1. Maher, Maribeth


Three recent studies consider nurses' worth, health, and professionalism.


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As analysts recognize the economic value of RNs, smoking-related deaths are shrinking nursing's ranks, and researchers are uncovering some surprising influences on public perception of nurses.

Figure. Nurses take ... - Click to enlarge in new windowFigure. Nurses take a cigarette break in 1947. A recent study found that smoking has had a "devastating impact" on nurses over the past 30 years. Photo (C) 2009 Regents of the University of California.

Economics: more nurses means dollars saved. What do you get when you add 133,000 full-time RNs to the acute care hospital workforce? An annual savings of about 5,900 lives, 3.6 million hospital days, and $6.1 billion in medical costs, according to Dall and colleagues. They estimated the economic value of professional nursing based on discharge data from the 2005 Nationwide Inpatient Sample and study results on the relationship between nurse staffing levels and nursing-sensitive patient outcomes (such as hospital-acquired pneumonia and sepsis).


The investigators, supported by Nursing's Agenda for the Future, the American Nurses Association (ANA), and others, calculated the risk of nosocomial complications-and attributable deaths, extended hospital stays, and increased health care costs-at three staffing levels: 6.4, 7.8, and 9.1 RN hours per patient day, which correspond, respectively, to the 25th, 50th, and 75th percentiles in a national sample of hospitals. Their findings suggest that, when estimates of the "productivity value" of lives saved are considered along with health care savings, the additional 133,000 full-time RNs required to bring RN staffing at all U.S. hospitals up to 9.1 hours per patient day represent an economic value of $57,700 per additional RN.


Health care savings are greater for insurers than for facilities, providing little incentive to hospitals to staff more nurses. But as ANA president Rebecca M. Patton points out, this is changing, as payers begin raising reimbursement rates for facilities that meet higher quality measures, and hospitals are seeing improved reputations, fewer malpractice payouts, and reduced turnover rates. "If you staff appropriately, it saves money," Patton says, and ensures patient safety.


In quantifying the economic value of RNs, this study demonstrates that hiring freezes and layoffs of nurses are "clearly foolish-especially now," and it highlights the need for investing in nursing education, Patton says. "Last year the federal government allocated about $8 billion for medical education and $156 million for nursing education." And without a substantial hike in that investment, "in 10 to 12 years, this country's going to have a nursing shortage like nothing we've ever experienced," she says.


Smoking: its impact on nursing is 'devastating.' An analysis of data from the Nurses' Health Study (NHS) suggests that the nursing shortage may be worsened by cigarettes. Despite a decline in the rate of smoking among female nurses, Sarna and colleagues found that in 2002-2003, the prevalence of smoking among RNs in the NHS was 8.4%-appreciably higher than the 1% prevalence among U.S. physicians surveyed in 2005. Similarly, say the researchers, smoking rates among nursing students are reportedly four times higher than those of medical students. And 40% of NHS smokers began the practice after age 20, at a time when they might have been in nursing school.


Ruth E. Malone, at the University of California, San Francisco, School of Nursing, says that in the United States alone more than 400,000 premature deaths annually are associated with tobacco use. Part of the solution, she says, is for health care institutions to have strong smoke-free policies, to offer support to nurses wanting to quit, and to provide continuing education to nurses on the social and clinical effects of tobacco.


Uniforms: people like nurses in white. Despite nurses' well-substantiated economic value and trustworthiness, public perception of their professionalism appears to be influenced-still-by what they wear. Albert and colleagues studied 390 adult patients and visitors and 109 pediatric patients who viewed photographs of the same RN, posed identically, in one of eight "pant set" uniforms. Participants rated each uniform on traits suggestive of professionalism, such as confident, competent, efficient, attentive (these were described in age-appropriate language for the younger patients). Although image scores assigned by children varied little, adults gave higher scores to two different white uniforms than to those in print or colored fabrics.


Maribeth Maher


Dall TM, et al. Med Care 2009;47(1): 97-104


Sarna L, et al. Nurs Res 2008;57(6): 374-82


Albert NM, et al. Appl Nurs Res 2008;21(4):181-90.