Saberon, Zeleen Ann O.

BSN 4-NG

From Medscape Nurses

Nurse Staffing and the Quality of Patient
Care
Linda H. Aiken, PhD, RN, FAAN, FRCN

Media coverage of nurse shortages and concerns about patient

safety in the nation's hospitals have been extensive. Surveys show that
the public, physicians, and nurses all agree that inadequate nurse
staffing is a threat to the provision of quality healthcare. Some key
findings:

• Physicians identify nurse understaffing and overwork of health

professionals the most serious threats to quality of care and
patient safety; consumers agree, adding poor communication
between health professionals to their top list.[1]
• Two thirds of staff nurses report there are too few nurses to
provide care of high quality, and substantial needed nursing care
is not given; yet nurses spend considerable time in tasks that do
not require their unique expertise, including patient transport,
meal delivery, housekeeping, and ancillary services.[2,3]
• Most hospital nurses report that quality of care has declined, and
nearly half would not recommend their hospital to a relative
needing care.[2]
• One out of 5 hospital staff nurses plan to leave their jobs within a
year; more than a third of staff nurses younger than 30 years of
age intend to leave.[2]

Nurse Staffing and Patient Outcomes

What is the evidence linking nurse staffing to patient outcomes? Loss of

confidence by health professionals and the public in the safety and
quality of hospital care has been accompanied by a surge of published
research documenting an irrefutable link between nurse staffing and
patient outcomes.

The risk of death following common surgical procedures increases by

7% for each patient added to the average nurse's workload. Thus, the
difference in mortality for surgical patients in hospitals in which nurses
on average care for 8 patients each is 30% higher than in hospitals in
which nurses have an average patient load of 4 patients.[4]

In addition, hospitals in which nurses have larger patient loads are

significantly less likely to save the life of a patient who develops a
serious complication.[4,5] "Failure-to-rescue" rates for patients with
complications[6] were 30% higher in hospitals where nurses cared for 8
or more patients than in hospitals in which nurses cared for 4 or fewer
patients.

Higher patient-to-nurse ratios are also associated with substantial

increased nurse burnout and job dissatisfaction. Dissatisfied, burned-
out nurses are 4 times more likely to report that they intend to leave
their job within a year than are nurses who are satisfied with their jobs
and not burned out.

Needle stick injuries to nurses are also more frequent when nurses
have higher patient caseloads,[7] as are patient and family complaints,
falls with injuries, medication errors, and hospital-acquired infections.
[8,9]

Features of the nurse practice environment affect nurse and patient

outcomes independently of staffing levels. Hospitals that entrust greater
autonomy and authority to nurses to act on behalf of patients, where top
management is responsive to nurses' concerns, and where physician-
nurse relationships are good have better nurse retention and better
patient outcomes than other hospitals. Thus, a poor practice
environment undermines the benefits of excellent staffing, and hospitals
with fewer nurses can achieve excellent outcomes by creating an
environment where nurses can be more efficient and effective.[8]

Improving Nurse Staffing and Work Environments

Inadequate nurse staffing is caused by a variety of factors. Among the

most important are: insufficient numbers of budgeted positions for RNs
and nonnursing support staff; vacancies in budgeted positions because
of high nurse turnover; and poor work design that deploys nurses
inefficiently.
Supply Strategies

Is the problem too few nurses?

• There is little evidence that the United States has too few RNs
and no evidence to suggest that differences in nurse supply
explain shortages. That Pennsylvania has almost twice as many
nurses per 100,000 population as California but both states report
widespread nurse shortages casts doubt on the effectiveness of
supply-oriented strategies to ameliorate the nurse shortage.
• The aggregate number of nurses continues to increase, although
the rate of increase is slower than in years past.
• The average age of nurses is increasing, and in some 10-15
years from now, retirements could create a major national nurse
shortage, but aging of the nurse workforce is not an explanation
for the current shortage.

The federal government, through the Nurse Reinvestment Act, recently

allocated $14.4 million in efforts primarily directed at increasing nurse
supply, and Johnson and Johnson launched a major advertising
campaign to attract more applicants to nursing schools. Both are
important initiatives to head off future shortages resulting from
retirements. About 20,000 nurses per year apply to immigrate to the
United States, but available evidence suggests that fewer than 5000 per
year are successful. American nurses oppose relaxing immigration
restrictions for fear that employers will not make the needed changes in
nurse practice environments.

Creating a Culture of Retention

How can RNs be encouraged to keep working?

Staffing legislation: California will implement mandatory nurse staffing

legislation in all of its hospitals in 2004. A third of states have nurse
staffing legislation under consideration. Our research suggests that
staffing mandates are credible policy approaches (if they can be
appropriately implemented) to stem the flight of nurses from hospital
practice, although voluntary efforts that would bring nurse staffing more
in line with levels nurses judge to be adequate would be much preferred
to legislation.

Overtime legislation: Federal legislation prohibiting mandatory

overtime for nurses was introduced in the Senate in February 2003
(S373), and similar legislation has passed or is pending in a number of
states. This legislation may be important to patient safety as the risk of
nurse errors is thought to increase with longer work hours.

Creating more satisfactory work environments: The ANCC Magnet

Recognition Program is an evidence-based approach to improving
nurses' work environments. The program seeks to implement 14
standards of nursing administration and nursing practice. Magnet
hospitals have lower mortality, lower rates of adverse patient outcomes,
higher patient satisfaction, higher nurse satisfaction, lower nurse burn
out, and better quality of care.[10]

The Magnet program is the single most successful hospital reform

initiative of the past 20 years. It is singled out in the federal Nurse
Reinvestment Act and in all recent blue ribbon reports on the nurse
shortage and patient safety as a model that holds promise for reducing
hospital nurse turnover and improving quality of care.

Ensuring patient safety and stemming the flight of nurses from hospital
practice will require a multifaceted approach. However, the bottom line
is that improved working conditions for nurses, particularly those
practicing in hospitals, is key to solving the nurse shortage and making
care safe.

Medscape Nurses. 2003;5(1) © 2003 Medscape