Nurse Staffing Levels Impact

Introduction

The focus of this section is to provide background on the issue of the levels of nurse staffing and its impact on patient outcomes. The statement of the problem and the rationale behind it has motivated the researcher to perform this study and demonstrate the influence of nurse staffing on patient safety and care. The aim, objectives, and the questions that the research seeks to answer are also presented along with its significance of the issue for managers of health care facilities.

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Background of the Study

There is an abundance of evidence that demonstrates the impact of nurse staffing levels on the patient outcomes in a health care setting. It has been established that increased nurse staffing has the potential to reduce the adverse events experienced by the patients and mortality rates (Beglinger 2006; Kane et al. 2007; Cho, Hwang & Kim 2008; Kiekkas et al. 2008; Department of Health 2010; Aiken et al. 2011; Needleman et al. 2011). Notably, there has been observed a decrease in mortality rates as a result of increasing RN staffing in the ICUs. The death rate of patients in the ICU decreased by 9% in response to the increase of the number of RNs. It has been estimated that a higher nurse-to-patient ratio would save the lives of five patients out of every 1000 admitted to the ICU (Griffiths et al. 2013).

There is the whole array of factors that influence nursing practice, from organizational climate to the environment of a unit within the healthcare facility. Although there are factors that contribute to the positive work environment such as constructive interactions between staff members, job satisfaction, sufficient autonomy, stress level, and low risk of burnout, nurse staffing remains an important predictor of both the quality of care delivered by the nurses and the health-related patient outcomes. For example, inadequate nurse staffing increases the risks of improperly identifying and responding to complications when health problems or complications are left untreated or unattended due to a reduced level of nurse staffing (Griffiths et al. 2013).

However, despite the existing relationship between nurse staffing and patient outcomes, the understanding related to the mechanisms that determine the impact of low nurse staffing on the mortality and patient outcomes is limited (Burnes et al. 2007). Further study is required to investigate the factors that are linked to nursing staffing levels and their influence on patient outcomes. Special attention should be dedicated to studying dynamics and mechanisms behind current as well as possible progressive nurse staffing practices.

Scholars and practitioners in the health care field have devoted their attention to the workload of nursing personnel. An increased focus on the issue of nurse staffing has led to performing numerous studies that have highlighted the distinctive significance of nurse staffing on patient outcomes regardless of the factors related to patients, physicians, or healthcare facilities (Estabrooks et al. 2005). The combined findings of these studies have indicated that low nurse staffing is associated with adverse patient outcomes in the hospital facilities (Kane et al. 2007; Shekelle 2013). Notably, reduced mortality rates among patients have been observed to be directly related to increased nurse staffing (Aiken et al. 2008; Aiken et al. 2011).

However, there is a greater context behind the need for more nurses to adequately address the health care needs of contemporary society. For decades, the members of the nursing profession have faced the challenges of having to cope with poor working environment, increasing stresses associated with working in the health care delivery system, a shortage of nursing personnel, and consequent risks to patient safety and care. These factors have led to lower job satisfaction, significant professional burnout rates, and higher staff turnover.Relevant studies have indicated that increased nurse staffing helps prevent adverse patient outcomes and complications (Kiekkas et al. 2008; Aiken et al. 2008; Needleman et al. 2011).

Nurse staffing is a strategic issue that impacts both the quality of care and profitability of healthcare facilities (Department of Health 2010). One example of finding the solution to low nurse staffing levels is the state of California’s legislation mandating mandatory nurse-to-patient ratios for hospitals. The District of Columbia and fourteen states have either established regulations requiring either written staffing plans or have adopted legislation mandating nurse-to-patient ratios, or have employed a combination of the two (Tevington 2011).

Aiken et al. (2010) researched were since the moment when mandated minimum nurse-to-patient ratios went into effect there were positive changes related to nursing and patient outcomes. The study compared a workload of over twenty-two thousand nurses from three states and found that nurse-to-patient ratios mandated in California account for better nurse retention (Aiken et al., 2010). Furthermore, the number of RNs in California has increased as well.

The developing shortages of nursing personnel have other societal roots, as well. The nursing workforce is aging as is the patient population, and this factor requires more nursing care. Moreover, the younger population currently lives under conditions that demand greater nursing assistance (Gordon, Buchanan & Bretherton 2008). This means the demand for nursing professionals will increase and managers of health care facilities need to develop solutions and policy recommendations adequate for facing future challenges of managing increased demand for nursing care and the increasing workload in the context of high turnover of nursing personnel and continuous shortage of nursing personnel.

Problem of the Study

Comparison of different healthcare systems indicates that the personnel at British National Health Service (NHS) hospitals experience extreme pressure and a great deal of stress. The stress is associated with the hospitals’ weakened ability to ensure the safety and quality of administered care at costs that are similar or lower than in previous years (Ham 2009). Recent reports in England focus on the quality of nursing care and its influence on patient outcomes. Low quality of care is associated with increased costs of healthcare worldwide. Department of Health (2013) conducted the Francis Inquiry to investigate the reasons behind the poor quality of care that most of the patients at the Mid Staffordshire NHS Foundation Trust Hospital experienced from 2005 to 2009.

The inquiry was initiated and performed when it was discovered that hospital mortality ratios significantly exceed commonly accepted norms and that nearly 400 patients have died in the course of two years. The inquiry investigated various negative experiences of patients regarding the essential aspects of nursing care. Negative experiences ranged from a lack of respect for patient autonomy and dignity to lack of safety and planning of the discharge to insufficient communication. The report identified that one of the core factors behind the negative patient experiences and low satisfaction was the failure to ensure adequate nursing staffing (Department of Health 2013).

Francis Report by the Department of Health (2013) found that two the most significant reasons behind the negligence of patient care were the failure of leadership to adequately manage the hospital and inadequate staffing levels of nursing personnel. This fact corroborates the importance of maintaining a sufficient nursing staffing level to the quality and effectiveness of patient care. The Francis Report clearly stated that an unacceptable standard of nursing care was directly associated with inadequate staffing levels and skills (Department of Health 2010).

The report encourages the management at health care facilities, chief nursing officers, commissioning board, and ward nurse manages to provide support and assistance to nurses and create the environment that facilitates the inclusive atmosphere, one that makes nurses feel and act as an integral part of the health care personnel called to ensure the excellence of care and patient safety. The Francis Report suggests that in the environment where the quality of care and patient safety suffer from shortages of nursing personnel, the leadership at health care facilities should cultivate organizational culture that facilitates the creation of practice settings in which nurses are recognized as a true health care professionals, and are motivated and encouraged to gain necessary skills and knowledge to provide the best possible nursing care.

Aiken et al. (2010) investigated instances of nurse-reported job-burnout and job dissatisfaction and the dynamics behind them in the context of existing nurse staffing practices. The author found that improving the nurse staffing levels led to the reduction of job dissatisfaction and burnout as the major precursors of high turnover rate and job resignation. In confirmation of these findings, Nelson (2008) claimed that adequate nurse-to-patient ratios increase job satisfaction and decrease turnover among nurses. Nelson’s study (2008) found that mandatory nurse-to-patient ratios have a significant positive impact on nursing personnel.

Since nurse staffing is a critical issue that impacts the quality of healthcare immensely, managers of health care facilities and policymakers have to find solutions to effectively manage the increasing workload, improve the work environment, minimize work-related stress, and implement proper incentive structures to recruit and retain more nurses (Gordon, Buchanan & Bretherton 2008).

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Also, it was found that safety was being compromised because of widespread shortages of nursing personnel since NHS trusts put a hiring freeze on vacant nursing positions in an effort to minimize costs. In 2013, the investigation of 14 hospital trusts with high death rates pointed out to inadequate staffing as a common factor behind high mortality rates since in some cases, patients were left unattended as nursing personnel was overloaded with work. As Donnelly (2013) stated, understaffing remains a real issue across the NHS, as many trusts maintain the bare minimum of nursing staffing levels due to efforts to cut costs (Donnelly 2013). The same article by Donnelly (2013) reported that since 2010, trusts have routinely enforced hiring freezes whenever nursing staff members retired or moved elsewhere, creating widespread shortages.

Therefore, responsible health care managers need to develop an understanding of the various problems responsible for the delivery of appropriate care across the NHS trust hospitals. Managers need to realize the critical linkage between mechanisms responsible for nurse staffing and patient safety and quality of care delivery at the hospitals. Moreover, managers need to focus on instances of negligence in the provision of some of the critical features of care. Taking into consideration the aforementioned needs of management in regard to ensuring both adequate nurse staffing and positive patient outcomes, there is a need to explore the influence of nurse staffing levels on patient outcomes and investigate the factors that might be responsible for both inadequate patient care and ensuring positive patient outcomes.

Topic Choice Rationale

During the investigation of staffing levels in 14 hospital trusts with high death rates, it was found that widespread shortages of nurses frequently account for numerous call bells being left unattended due to the overwhelming workloads among nursing staff (Donnelly 2013). Additionally, several factors attracted the attention of the researcher to perform a study that can provide insight into the phenomenon of association between nurse staffing levels and patient outcomes.

First, it is vital to further research the linkage between nurse staffing and patient outcomes and mortality rates in particular. Second, it is imperative to study factors that contribute to the negligence on the part of nurses in regard to patient care, in order to address and minimize negative patient outcomes. For example, patients in acute hospital wards may require immediate care delivered by nurses. Lastly, in order to thoroughly investigate dynamics and factors that cause nurse shortages, it is critical to find out whether there is a connection between low nurse staffing and work satisfaction and professional burnout.

Aim and Objectives

The author of this research aims to explore the influence of nurse staffing on the quality and safety of patient care in hospital facilities. The author established following objectives based on the goals of reviewed studies.

  1. To explore how shortages of nursing personnel influence the quality of administered nursing care.
  2. To investigate how staffing levels of registered nurses are associated with patient clinical outcomes.
  3. To research the dynamics that influence staffing levels as a result of nurses’ burnout and low job satisfaction (Sheward et al. 2005; Rafferty et al. 2007; Shuldham et al. 2009; Griffiths et al. 2010; West et al. 2014; Aiken et al. 2014).

Research Questions

  • (a) Does the staffing level of registered nurses impact patient outcomes in a hospital setting?
  • (b) Does the staffing level influence job satisfaction and burnout rates among registered nurses?

Research questions are aligned with the needs of the current dissertation and topics of selected studies by Sheward et al. 2005, Rafferty et al. 2007, Shuldham et al. 2009, Griffiths et al. 2010, West et al. 2014, and Aiken et al. 2014.

Significance of the Study

This study contributes to the knowledge base contained in the current literature regarding the factors that impact patient outcomes due to nurse staffing levels. The association of nurse staffing levels and its influence on the patient outcomes discussed in this review is also valuable for understanding the importance of nurse staffing on mortality rate in the hospital setting. The critical evaluation of the effects of the level of nurse staffing on clinical outcomes could prove valuable for establishing the guiding framework for policymakers involved in patient care, in order to ensure the proper delivery of care and overcome the hindrance in the way of effective care provision.

Outline of the Study

Chapter 1 - Introduction: This part addresses the background, context, and rationale behind the need to investigate the issue of nursing shortages. Also, the essence of the problem along with the rationale for selecting the topic is described. Additionally, this section identifies the aims and objectives of the research and provides an overview of the dissertation. The research questions and significance of the research are discussed as well.

Chapter 2 – Literature Review: The section represents the methodology that has been used to perform the current study. The justification for the selection of specific research design and the process of selection of appropriate methodology is also provided.

Chapter 3 - Methodology: This chapter provides the literature review and assessment of the studies, focusing on the importance of nurse staffing levels’ impact on patient outcomes.

Chapter 4 - Results: This chapter contains the outcomes of the study and includes an analysis of the data in a thematic manner via the review of selected studies.

Chapter 5 - Discussion: This part compares the research results with outcomes of other studies on the topic under consideration.

Chapter 6 - Conclusion: The summary of the research is provided in this section. Recommendations for further research and implications of the review for current staffing practices and improving patient outcomes are also presented.

Literature Review

Literature that addresses the impact of nurse staffing on patient clinical outcomes is reviewed. Outcomes of insufficient nurse staffing levels are explored. Finally, the effects of nurses’ working environment on patient safety and quality of care are evaluated.

Sheward et al. (2005) performed a study to explore the relationship between nurse staffing, burnout and job satisfaction among nurses. The study employed a quantitative analysis via descriptive statistical analysis and logistic regression. Data collection was performed by offering RNs in English and Scottish hospitals to fill in survey questionnaires. The study was supported by respective authorities and did not require ethical approval. The sample group was comprised of 27 hospitals in Scotland out of which 25 were acute care trusts and 32 hospitals from England. There was an increased level of stress among the nurses in English and Scottish hospitals, who admitted that they were working in an environment characterized by a high level of stress.

However, 34% of English nurses reported stress due to low staffing and caused by the increased workload. However, only 27% of Scottish nurses reported feeling stressed. Nevertheless, 60% of RNs in English and Scottish hospitals reported that they were satisfied with their jobs. Exhaustion was reported by 30% of English nurses; burnout scores tended to increase in situations with lower patient-to-nurse ratios. Increased nurse-to-patient ratios accounted for reduced burnout and higher job dissatisfaction among nurses (Sheward et al. 2005).

Rafferty et al. (2007) performed another study aimed at determining the effects of variations in levels of nurse staffing on patients outcomes such as mortality and FTR, and nurse outcomes such as burnout, low job satisfaction, and quality of administered care. The study employed cross-sectional analysis and logistic regression analysis of the patient data. Collection of data was performed via a survey conducted among nurses, most of whom were RNs. The study received approval from ethical review board of the involved institutions. The sample group was comprised of 3984 nurses and 118752 patients in 30 English trusts of acute care. It was observed that hospitals with lower nurse-to-patient ratios had a mortality rate that was 26% higher in comparison with the hospitals that had higher nurse-to-patient ratios.

Furthermore, low job satisfaction and burnout among nurses were more frequently observed in hospitals with lower nurse-to-patient ratios. Therefore, lower quality of care increased patient mortality, and FTR was found to be a consequence of lower nurse-to-patient ratios. Low job satisfaction and high burnout rates among nurses due to low nurse staffing can also impact negatively patient outcomes. Subsequently, higher nurse-to-patient ratios should be maintained in order to overcome nurse staffing-related negative effects on patient care.

The study by Shuldham et al. (2009) explored the impact of nursing hours per shift on the outcomes of patients with different health conditions. The study design represented a qualitative case study. The data collection was performed through the data of PAS extracted into the Oracle database. The research was approved by the institutional ethics committee. The sample group of the study was comprised of 25,507 patients admitted to two NHS hospital trusts in England. Although no association was observed between the nursing hours per patient daily and patient outcomes in units where patients did not require critical care, the study showed that rates of such adverse patient outcomes as sepsis were significantly reduced as a result of increasing the ratio of permanent nursing staff-per-patient hours.

Therefore, although the study demonstrated the relationship between nurse staffing and patient outcomes, the associations found were weak and did not reliably corroborate the findings of the existence of a strong relationship between nurse staffing levels and patient outcomes across various hospital settings (Shuldham et al. 2009).

Griffiths et al. (2010) investigated the relationship between the nurse staffing level and the quality of care administered to patients. The study design was a cross-sectional analysis through multi-level modeling. Ethical approval was not required in the course of this research. The data was collected from a number of databases including Office for National Statistics, University of Manchester, and NHS. The sample group was comprised of 7456 RNs. The study showed that increased nurse staffing was associated with improved patient outcomes and higher quality of care in several clinical domains (Griffiths et al. 2010).

Also, the employment of a higher number of nurses improved the work performance and quality of care administered by the nurses. Thus, a higher level of nurse staffing and fewer patients per nurse was significantly associated with better patient outcomes in instances of such illnesses as diabetes, hypertension, coronary heart disease, and chronic obstructive pulmonary disease (Griffiths et al. 2010). The study concluded that the employment of more nurses accounts for better intermediate clinical outcomes.

The study conducted by West et al. (2014) observed the impact nurses and other hospital staff members had on patient outcomes and mortality in particular. The study employed cross-sectional analysis to perform an observational retrospective study. Collected data provided the database used during the study. Approval was received from the ethics committee of involved institutions. The sample group was comprised of 38,168 patients at 65 ICUs of the UK hospitals. High survival rates were observed in the ICUs that had a higher nurse-per-bed ratio. It was observed that nursing personnel had a greater impact on survival rates of patients than other medical staff. Also, the higher number of nursing personnel was found to significantly reduce the patient mortality rate in the ICUs.

Aiken et al. (2014) performed a study aimed at determining the association between workload and education of nurses with mortality of the patients following surgical procedures. The research design was a quantitative observational study. Collection of data was performed via the surveys among bedside nurses in nine European countries. Ethical approval was received at country and institutional levels. The sample group was comprised of 26,516 bedside nurses. The study results showed that there was a seven percent increase in the patient mortality rate when every nurse had to care for one more patient in on top of the average workload.

However, the increase in the number of nurses with a Bachelor’s degree reduced the patient mortality rate by seven percent. The study found that patients in hospitals where two-thirds of nurses had a bachelor's degrees and nurses cared for six patients on average had nearly thirty percents lower mortality rates than patients in hospitals where only one-third of nurses had bachelor's degrees and nurses cared for eight patients on average (Aiken et al. 2014). Therefore, the study concluded that the workload and education of nurses do affect patient mortality, and sufficient nurse staffing should be ensured in hospitals as such that promotes and ensures greater patient safety (Aiken et al. 2014).

Methodology

Methodology, as a significant constituent of the study, reflects the approach undertaken to perform the research. Therefore, selecting suitable research design is crucial for obtaining credible and valid results. Taking the aforementioned factors into consideration, the rationale concerning the research design that has been selected for performing this study is provided in this section. The inclusion and exclusion criteria and parameters of the literature search are presented as well. The process of analyzing data that constitutes the foundations of the literature review is also provided. Key ethical considerations and limitations of this research that were encountered during the course of study are discussed.

Research Design

The development of a systematic, ordered, and unambiguous approach is essential for all the researches aimed at investigating various topics through the employment of methods that are most suitable to adequately address the research questions (Denscombe 2010). Secondary analysis is used to describe different analytical practices that use already existing data either to investigate new research questions or to reexamine primary study questions for purposes of corroboration (Burls 2009). The re-use of qualitative data remains underdeveloped, while the secondary analysis of statistical data is a well-documented methodology (Bryman 2012).

Primary and secondary data are collected by the primary and secondary methods of data collection respectively. Primary data provides access to first-hand resources while secondary data provides information that has been presented previously by other researchers about the topic that is being studied. Secondary analysis allows the researcher to explore areas of interest without having to go through the process of collecting data in the field. The problem with using fieldwork methods for writing dissertations, however, is that fieldwork may be time-consuming and costly in terms of resources (Denscombe 2010; Bryman 2012).

Considering the described aspects of secondary research, this study will be performed via the employment of the chosen design. The secondary research facilitated the researcher in assessing the outcomes of numerous studies and deducing them to a concise overview of the topic. Secondary research data will be selected for performing this study because it provides the opportunity to address the aim and meet the objectives of the dissertation. Moreover, a secondary method of data collection that will be applied is based on the selection of studies that provide major amount of relevant data associated with the topic.

The following advantages of secondary research design have served as the basis for the selection of this particular design. The primary advantage of the literature review is the opportunity to target an in-depth investigation of the topic and obtain a scientifically based understanding of the reality (Cresswell 2009). This research design allows for exploiting data that is extensively detailed and rich with information pertinent to the content of the research. Thus, the systematic review of the selected studies has been selected as the approach for performing a secondary qualitative study. The literature review highlights the existing literature and enables the researcher to gather momentous information (Denscombe 2010). The information considered imperative to the topic has been included in the review.

Parameters for the Literature Search

A search of the literature will be performed by the researcher both through electronic databases and libraries consisting of hard copies. The credibility of the studies will be established via finding publications in the peer-reviewed scholarly sources. The electronic databases PubMed, Medline, CINAHL, BMJ, Cochrane, and Medscape provide free access to scholarly articles for this report. For example, the Cochrane online library was accessed since it specializes in collecting of meta-analyses and systematic reviews that interpret the results of various healthcare-related researches. The Department of Health and NHS provides free information on the issues of national health and social care policies.

The researcher also investigated the most recent Francis Report on the care quality at the Mid Staffordshire NHS Foundation Trust conducted in 2013 and commissioned by the government in response to concerns about poor governance of the hospital facility (Department of Health 2013). The articles that were published from 2004 to 2014 will be used as anything older could contain misleading or outdated information. This restriction had been adhered to in order to obtain all the recent studies that contain relevant information regarding the impact of nurse staffing level and patient outcomes and published in the English language.

Keywords Used for Searching the Literature

Numerous keywords will be used for performing the search based on their relevance to the topic. This will permit the retrieval of studies dedicated to exploring the association of levels of nurse staffing and clinical outcomes. The keywords that are used for search are comprised of a combination of words by utilizing the Boolean operators ‘AND’, ‘NOT’, and ‘OR’ with words such as ‘Nurse’, ‘Staffing’, ‘Levels’, ‘Patient’, ‘Outcomes’, ‘Mortality’, ‘Adverse Events’, ‘Safety’, ‘Management’, ‘Enthusiasm’, ‘Exhaustion’, and ‘Job Satisfaction’.

Boolean Logic

Boolean Logic is the system based on the logical search of the relevant literature through the combination of various search terms. It ensures the retrieval of appropriate information and exclusion of the inappropriate material. This system is based on the Boolean operators used to combine, eliminate, or intensify keywords when performing a search. This process includes the combination of various keywords combined by the utilization of Boolean operator ‘AND’ to limit the search and ‘OR’ to amplify the search. It also includes ‘NOT’ that is used for excluding the irrelevant information and reefing the search (See Appendix 1). It not only ensures the effective search, but also enables the researcher to save time.

Inclusion and Exclusion Criteria

It is recognized that the initial search of the literature frequently supplies rather superficial and inappropriate materials. In order to conduct a search of existing literature, it is necessary to eliminate unrelated and irrelevant literature by establishing the inclusion and exclusion criteria (Blaxter, Hughes & Tight 2006). Exclusion and inclusion criteria should be determined prior to make a decision about the studies deemed appropriate for including in the literature review. Selected studies should come from peer-reviewed journals and their full texts should be available. Additionally, relevant studies dated from 2004 to 2014 will contain the most recent information regarding the association between patient and nurse staffing outcomes.

While there might be relevant information from Health Watch England on the issues of patient satisfaction and staffing level prior to 2004, any data older than 10 years can be misleading or outdated. The restriction of language has also been established to include studies in the English language, excluding studies in other languages. The inclusion criteria should facilitate the selection of articles that

  • (a) explore the impact of nurse staffing level on patient care and the workload of nurses;
  • (b) are peer-reviewed and use correlational, experimental, retrospective, or observation methodologies allowing for a degree of generalization and description of the relationship between registered nurse staffing and patient care outcomes, or professional burnout and nurses’ job satisfaction.

Studies performed in nursing homes and communities or ones that examine different healthcare-related professional issues such as other medical staff ratios or partnership between nurses and other health care professionals will be excluded.

Studies Included in Review of Literature

During the process of selecting studies to be reviewed, the inclusion and exclusion criteria ensured that only those studies that provided reliable scientific findings are used in this report. The initial search of the literature had resulted in the retrieval of 200 studies that were considered relevant. Selected studies were further screened to exclude those studies that did not meet the inclusion criteria. One hundred and eighty-five studies were excluded such as duplicated articles to reduce repetition of same information or as those that lacked reliability and credibility of their findings. Finally, 15 remaining studies were reviewed on the basis of inclusion and exclusion criteria. As a result of the evaluation, nine more studies were excluded and six qualitative and quantitative studies were included (See Appendix 2).

Analysis of the Data and Quality Appraisal of the Studies

The data for the current secondary research is based on the literature review. It is critically important to perform the quality appraisal of the studies selected for the review since quality appraisal allows the assessment of the credibility and veracity of evidence presented in the studies (Greenhalgh 2006; Burls 2009). Therefore, the method of critical appraisal was selected for evaluating selected studies and assessing their limitations and vigor. Blaxter, Hughes, and Tight (2006) provide the guiding procedure for quality appraisal during secondary studies.

The authors provide the framework that analyzes the analytical, objective, and distinct viewpoints of the studies included in the review. Blaxter, Hughes, and Tight (2006) identified tools that help to recognize the strengths and weaknesses of the selected studies and facilitate analysis of the implications of the study outcomes for practice. Analysis provided by authors helped to identify themes directly related to the issue of nurse staffing levels and patient outcomes and specifically address factors that contribute to the negligence in nursing care and result in adverse patient outcomes.

Ethical Considerations

There are ethical considerations to be observed prior to initiating and during the research. Cresswell (2009) suggested that ethical issues are an important aspect of the writing and dissemination process of the research. Therefore, the researcher ensured that ethics were given significant consideration while conducting a review of the literature. For example, proper citation and referencing of the information was applied to avoid the possibility of unintentional plagiarism. The probability of bias on the part of the researcher in regards to the interpretation of the findings of other researchers has been minimized. As part of being a reviewer of the work that has been performed by others, the author of this study conducted a responsible review of studies performed by other researchers.

Limitations

Secondary research is frequently used for data collection. This methodology helps to access data that has already been gathered by previous primary researches. Secondary research includes collecting information from third-party sources such as sales and accounting records, magazine articles, journals, and marketing research reports. Also, the advantage of secondary research is the relative ease of accessing relevant information at a little to no cost. Secondary research might help to clarify the research question and is often used prior to primary research to help clarify the research focus or align the focus of large scale primary research (Blaxter, Hughes & Tight 2006). When conducting secondary research, the researcher might find that the issue under consideration has already been studied and discussed. This might include information describing the procedures used in data collection, as well as difficulties encountered in conducting the primary research (Bryman 2012).

However, there are disadvantages to using secondary research. Frequently, primary researches are largely self-governed and controlled by the researcher or a sponsor. Therefore, secondary research must be scrutinized closely since primary studies may be biased and lack credibility. Moreover, the researcher has to critically evaluate the validity and reliability of the information provided (Greenhalgh 2006). Although it may be easy to locate and gather secondary data, such data may have the aforementioned limitations and the problems might arise if these limitations are disregarded.

Limitations of the Secondary Research

  1. It may be too general and vague and may not help clarify the issue under consideration.
  2. The information may lack accuracy. The credibility of the data source must always be verified.
  3. The data may be outdated, irrelevant, or misleading.
  4. The sample used to generate the secondary data may be too small.
  5. The data publishing source may not be reputable.

The primary limitation faced during this study was the availability of full-text articles since it was not possible to retrieve all the relevant information from the databases. Furthermore, access to some specific studies was restricted. Also, time constraints were an important restriction since there was not much time for the review of all the information that was considered to be important.

Summary

A secondary research design was selected for performing the research. A systematic review of the literature was chosen as an appropriate approach for achieving this purpose. A search for the relevant literature was conducted by searching the electronic databases PubMed, Medline, CINAHL, BMJ, Cochrane, and Medscape along with the manual search of the literature. Various keywords were utilized through the application of Boolean operators. The study inclusion and exclusion criteria ensured that studies included in the review had been published during the years 2004 to 2014. Articles written in languages other than English have been excluded. Quality appraisal of the studies was performed via the systematic analysis. The researcher took ethical considerations into account as well. Limited time available for conducting the research and the impossibility of reviewing all of the relevant information served as limitations of this research.

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Results

Qualitative appraisal of the studies that were selected for the review is presented in this section. The appraisal is followed by the thematic analysis of the results of the studies in order to provide an analysis of the association of nurse staffing with patient outcomes. Various aspects of patient outcomes such as patient safety and quality of care delivered by nurses under the conditions of low nurse staffing are also discussed. The assessment of the usefulness of the policies that have been designed to improve nurse staffing practices is also provided.

Quality Appraisal and Thematic Analysis of the Studies

The review of the selected studies has lead to the discussion of themes that have emerged regarding the topic under study. The discussion of associated themes allows for conducting a comprehensive analysis of the impact that nurse staffing levels have on patient outcomes. One identified theme is the issue of improved patient outcomes due to increased nurse staffing levels and the influence of patient-to-nurse ratios for determining the patient mortality rate. Another related theme that emerged during the research is the workload of nurses and its impact on patient outcomes. Lastly, the subject of the effects of inappropriate staffing levels on job dissatisfaction and burnout rates among nurses is also discussed.

Improved Patient Outcomes and Increased Nurse Staffing

An improvement in patient outcomes has been associated with an increase in the level of nurse staffing, in particular at hospital facilities (West et al. 2014). However, increased nurse staffing also influences the outcomes of the patients in various clinical domains as well. Griffiths et al. (2010) argued that increased nurse staffing leads to positive outcomes when treating coronary heart disease, hypertension, pulmonary disease, diabetes, and chronic obstructive disease. The ability of nurses to perform efficiently is enhanced by the increased level of nurse staffing at the hospitals since it reduces the workload and enables the nurses to more carefully tend to each patient’s clinical needs (Rafferty et al. 2007). Adequate time and attention given by nurses to the patients as a result of increased staffing leads to improved patient outcomes. Patient outcomes are improved by increased nurse staffing, ranging from the lower incidence of various diseases to patient mortality, and facilitates administering adequate care to patients.

Impact of Nurse Staffing on Patient Mortality

Nurse staffing has a significant impact on the provision of appropriate nursing care and the mortality rate of patients that require critical care. It has been observed that patient mortality rates increase when a nurse is responsible for a greater number of patients (Aiken et al. 2014). Therefore, the analysis of reviewed studies provides substantial evidence in favor of the argument that increased workload does negatively influences patient mortality rates. Similarly, lower mortality among patients is associated with the employment of nurses that have a higher educational level (Aiken et al. 2014). The increase in the number of nurses in the ICUs led to the increased patient survival rate in UK hospitals. When they studied mortality rate in ICU, West et al. (2014) found that mortality rates ranged from 8.1% to 33.9% depending on the nurse staffing levels.

Another study by Rafferty et al. (2007) observed a 26% higher mortality rate in hospitals with lower levels of nurse staffing in comparison to the hospitals with higher nurse staffing levels. The study of the mortality analyzed the cases of 118,752 patients in 30 English trusts and suggested that mortality rates are considerably impacted by the level of nurse staffing in the acute care hospitals (Rafferty et al. 2007). Therefore, reviewed studies demonstrate commonalities of the results of their findings and support the notion of the existence of a strong association between nurse staffing and patient mortality rates.

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Nursing Workload and Patient Outcomes

There is significant evidence regarding the association of increased workload of the nursing staff and its effect on the outcomes of the patients (Sheward 2005; Rafferty et al. 2007; West et al. 2014; Aiken et al. 2014). According to Schuldham et al. (2009), based on a study of 25,507 patients admitted to the acute care units of two hospitals that belonged to NHS trust, the increased workload among nurses did not have an impact on patient outcomes. However, there was an increased incidence of sepsis among patients that required critical care. Notably, Schuldham et al. (2009) argued that the increased workload of nurses is not related to outcomes of the patients that do not require critical care.

However, the study by Rafferty et al. (2007) found that an increase in the workload of nurses significantly affects patient outcomes and that nurses in UK hospital wards with reduced levels of nurse staffing report increased workload and higher mortality rates. Therefore, it seems that the increased workload of nurses has varying outcomes depending on the type of care the patient receives and patient health needs. However, out of the six studies reviewed, five showed an association between the workload of nurses and patient outcomes across various clinical domains while only one study, by Schuldham et al. (2009), found the relationship between the workload of nurses and patient outcomes only in ICU units setting.

Relationship between Patient-to-Nurse Ratio and Patient Outcomes

The patient-to-nurse ratio has been found to be an association with patient outcomes and mortality rates of patients in the ICUs. Rafferty et al. (2007) observed that hospitals that had a higher nurse-to-patient ratio and other than nurse medical staff-to-patient ratio per patient bed had a reduced rate of patient mortality in comparison with the hospitals that had a lower number of nurses and other medical staff per patient. Interestingly enough, the association between involvement and staffing of other medical staff in the patient care at ICUs and the rate of patient mortality was not as significant compared to the relationship between the nursing staff and mortality rate (Shuldham et al. 2009).

Rafferty et al (2007) found that ICUs that had higher nurse-to-patient ratios enjoyed better survival rates of patients compared to the ICUs that had lower nurse-to-patient ratios. Sheward et al. (2005) claimed that the burnout rate of nurses is lower in units with increased nurse-to-patient ratios. It was also found that in the UK hospitals, nurses that experience burnout are more likely to deliver lower-quality care, which leads to adverse patient outcomes (Sheward et al. 2005). The aforementioned studies showed that the nurse-to-patient ratio has a significant impact on patient outcomes of the patients by affecting the nurses’ capabilities and efficiency during the delivery care process. Subsequently, lower rates of nursing fatigue were reported in units with higher nurse-to-patient ratios.

Job Satisfaction, Burnout, and Exhaustion among Nurses due to Low Nurse Staffing

Nurse staffing levels have been found to influence patient outcomes both directly and indirectly. Low job satisfaction that nursing staff experience at the hospitals as a result of lower nurse-to-patient ratios leads to the inability of nurses to deliver quality care to patients and impact patient clinical outcomes. In some cases, FTR has been observed as a result of exhaustion that prevents nurses from ensuring proper and reducing the risk of complications (Rafferty et al. 2007). Stress was reported by 34% of English RNs and 27% of Scottish RNs at hospital wards. The stress has been associated with the increased workload that resulted due to low nurse staffing. Nevertheless, 60% of the RNs reported that they were satisfied with their job.

Nurses at English hospitals experienced exhaustion and burnout due to lower patient-to-nurse ratios and subsequent lower quality of patient care (Sheward et al. 2005). The aforementioned studies have provided evidence of an association between nurse outcomes and patient outcomes. The analysis of these two studies leads to conclusions that managers of hospital facilities should strive to ensure sufficient nurse staffing in order to properly adhere to patient care requirements, raise job satisfaction and reduce stress, exhaustion, and burnout among nurses.

Summary

Quality appraisal of the selected studies found these studies to be relevant, appropriate, and well-suited to be included in the examination of the impacts of nurse staffing levels on the quality and safety of patient care since they provide valid and reliable findings contained in credible and respectable scholarly journals. Higher nurse staffing levels have been found to be strongly related with improved patient outcomes, in particular in the acute care units. A decreased number of nurses in the ICUs account for a higher probability of patient mortality. However, the workload of nurses was found to affect patient outcomes only with the patients requiring critical care.

Discussion

The discussion of the reviewed literature is based on the comparison of findings of the reviewed studies with other studies addressing the topic of the dissertation. The association of nurse staffing levels with patient outcomes will be analyzed and discussed. In addition, impacts of nurse staffing levels on patient outcomes, mortality, and workload-related outcomes will be compared. Finally, nurse-to-patient ratios and their influence on job satisfaction, burnout, and exhaustion among the nurses will be evaluated.

Nurse Staffing

Despite the predominance of views associated with nurse staffing and the workload of nurses, there is still an inconsistency in the literature regarding this fact. The measures that are commonly used for identification of the staffing problems include nurse-to-patient ratios and hours of nursing care delivered to the patients on a daily basis. However, each measure carries with it inherent assumptions regarding the workload of nurses. Therefore, hospital administrators usually set the nurse-to-patient ratio in accordance with the needs of the patients in each unit (Beglinger 2006). Such practices take place since a significant factor affecting the nursing workload is the number of patients assigned to each nurse (Unruh & Fottler 2006).

Nurse staffing at the hospitals is designed to adhere to the various requirements of patients at different units. Variations in the needs of patients depending on the intensity of nursing care account for different intensity and requirements for nursing care. Another factor that determines the intensity of care required by the patients is the nature of illness since the patients in ICU require a higher level of care compared to those in the surgical/medical units. Thus, the patients’ medical needs are at the basis of the arrangements whereby fewer patients in ICU require a greater number of nursing personnel in comparison with other units.

However, measurements related to the patient acuity and amount of care required and delivered by nurses are still not completely understood because there are disparities among the scholars and a lack of agreement regarding the specific description of criteria of patient acuity (Brennan & Daly 2009). Several studies have found a strong positive relationship observed to exist between increased levels of nurse staffing and decreased mortality rate among the patients (Aiken et al. 2008; Kiekkes et al. 2008; Diya et al. 2010; Aiken et al, 2011; Trinkoff et al. 2011; Park et al. 2012; Aiken et al. 2014).

A significant association between nurse staffing levels and adverse events experienced by patients and mortality has also been observed in a study included in a review and performed by West et al. (2006). That study thoroughly discusses the relationship between morbidity and mortality of the patients and levels of nurse staffing. However, the primary limitation of this review is the nature of the study since it is based on retrospective and observational methods of gathering the information. This aspect indicates the need to corroborate the research’s findings with strong empirical findings.

Working Environment of Nurses

The organizational environment is characterized by the working environment of nurses that either supports or minimizes the ability of nursing personnel to practice independently and at a level corresponding with their competency. The working environment consists of various organizational features that influence the quality of care, patient safety, and job satisfaction of the nurses (Lake 2007). The definitions of work environment involve factors such as leadership, professional collaboration, and shared decision making (Lake & Friese 2006). The professional practice of nurses is molded by the work environment to a large degree. Positive feelings and job satisfaction are developed when adequate support is provided by the management that enables the nurse to practice autonomously.

Also, job satisfaction is greater when other healthcare professionals demonstrate respect for nurses, and when nurses feel like they are part of the hospital organizational process. Among the nurses, an enhanced sense of confidence, engagement, and accomplishment are developed through the experience of workplace-related positive feelings (Miller 2011). Job dissatisfaction and burnout are less likely to be experienced by the nurses when they are confident, engaged, and accomplished. These nurses are also less inclined to leave the field of medical care (McHugh et al. 2011; Liu et al. 2012).

Some of the studies have observed the association of patient outcomes and the working environment of nurses. Hospitals that have a better work environment for nurses have achieved decreased rates of mortality among surgical patients (Aiken et al. 2011). Kutney-Lee et al. 2009 argue that in comparison with hospitals that have a less favorable work environment for nurses versus hospitals that are better report fewer safety issues and instances of missed care. Also, a connection between greater patient satisfaction and a better work environment of nurses was also observed (Kutney-Lee et al. 2009).

Patient Outcomes

Failure of the nurses to rescue patients and increased mortality among patients have been confirmed as the two most critical nurse-sensitive patient outcomes related to matters of urgent care patients (Needleman et al. 2011; Park et al. 2012). Also, Anthony et al. (2010) identified the safe administration of medication as a nurse-sensitive outcome. FTR and patient mortality have been frequently linked to the issue of nurse staffing levels. In cases where nurse staffing is less favorable, an increased risk of patient mortality and FTR was identified. Therefore, patient mortality and FTR are two important patient outcomes that were found to be affected by nurse staffing (Needleman et al. 2011; Park et al. 2012).

 

Patient Mortality and FTR

One of the patient outcomes frequently used in health care research to perform a comparison of the quality of care in hospitals is the mortality rate. It has been observed that a positive work environment for nurses and sufficient levels of nurse staffing are associated with lower rates of patient mortality (Park et al. 2012). The incidence of death as a consequence of complications that could have been prevented is defined as FTR (Silber et al. 2007). Calculation of mortality rates is performed by calculating the number of patients who died from among the total number of patients. Rates of FTR are calculated by counting the number of patients that have died among the patients who had experienced complications. Although it is not possible for the hospitals to control the patient characteristics that predispose patients to increased rates of mortality, hospitals can influence the factors associated with FTR via managing nursing care.

Patient Safety

Factors that influence patient safety may be unintentionally missed in the course of nursing care, which causes serious risks to patients’ health. These risks include increased mobility, FTR, and inadequate nutritional intake (Kane et al. 2007; Hugonnet, Uckay & Pittet 2007; Park et al. 2012; Griffiths et al. 2013). Kalisch et al. 2009 studied three hospitals with 459 nurses. The study assessed the consistency and effectiveness of administering medications, mouth care, turning patients every 2 hours, patient ambulation, timely administration of medication, and teaching patients identified six most recurrent kinds of missed care. This study reported incidents of missed care by nursing personnel as a result of insufficient nurse staffing (Kalisch et al. 2009).

A positive correlation was found between the increased levels of RN hours per patient during the working day and decreased rates of missed care by the nurses in a study conducted in 110 care units with 4,288 nurses involved (Kalisch et al. 2011). These findings suggest that missed care on the part of nurses is related to lower levels of nurse staffing (Kalisch et al. 2011). Thus, the author of this dissertation views the association between the missed care and nurse staffing as an indication in favor of the existence of a strong linkage between levels of nurse staffing and patient outcomes as confirmed by reviewed studies (Shewar et al. 2005; Rafferty et al. 2007; Griffiths et al. 2010; West et al. 2014; Aiken et al. 2014).

Infections in Patients

A study by Rogowski et al. (2013) has found that high levels of nurse staffing account for lower rates of infections during hospitalization. Similarly, the spread of infections is associated with low levels of nurse staffing. However, the strength of the association between levels of nurse staffing and incidence of infection may vary depending on the type of care unit (Rogowski et al. 2013). Schwab et al. (2006) found similar results when they studied incidents of bloodstream infections in patients in 128 ICUs. The author came to the conclusion that there was a decreased incidence of nosocomial infections in units with higher nurse-to-patient ratios.

However, infections were also related to the increased duration of hospitalization (Schwab et al. 2012). Infections incurred as a result of inadequate nursing care caused by decreased levels of nurse staffing are the fifth most common cause of patient mortality in acute care hospitals (Dancer et al. 2006). Therefore, the levels of nurse staffing can influence patient outcomes in acute care settings by increasing the risk of incurring infections, morbidity, and mortality.

Occupational Outcomes of Nurses

Since retention rates of nurses is an important factor that affects patient outcomes, high job turnover of nurses can lead to increased expenditures and negatively influence the morale of the nursing staff (Duffield et al. 2011). Reduced levels of nurse staffing can lead to professional burnout among nurses, characterized by cynical and estranged feelings that impede the ability of the nurses to work efficiently. The burnout also leads to the loss of positive emotions, as well as respect and sympathy for patients on the part of nurses. Subsequently, the burnout of nursing personnel has its implications on patient care. As a result of burnout, nurses might lack the required emotional capacity to connect effectively with the patients and might provide less attention to patients, subsequently impacting the patient outcomes.

Higher levels of burnout have been reported in situations where nurse staffing was inadequate or the working environment was not favorable for improving professional performance (Aiken et al. 2008). Professional burnout among nurses develops mostly due to decreased levels of nurse staffing and has a considerable impact on patient outcomes. Therefore, it is imperative to understand the relationship between nurse staffing and the impact this relationship has on patient outcomes.

One of the most alarming tendencies contributing to the shortage of nurses is that a significant number of nursing professionals leave the profession and subsequent high retention rates of nursing professionals. Departing nurses report extremely high levels of stress and dissatisfaction with the workplace environment that account for emotional, mental, and physical fatigue. Rushton (2006) and Zuzelo (2007) argue that when nurse managers provide information and support for nurses, the result is higher performance and job satisfaction, as well as a reduction in fatigue among nursing personnel. The authors suggest for hospital ethics committees to be actively involved in helping to manage and overcome professional fatigue among nurses. Therefore, it seems that an effective immediate solution for the prevention of professional fatigue among nursing staff would be a line of communication about the issue between nurse managers and the hospital ethics committee.

Nurse Staffing Policies

Patient outcomes are frequently used to appraise the efficacy of healthcare (Aiken et al. 2008; 2011). There are several approaches to nurse staffing being currently practiced. The policy number one is the ratio of nurse staffing (number of patients attended by nurses in a day). The second policy regulates care hours spent per patient. Staff mix is another policy measure that determines the number of hours spent by a group of health care professionals with mixed set of skills for administering patient care. One more policy element is the rotation of shifts since the increased length of the shift is related to an increased number of working hours and increased workload of nurses. The employment of part-time nurses and nurses working in few units simultaneously is another policy-related solution. Kane et al. (2007) observed that factors associated with the care of patients in hospital units influence nurse staffing policies.

For example, increased shift length may be the result of an increased influx of patients. In this case, patient care at the unit level depends on nurse staffing and the ability of a particular number of nurses to effectively react to the needs of the patient. Experience and education levels of the nurses also determine how well patients were being cared for (Aiken et al. 2014). Although patient-related factors determine nurse staffing needs, leadership qualities of nurses and organizational factors within health care facilities greatly influence nurse staffing needs and policies as well (Department of Health 2013). In response to the issue of nurse staffing, there have been attempts to assess such nurse staffing solutions as staff mix, written staffing plans, mandatory nurse-to-patient ratios, or combination of the above solutions compliment (Tevington 2011).

Nurse-to-Patient Ratios

The number of patients that are being cared for by a nurse determines the nurse-to-patient ratio. However, this measure may have its limitations when all of the assigned nursing personnel at the unit are included in calculating the ratio since non-clinical care is added to patent care (Kane et al. 2007). In the US, various legislation regarding nurse staffing has been introduced and adopted in over a dozen states. For example, legislation in California establishes mandatory nurse-to-patient ratio mandates that the minimum ratio of the patient-to-nurse at acute care hospitals must be 4:1 for the department of general emergency, 2:1 for the nursing of critically ill patients, and 1:1 for trauma patients. It has been found that increased mortality rates are associated with hospitals that had lower nurse-to-patient ratios or did not have the law regarding the staffing of nurses. By contrast, hospitals that had adopted legislation mandating higher nurse staffing have lower rates of patient mortality (Kane et al. 2007; Aiken et al. 2010).

Nelson (2008) corroborates previous findings and claims that mandatory nurse-to-patient legislation increases job satisfaction among nurses and decreases turnover. Nelson’s study (2008) states that the new legislation mandating nurse-to-patient ratios in the US has resulted in a large increase in the number of registered nurses since the ratio law has come into effect. Therefore, analysis shows that the mandatory nurse-to-patient ratio has a significant positive impact on nursing personnel.

Notably, numerous studies reported that negative outcomes that have been found to be related with lower nurse-to-patient ratio include adverse events, cardiac complications, postoperative complications, and higher FTR rates (Schuldham 2009; Schwab et al. 2012; Liu et al. 2012; Shekelle 2013; Rogowski et al. 2013). Additionally, Lin and Liang (2007) found significant and sizable positive effects of registered nurse staffing on preventable deaths and showed that nurses contributed significantly to early detection, surveillance and timely interventions that have saved lives. Kutney-Lee et al. (2009) found that hospitals with higher hours per patient attendance by the nurses reported greater patient satisfaction. The aforementioned study showed that nurse staffing improves patient satisfaction by positively influencing patients’ experience with and the perception of administered care.

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Arguments against Mandatory Ratio

Although the premise behind the nurse-to-patient ratio is that mandated minimum nurse staffing levels account for better patient outcomes, increased job satisfaction among nurses, and lighter workload, mandatory minimum ratios have their opponents. For example, the passing of the nurse-to-patient legislation in the US triggered heated arguments about the pros and cons of mandatory ratios. One argument presented was that there was no nursing crisis or negative impact of existing nursing practices on nursing care and patient outcomes (Gordon, Buchanan & Bretherton 2008). Moreover, the legislation opponents claimed that higher ratios could not be met and hospital facilities would be forced to offer fewer beds in order to adhere to the requirements of the new law.

Furthermore, opponents of the mandatory nurse-to-patient ratios argue that the adoption of new staffing requirements would increase the costs of health care to the point of making health care services significantly more expensive and less affordable (Lowes 2010). It was argued that expenses incurred with hiring additional nursing personnel would place undue financial pressure on hospitals. If these contrary claims end up being true, the long-term consequences of adopting and practicing higher ratios will impair the delivery of nursing care and make nursing services costly and irrelevant to the society’s health care needs.

Nevertheless, Thungjaroenkul, Cummings, and Embleton (2007) performed a study that investigated the impacts of nurse staffing on hospital costs. The authors found that higher ratios of registered nurses reduced hospital costs. Cost reduction occurred since a higher number of RNs helps to prevent patient adverse events that cause prolonged hospital stay. Additionally, a higher number of RNs facilitates the provision of more efficient nursing care and reduces resource consumption (Thungjaroenkul, Cummings & Embleton 2007).

Discussion of the Findings

The findings of this review corroborate the findings of other research that studied the impact of nurse staffing levels on various aspects of patient outcomes. An increase in levels of nurse staffing was found to impact the clinical outcomes, including the incidence of diseases such as hypertension, chronic obstructive disease, coronary heart disease, pulmonary disease, and diabetes (Griffiths et al. 2010). The patient-to-nurse ratio is identified as an important predictor of patient outcomes. Low patient-to-nurse ratios result in adverse patient outcomes such as incidences of infections and other chronic conditions, and higher mortality rates (Rafferty et al. 2007). This study’s findings are consistent with the results of a study by Blot et al. (2011) that established the association of patient-to-nurse ratio with the risk of incurring ventilator-associated pneumonia in the patients requiring critical care.

Units where the patient-to-nurse ratio was 1:1 reported lower risk of ventilator-associated pneumonia in comparison to those units where the nurse-to-patient ratio exceeded 1:1 proportion (Blot et al. 2011). Increased incidence of ventilator-associated pneumonia was observed among the ICU patients in the hospital of Geneva. Ventilator-associated pneumonia occurred in 22.3% of the ICU patients. Notably, multivariate regression showed that there was a decrease in the rate of incurring ventilator-associated pneumonia in patients of units with increased nurse-to-patient ratio (Hugonnet, Uckay & Pittet 2007).

An increase in the level of nurse staffing reduces patient mortality while reduced nurse staffing levels predict a higher risk of mortality. The mortality rate in the ICUs of English hospitals ranged from 8.1% and 33.9% depending on nurse staffing levels (West et al. 2014). An increased rate of patient mortality have been also observed in acute care hospitals in Illinois and North Carolina. Mortality rates due to pneumonia were reported to be considerably high as a consequence of the increased workload of nurses.

Excessive workloads deprived nurses of the ability to deliver sufficient patient care. For example, a higher risk of myocardial infarction was related to an increased workload of nurses and insufficient nurse staffing levels (Trinkoff et al. 2011). In English trusts, it was observed that there was a 26% higher risk of mortality in hospitals with low levels of nurse staffing (Rafferty et al. 2007). Reduced rates of mortality were found to be related to increased nurse staffing (West et al. 2006; Aiken et al. 2008; Diya et al. 2010; Aiken et al. 2011; Park et al. 2012).

The workload of nurses was found to affect adequate delivery of nursing care and result in adverse patient outcomes in situations requiring critical care (Shuldham et al. 2009). A decreased nurse-to-patient ratio impacts the outcomes of patients by increasing burnout, FTR rates, and decreasing quality of care (Sheward et al. 2005). An increased number of nurse hours per patient reduces the rate of missed care and improves patient outcomes. Also, fewer instances of missed care by nurses were reported as a result of increased nurse staffing levels (Kalisch et al. 2011). The following are some of the solutions hospital manages can employ to facilitate finding solutions to nursing shortages via establishing effective incentives and providing career support. Buchan and Aiken (2008) state that nurses are more attracted to work and remain in the profession if they have an opportunity to gain autonomy, develop professionally, and participate in decision making while being fairly rewarded.

May, Bazzoli, and Garland (2006) provide further suggestions for how to maintain higher job satisfaction and prevent shortages of nursing personnel via compensations, bonuses, and nurse education. The authors identify these factors as strategies that can effectively address nurse shortages and meet future nursing needs. May, Bazzoli, and Garland (2006) found that competitive salaries and financial benefits were effective short-term strategies to attract nurses. However, the authors noted that financial compensation alone was not sufficient to keep nurses working at hospitals. The study suggested that a conducive work environment is critical in retaining nursing personnel and hospitals should maintain a pleasant workplace environment to retain more nurses (May, Bazzoli & Garland 2006).

These authors provided further suggestions for hospital managers on how to maintain a higher level of nurse staffing and avoid high retention rates. They stated that investments in nurses’ education serve as an effective strategy that helps to maintain an adequate number of nurses. Educational initiatives that management may undertake range from providing flexible hours and training for current staff to training, opening and operating nursing schools, assisting nurses in obtaining nursing degrees, providing tuition reimbursements, and covering nurse’s education costs in return for a work commitment.

Among other tactics that facilitate career support and enhance nurse education opportunities are such initiatives as paying for advanced education or certifications, offering clinical rotations, and providing trainings in particular clinical areas. Hospitals may also practice orientation periods to let nurses rotate through various units to identify the best fit (May, Bazzoli & Garland 2006). These practices provide valuable experience for new nurses, can help increase job satisfaction and prevent professional burnout. Subsequently, shortages of nursing personnel will be preempted, the quality and safety of patient care will be higher resulting in better patient and nurse outcomes.

Sufficient patient-to-nurse ratios have been identified to be of critical value in the care of patients as directly related to patient outcomes. Hospitals that maintain nurse staffing levels that ensure adequate catering to workplace demands report decreased mortality rates (Aiken et al. 2010). These results are similar to the findings of several earlier studies of the dependence on mortality rates and patient-to-nurse ratio (McGillis Hall 2005; Kane et al. 2007). Adding a single additional patient per RN in Korean hospitals increased the mortality rate in ICUs by 9% (Cho, Hwang & Kim 2008).

Increased workload among nurses may also lead to a loss of feelings of respect and sympathy for patients. It may also result in the inability of the nurses to provide sufficient attention and lead to increased FTR rates (Aiken et al. 2008). However, a study by Rogowski et al. (2013) presented divergent observations that found no significant relationship between nurse staffing levels and patient outcomes such as the incidence of infections. The research findings contradict the findings of Rogowski et al. (2013) and support the results of several previously discussed studies that demonstrated findings similar to the study by Shuldham et al. (2009). For example, Shuldham et al. (2009) established a relationship between higher incidence of sepsis in patients that required critical care due to insufficient nurse staffing at the hospital.

Low job satisfaction among nurses is a vital aspect of patient care because it determines the psychological condition of the nursing staff. Nurses who are dissatisfied with their job have a hard time adhering to the guidelines that ensure the provision of appropriate patient care. The inability of nurses to deliver adequate care to patients is closely related to unfavorable patient outcomes. However, the working environment of nurses is also known to influence patient outcomes (Kutney-Lee et al. 2009). The common finding of discussed studies is that nurse staffing determines the extent and quality of care nurses deliver across various hospital units by influencing nurses’ attitudes and behaviors (Sheward et al. 2005).

Hospital managers can act as advocates on nurses’ behalf by emphasizing to the hospital leadership the need for incentives and career support for nursing personnel and promote the benefits of additional investments in the education of nurses and relevant incentive mechanisms (Rushton 2006). Therefore, advocacy by hospital mangers may play an important role in benefitting both nurses and hospitals where they work (Zuzelo 2007).

The most prominent outcome of patients that have been observed in this review is patient mortality. Most of the reviewed studies have reported an increased rate of patient mortality at hospitals that do not have sufficient nurse staffing levels (Rafferty et al. 2007; Aiken et al. 2014; West et al. 2014). The death of a small percentage of patients shortly after being admitted to hospitals has been a growing concern of hospital administrations. Notably, there is evidence that suggests that the mortality rate could be controlled via proper nursing care (Kiekkas 2008).

ICU at a Greek hospital has reported the incidence of increased mortality among patients that were tended to by nurses with excessive workload. The study that investigated the reasons behind deaths of 102 out of 396 patients presented the evidence that nurse staffing levels significantly affect patient outcomes in acute care hospitals. According to the study, decreased nurse staffing can lead to severe patient outcomes while an increase in staffing levels can improve patient outcomes across various clinical settings (Kiekkas et al. 2008).

Summary

This chapter discussed the relationship between nurse staffing levels and patient health outcomes. The research indicates that factors that influence nurse staffing depend on the requirements of administered care and organizational factors such as nurse staffing policies. Also, an increase in working hours can result in a greater workload and lead to insufficient and even missed patient care. Additionally, nurses’ working environment has an impact on the effectiveness of care nurses administer to patients. Lower nurse staffing and subsequent increased workload can trigger inappropriate behavior among nurses. Increased patient mortality has been identified as a major patient outcome related to decreased nurse staffing. Subsequently, patient safety is impaired as a result of reduced nurse staffing. Furthermore, burnout among nurses and low job satisfaction is related to inadequate nurse staffing and has been observed to negatively affect patient outcomes.

Conclusion

This section provides a summary of the results of the performed literature review and includes the information regarding the association of nurse staffing levels in acute care hospitals with patient outcomes. The impact of patient-to-nurse ratio on mortality and other clinical outcomes is also presented in accordance with findings of a current review. Recommendations regarding future studies and implications of the results of the review for nursing practice are also provided.

Nurse staffing levels are the primary predictors of patient outcomes since they are linked with the delivery of nursing care both directly or indirectly. Acute care hospitals that have adequate levels of nurse staffing report lower rates of adverse patient outcomes that range from minimum severity in clinical conditions to patient mortality. Nurse-to-patient ratios have been commonly viewed as a key measure of nurse staffing by policymakers. An increase in nurse staffing has been associated with improved patient outcomes and lower incidence of various diseases and patient mortality (West et al. 2014).

Nurse-to-patient ratio determines the workload of nurses that ultimately impacts patient outcomes by preventing burnout and low job satisfaction among nurses (Shuldham et al. 2009). Current dissertation has found a significant relationship between nurse staffing levels and patient outcomes and the need of hospital management to ensure appropriate nurse staffing for improving patient outcomes.

Recommendations

Since the results of this study are based on the review of literature, further empirical studies are required to observe and verify the studies identified by this review association between nurse staffing levels and patient outcomes. Recommended studies should employ longitudinal observation designs to perform a long term observation of patient outcomes that take place as a consequence of inappropriate nurse staffing levels. The relationship between nurse staffing levels with various nurse outcomes and their impact on the care of patients must be further explored. In spite of reviewed evidence that supports efficacy of higher nurse-to-patient ratios, Tevington (2011) states that there is a need for more empirical studies to further confirm effectiveness of new staffing practices. The reason behind what seem as uncertainty of mandatory nurse-to-patient ratio outcomes is that ratios were introduced relatively recently, and their long-term effects may not be considered clear yet (Nelson 2008).

Also, further research is required to appraise the effectiveness of new nurse staffing practices in relation to the working environment of hospital facilities, nurses’ experience and qualifications, patient satisfaction, availability of resources and trainings, unit characteristics, and particular types care provided by nurses (intensive, surgical, or general medical). Debates about the mandatory nurse-to-patient ratio can benefit from establishing measures/metrics that enable scholars and practitioners at the hospital facilities to measure the effectiveness of nursing care. The development of such measuring mechanisms will help establish more precisely the relationship between new staffing practices and organizational, patient, and nurse outcomes (Joseph 2007).

Since there are valid concerns that higher nurse staffing levels will drive up the costs of the healthcare and impact the affordability of health care services, further studies are required to explore the impacts of nurse staffing on hospital costs and the relationship between costs and nurse staffing. Further evidence is needed to find whether more efficient nursing care can reduce resource consumption.

Considering that there are both proponents and opponents of higher levels of nurse staffing and nurse-to-patient ratios, the process of instituting adequate changes may face criticism and opposition. Therefore, it is recommended that the stakeholders develop avenues that facilitate the process of lobbying and nursing advocacy to facilitate patient care protection by meeting professional interests of hospital facilities and registered nurses via establishment of higher nurse staffing levels. Appropriate advocacy measures may play a vital role in legislating and adopting mandatory ratios, as well as in promoting effective recruitment and retention tactics that will help to solve responsible problems of the nursing shortages in NHS hospital wards. Notably, the advocacy role may frequently be fulfilled by scholars and practitioners who study the issue of nursing shortages and provide the evidence in favor of higher staffing levels of the nursing staff at hospital facilities.

Implications for Practice

The results of this study provide information that must be considered by practitioners, scholars, and policymakers to design and implement nurse staffing policies and legislations that ensure sufficient nurse staffing based on the current needs of patients across various hospital units. The hospital management should work to maintain adequate nurse staffing levels to effectively cater to the needs of patients. Further studies of the relationship between nurse staffing practices and patient outcomes and mortality must be performed at regular intervals to make evidence-based suggestions and amendments to current policies and legislations.

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