Health Essentials

In influential studies over the last two decades, professor and department chair Jack Needleman has shown the critical role of registered nurses in hospital outcomes.

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JACK NEEDLEMAN was reading The Boston Globe one morning in 1998 when he came across an article that would alter the course of his career.

The story was about nursing organizations and others in Massachusetts decrying the levels of staffing in hospitals — arguing that low staffing, implemented to save hospitals money, was endangering patients. “Labor is the largest component of hospital costs, and nursing is the largest component of labor,” notes Needleman, the Fred W. and Pamela K. Wasserman Chair of the Department of Health Policy and Management at the Fielding School. The argument that nurse staffing would influence patient outcomes seemed logical, but there was a problem: Little research had been done to support the claim.

Needleman wasn’t a nurse, nor had he studied nursing. “I just recognized that this was an important question — what effect did nurse staffing have on patient outcomes? — and, with data, I could begin to address it,” he says. “So I started what turned into a 20-year research program.”

The journey began with a three-year study in which Needleman and his colleagues analyzed data from nearly 800 hospitals in 11 states, culminating in a widely cited 2002 New England Journal of Medicine article. Needleman’s group found that facilities with lower nurse staffing levels — defined by both nursing hours and the proportion of registered nurses on the staff — were associated with longer lengths of stay and higher rates of death, hospital-acquired infections, cardiac arrest, and gastrointestinal bleeding. “This made a powerful case for keeping nurse staffing levels high,” Needleman says. “But it left unanswered the question of cost: Is it affordable?”

His research group made the business case for nurse staffing in a 2006 study published in the journal Health Affairs. The study found that when considering the higher costs of longer length of hospital stay and adverse events, increasing the proportion of nursing staff who are RNs — as opposed to cutting costs by hiring less-skilled nursing support staff — saved money.

Because these studies had compared low- with high-staffed hospitals, Needleman next asked whether something other than staffing might explain the results. He addressed that concern in a 2011 study, which found that within a single hospital, patients exposed to lowstaffed shifts had higher death rates than patients on sufficiently staffed shifts. Needleman has continued to validate and extend these findings through subsequent studies, including one published in 2019.

The work has had wide-ranging impact. “Jack Needleman’s studies have been utilized by policymakers across the United States to establish staffing rules for nurses working in acute-care settings,” says Linda Burnes Bolton, senior vice president and chief health equity officer for Cedars-Sinai, and past president of the American Academy of Nursing (AAN). “His research on quality and nurse staffing has also served as the basis for other studies on the impact of nurse staffing on desired patient-care outcomes.”

Less than a decade after the fateful newspaper article, Needleman was inducted into the AAN as an honorary fellow. “I recently told a prospective student that you have to have a passion for research, but it can either be a specific topic or simply a desire to better understand the world,” Needleman says. “My passion is understanding, and I discovered a topic that was worth investing 20 years in.”

Faculty Referenced by this Article

Jack Needleman
Jack Needleman
Health Policy and Management
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