Substituting lower-wage staff for hospital RNs is a poor business model

August 28, 2024 — When hospitals replace registered nurses (RNs) with licensed practical nurses and unlicensed assistive personnel, patients are more likely to die, experience readmissions, and have longer hospital stays, and Medicare must bear millions of dollars annually in avoidable costs. Moreover, there is no business case for this practice—hospitals actually experience a negative return on investment. Those conclusions come from a study in the latest issue of Medical Care, the official journal of the Medical Care Section of the American Public Health Association, published in the Lippincott portfolio by Wolters Kluwer. 

Multiple state and federal laws are proposing minimum hospital nurse staffing levels to improve safety. Yet many hospital leaders—and national organizations—are instead resurrecting the outdated “team nursing” model that was adopted as a stopgap measure after World War II. “‘Team’ in this context is not a multidisciplinary team of professionals, which research shows enhances patient outcomes, but substitutes lower-wage workers for RNs, the effect of which is a reduction of RN care to patients,” Karen B. Lasater, PhD, RN, FAAN, Associate Professor of Nursing at the University of Pennsylvania, and colleagues explain. 

Quantifying the harms of reducing RN care 

Dr. Lasater’s group evaluated the effects on patients, payers, and hospitals of reducing RN care. They analyzed data from the American Hospital Association, Medicare, and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS, which collects patient satisfaction ratings). 

Based on the experience of 6,559,704 Medicare patients admitted to 2,676 general acute care hospitals in 2019, they found that a 10-percentage-point reduction in the proportion of RNs to total hospital nursing staff is associated with: 

• 7% higher odds of in-hospital mortality 
• 4% higher odds of death within 30 days 
• 1% higher odds of hospital readmission within 30 days 
• 2% increase in the number of days per hospital stay 
• 23% higher odds of losing a star on “overall hospital rating” in the HCAHPS 

Using projected figures, the researchers also estimated that with a 10-percentage-point reduction in RN care: 

• 10,947 avoidable patient deaths would occur annually 
• 5,207 avoidable readmissions would occur annually, costing Medicare $68.5 million extra 
• Hospitals would miss out on $2.9 billion in cost savings annually because of longer patient stays 
• Hospitals would save $31.94 per patient day in labor costs, but they would lose $66.03 per patient day due to longer stays; for a 500-bed hospital with average occupancy rate, this translates to a $5 million loss annually 

“Though substituting lower-wage nursing staff for RNs is associated with reductions in hospital labor costs, those savings will likely be much reduced, if not nullified, by longer expected patient stays, unfavorable performance on value-based purchasing metrics, and added costs of RN turnover and labor actions,” Dr. Lasater and her co-authors conclude. “The cost is ultimately paid by patients who are more likely to die, be readmitted, have longer hospital stays, and experience less satisfactory care.” 

“With roughly half of hospital RNs reporting high levels of burnout, hospitals should focus on fixing the root causes of their burnout—chronic understaffing and poor work environments—not replacing RNs with lesser trained nursing staff that the evidence shows is likely dangerous to patients,” Dr. Lasater noted. 

Read Article: Alternative Models of Nurse Staffing May Be Dangerous in High-Stakes Hospital Care 

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