The Effects of Nurse Staffing On the Medical Surgical Unit Involving Patient Safety and Quality
of Care
Mariah Bianco, Olivia Engle, Kaitlyn Kalicatzaros, Rebecca Platt, Mackenzie Stanley
04/03/2017
Abstract
This research looked at how staffing in hospitals can have an effect on patient safety.
Several sources were used that studied how a high nurse to patient ratios may adversely affect
the safety of a patient on a medical surgical floor in a hospital. These sources included both
literature reviews and qualitative studies. Medication errors, patient falls, and pressure ulcers
were the different factors of patient safety that were explored. It was found that the more patients
that a single nurse is responsible for, the more likely it is that a patient will be injured. Evidence
was found to support the fact that if a nurse is responsible for more patients, it is more likely that
a medication error will occur, a patient will fall or that skin breakdown will begin to occur. All
The Effects of Nurse Staffing On the Medical Surgical Unit Involving Patient Safety and Quality
The rising levels of patients within hospital setting continues to increase and this can
often lead to an undesirable number of patients assigned to one single registered nurse (RN).
This increase in nurse to patient ratio not only affects the nurse, but the patient’s safety as well.
Many research studies have been conducted pertaining to the effect of these high ratios and what
affect it has on patient safety. The studies have suggested if a nurse is responsible for a higher
number of patients that there is a greater risk for medications errors, developing pressure ulcers,
and falls. This presents an issue to the nursing profession due to the fact that it puts patient’s
safety at a greater risk. Therefore, the following research question was addressed: In hospitalized
patients on a medical surgical unit, how does nurse staffing influence patient safety regarding
Literature Review
Introduction
We acquired our information on this topic using Medscape, ProQuest, CINHAL, and Google
Scholar. We used a total of ten sources to review and research how nurse staffing on a medical
surgical unit influences patient safety. Medication errors, patient falls, and pressure ulcers will be
discussed specifically.
Medication Errors
events, and can ultimately impact the safety of both the patients and the nurses. In particular,
nursing shortages and high patient-to-nurse ratios can lead to medication errors, which can
nurse is required to perform the “five rights” rule of medication administration to reduce
medication errors and harm; the “five rights” rule requires the nurse to verify the right patient,
the right drug, the right dose, the right route, and the right time (Federico, 2017). If the nurse
disregards the “five rights” medication rule, the patient may face an undesirable or life-
threatening situation.
According to Anderson, Fong, Frith, and Tseng (2012), medication errors have attracted a
considerable amount of attention because of the complications such as high mortality rates and
the overwhelming cost of health-care. Shahrokhi, Ebrahimpour, and Ghodousi (2013) found in
the United States, deaths related to medication errors have surpassed the number of deaths
related to car accidents, breast cancer and human immunodeficiency virus/acquired immune
deaths occur each year in the United States hospitals and it costs between six to 29 billion dollars
to compensate for the adverse effects of such errors. Studies show that some factors related to the
medication errors made by the nurses include medication miscalculations, lack of knowledge and
proficiency. The study also argued that nurses are neglecting the hospital's medication protocol
due to lack of time, extreme tiredness, heavy workload, a shortage in the nursing workforce,
inadequate work experience, an inappropriate work environment, and spending an excess amount
of time documenting and completing other tasks instead of monitoring the patient (Shahrokhi,
In the research study produced by Anderson et al., (2012), the most prevalent
contributing factor among nurse-related medical errors was careless performance with
medication administration; tiredness is the second most effective factor, and inadequate
to prevent medication miscalculations and drug incompatibilities, some hospitals require nurses
knowledge and remain updated on new techniques, drug side-effects, drug incompatibilities, and
Although some medication errors can be reversed, others can produce life-threatening
effects. The purpose of the study performed by Anderson et al., (2012) was to examine the
relationship between nurse staffing and medication errors on medical-surgical units. The
researchers found when nurses were unable to meet the needs of the patients, they omitted steps,
took shortcuts, or disregarded approved standards in order to complete their tasks. In this study,
24 medical-surgical units among eight hospitals were analyzed. Their results revealed that out of
31,080 patients, 335 medication errors occurred; these numbers represent the amount of patients
admitted to the medical-surgical units over a two-year time period. Their findings revealed that
nurse staffing is an important human resource to keep patients safe from medication errors. The
researchers suggest nurse administrators to evaluate the potential impact of reducing the nurses’
hours of care and number of assigned patients in regard to improving patient outcomes and
Although medication errors are preventable, the number of tasks and medications needed
to be administered are affecting the quality of care provided by the nurse, especially when
assigned to a number of patients beyond a safe level. Henderson (2016) found the most common
medication errors occurred on medical-surgical units, and the next most common errors occurred
on Intensive Care Units. The most common medications associated to medication errors were
cardiovascular agents, especially anticoagulants. The next most common medication errors
included antimicrobials, electrolytes, endocrine drugs, and analgesics. The most common drugs
EFFECTS OF NURSE STAFFING AND PATIENT SAFETY 6
that harmed patients were furosemide, enoxaparin, insulin, and vancomycin. "Nurses play a
critical role in patient safety and carry an ultimate responsibility for preventing medication errors
(Henderson, 2016).”
units, as well as other units, nurses should complete several steps before administering
medications. Some important aspects associated with performing safe medication administrations
are to verify the medication orders with the prescriber and the nurse from the previous shift,
question any conflicting medication orders, exhibit pharmaceutical knowledge, follow the “five
understand medication calculations, and be cautious of the adverse effects associated with the
medications prescribed. When attempting to achieve desirable patient outcomes, nurse staffing
strategies should be implemented in regard to providing measures for both the patient and the
nurse.
Pressure Ulcers
According to Cho, Chin, Kim, and Hong (2015), the three most frequently reported
adverse events, regarding staffing and nurse patient ratio, brought up by nurses are medication
errors, injury from falls, and pressure ulcers. Pressure ulcers, also referred to as pressure
injuries, or bedsores, are caused by pressure or shearing of the skin over a bony prominence for
an extended period of time. This pressure causes injury to the outside skin and underlying tissue
(Gillespie et al., 2014). Risk for developing pressure ulcers increases with poor circulation,
impaired mobility, poor nutrition, incontinence, and rubbing or friction against the skin. Those at
high risk are patients that are recovering from surgery, the elderly, those with an injury or
condition requiring bedrest, diabetics, and paralyzed or comatose patients (Jiang et al., 2014).
EFFECTS OF NURSE STAFFING AND PATIENT SAFETY 7
When a patient comes to the hospital without any documented pressure ulcers but develops one
during their stay, it is referred to as a “hospital-acquired” pressure ulcer. Not only does the
development of pressure ulcers cause the patient more complications, such as pain, infection,
prolonged and expensive hospital stay, and increased risk of death in certain patients, it also
costs the hospital more money (Jiang et al., 2014). In a study conducted by Spetz, Brown, Aydin
and Donaldson (2013) they studied the savings associated with implementing nursing
interventions to prevent hospital- acquired pressure ulcers. They found that on average they
saved $127.51 per patient when preventative actions were implemented. Therefore, they
concluded that preventive measures can be cost savings to the hospital and beneficial to the
health of the patient (Spetz et al., 2013). Prevention is key in the management of pressure ulcers.
This is why nursing care and the nurse to patient ratio plays such a large part in preventing
One of the most effective nursing interventions in preventing and managing pressure
ulcers is repositioning or turning patients. Most hospitals will have different guidelines or orders
on turning patients that may depend on the ulcer or condition of the patient. Most patients will be
scheduled for turns every two hours. While more serious conditions such as paralysis patients,
should be turned every thirty minutes. Manually repositioning patients aids in preventing
pressure ulcers by redistributing pressure on the skin (Gillespie, et al., 2014). Lying or sitting in a
certain position for an extended period of time causes a lack of oxygen to that part of the body.
Under normal circumstance, people will feel discomfort or pain and reposition themselves.
However, patients who are unable to move themselves or have impaired sensation and are unable
to feel this pain, need nurses to aid them in repositioning (Gillespie, et al., 2014).
EFFECTS OF NURSE STAFFING AND PATIENT SAFETY 8
Repositioning and turning schedules seem like an easy fix for preventing hospital
acquired pressure ulcers and treating current pressure ulcers. However, the nurse to patient ratio
on some hospital floors prevents nurses from having the time and ability to complete these turns
on every patient. Cho et al. (2015) completed a study examining the relationship between nurse
staffing and adverse patient outcomes. They found that a large number of patients per nurse was
significantly associated with a greater number of pressure ulcers with an odds ratio greater than
one. A better work environment and smaller nurse to patient ratio showed reports of pressure
ulcers were thirty-nine percent lower. They concluded that the study showed a larger number of
patients per nurse increased the incidence of pressure ulcers and other adverse events (Spetz, et
al., 2013).
In other research the association between characteristics of the nurse work environment
and five nurse-sensitive patient outcomes in hospitals, including pressure ulcers was studied (de
Brouwer, Kaljouw, Schuurmans, & Staplers, 2015). However, they found mixed results for
nurse staffing and patient ratio related to pressure ulcers. In their results they stated, that other
characteristics of work environment other than nurse staffing, showed significant effects such as
was associated with lower rates of pressure ulcer and nursing experience; lower levels of
experience were related to more patient falls and higher rates of pressure ulcers (de Brouwer, et
al., 2015).
In another study presented by Still, et al. (2012) they researched the idea of a “turn team.”
The purpose of the study would be to determine if a team designated to turning patients, rather
than nurses, would decrease the amount of pressure ulcers. The studies include 507 patients.
They found that when turning patients was encouraged but not required by the nurses, forty-two
EFFECTS OF NURSE STAFFING AND PATIENT SAFETY 9
out of 278 patients developed pressure ulcers. However, when a specialized team was designated
to turn the patients only twelve out of 229 patients developed pressure ulcers. They concluded
that a turning team specifically for repositioning patients decreased the incidence of pressure
Falls
Falls are a continuous challenge in many patient facilities, which is why it is especially
important to assess a patient whether they are at a low or high risk for falls because of patient
safety. Patient falls are still considered to be a leading cause of injuries in hospitals and also
continue to be a big patient safety concern (Trepanier & Hilsenbeck, 2014). In the hospital, falls
are the most common occurrence especially in the older population (National Patient Safety
Agency (NPSA) 2013). According to the Royal College of Physicians (RCP, 2015), there was a
national audit of inpatient falls which found that the rate of falls in the older population ranged
from 0.82 to 19.20 falls per 1,000 occupied bed days, along with a mean rate of 6.63 falls per
1,000 occupied bed days. But not all falls are learned, especially when the patient was not
harmed so it is likely that these fall rates are miscalculated (Shorr, 2013).
Falls can happen to patients of any age while being in the hospital. But, older patients are
at increased risk while being in the hospital because of their instability, which is associated with
their illness, treatments and being in the hospital environment (NPSA, 2013). According to
NPSA (2013), 82.2% of falls occurred in patients aged 65 years and over, and 67.6% of falls
occurred in patients aged 75 years and over in hospital falls. It was found that approximately
31% of inpatient falls result in a physical injury such as contusion, laceration, fractures, injury of
the brain, and even patient death (NPSA, 2013). The mean rate of falls that resulted in moderate
and severe harm, and even death was 0.19 per 1,000 occupied bed days with a range of 0.01-2.00
EFFECTS OF NURSE STAFFING AND PATIENT SAFETY 10
recorded in a national audit of inpatient falls (RCP, 2015). A fall may affect a patient
psychologically, socially, and economically including physical effects, such as a fear of falling,
anxiety, depression, loss of self-confidence, a longer stay in the hospital, and increased
There are many risk factors that are associated with inpatient falls on the medical surgical
unit in the hospital. Parkinson’s disease can impair a patient’s movement and posture causing
them to be unstable. Stroke, degenerative joint diseases, and arthritis can cause the muscles to
weaken and impair the patient’s balance and coordination. Other conditions that put the patient
at an increased risk for falls include altered mental status, confusion, delirium, cognitive
impairment, urinary incontinence, depression and postural hypotension (Todd & Skelton, 2014).
Visual impairment and medications, especially if the patient is taking more than four
medications, are important risk factors as well (Todd & Skelton, 2014). Environmental factors
also put the patient at an increased risk for falls including slippery floors, bed rails and assistive
devices, and low or inadequate lighting. Patient activities such as walking, transferring, or
attending to urinary or bowel elimination needs also increases their risk for falls (Zhao & Kim,
2015). It is important to know if the patient has had previous falls in the past because it is a
significant predictor of future falls. This is why it is important to assess the patient using a falls
risk assessment tool and falls risk screening tool upon patient admission to score them
accordingly and determine whether they are a low or high risk for falls, and that way the nurse
can prioritize their patients based on their medical needs (National Institute of Health and Care
Medical-surgical units have the highest rates of falls nationally and can cause significant
injuries resulting in an increased length of stay, unexpected surgeries, and deaths (Bouldin, 2013)
EFFECTS OF NURSE STAFFING AND PATIENT SAFETY 11
(Williams, Szedkendi, & Thomas, 2014). According to Tzeng & Ying (2013), researchers have
shown that using effective teamwork through successful integration of standard evidence-based
practice tools reduces preventable inpatient falls significantly. Successful fall prevention
strategies included staff education, post-fall assessments, alarm devices, side effects of
medications, hourly rounding, call bell usage and offering toilet use more frequently (Tzeng &
Yin, 2013). It has been found that with teamwork among nurses and staff, and situational
awareness are the most crucial in mitigating risk for falls and improving patient safety on the
medical-surgical unit (Gadlock, Christiansen, & Feider, 2016). It is also important for nurses to
prioritize their patients accordingly based on their level of care and needs. For example, the
nurse should put a high fall risk patient with dementia at the top of their list to help prevent any
upcoming falls and/or injuries associated with patient falls. In conclusion, falls are a high risk on
medical-surgical unit floors in the hospital and it is important to do frequent checks on the
Conclusion
When addressing how staffing in hospitals can have an effect on patient safety, research
shows that a high nurse to patient ratio can lead to undesirable outcomes for the patient. These
high nurse to patient ratios lead to an increasing prevalence in medication errors which can
ultimately impact the safety of the nurse and the patient. Studies have shown that there was also
an increase in the development of pressure ulcers based on these high nurse to patient ratios. It
was shown that patients were put at a high risk for falls due to these high nurse patient ratios.
Patient falls are considered to be the leading cause of injury within the hospital setting and put
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