Nurse Staffing & Patient Outcomes

Elizabeth Bewley, LPN

Catherine Deaton, LPN

Susanna Olgin, RN
Stephane Orsini, LPN
Melissa Thibodeaux, LPN

OU College of Nursing Tulsa 2013

Identification
of the
Problem

PICO Question:

In hospitalized patients,
how do low patientnurse ratios compared to
high patient-nurse ratios
affect patient
outcomes?

population
Our question focuses on hospitalized adults

intervention
Our question looks at LOW patient to nurse
ratios

comparison
Compared to HIGH patient to nurse ratios

outcomes

mortality

readmission
rates

patient
safety

patient
satisfaction

PICO question: Impact

Soaring costs of healthcare and nursing shortages
have led to higher patient to nurse ratios.

Quality of care is compromised with increases

in patient to nurse ratios.
This leads to nurse frustration and adverse patient
outcomes.

Literature-Indicated Problems
Lack of information on the quality of medical and surgical
treatment
Competence and skill of nurses
Lack of cost-effective analysis defining the best level of
nurse staffing
Difficult to set fixed standard RN ratios
Differing patient classification systems among hospitals

Prevalence of Problem
Increased hospital related mortality
Adverse patient events
Nurse-sensitive outcomes such as:
failure to rescue, unplanned
extubation, and cardiac arrest

Research
Meta-Analysis
(Systematic Review)
Kane (2012)

Integrative
Reviews

Professional
Guidelines

Research Articles
ONA Position Statement (2012)
McGahan (2012) ANA Principles (2012)
Local hospital guideline
Garrett (2008)

Qualitative
Kalisch (2012)
Non-Experimental
Seago (2010)
Unruh (2012)

Review of
Literature

Pros
Increased patient satisfaction
Increased nurse satisfaction
Increased physician satisfaction
Increased patient safety
Improved safety outcomes
Increased financial savings for facilities

Review of
Literature

Cons
Costly to establish adequate staffing
No proven causal relationship to patient outcomes
Fixed ratios difficult to determine
Nursing shortage makes maintaining staffing levels more
difficult
Hospitals may need to reduce capacity
No consensus for patient classification

Review of
Literature

Summary

1. Increased staffing levels reduce missed nursing care.

2. Higher RN staffing was associated with lower
odds of hospital related mortality and adverse
patient effects.
3. Failure to rescue and postoperative sepsis had
a consistently negative relationship to nurse staffing.
4. Mandated staffing levels did improve patient outcomes in
California.

Review of
Literature

Kane (2012)

2858 potentially relevant studies were narrowed to 101 which

met eligibility requirements for review
Examined the association between RN staffing and patient
outcomes in RN-to-patient ratio

Increased nursing staffing in hospitals associated with

improvements in patient care outcomes

Hospital related mortality 9-16% lower with each additional RN

Higher staffing levels produce stronger effects for nurse

sensitive outcomes than for general outcomes

Kalisch, Gosselin, & Choi (2012)

Focus groups conducted

110 units from 10 hospitals
-5 units with most missed nursing care
-5 units with least missed nursing care

Least amount of missed nursing care:

Adequate staffing, ability to adapt to shortages
Continuous communication and monitoring
of patients
Low RN turnover

Kalisch, Gosselin, & Choi (2012)

Highest level of missed nursing care:

Poor staffing, leading to adverse events
Drop in patient satisfaction scores,
Significant increase in turnover

Seago (2010)

Survey study from almost 80,000 RNs in

California, Pennsylvania, and New Jersey
Final sample size of 22,336 hospital staff
nurses
2004 California mandated ratios
On average 1 less patient
med/surg 2 less patients

Lower mortality rates

Better patient outcomes
Better nurse retention

Unruh(2012)

RN FTE and RN per adjusted patient day analyzed

Negative relationship between RN staffing and decubitus

ulcers, infections, postoperative sepsis, and
failure to rescue.

Failure to rescue had the highest relationship to

RN staffing.

Garrett (2008) and McGahan et al. (2012)

Garrett :

Inadequate staffing leads to adverse patient outcomes and

increased nurse burn out.

Investment should be made in adequate nurse staffing to

improve patient safety and increase nurse retention.

McGahan:

Trend exists between increased staffing levels and decreased

adverse effects.

Further strong research needs to be conducted.

Professional Guidelines

ANA defines appropriate nurse staffing as

a match of registered nurse expertise
with the needs of the recipient of

nursing care services in the context of

the practice setting and situation.

Professional Guidelines

ONA Position Statement on Staffing

Appropriate nurse staffing is a dynamic process
affected by unpredictable changes impacting care

including census, acuity and number of available

skilled and experienced nursing staff

Professional Guidelines

Local Hospital Staffing Matrix

We looked at one local hospitals staffing matrix
for a specialty medical-surgical unit.
Staffing ratio (including charge nurse) is per
1 RN per every 4 to 6 patients.
Higher patient to ratios are maintained

on evening and night shifts than on day shifts.

Recommended Protocol

Staffing
Standards
For lower patient/nurse ratio

Acuity based
Specialty specific
California guidelines as
a benchmark/precedent

Further research needed:

Variety of types of units
Research specific adverse
events

Recommended Protocol

Rationale for
Recommendation

Higher RN staffing associated with lower mortality

Increased staffing reduced nursing staff errors
Patient outcomes improved with California
benchmark standards
Low RN staffing negatively affected Patient Safety
Indicators

Methods for evaluating effectiveness

Mortality rates, patient experience surveys,
patient safety indicators

Other Approaches

Further, high quality,

formal research
needed

Studies on a variety of
units
Previous research
mostly confined to
Intensive Care
Control of variables
necessary
Study specific adverse
affects

New Research
Questions

What is the best way to determine

optimal staffing levels?
How strong is the relationship
between nurse to patient ratios and
patient outcomes?
Is there a cause and effect
relationship between high nurse to
patient ratios?

New Research
Questions

How does nurse staffing affect

the effectiveness of patient care?

What other related factors

(hospital culture, quality of care)
influence patient outcomes related
to nurse staffing?

References

ANAs Principles of Nurse Staffing. (2012). American Nurses Association.

Retrieved from:
http://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNu
rsing/NursingStandards/ANAPrinciples/ANAsPrinciplesofNurseStaffing.pdf.
aspx

Garrett, C. (2008). The effect of nurse staffing patterns on medical errors and
nurse burnout. AORN Journal, 1191-1192, 1194, 1196-1197, 1200,
1202-1204.

Kalisch, B., Gosselin, K., & Choi, S.H. (2012). A comparison of patient care units
with high vs. low levels of missed nursing care. Health Care Management
Review, (31)4, 320-328.

Kane, R. L., Shamilyan, T. A., Mueller, C., Duvall, S., & Wilt,
T. L. (2012). The association of registered nurse staffing levels and
patient outcomes. Medical Care, 45, 1195-1204.

McGahan, M., Kucharski, G., & Coyer, F. (2012). Nurse staffing levels and the
incidence of mortality and morbidity in the adult intensive care unit: A
literature review. Australian Critical Care, 25, 64-77.
doi:10.1016/J.aucc.2012.03.003

References

Oklahoma Nurses Association Position Statement on Staffing. (2012). Oklahoma

Nurses Association. Retrieved from:
http://www.oknurses.com/associations/7366/files/ONA%20Staffing%20Posi
tion%20Amended%202012.pdf

Seago, A., Spetz, J., & Smith, H. (2010). Implications of the California nurse
staffing mandate for other states. Health Research and Educational Trust,
45(4), 904-921.

Unruh, L., & Ning, J.Z. (2012). Nurse staffing and patient safety in hospitals:
new variable and longitudinal approaches. Nursing Research, 61(1), 3-12.