What’s the big takeaway from your research study?

While our health care system may be in the midst of a nursing shortage, the decision about hospital nursing staff levels is really a business issue. In our study, we talked to nurse practitioners and nursing faculty, and we learned that nurses have historically been viewed as a major cost center. As a result, hospital managers often impose tighter budget restrictions on nursing, leading to chronic underpayment and understaffing.

Can you elaborate on that?

When hospitals get reimbursed by insurers, nurses don’t have their own line item, meaning hospitals don’t get reimbursed specifically for nursing services they provide. The result is hospitals treat nursing more like a fixed cost that they have to absorb. But you have to also remember that nurses are responsible for 90% of the time spent with patients — they make up the majority of the hospital’s human capital. When the hospital manager looks at the budget, they look at this huge pool of workers that aren’t necessarily associated with any revenue. Yes, they care about patient outcomes, but for those managers, they’re looking at cost because they also have to care about the hospital’s bottom line, especially when a hospital looks to cut its budget, which happens frequently.

At the same time, a lot of people say we don’t have enough nurses, so it wouldn’t matter if hospitals wanted to hire more of them. But that’s not true. We have a lot of nurses who are perfectly eligible to provide this level of care, but they end up quitting because of overwork and underpay. Our study shows that hospitals can easily pay their nurses a little more and hire one or two additional nurses in the emergency room, which would lighten the workload for all nurses. Combined, this would alleviate both issues.

How important are nurses to a hospital’s bottom line?

Nurses can significantly impact a hospital’s bottom line by enhancing both service rate and quality, allowing hospitals to treat more patients. Using my Emory colleague’s sophisticated machine learning technique, we were able to estimate what happens to the speed of service when you increase or decrease the number of nurses in the emergency department.  

We found that reducing a nurse’s patient load by just one leads to a 14% increase in service speed or productivity for every patient under the nurse’s care.

To further quantify the economic impact of hiring additional nurses, we constructed a naturalistic emergency department in our study that simulated changes in nursing staffing levels. We found that adding just one nurse to the busiest 12-hour shift each day yields substantial benefits for both society and the hospitals.

On the societal level, one extra nurse in the emergency department reduced the wait time for patients, who can go back to work sooner.  This means that for every 10,000 visits to the emergency room, patients avert $160,000 in lost wages. The hospital benefits because if you reduce the nurse’s workload by just one patient, then hospitals can treat more patients, generating $470,000 in additional net revenue per 10,000 visits.

From the hospital’s perspective, if you ramp up the emergency department operations, you’ll be getting more patients treated and more revenue. This revenue significantly outweighs what you’re paying the extra nurse or two. In other words, you can easily pay [all] your nurses a little more and hire one or two additional nurses in the emergency room.

In conducting our research study, we also learned that the quitting rate can be as high as 50% or higher in the emergency department in a year. Think of what that means. The doctors rely on the nurses. The patients rely on the nurses, and the nurses are all familiar with the hospital setting. If a large number of them are gone in a year, you don’t have to read medical papers to understand how bad that must be for the hospital’s bottom line and the patient outcomes.