By Liz Borkowski

Hundreds of nurses are on strike in Kentucky and West Virginia after contract negotiations with Appalachian Regional Healthcare failed. The nurses refused to accept a package that reduced their holiday pay and increased their insurance premiums (canceling out the proposed wage increase) and that failed to add staffing that would offset mandatory overtime. (AP) Anyone who might one day be a patient in a U.S. hospital should pay particular attention to that last item, because nurse staffing affects patient care.

Here’s the Lexington Herald-Leader on the nurses’ position:

Anita Jones, a 31-year veteran at the Hazard hospital, said most nurses work 16-hour days and mandatory overtime because of understaffing.

“You work when they want you to work,” said Pat Tanner, a negotiator with the West Virginia and Kentucky nurses associations.

In Hazard, about two dozen nurses stood along the street outside the ARH hospital holding signs that read, “Every patient deserves a nurse!” and “We demand safe staffing.”

A 2006 report on nursing staffing from the Institute for Women’s Policy Research explains the consequences of relying on long days and mandatory overtime (footnotes omitted):

Extended shifts and mandatory overtime can harm quality of patient care. The Institute of Medicine found, for instance, that longer work hours and fatigue reduce nurses’ job functioning. The likelihood of error increases with longer work hours and with any performance of overtime, regardless of the length of the original shift. Error likelihood is three times greater when shifts exceed 12.5 hours. These results are particularly salient given that full-time hospital staff registered nurses work an average of 55 minutes longer than scheduled each day, and 40 percent of registered nursing shifts worked in hospitals exceed 12 hours.

The report notes that staffing issues are cited as the cause of 24% of unexpected negative patient outcomes (up from 16% in 1998), and that more nursing care per patients shortens hospital stays, reduces rates of urinary tract infections and gastrointestinal bleeding in medical patients, and lowers rates of death and occurrence of pneumonia in surgical patients. Of course, the links between nursing staffing levels and quality of care have financial implications:

The costs to hospitals of adding nurses may be at least partially balanced by savings from fewer adverse patient outcomes such as nosocomial pneumonia or other hospital-acquired infections. For instance, pneumonia is associated with more than five additional days spent in the hospital, an increase in the chance of death of approximately 5 percent, and around $25,000 in additional costs; higher nurse staffing levels are associated with lower rates of postsurgical pneumonia.

Because patients receive more care when nurse staffing levels are higher, patient outcomes are better. Kovner and Gergen note that this effect “is good for patients, good for a hospital’s reputation, and—depending on the cost-effectiveness—may be fiscally good for hospitals as well.” Thus, while hospitals’ operating costs increase when the nurse workforce expands, some research suggests that hiring more nurses may not affect hospitals’ profitability.

The financial case for higher nursing staffing levels is even stronger now that Medicare is planning to deny hospitals reimbursement for treatment of conditions the hospital could have prevented.

The question here, and across the country, is whether hospitals will spend the money to improve patient health, and potentially their own overall profitability, or whether their fixation on a single expense line will perpetuate an unhealthy cycle.

Liz Borkowski works for the Project on Scientific Knowledge and Public Policy (SKAPP) at George Washington University’s School of Public Health and Health Services.