Background
Although there is substantial evidence to support the fact that there is a relationship between nurse staffing and nurse/patient outcomes, less effort has been directed towards improving nurse-patient ratios in hospitals. Nurse dissatisfaction, turnover, and poor patient outcomes are often attributed to heavy workloads and understaffing in hospital units. Research indicates that heavy workloads and low staff-patient ratios often jeopardize patient safety and quality of patient care (Needleman et al., 2006). Moreover, many adverse effects have been associated with inadequate nurse staffing including complacency, increase in nosocomial infections, and medication errors. On the other hand, adequate staffing has been associated with shorter hospital stays, reduced mortality, and high patient satisfaction. About nurse outcome, better nurse staffing has been associated with improved nurse satisfaction due to a balanced workload (Needleman et al., 2006). Thus, it is evident that adequate staffing has benefits to a hospital. However, evidence to support improved nurse staffing ratios is scanty.
Inadequate staffing is largely attributed to the nursing shortage experienced in the U.S. Before 1965, hospitals were properly staffed as over 80 percent of nurses were enrolled in hospital-based programs (Needleman et al., 2006). However, a return to college-based programs in the 1970s coupled with changes in the Medicare reimbursement policy (to include some diagnosis categories) created demand in hospitals leading to under-understaffing then several efforts and policies have been adopted by hospitals to increase staffing in the current nursing shortage. Nursing retention strategies such as reduced workload, better work conditions, and competitive pay packages have been widely adopted. Moreover, efforts have been made to increase funding for nursing students in order to attract students to pursue the nursing profession.
Despite empirical evidence indicating that under-sunderstaffingpitals affects nurse and patient outcomes, few hospitals have implemented measures to increase nurse staffing. To evaluate the effect of staffing levels on nurse and patient satisfaction, this paper reviews current literature on staffing levels and nurse/patient outcomes. Based on the findings, recommendations on effective staffing approaches are given.
The Question
Will the implementation of a higher nurse-to-patient ratio for hospital nurses improve quality of care and increase nurse job satisfaction compared to a lower nurse-to-patient ratio?
Literature Search, Review, and Synthesis
Literature Search
There is little scientific evidence directly linking high nurse-patient ratios with improved patient and nurse outcomes. In order to determine the effect of staffing on nurse and patient outcomes, the writer of this paper reviewed past studies published from 1990 to 2012 on the topic. Four academic databases (CINAHL, Medline, EconLit and Academic Search Premier) were searched for relevant evidence. The initial search for the studies involved four MeSH terms including “hospital nurse staffing”, “nurse workload”, “nurse shift hours” and “bedside care skills”. These terms were combined (one at a time) with terms related to patient care including “patient outcomes”, “quality care”, “length of stay”, “nosocomial infections” and “medical errors”. The search terms were also combined with terms related to negative nurse outcomes such as “burnout”, “retention” and “job satisfaction”.
The studies eligible for inclusion were original (relied on primary data). Dissertations and web sources were excluded from the review. In total, 65 studies (45 in the U.S. and another 20 in the other countries) met the inclusion criteria. The writer settled on five studies that have focused on the effect of nurse staffing (staffing ratios) on nurse and patient outcomes.
Review and Synthesis
The findings of two studies conducted in 2002 and 2006 (Aiken et al. and Needleman et al.) reveal that a high staffing ratio has a positive impact on nurse/patient outcomes. Aiken et al. (2002) study, which involved 168 hospitals, found that, on average, the nurse-patient ratio in the hospitals ranged from 1/4 to 1/8 and any additional patient increased the likelihood of adverse events (30-day deaths) by 7 percent (with other hospital characteristics held constant). The study also established that Job dissatisfaction and burnout increase when there is a higher number of patients per nurse.
By comparison, Needleman et al. (2006) study involved 799 hospitals and established that nurses (RNs) spend an average of 11 hours a day in direct patient care. They examined the different nurse staffing strategies that have been adopted in the hospitals including varying the nursing skill mix (RNs vs. LPNs) and increasing care hours dedicated for each patient. A higher number of RN patient-care hours were associated with positive patient outcomes (shorter hospital stays, fewer patient deaths and fewer nosocomial infections (UTI) incidences). In sum, the two studies made the following three findings: (1) high RN staffing reduces nosocomial (UTI) infections such as pneumonia; (2) surgical units with high nurse-patient ratios have less surgical complication and medication error incidences; and (3) a better RN staffing reduces patient mortality.
On their part, Thungjaroenkul, Cummings and Embleton (2007) found a positive relationship between staffing (skill mix) and patients’ length of stay (LOS) in hospitals. The authors reviewed studies on the impact of nursing staff on the patients’ hospitalization duration and concluded that LOS can be significantly reduced with higher nurse staffing ratios. In particular, a high number of RNs reduces the likelihood of adverse events happening, which shortens the patients’ LOS. Another study by Rafferty et al. (2006) examined the impact of nurse staffing on patient and nurse outcomes in various US hospitals. The nurse variables explored in this study included burnout, job satisfaction and quality of nursing care, whereas the patient variables included LOS and patient mortalities. The authors found out that hospitals with high nurse staffing (high nurse-to-patient ratio) have better patient outcomes (low mortality) and nurse outcomes (low job dissatisfaction and low burnout) compared to those with low nurse staffing.
On their part, Trinkoff et al. (2011) explored the effect of nurse work schedules and staffing on patient mortality. The survey involved 633 nurses from 70 hospitals in the US. The researchers found a positive correlation between nurse work schedules and patient mortality. In particular, deaths related to pneumonia, congestive heart failure and acute myocardial infarction were prevalent in hospitals where nurses complained of heavy workload (long patient care hours) and inadequate sick leaves.
Three themes emerge from the review of the studies. First, improved staffing levels result in better patient outcomes. Among the positive patient outcomes that can be gained from high nurse-patient ratios are low risk of nosocomial (UTI) infections, reduced patient deaths, reduction in length of hospital stay and increase in nursing care hours. These factors contribute to improved quality of care. The second theme apparent in these studies relates to the importance of a high RN skill mix. A high proportion of RNs in a hospital is associated with improved patient outcomes (Needleman et al., 2002). The third theme is the relationship between nurse staffing and nurse outcomes. Adequate nurse staffing is associated with low workload, reduced stress and improved physical and mental health of nurses (Trinkoff et al., 2011). This has implications on job satisfaction and turnover.
Although the five studies were conducted in clinical settings, they do have some similarities and differences. The studies by Aiken et al., Needleman et al., and Rafferty et al. involved cross-sectional surveys and took place in acute-care hospitals in the US whereas the study by Trinkoff et al. interviewed nurse participants. It also involved a cross-sectional research design. In contrast, the study by Thungjaroenkul, Cummings and Embleton involved a systematic review of evidence on the effect of nurse staffing on LOS and hospital costs. The studies differed in the number of nurse or patient variables investigated. Aiken et al. examined the following three variables: patient deaths, nurse retention factors and failure-to-rescue. In contrast, Needleman et al. examined RN skill mix, patient deaths, length of hospital stays and postoperative complications. The study by Trinkoff et al. explored nurse staffing, work schedules and patient mortality while Rafferty et al. focused on nurse job satisfaction, quality of patient care, nurse burnout, nosocomial infections during hospital stays and patient mortality. In contrast, Thungjaroenkul, Cummings and Embleton study focused on nurse staffing, LOS and hospital costs.
This paper evaluates the findings of these studies based on the PICO question posed above to determine if there is a significant relationship between high nurse-patient ratios and patient/nurse outcomes. In this regard, all of the five studies reviewed found a significant association between hospital staffing and patient/nurse outcomes. Among the staffing variables examined include nurse patient care hours (Needleman et al.), proportion of RNs (Trinkoff et al.) and workload (Aiken et al.). The studies also examined the impact of staffing ratios on nurse outcomes. The positive patient outcomes identified from these studies include reduced adverse events, low patient deaths, increased patient satisfaction, shorter hospital stays and reduced nosocomial (pneumonia) infections. On the other hand, nurse outcomes include less stress, increased job satisfaction, reduced workload and low turnover. Thus, the findings underscore the fact that there is a significant relationship between high nurse-to-patient staffing ratios and patient/nurse outcomes.
The findings from most of the studies reviewed are reliable and valid. Trinkoff et al. base their findings on large data sets. This particular study surveyed 633 nurses from 71 hospitals in two states (Illinois and North Carolina). The large data sets enhanced external validity in this study. Aiken et al. also analyzed large amounts of data (10,184 nurse and over 232,000 patient participants), which enhanced external validity in this study. Thus, their findings can be applied in other care settings. Rafferty et al. is another reliable study. It involved nurse participants drawn from three nursing units (orthopedic, surgical and general) with a total of 3,984 nurses and 118,752 patient participants. Needleman et al. provide reliable findings because of the large dataset they used. This study surveyed 799 hospitals. The authors found that high patient care hours reduce patient deaths by as much as 6,700 annually. On the other hand the study by Thungjaroenkul, Cummings and Embleton involved a review of only 17 studies. This small number of studies reviewed limits the validity of its findings.
The relationship between nurses’ health (physical and mental) and staffing is not covered by the five studies. Low staffing levels lead to heavy work load, which may affect the physical health of the nurses. Other studies have identified a relationship between heavy workload and back/neck injuries. Heavy workload has also been blamed for the high nurse turnover and shortage. Workload-related exhaustion cause psychological stress, which compromise the quality of care. Thus, excessive work, besides affecting the quality of care, can affect nurse outcomes.
Also, the relationship between hours of direct patient care and burnout is not covered in these studies. It is evident from the studies that heavy workload (low staffing levels) correlate with nurse stress and burnout. However, the actual effect of patient care hours (work demands) on nurse outcomes has not been identified in the five studies. Workload is an aspect of nurse staffing, which has implications for nurses’ job satisfaction, turnover and quality of care. Long patient care hours cause psychological stress, which may lead to job dissatisfaction and increased absenteeism.
Recommendation
The five studies reviewed indicate that adequate staffing (low patient-nurse ratios) increases nurse and patient outcomes. In a hospital context, low workload and adequate staffing have immense financial benefits. Therefore, it is recommended that hospitals implement measures to improve nurse staffing as a way of improving the quality of care. Increasing patient-nurse ratio to about 6 to 1 would help maintain a balanced nurse workload and eliminate the negative outcomes associated with heavy workload. This would require the hospital’s chief nursing officer, the clinical nurse leader and the unit managers to liaise with nurses and patients to determine an appropriate staffing ratio for each unit. Patient acuity systems may be required to determine the patients’ nursing care needs and the nurses’ workload.
References
Aiken, L., Clarke, S., Sloane, D., Sochalski, J., & Silber, J. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. The Journal of the American Medical Association, 288(16):1987-1993.
Needleman, J., Buerhaus, P., Stewart, M., Zelevinsky, K., & Mattke, S. (2006). Nurse staffing in hospitals: is there a business case for quality? Health Affairs, 25(1):204-211.
Rafferty, A., Clarke, S., Coles, J., Ball, J., James, P., McKee, M., & Aiken, L. (2011). Outcomes of variation in hospital nurse staffing in English hospitals: Cross-sectional analysis of survey data and discharge records. Nursing Research, 60(1), 1–8.
Thungjaroenkul, P., Cummings, G., & Embleton, A. (2007). The Impact of Nurse Staffing on Hospital Costs and Patient Length of Stay: A Systematic Review. Nursing Economics, 25(5):255-265.
Trinkoff, A., Johantgen, M., Storr, C., Gurses, A., Liang, Y., Han, K. (2007). Nurses’ Work Schedule Characteristics, Nurse Staffing, and Patient Mortality. International Journal of Nursing Studies, 44(7): 175–182