The Effects of Staffing Levels on Nursing Quality and Care In recent years, the healthcare industry has seen a significant decline in the quality of patient care it provides. This has been the result of reduced staffing levels, overworked nurses, and an extremely high nurse to patient ratio. The importance of nurse staffing in hospital settings is an issue of great controversy. Too much staff results in costs that are too great for the facility to bear, but too little staffing results in patient care that is greatly hindered.

Moreover, the shaky economy has led to widespread budget cuts; this, combined with the financial pressures associated with Medicare and private insurance companies have forced facilities to make due with fewer personnel. The resulting struggle between the nursing staff and management has been an ongoing one. The issues related to this have been documented in many studies, and all seem to come to the same conclusion: nurse staff levels have a substantial impact on care received. The studies vary in focus from patient mortality to job dissatisfaction and nurse burnout.

These studies show a direct correlation between the amount of patients nurses are assigned, and the quality of care they are able to provide. A study conducted by the Harvard School of Public Health Human Subjects Committee studied the correlation between staff levels of registered nurses, and six outcomes. The outcomes were comprised of length of hospitalization, rates of urinary tract infections, upper gastrointestinal bleeding, hospital acquired pneumonia, shock or cardiac arrest, and failure to rescue. Researchers used statistics from 799 hospitals in 11 states from different regions of the country.

They were careful to limit their consideration to hospitals with average staffing levels, excluding hospitals with unusually high or low staff levels. The conclusion of the study showed a positive association between the number of hours that a patient received direct care from a registered nurse, and the rate in which they experienced any of the six outcomes. A higher proportion of hours dedicated to a patient’s care resulted in lower occurrence of each of the six measured outcomes. (Needleman et al. , Nurse-staffing Levels)

Another study, conducted by some of the same researchers from the Harvard study previously mentioned, examined another aspect of this issue. In this study, the researchers examined a large academic medical center, involving 197,961 admissions and 176,696 nursing shifts within 43 hospital units. The purpose of this study was to examine the association between patient mortality and their exposure to understaffed nursing shifts. Researchers also examined the association between mortality rates and patient turnover rates, including admissions, transfers and discharges.

Researchers concluded that there was a substantial association between increased mortality and increased exposure to understaffed nursing shifts. According to the study, the association between increased mortality and patient turnover rates was also substantial; concluding that the higher the intake and discharge level of the hospital, the higher the chance that someone will be neglected. A reduction in the ratio of Registered Nurses to patients will result in a decrease in the level of patient care which causes an increase in patient mortality rates.

This retrospective observational study helps to reinforce the necessity for adequate staffing. (Needleman et al. , Nurse Staffing and Inpatient) Another study, listed in the Journal of the American Medical Association, conducted research within 168 hospitals located in Pennsylvania. Their findings reinforced the association between patient to nurse ratios and patient mortality rates. It also inquired into how the patient to nurse ratio relates to nurse retention, nurse burnout, and job dissatisfaction. Within the 168 hospitals considered, once again, patient mortality rates were directly associated with patient to nurse ratios.

This study concluded with astounding results; each additional patient per nurse was associated with a 7% increase in the likelihood of a patient dying within 30 days of admission, and a 7% increase in the odds of failure to rescue. Additionally, the study found that a high patient to nurse ratio resulted in greater emotional exhaustion and greater job dissatisfaction amongst nurses. Each additional patient per nurse was associated with a 23% increase in the likelihood of nurse burnout, and a 15% increase in the likelihood of job dissatisfaction.

Moreover, 40% of hospital nurses have burnout levels exceeding the normal level for healthcare workers, and job dissatisfaction among hospital nurses is four times greater than the average for all US workers. 43% of nurses involved in this study that reported job dissatisfaction intended to leave their job within the upcoming year. (Aiken et al. ) This highly studied issue is one of great importance. A majority of the studies conducted on this topic, including the ones mentioned above, have concluded with the same grim results: understaffed hospitals result in needless patient deaths.

Chapter twenty-five in the Patient Safety and Quality: An Evidence-Based Handbook for Nurses provides a substantial overview of the studies that have been carried out on this topic; it reiterates the concepts of the studies, and strengthens their findings: high patient to nurse ratios result in heavier workloads, decreased job satisfaction and patient danger. Conversely, this chapter also maintains that, while the results are based upon solid information, they are still relatively uncommon; even in situations of extreme understaffing. While the statistics are substantial, they do not account for every possible situation. Clarke et al. ) Nurses are a critical aspect of quality patient care and, are unable to provide such care without adequate staffing. Researchers have found that lower staffing levels are associated with higher risks of poor patient outcomes. Staffing levels related to nurse workload also appear to be related to occupational health issues and psychological issues, resulting in burnout and high turnover rates. -Patient safety -RN’s have become increasingly dissatisfied with their working conditions -Report – spend less time taking care of patients, which decreases the quality of care they receive Purpose of nurses Ensure safe, quality care Reasons for nursing shortages -Unfilled faculty positions, resignations, projected retirements, and the shortage of students being prepared for the faculty role pose a threat to the nursing education workforce over the next five years. The referestrengthens the argument adequate staffing will save lives issue of safety unnecessary loss of life, complication of illness patient to nurse ratios must be changed/enforced unrealistic nurse workloads – provide inadequate medical care determined more favorable patient to nurse ratio is assoc. with lower burnout rates and high job satisfaction with RN’s

In the March-April 2005 issue of Nursing Economic$[->0], Dr. Peter Buerhaus and colleagues found that more than 75% of RNs believe the nursing shortage presents a major problem for the quality of their work life, the quality of patient care, and the amount of time nurses can spend with patients. Looking forward, almost all surveyed nurses see the shortage in the future as a catalyst for increasing stress on nurses (98%), lowering patient care quality (93%) and causing nurses to leave the profession (93%). http://www. nursingeconomics. net/cgi-bin/WebObjects/NECJournal. oa According to a study[->1] in the October 2002 Journal of the American Medical Association, nurses reported greater job dissatisfaction and emotional exhaustion when they were responsible for more patients than they can safely care for. Researcher Dr. Linda Aiken concluded that “failure to retain nurses contributes to avoidable patient deaths. ” High nurse turnover and vacancy rates are affecting access to health care. ·In September 2007, Dr. Christine T. Kovner and colleagues found that 13% of newly licensed RNs had changed principal jobs after one year, and 37% reported that they felt ready to change jobs.

These findings were reported in the American Journal of Nursing[->2] in an article titled “Newly Licensed RNs’ Characteristics, Work Attitudes, and Intentions to Work. ” ·In March 2005, the Bernard Hodes Group[->3] released the results of a national poll of 138 health care recruiters and found that the average RN turnover rate was 13. 9%, the vacancy rate was 16. 1% and the average RN cost-per-hire was $2,821. Impact of Nurse Staffing on Patient Care Many recent studies point to the connection between adequate levels of registered nurse staffing and safe patient care. In a study publishing in the April 2011 issue of Medical Care[->4], Dr. Mary Blegen and her colleagues from the University of California, San Francisco found that higher nurse staffing levels were associated with fewer deaths, lower failure-to-rescue incidents, lower rates of infection, and shorter hospital stays. ·In March 2011, Dr. Jack Needleman and colleagues published findings in the New England Journal of Medicine[->5], which indicate that insufficient nurse staffing was related to higher patient mortality rates.

These researchers analyzed the records of nearly 198,000 admitted patients and 177,000 eight-hour nursing shifts across 43 patient-care units at large academic health centers. The data show that the mortality risk for patients was about 6% higher on units that were understaffed as compared with fully staffed units. In the study titled “Nurse Staffing and Inpatient Hospital Mortality,” the researchers also found that when a nurse’s workload increases because of high patient turnover, mortality risk also increases. ·In a study published in the April 2010 issue of Health Services Research[->6], Dr.

Linda Aiken and colleagues found that lower nurse-patient ratios on medical and surgical units were associated with significantly lower patient mortality rates. ·In the June 2009 issue of the International Journal of Nursing Studies[->7], a research team lead by Dr. Koen Van den Heede found a significant association between the number of baccalaureate-prepared RNs on cardiac care units and in-hospital mortality. Data analyzed by this international team of researcher that included representatives from Belgium, Canada, the Netherlands, and the United States showed that there were 4. fewer deaths per 1,000 patients on intensive care units staffed with a higher percentage of nurses with bachelor’s degrees. ·A growing body of research clearly links baccalaureate-prepared nurses to lower mortality and failure-to rescue rates. The latest studies published in the journals Health Services Research in August 2008 and the Journal of Nursing Administration in May 2008 confirm the findings of several previous studies which link education level and patient outcomes.

Efforts to address the nursing shortage must focus on preparing more baccalaureate-prepared nurses in order to ensure access to high quality, safe patient care. See www. aacn. nche. edu/Media/FactSheets/NursingWrkf. htm[->8]. ·In March 2007, a comprehensive report initiated by the Agency for Healthcare Research and Quality was released on Nursing Staffing and Quality of Patient Care[->9]. Through this meta-analysis, the authors found that the shortage of registered nurses, in combination with an increased workload, poses a potential threat to the quality of care.

Increases in registered nurse staffing was associated with reductions in hospital-related mortality and failure to rescue as well as reduced length of stays. In settings with inadequate staffing, patient safety was compromised. ·Published in the March 2006 issue of Nursing Economic$, a comprehensive analysis of several national surveys on the nursing workforce[->10] found that majority of nurses reported that the RN shortage is negatively impacting patient care and undermining the quality of care goals set by the Institute of Medicine and the National Quality Forum. In an article published in the September/October 2005 issue of Nursing Economic$[->11], Dr. Peter Buerhaus and associates found that the majority of RNs (79%) and Chief Nursing Officers (68%) believe the nursing shortage is affecting the overall quality of patient care in hospitals and other settings, including long-term care facilities, ambulatory care settings, and student health centers. Most hospital RNs (93%) report major problems with having enough time to maintain patient safety, detect complications early, and collaborate with other team members. In November 2004, results from the National Survey on Consumers’ Experiences with Patient Safety and Quality Information[-;12] were released and found that 40% of Americans think the quality of health care has worsened in the last five years. Consumers reported that the most important issues affecting medical error rates are workload, stress or fatigue among health professionals (74%); too little time spent with patients (70%); and too few nurses (69%). This survey was sponsored by the Kaiser Family Foundation, the Agency for Healthcare Research and Quality and the Harvard School of Public Health. A shortage of nurses prepared at the baccalaureate level may be affecting health care quality and patient outcomes. In a study published in the September 24, 2003 issue of the Journal of the American Medical Association[-;13] (JAMA), Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a “substantial survival advantage” if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level. In hospitals, a 0 percent increase in the proportion of nurses holding BSN degrees decreased the risk of patient death and failure to rescue by 5 percent. ·A survey reported in the December 12, 2002 issue of the New England Journal of Medicine[-;14] found that 53% of physicians and 65% of the public cited the shortage of nurses as a leading cause of medical errors. Overall, 42% of the public and more than a third of US doctors reported that they or their family members have experienced medical errors in the course of receiving medical care. The survey was conducted by the Harvard School of Public Health and the Henry J.

Kaiser Family Foundation. [-;15] ·According to a study[-;16] published in the October 23/30, 2002 issue of the Journal of the American Medical Association, more nurses at the bedside could save thousands of patient lives each year. Nurse researchers at the University of Pennsylvania determined that patients who have common surgeries in hospitals with high nurse-to-patient ratios have an up to 31% increased chance of dying. Funded by the National Institute for Nursing Research, the study found that every additional patient in an average hospital nurse’s workload increased the risk of death in surgical patients by 7%.

Having too few nurses may actually cost more money given the high costs of replacing burnt-out nurses and caring for patients with poor outcomes. [->17] ·In Health Care at the Crossroads: Strategies for Addressing the Evolving Nursing Crisis, a report released in August 2002 by the Joint Commission on Accreditation of Healthcare Organizations[->18] (JCAHO), the authors found that a shortage of nurses in America’s hospitals is putting patient lives in danger.

JCAHO examined 1609 hospital reports of patient deaths and injuries since 1996 and found that low nursing staff levels were a contributing factor in 24% of the cases. ·According to a study published in the New England Journal of Medicine[-;19] in May 2002, a higher proportion of nursing care provided by RNs and a greater number of hours of care by RNs per day are associated with better outcomes for hospitalized patients. This extensive study was conducted by Drs. Jack Needleman and Peter Buerhaus. Strategies to Address the Nursing Shortage In September 2010, AACN announced the expansion of NursingCAS, the nation’s centralized application service for RN programs, to include graduate nursing programs. One of the primary reasons for launching NursingCAS was to ensure that all vacant seats in schools of nursing are filled to better meet the need for RNs, APRNs, and nurse faculty. In 2009, almost 55,000 vacant seats were identified in baccalaureate and graduate nursing programs. NursingCAS provides a way to fill these seats and maximize the educational capacity of schools of nursing. See www. aacn. nche. edu/Media/NewsReleases/2010/ExpanNursingcas. tml[-;20] ·In July 2010, the Robert Wood Johnson Foundation (RWJF) released its Charting Nursing’s Future newsletter focused on “Expanding America’s Capacity to Educate Nurses: Diverse, State-Level Partnerships Are Creating Promising Models and Results. ” This policy brief describes the capacity innovations of 12 partnerships that are effectively addressing the nursing and nurse faculty shortages. Among the policy recommendations advanced in this brief are requiring all new nurses to complete a BSN program within 10 years of licensure and enhancing the pipeline into baccalaureate and graduate nursing programs.

See www. rwjf. org/files/research/20100608cnf. pdf[-;21] ·In February 2009, Senator Richard Durbin (D-IL) introduced the Nurse Education, Expansion and Development Act[-;22] (NEED Act). If passed, the NEED Act would amend Title VIII to authorize Capitation Grants (formula grants) for nursing schools to increase the number of faculty and students. Capitation grants have been effective in addressing past nursing shortages. Representative Nita Lowey (D-NY), who has championed the NEED Act since 2004, plans to reintroduce the bill later this spring. In February 2009, academic and healthcare leaders from 47 states gathered in Baltimore for the 2009 Nursing Education Capacity Summit to help identify and advance strategic solutions to the nursing shortage. Sponsored by the Center to Champion Nursing in America[-;23], HRSA and the U. S. Department of Labor, participants shared best practices related to strategic partnerships and resource alignment; policy and regulation; increasing faculty capacity and diversity; and redesigning educational curricula. ·Many statewide initiatives are underway to address both the shortage of RNs and nurse educators.

For example, in September 2008, Pennsylvania Governor Edward G. Rendell announced that the state’s investment of $750,000 to address the nursing shortage would be matched by at least $870,000 in private-sector funds. This public-private partnership yielded new money for schools to hire more nurse faculty and educate more students. For a listing of other state-based initiatives, see www. aacn. nche. edu/Publications/issues/Oct06. htm[->24] and www. aacn. nche. edu/Media/PartnershipsResource. htm[->25]. ·Nursing schools are forming strategic partnerships and seeking private support to help expand student capacity.

For example, Shenandoah University in Virginia announced in November 2008 that the school of nursing formed a partnership with Inova Health System to support the school’s accelerated BSN program. Through a two-year agreement, Inova will award $7,500 scholarships to up to 55 students who make an employment commitment to Inova after graduation. The health system will also contribute $500,000 to fund new classrooms, skills/simulation labs and/or administrative spaces and provide additional clinical rotation slots at three Inova hospitals.

For details on similar initiatives, see www. aacn. nche. edu/Media/PartnershipsResource. htm. ·In July 2007, PricewaterhouseCoopers’ Health Research Institute released a report titled What Works: Healing the Healthcare Staffing Shortage[->26] which advanced several strategies for addressing the nursing shortage, including developing more public-private partnerships, creating healthy work environments, using technology as a training tool, and designing more flexible roles for advanced practice nurses given their increased use as primary care providers. In an article published in the June 2006 issue of Health Affairs titled “Hospitals’ Responses to Nurse Staffing Shortages[->27],” the authors found that 97% of surveyed hospitals were using educational strategies to address the shortage of nurses. Specific strategies include partnering with schools of nursing, subsidizing nurse faculty salaries, reimbursing nurses for advancing their education in exchange for a work commitment, and providing scheduling flexibility to enable staff to attend classes. The paper ends with a call for more public financing support for the nursing educational system to expand student apacity. ·In June 2005, the US Department of Labor[->28] awarded more than $12 million in grant-funding through the President’s High Growth Job Training Initiative, $3 million of which will help to address the nurse faculty shortage. This latest round of funding brings the DOL’s commitment to health care workforce through the High-Growth program to more than $43 million. Details on all grant-funded programs are posted online. [->29] ·In February 2002, Johnson & Johnson launched the Campaign for Nursing’s Future[-;30], a multimedia initiative to promote careers in nursing and polish the image of nursing.

This multimillion dollar effort includes television commercials, a recruitment video, a Web site, brochures, and other visuals. In 2007, Johnson & Johnson generously committed to extending this winning campaign for another five years. References Aiken, Linda H. , eta l. “Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction. ” The Journal of the American Medical Association. 288 (2002): 1987-1993. Web. 9 July. 2001. http://jama. ama-assn. org/content/288/16/1987. full#sec-7 Clarke, Sean P. , and Nancy Donaldson. Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

Maryland: Hughes RG, 2008. Print. Needleman, Jack, et al. “Nurse Staffing and Inpatient Hospital Mortality. ” The New England Journal of Medicine. 364 (2011): 1037-1045. Web. 9 July. 2011. http://www. nejm. org/doi/full/10. 1056/NEJMsa1001025 Needleman, Jack, et al. “Nurse-Staffing Levels and the Quality of Care in Hospitals. ” The New England Journal of Medicine. 346 (2002): 1715-1722. Web. 9 July. 2011. http://www. nejm. org/doi/full/10. 1056/NEJMsa012247#t=abstract [-;0] – http://www. nursingeconomics. net/cgi-bin/WebObjects/NECJournal. woa [-;1] – http://jama. ma-assn. org/content/288/16/1987. full [-;2] – http://www. ajnonline. com/ [-;3] – http://www. hodes. com [-;4] – http://journals. lww. com/lww-medicalcare [-;5] – http://www. nejm. org/doi/pdf/10. 1056/NEJMsa1001025 [-;6] – http://www. nursing. upenn. edu/chopr/Documents/Aiken. 2010. CaliforniaStaffingRatios. pdf [-;7] – http://www. journalofnursingstudies. com/ [-;8] – http://www. aacn. nche. edu/Media/FactSheets/NursingWrkf. htm [-;9] – http://www. ahrq. gov/downloads/pub/evidence/pdf/nursestaff/nursestaff. pdf [-;10] – http://www. medscape. om/viewarticle/525650 [-;11] – http://www. medscape. com/viewpublication/785_index [-;12] – http://www. kff. org/kaiserpolls/pomr111704pkg. cfm [-;13] – http://jama. ama-assn. org [-;14] – http://content. nejm. org [-;15] – http://content. nejm. org [-;16] – http://jama. ama-assn. org/content/288/16/1987. full [-;17] – http://www. nursing. upenn. edu/news/detail. asp? t=2=23 [-;18] – http://www. jcaho. org [-;19] – http://content. nejm. org [-;20] – http://www. aacn. nche. edu/Media/NewsReleases/2010/ExpanNursingcas. html [-;21] – http://www. rwjf. rg/files/research/20100608cnf. pdf [-;22] – http://www. aacn. nche. edu/Government/pdf/CapGrants. pdf [-;23] – http://www. championnursing. org [-;24] – http://www. aacn. nche. edu/Publications/issues/Oct06. htm [-;25] – http://www. aacn. nche. edu/Media/PartnershipsResource. htm [-;26] – http://www. pwc. com [-;27] – http://content. healthaffairs. org/cgi/content/abstract/25/4/W316 [-;28] – http://www. doleta. gov/BRG/Indprof/Health. cfm [-;29] – http://www. aacn. nche. edu/Publications/positions/tricshortage. htm [-;30] – http://www. discovernursing. com