Registered Nurse Journal (RNJ): What is your research telling you about the relationship between nurse practitioners, health outcomes and costs?

Peter Buerhaus (PB): The cost for the services provided by nurse practitioners is (10 to 30 per cent) lower than that provided by physicians, even when controlling for factors that can influence costs and outcomes, such as severity of illness. Our study of Medicare beneficiaries in the United States, who tend to be older and challenging to treat, showed doctors ordered slightly more tests for those with chronic care conditions, while NPs were more able than physicians to keep beneficiaries out of the hospitals and from being  readmitted to hospital in 30 days. NPs also were significantly more likely than physicians to lower emergency department use.  

RNJ: Does this suggest NPs might do better with preventive health care?

PB: That is one of the leading theories: NPs are more likely to provide preventative care, and with their communication skills, build trusting relationships that allow patients to discuss other aspects of their lives that can affect health, a dialogue that can speed recovery from illness.

RNJ: In the U.S., what has been the approach taken towards hiring nurses with a baccalaureate degree in nursing?

PB: The Institute of Medicine, which is part of the National Academies of Sciences, often advises the U.S. Congress, and in a 2010 report, recommended that 80 per cent of nurses have a baccalaureate degree by 2020. This is not a mandate but it is a goal.

RNJ: What do you make of its recommendation?

PB: A substantial amount of research has shown patients in hospitals that are staffed with a higher percentage of their nurses with a (four-year) bachelor degree, compared to two-year associate’s degree, had a much reduced risk of dying. These studies have been replicated, some in Canada. Insurers and our government started to tell hospitals, if you have patients who suffer complications and they are related to nurse staffing, you are not going to be reimbursed for the extra time that patients stay or the extra services required. So those two things really drove the hospital industry here to start increasing the hiring of bachelor of science nurses. We’re not going to get to 80 per cent, but we’re definitely making a significant improvement and the well-being of our patients should benefit.

RNJ: What evidence might drive these kinds of staffing changes in Canada?

PB: I don’t have a great answer to what might happen in Canada, but I think what happened here in the States is that the 1999 National Academy of Medicine reported that about 100,000 people die every year due to medical errors. That shocked a lot of people and our government. Private insurers and the Medicare program, which pays for acute care provided in hospitals for about 60 million Americans, said to hospitals, there is no way we are going to pay for preventable in-patient complications. In 2002, a colleague and I published results that showed poor staffing in hospitals was associated with five or six adverse outcomes. The fact that we had produced evidence that connected nursing and staffing and outcomes led to the adoption of measures linked to nurse staffing and these measures have become routinely assessed and monitored in American hospitals. 

RNJ: Beyond nursing education levels, what other staffing issues do you find related to outcomes?

PB: For periods of time on a hospital unit, there may be patients going off the unit for a procedure, test or surgery, and at the same time there are people being discharged (and) admissions coming in. So you can have a nurse who is juggling between patients she has to discharge and admit, all the while dealing with others who are returning from surgery or procedures. In a study we published in the New England Journal of Medicine (2011), (this) patient “churning” was shown to be associated with a higher risk of mortality. Nurses can be overwhelmed trying to keep up, creating situations where some patients are at risk of suffering an adverse outcome, and increasing their risk of mortality.

RNJ: Speaking of churning, major hospitals in Ontario routinely staff to be at, near or above 100 per cent capacity. Because of that, and the lack of care in the community and long-term care sectors, some hospitals are placing patients in hallways rather than rooms. In fact, hallway health care protocols are in place at some large hospitals. It’s become institutionalized. When you hear that, knowing what you know about churning and risk, what’s your reaction?

PB: I’m saddened to hear this. I look up to Canada. I shudder to think what your outcomes might be under such conditions and how hard your staff – nurses, physicians, and others – must be working to overcome these barriers that are a bit shocking. I find it surprising, even unconscionable if this practice has become institutionalized. I think patients deserve better. I’m not saying the U.S. has a perfect system by any means, but we rarely assign patients to a hallway as the location of their in-patient care. I can’t tell you the last time I heard of patients being in hallways other than maybe someone is in the hallway temporarily while their room is being cleaned and prepared.  

RNJ: Costs have always been a driver of health care, but how much more important might costs become in an era of expensive biologic drugs, graying demographics, and a dramatic increase in chronic disease?

PB: The American nursing profession has voiced concern about costs, but has done very little about lowering them. Nurses have been far more focused on improving clinical outcomes, and they are good at that. Unfortunately, they are not good at focusing on economic issues, lowering costs, and eliminating waste of resources. That’s going to change. It needs to change. It’s another reason people are saying we’ve had enough of our acute care, disease-focused health-care system. The U.S. needs more community health, a lot more prevention, a greater focus on addressing social determinants of health and improving behavioural health care. We need to get at the factors that create poor health. So there’s change going on and nurses in the U.S. need to figure this out pretty quickly or they are going to be left out of new care delivery systems.
 
RNJ: Does that make it more important for RNAO to play a guiding role?

PB: I think it does. Associations like RNAO can be a bridge that brings the employers, the educators, the nurses, and policy makers together for these discussions aimed at changing for the good of the people you serve.