Nurse Understaffing and Burnout Linked to More Hospital Infections

Lower levels of nurse staffing and higher nurse burnout rates contribute to higher rates of hospital-associated infections, according to a new study conducted at the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing in Philadelphia.  The study also found that improving nurse staffing and the work environment could save facilities millions of dollars.

Linda H Aiken, PhD, FAAN, FRCN, RN, said that a link between nurses and infection rates was first evidenced when Florence Nightingale showed that the introduction of educated nurses into hospitals resulted in a sharp drop in infections.

“Hospital-acquired infections remain a major quality concern because of the toll they exact on patients’ well-being, the high costs associated with treating them, and the fact that most are preventable,” said study co-author Linda H Aiken, PhD, FAAN, FRCN, RN, the Claire M. Fagin Leadership professor of nursing and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania.

“In this paper, we point to promising strategies for preventing common hospital-acquired infections that have not received adequate attention, namely safe nurse staffing levels and work environments that facilitate high-quality nursing care,” Aiken said.

Jeannie P. Cimiotti, DNSc, RN, said, to prevent infections, we need hospitals well staffed and an organizational climate that is supportive of nursing and nursing practice.

While at Penn, lead author Jeannie P. Cimiotti, DNSc, RN, now executive director of the New Jersey Collaborating Center for Nursing, at Rutgers University College of Nursing in Newark, and colleagues came up with the hypothesis that burnout might be a contributing factor in the development of infections. They analyzed data collected by the Pennsylvania Health Care Cost Containment Council, the American Hospital Association Annual Survey, and a 2006 survey of more than 7,000 registered nurses from 161 hospitals in Pennsylvania to study the effect of nurse staffing and burnout on catheter-associated urinary tract infections (CAUTI) and surgical site infections, two common hospital-associated infections.

The investigators found, and reported in the August issue of American Journal of Infection Control, that for each additional patient a nurse is assigned, there was approximately one additional infection per 1,000 patients, and for each 10 percent increase in a hospital’s number of high-burnout nurses, there was one additional urinary tract infection and two additional surgical site infections.

“Our findings suggest that inadequate hospital nurse staffing and associated high levels of nurse burnout, that commonly affect 30 percent of hospital bedside care nurses, erode nurses’ vigilance and strict adherence to infection control practices,” Aiken said. “We find that nurse burnout is a significant factor associated with higher infection rates, not just because burned out nurses may inadvertently experience a lapse in hand hygiene, but because nurses--if they have the time and authority--also ensure adherence to infection control practices among others on the interdisciplinary care team.”

Staffing and burnout effects

“It’s hard to say what is causing the lapses in aseptic technique, and that’s what it is,” said Cimiotti, adding that burned-out nurses may be detached and not paying attention.

Marcia Patrick, RN, MSN, CIC, said hospitals must change to a culture of safety and that will pay off in fewer infections and improved outcomes.

Marcia Patrick, RN, MSN, CIC, a member of the Association for Professionals in Infection Control and Epidemiology board of directors and an infection prevention consultant in Tacoma, Wash., explained that several things come into play when the patient load is heavy day after day.

“Sometimes essential steps can be skipped, and people may not be as conscientious about hand hygiene,” Patrick said.

Aiken added that, typically, quality-improvement initiatives, including infection prevention, focus on changing specific high-risk behaviors among hospital staff. Less attention is given to the root causes of poor hand hygiene and poor techniques in the care of surgical wounds and urinary-catheter care.

“Job-related burnout, associated with chaotic, inefficient nurse work environments where nurses have too many patients each to maintain a high level of vigilance in hand hygiene and adherence to sterile technique in their own practices and those of others providing care on their units, is the reason why there is a link between poor staffing and higher patient infections,” Aiken said. “Our findings suggest that if management would undertake the necessary changes in the hospital work environment to support high-quality nursing care, that burnout would decrease and so would hospital-acquired infections.”

Infection costs

To reach administrators and policymakers, with their backgrounds in finance and/or economics, Cimiotti said the team completed a cost analysis.

With the average cost related to CAUTIs ranging from $749 to $832 each and surgical site infections $11,087 to $29,443 each, the researchers estimate that if Pennsylvania hospitals could decrease nurse burnout rates from an average of 30 percent to 10 percent, it could prevent an estimated 4,160 infections annually with an associated savings of $41 million.

“Our study also confirms that it can cost hospitals significantly more to underinvest in nurse staffing and work environment reforms when the high cost of caring for infections is taken into account,” Aiken said. “Increasingly hospitals will not be reimbursed for treatment of preventable infections. Thus the cost to the hospital of infections will be more than simply making the appropriate investments in safe staffing and good work environments.”

Parker thought the cost estimates are likely on the low side. In her experience, decreasing infections can save a hospital millions of dollars.

“Does quality pay? Absolutely,” Parker said. In addition, she cited the human toll of increased morbidity and mortality. A hospital-associated infection can become a life-changing event for patients and create a cascade of negative outcomes.

Workload is one burnout contributing factor, but other elements, such as the environment, support from leadership and relationships with colleagues, also come into play, said Cimiotti, who added that she understands hospitals may not have the financial resources to add more nurses, but improving the organizational climate costs nothing.

“Part of it is changing the culture of organizations to one of patient safety,” Patrick said. “Quality pays, and just throwing people at it is not the answer. You have to have that culture of safety and the things the authors mentioned in the article--support and engagement and all of those things.”