-
shift turnover for that unit, and a dummy vari- dard deviations for continuously scaled variables
able for high turnover was merged into the pa- and counts and percentages for nominal vari-
tients’ unit-shift record. ables. We calculated the proportion of shifts with
actual staffing levels that were 8 hours or more
Other Unit and Shift Measures below target and examined the distribution of
To account for mortality-associated differences below-target shifts according to unit shift and
across units, our models included an indicator of shift time. We calculated means and standard
the unit to which the patient was initially admit- deviations for patient turnover and the propor-
ted. We included unit service type and indicators tion of shifts with high turnover. By aggregating
for day, evening, and night shifts as time-varying data across all hospital stays and using the in-
covariates for each shift. To adjust for possible hospital rates of death from the national inpatient
confounding between measures of below-target samples for each DRG, we calculated a standard-
staffing and mortality, the models included start- ized mortality ratio and 95% confidence interval
of-shift census and target staffing for the shift. to compare observed mortality with predicted in-
hospital mortality.
Patient-Level Measures We analyzed associations between mortality,
We used patient-level measures to adjust for the levels of RN staffing, and other variables using Cox
risk of death, including age, sex, payment source, proportional-hazards regression models. We used
type of admission, whether the patient was a lo-cal the time elapsed during the hospital ad-mission,
resident or out-of-area referral, and the 29 co- accounting for the date of the admis-sion in order to
existing conditions included in the Elixhauser adjust for potential temporal differences in
algorithm.26 (A list of these conditions is pro-vided mortality, as the time scale. Follow-up for all
in the Supplementary Appendix, available with the patients was stopped after 90 shifts (approximately
full text of this article at NEJM.org.) In 30 days) because 99.9% of pa-

tients were discharged within 90 shifts. Unit- over across shifts averaged 10.4% but was highly
shift and patient-level variables were included in variable (SD 13.5%); 6.9% of shifts were catego-
the models to account for differences in the risk rized as having a high turnover.
of death. When values for unit- and patient-level The target staffing for RNs in ICUs was quite
variables changed (e.g., changes to the unit cen- consistent across day, evening, and night shifts,
sus), they were treated as time-varying whereas step-down and general care units had
covariates. Cox models included cumulative higher levels of staffing in the daytime and lower
time-varying measures of each patient’s levels at night (Table 2). On average, actual staff-
exposure to shifts with staffing levels of 8 hours ing was close to target across all units; however,
or more below target and high-turnover shifts. 15.9% of all shifts had actual staffing levels that
Because patients with longer lengths of hos- were 8 hours or more below target. Nearly one fifth
pital stay have increased opportunities to be ex- (19.4%) of critical care units had staffing levels that
posed to below-target and high-turnover shifts, were 8 hours or more below target, with night shifts
we performed several secondary analyses to most likely to fall below target. On general care
check the robustness of the findings. These units, 14.0% of shifts had staff-ing levels that were
analyses included counting below-target and 8 hours or more below tar-get, with day and
high-turn-over shifts occurring only within the evening shifts more likely to be below target. On
first 5 days of each stay, the inclusion of patients step-down units, 18.7% of shifts had staffing levels
who had stayed only on general units, and the that were 8 or more hours below target, with day
inclusion of exposure to below-target and high- and evening shifts more likely than night shifts to
turnover shifts in a rolling window of six shifts be below target staff-ing. The proportion of shifts
(2 days) before the current shift. with high turnover was consistent across units:
We used regression models that included 14.9% on day shifts, 5.6% on evening shifts, and
these variables to estimate hazard ratios and 95% 0.2% on night shifts.
con-fidence intervals. Hazard ratios were tested
for significance with the use of two-sided Wald BELOW-TARGET STAFFING, HIGH
tests. A P value of less than 0.05 was considered TURNOVER, AND MORTALITY
to in-dicate statistical significance. All statistical Of all the patients who were evaluated during the
analy-ses were conducted with the use of SAS first 30 days after admission, 31.9% stayed in
software, version 9.1. units in which no shifts had actual staffing levels
that were 8 hours or more below target, whereas
R E SULT S 34.6% stayed in units that had three or more
shifts with below-target staffing; 39.7% of pa-
CHARACTERISTICS OF tients were not exposed to any high-turnover
PATIENTS, UNITS, AND STAFFING shifts, whereas 12.6% were exposed to three or
Of the 197,961 patients who were included in the more shifts with high turnover (Table 3).
study, 51.4% were men (Table 1). The mean age was In survival models with adjustments for mea-
60.2 years. Although we excluded pediatric units, sures of patient, unit, and shift risk, there was a
pediatric patients who were treated on adult units were significant association between mortality and
included in the analysis, and 4443 ad-missions (2.2%) exposure to below-target or high-turnover shifts
were for patients below the age of 21 years. Eighty (Table 4). For all hospital admissions, the risk of
percent of patients were from outside the local area, death increased with exposure to an increased
reflecting the institution’s substantial referral practice. number of below-target shifts (hazard ratio per
Medicare was the most frequent payer. The average below-target shift, 1.02; 95% CI, 1.01 to 1.03;
predicted mor-tality was 3.1%, whereas actual P<0.001). When counts of below-target shifts were
mortality was sub-stantially lower (1.9%) restricted to those in the first 5 days after
(standardized mortality ra-tio, 0.61; 95% confidence admission, the hazard ratio increased to 1.03 (95%
interval [CI], 0.59 to 0.63). CI, 1.02 to 1.05; P<0.001). When the expo-sure
During the study period, there were 176,696 was specified only in a sliding window of the
staffed unit-shifts; two thirds were in general previous six shifts, the hazard ratio was 1.05 (95%
care units, with the remainder split between CI, 1.02 to 1.07; P = 0.001). When the analy-sis
critical care and step-down units. Patient turn- was restricted to patients with no exposure

Table 1. Characteristics of the Patients, Units, and Nursing Shifts.*
Variable Value
Patients
No. of admissions 197,961
Deaths — no. (%) 3,681(1.9)
Age — yr
Mean 60.2±18.0
Range 0–105.0
Male sex — no. (%) 101,694(51.4)
Payer — no. (%)
Medicare 95,779(48.4)
Commercial 84,743(42.8)
Other government 12,224(6.2)
No insurance 5,215(2.6)
Admission type — no. (%)
Routine 117,991(59.6)
Emergency 65,522(33.1)
Urgent 14,384(7.3)
No. of ICU shifts per admission
Mean 2.3±9.6
Range 0–510.0
Local residence — no. (%) 38,449(19.4)
Predicted mortality on the basis of modified diagnosis-related group — %
Mean 3.1±4.1
Range 0–31.6
Units
No. of units 43
Type of unit — no. (%)
ICU 8 (18.6)
Step-down care 7 (16.3)
General care 28 (65.1)
Medical units — no. (%) 20 (46.5)
Shifts
No. of patient unit-shifts 3,227,457
Type of unit per shift — no. (%)
Intensive care 459,054 (14.2)
Step-down care 682,607 (21.1)
General care 2,085,796 (64.6)
Type of service per shift — no. (%)
Medical 1,392,404 (43.1)
Surgical 1,835,053 (56.9)
Patient turnover per shift — %
Mean 0.09±0.15
Range 0–0.14
High-turnover shifts — no. (%)† 12,242 (6.9)
* Plus–minus values are means ±SD. In addition to the listed variables, for each patient, a dummy variable was
created for each of the 29 coexisting conditions in the Elixhauser algorithm. The percentage of patients with
each condition ranged from approximately 0% for peptic ulcer disease with bleeding and for the acquired
immunodeficiency syndrome to 43% for hypertension. ICU denotes intensive care unit.
† This percentage is based on 176,696 shifts that were staffed on all units during the study.

Table 2. Levels of RN Staffing and Patient Turnover, According to Type of Unit and Shift.*
Step-Down General Care

Variable ICUs Units Units All Units
Day shift
No. of shifts 11,663 10,183 37,141 58,987
No. of target hours 92.6±41.1 76.4±25.9 56.3±21.9 67.0±31.1
No. of actual hours 89.0±35.6 72.2±23.7 54.6±20.5 64.4±28.3
Shifts with actual staffing level 8 hr or more below target (%) 13.7 20.4 15.6 16.1
Shifts with high turnover (%) 15.1 15.3 14.8 14.9
Evening shift
No. of shifts 11,660 10,179 37,048 58,887
Night shift
No. of shifts 11,650 10,172 37,000 58,822
Shifts with high turnover (%) 0.1 <0.1 0.3 0.2
All shifts
No. of shifts 34,973 30,534 111,189 176,696
* Plus–minus values are means ±SD. ICU denotes intensive care unit.
to shifts in an ICU, the estimates were similar to 1.10; P<0.001). A similar pattern was found in
those for all patients, with higher hazard ratios the sensitivity checks that considered patients
when counts of below-target shifts were with no admission to an ICU or that restricted
restricted to those during the first 5 days after the sample to first admissions and patients with
admission. The results were similar for other initial admissions to general care units. The ex-
sensitivity checks (i.e., restricting the sample to ception to this pattern occurred when exposure
patients admitted to general units but including was specified as a time-varying rolling window
patients transferred to the ICU, restricting the of the previous six shifts, for which the hazard
sample to first admissions, and changing the ratio was close to 1.0 and was not significant
sliding win-dow to 30 shifts). (Table 4).
Exposure to high-turnover shifts was also
significantly associated with an increased risk of ASSOCIATION BETWEEN OTHER
death. For the analyses that included all hospital VARIABLES AND MORTALITY
admissions and counted cumulative exposure In the survival analysis, units were analyzed as
during the first 30 days, the hazard ratio per high- fixed effects to account for any mortality-associ-
turnover shift was 1.04 (95% CI, 1.02 to 1.06; ated differences across units. Of the variables
P<0.001). When counts of high-turnover shifts that were included in all analyses (Table 1), sex
were restricted to those in the first 5 days, the was the only variable that was not significantly
hazard ratio increased to 1.07 (95% CI, 1.03 to associated with mortality in all four models. (De-

Table 3. Exposure of 197,961 Patients to Shifts with an Actual Staffing Level 8 Hours or More below Target and
with a High Turnover of Patients, According to the Number of Shifts and Days after Admission.*
Number
of Shifts Exposure during First 30 Days after Admission Exposure during First 5 Days after Admission
Below Staffing Target High Patient Turnover Below Staffing Target High Patient Turnover
number of patients (percent)
0 63,145 (31.9) 78,533 (39.7) 67,915 (34.3) 88,905 (44.9)
1 39,033 (19.7) 63,781 (32.2) 42,337 (21.4) 68,464 (34.6)
2 27,082 (13.7) 30,669 (15.5) 29,533 (14.9) 28,631 (14.5)
3 18,168 (9.2) 12,335 (6.2) 19,651 (9.9) 8,496 (4.3)
4 12,143 (6.1) 5,761 (2.9) 12,958 (6.5) 2,541 (1.3)
5 8,419 (4.3) 2,771 (1.4) 8,788 (4.4) 700 (0.4)
6 6,118 (3.1) 1,682 (0.8) 5,985 (3.0) 176 (0.1)
7 4,635 (2.3) 930 (0.5) 4,068 (2.1) 38 (<0.1)
8 3,502 (1.8) 595 (0.3) 2,574 (1.3) 8 (<0.1)
9 2,702 (1.4) 303 (0.2) 1,730 (0.9) 2 (<0.1)
10–14 7,316 (3.7) 526 (0.3) 2,362 (1.2) 0
15–19 2,791 (1.4) 71 (<0.1) 60 (<0.1) 0
20–24 1,333 (0.7) 4 (<0.1) NA NA
25–29 763 (0.4) 0 NA NA
30 or more 811 (0.4) 0 NA NA
* NA denotes not applicable.
tails are provided in the Supplementary Appen- exposed. In our analyses, we addressed many of
dix.) The patient census at the beginning of the the criticisms of previous research, since our
shift, target staffing, and the cumulative number findings were adjusted for many patient-specific
of shifts in an ICU were significantly associated and unit-specific factors associated with mortal-
with mortality in all four models. However, the ity and included direct measurement of individ-
exclusion of these variables did not substantively ual patients’ exposure to staffing levels.
change the hazard ratios, which reinforces the For hospitals that generally succeed in main-
robustness of the findings of an association be- taining RN staffing levels that are consistent with
tween an increased risk of death and below-tar- each patient’s requirements for nursing care, this
get staffing and high patient turnover. Results study underscores the importance of flexi-ble
were similar when the sample was restricted to staffing practices that consistently match staffing to
first admissions for patients with multiple hospi- need throughout each patient’s stay. For hospitals
talizations. that do not maintain nurse staff-ing levels
consistent with each patient’s nursing care
DIS C US SION requirements, our findings underscore the need to
use systems for tracking such require-ments and the
In an institution with a history of success in patient census and to implement practices that
meeting staffing levels and with a level of patient improve the match between staffing and patients’
mortality that was substantially below that pre- needs. Our findings suggest that nurse staffing
dicted by its case mix, we found that the risk of models that facilitate shift-to-shift decisions on the
death increased with increasing exposure to shifts basis of an alignment of staffing with patients’
in which RN hours were 8 hours or more below needs and the census are an important component
target staffing levels or there was high turn-over. of the delivery of care.
We estimate that the risk of death increased by 2% We also found that the risk of death among
for each below-target shift and 4% for each high- patients increased with increasing exposure to
turnover shift to which a patient was shifts with high turnover of patients. Staffing

Table 4. Risk of Death Associated with Exposure to a Shift with an Actual RN Staffing Level 8 Hours
or More below Target, High Patient Turnover, and Other Variables.*
Hazard Ratio
Variable (95% CI) P Value
Total of 197,961 patients
Each shift with RN staffing level below target or high turnover
during first 30 days after admission
Shift with RN staffing level 8 hr or more below target 1.02 (1.01–1.03) <0.001
Shift with high patient turnover 1.04 (1.02–1.06) <0.001
Shift with high patient turnover 1.07 (1.03–1.10) <0.001
during the previous six shifts
Shift with RN staffing level 8 hr or more below target 1.05 (1.02–1.07) 0.001
Shift with high patient turnover 0.98 (0.93–1.04) 0.55
Total of 171,041 patients with no shifts in an ICU
* Listed are results from four separate Cox proportional-hazard regressions for mortality within the first 90 shifts (approxi-
mately 30 days) after admission. All regressions include 197,961 patients and 3,227,457 unique observations of patient
unit-shifts. Descriptions of regression models specify the measure of understaffing included in the analysis. All regres-
sions include measures of patients’ age, sex, local residence or referral, type of payer, type of admission, rate of death
as predicted by AHRQ national inpatient data for the modified diagnosis-related group, 29 coexisting conditions includ-
ed in the Elixhauser algorithm, type of current unit (intensive care, general, or step-down), medical or surgical service of
current unit, dummy variable for the unit of initial admission, target RN hours for current shift, unit census, and number
of shifts in an intensive care unit (ICU).
projection models rarely account for the effect on of these differences. Although we studied the
workload of admissions, discharges, and trans- risk of death through the first 90 shifts (approxi-
fers. Our results suggest that both target and mately 30 days) after admission, we did not
actual staffing should be adjusted to account for study factors influencing mortality after this time
the effect of turnover. In light of the potential or outside the hospital. Our data did not allow us
importance of turnover on patient outcomes, to identify patients who had do-not-resuscitate
research is needed to improve the management orders, a factor that influences the interpretation
of turnover and institute workflows that mitigate of overall mortality and may influence staffing
28
the effect of this fluctuation. decisions. Additional research is needed to
Our study has several limitations. As in any under-stand the complex interplay among nurse
observational study, confounding is a concern. We staff-ing, patient preferences, and other factors,
did not explicitly include information on care in-cluding staffing levels for physicians and
delivery models, the availability of staff mem-bers other non-nursing personnel, technology, work
aside from RNs, or differences in physical pro-cesses, and clinical outcomes.
characteristics of units, although the inclusion of Efforts to reform the delivery and financing of
unit fixed effects implicitly controlled for many health care, including new payment mecha-

nisms designed to increase accountability and ing. In addition, providing sufficient resources to
29
efficiency and to bundle services, mean that ensure that staffing is adequate and paying close
the costs and outcomes of nursing care will be attention to patient transfers and other fac-tors
under increasing scrutiny in the years ahead. Our that have a major effect on workload should
finding that below-target nurse staffing and high become an active part of daily conversations
patient turnover are independently associ-ated among nurses, physicians, and hospital leaders in
with the risk of death among patients sug-gests planning for the care of their patients.
that hospitals, payers, and those concerned with
Supported by a grant (R01-HS015508) from the Agency for
the quality of care should pay increased at- Healthcare Research and Quality.
tention to assessing the frequency with which Dr. Buerhaus reports serving on an unpaid advisory board for
actual staffing matches patients’ needs for nurs- the Johnson & Johnson Campaign for the Future of Nursing and
ing care. The results of our study can be used to reports that his institution has received grant support from the
Johnson & Johnson Campaign for the Future of Nursing on his
shift the national dialogue from questions about behalf. No other potential conflict of interest relevant to this
whether nurse staffing levels have a significant article was reported.
Disclosure forms provided by the authors are available with
effect on patient outcomes to a focus on how
the full text of this article at NEJM.org.
current and emerging payment systems can re- We thank Walter Kremers, Ph.D., for his contribution of time,
ward hospitals’ efforts to ensure adequate staff- effort, and encouragement in the preparation of the manuscript.
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Nurse Staffing and Inpatient Hospital Mortality: Special Article

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T h e NE W ENGL A ND JOUR NA L o f MEDICINE

Nurse Staffing and Inpatient

N ENGL J MED 364;11 NEJM.ORG MARCH 17, 2011 1037

E VIDENCE FROM AN INCREASING

1038 N ENGL J MED 364;11 NEJM.ORG MARCH 17, 2011

The New England Journal of Medicine

N ENGL J MED 364;11 NEJM.ORG MARCH 17, 2011 1039

1040 N ENGL J MED 364;11 NEJM.ORG MARCH 17, 2011

The New England Journal of Medicine

Table 1. Characteristics of the Patients, Units, and Nursing Shifts.*

N ENGL J MED 364;11 NEJM.ORG MARCH 17, 2011 1041

Step-Down General Care

The New England Journal of Medicine

* NA denotes not applicable.

N ENGL J MED 364;11 NEJM.ORG MARCH 17, 2011 1043

1044 N ENGL J MED 364;11 NEJM.ORG MARCH 17, 2011

The New England Journal of Medicine

N ENGL J MED 364;11 NEJM.ORG MARCH 17, 2011 1045

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