Inadequate Nurse Staffing To Patient Care Essay Paper

The Effect Of Inadequate Nurse Staffing To Patient Care Essay Paper

The Effect Of Inadequate Nurse Staffing To Patient Care Essay Paper

Many nurses face the issue of understaffing and having too much of a workload during one shift. When a unit is understaffed not only do the nurses get burnt out, but the patients also don’t receive the care they deserve. The nurse-patient ratio is an aspect that gets overlooked in many facilities that could lead to possible devastating errors. Nurse- patient ratio issues have been a widely studied topic and recently new changes have been made to improve the problem. Identifying and maintaining the appropriate number of mixed nursing staff, RN/LPN/CNA, is critical to the delivery of quality patient care. Many studies reveal an association between a higher level of experienced RN staffing and lower rates of adverse patient outcomes  The Effect Of Inadequate Nurse Staffing To Patient Care Essay Paper
Laws like these are being implemented and changed widely across the United States to help ensure patients are receiving adequate care that they deserve. The American Nurses Association supports a legislative model in which nurses are encouraged to create staffing plans specific to each unit. This approach will aide in establishing staffing levels that are flexible and can be changed based on the patients needs, number of admissions to the unit, discharges and transfers during each shift (“Nurse staffing plans,” 2013). This model will assist in keeping the unit staffed appropriately and organized in need of a change during each shift. Without an organized plan like this, a nurse may be required to take on a new admission and already have too big of a workload. Each facility has their specific way of scheduling and protocol for staffing; not every facility uses a model that has other nurses’ help decide the next shifts nursing assignment.

Over the past 2 decades, a significant body of research has substantiated the link between nurse staffing factors and patient outcomes. For instance, the number of nurses available to care for patients, measured by full-time equivalents and hours per patient day (HPPD), was found to be inversely correlated with patient mortality and failure to rescue.1,2 Likewise, lower HPPD correlated with longer length of stay.3 And when staffing targets weren’t met, mortality increased.4 Higher levels of education for nurses, especially BSN preparation, correlated with decreased mortality and failure to rescue, and higher RN skill mix was associated with decreased pneumonia and decreased mortality.5,6


These sentinel studies led to significant policy changes. Legislation mandating specific nurse-patient ratios passed in California, with the federal government and other states also considering legislation.7 In addition, the National Academy of Medicine (formerly the Institute of Medicine) recommended increased educational levels for nurses in all areas of practice, with a target of 80% of the American RN workforce being BSN-prepared by 2020.The Effect Of Inadequate Nurse Staffing To Patient Care Essay Paper

Despite progress in the healthcare industry toward achieving these goals, nurse managers and administrators working on hospital units continue to struggle with knowing what constitutes the right number and quality of nurses matched to patients’ needs to achieve clinical outcome targets. (See Historical context.) This knowledge is critical in a climate of reimbursement uncertainty given that achieving the right balance of nurses to meet patient care needs defines fiscally responsible staffing.

Consider that in 2016, 62.2% of the country’s 2.6 million nurses worked in hospitals with a median pay of $68,450 per year.9 With salaries making up nearly half of U.S. hospitals’ expenses and nursing comprising about 30% of salaries, effective management of nursing resources, including staffing, is imperative for meeting financial outcomes.10

Likewise, managing the safety and quality of patient care is paramount, and failure to do so is expensive. The average cost of a single central line-associated bloodstream infection (CLABSI) is over $45,000, and a patient fall with injury costs $14,000 on average.11,12 Additionally, under the Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS) will withhold payment to hospitals if quality care targets aren’t met.13 With studies showing that these patient outcomes are sensitive to nurse staffing variables, continued development of the evidence base for nurse staffing is vital. The goal must be providing unit-level evidence-based data for frontline managers to predict and monitor staffing factors related to patient care.

This article provides a summary of the current body of published nurse staffing research, explores gaps in the literature that explain why translation into clinical practice has been difficult, and suggests ways that hospital nurse managers and administrators can help move the science forward. It’s important to realize the role hospitals must play in advancing unit-level nurse staffing research. It can’t be accomplished without strong collaboration between clinical nurse experts and researchers.The Effect Of Inadequate Nurse Staffing To Patient Care Essay Paper

Nurse characteristics
The experience and skills of the nurses on any given unit vary in terms of education level; years of experience; the amount of experience working on a specific unit or with a specific patient population; and the knowledge, or competency, to perform certain skills. This variation impacts individual nurse workload, as well as overall unit workload, and is weighed into staffing decisions and patient assignments. Nursing workload has been defined as a combination of factors, including nursing time spent in direct patient care and other work, competency, physical exertion, and complexity of care.15

Several studies have highlighted the importance of an educated, experienced nursing workforce for producing desirable patient outcomes. A workforce with proportionately more BSN preparation was associated with decreased mortality and failure to rescue.5,16,17 Higher levels of specialty certification in a group of nurses correlated with lower patient mortality and fewer failures to rescue if the nurses were baccalaureate-prepared or higher.17 Odds of patient death on CCUs were highest when 20% or more of the nurses had fewer than 2 years’ experience.18

Collectively, the results of these studies support having a nursing workforce with higher levels of experience, education, and certification to produce safer patient care, but they don’t tell us how much is the right amount or allow for causal conclusions, leaving plenty of room for future research.

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Patient acuity, nursing workload, and unit workflow
Patient acuity and nursing workload are entwined in clinical practice and in the literature because patient care needs demand nurses’ time and attention. Patient acuity, also called patient classification, is defined as assessing the nursing care requirements of patients to determine the amount of nursing time needed to meet those requirements.14,19,20,21 Patient classification tools have been used since the 1960s, yet there’s no consensus on the best methods for measuring nursing workload or determining the optimal amount of time for completion of specific nursing activities.14,21,22 Confounding variables are numerous and complex, including individual patient characteristics and nursing unit environmental factors.The Effect Of Inadequate Nurse Staffing To Patient Care Essay Paper

There’s essentially a tug-of-war in the practice of measuring patient acuity between the desire to objectively determine required nursing work and the need to rely on the professional judgment of nurses to know which patients need more or less of their time. The goal of both strategies is to predict the amount of nursing care, or time, patients will require and use this information to determine staffing levels. Although not perfect, factoring patient acuity into staffing decisions is a better approach than relying solely on nurse-patient ratios or financial targets, such as budgeted HPPD, to determine unit-level nurse staffing needs.21 This approach is supported by the results of a study that examined nurses’ workloads on a unit where patients were assigned to maintain mandated nurse-patient ratios without regard to differences in patient needs. The workloads of the individual nurses were significantly different even though the numbers of patients in their care were similar.24

Unit workflow also impacts nursing workload. Admissions, discharges, and transfers of patients, often called patient turnover, take additional nursing time, which may not be accounted for in prescribed nurse-patient ratios or average budgeted HPPD that doesn’t recognize shift-by-shift variability.25-27 An ethnographic study of patient turnover found that workflow disruptions, such as admissions and discharges, led to increased workload for nurses, noting that dispersed patient turnover was less disruptive to workflow than clustered turnover.26 Another study found that understaffed shifts with high patient turnover were correlated with increased patient mortality risk, linking the combined effect of staffing levels and workload to clinical outcomes.28

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Unit and hospital characteristics
Unit-level hospital staffing decisions occur within a nested framework of unit, hospital, and external factors, yet the body of literature examining the impact of unit and organizational characteristics on nurse staffing is limited. Aiken and colleagues found that a better patient care environment, as measured using the National Quality Forum’s Practice Environment Scale of the Nursing Work Index (PES-NWI), was associated with lower patient mortality and better nurse outcomes.29 The PES-NWI captures nursing foundations for quality of care, nurse manager characteristics, and nurse-physician relations, and is widely administered as part of the National Database of Nursing Quality Indicators® (NDNQI®) nurse satisfaction survey.

Other work in this area has focused on staff scheduling factors. Longer shift lengths and shorter time periods away from work for nurses correlated with increased patient mortality in adults and poorer quality outcomes for pediatric patients.30,31 Increased overtime correlated with more catheter-associated urinary tract infections and pressure injuries, but also a slightly lower CLABSI rate.32

Although supportive of the overall theme that nurse staffing factors are tied to patient outcomes, these studies, like many others, used a cross-sectional design. Therefore, conclusions about cause and effect can’t be made.The Effect Of Inadequate Nurse Staffing To Patient Care Essay Paper

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Limitations of current knowledge
Translating nurse staffing research findings into practice at the unit level, where staffing decisions are made, is hampered by three major limitations. The most outstanding problem is the use of aggregated hospital-level data, rather than unit-level data, making it nearly impossible to replicate results at the unit level.33 Many nurse staffing studies used data from large national databases, such as the CMS and NDNQI. Databases like these offer the convenience of accessibility and the statistical power that comes from using large data sets. The downside, however, is that researchers are limited to the preexisting definitions and quality of variables in the database, and aren’t necessarily able to define and choose measures based on theoretical constructs that may be more meaningful to those in clinical practice.

Although we can conclude that certain factors, such as increased BSN preparation and lower nurse-patient ratios, are important enough to change workforce and staffing resources, this information isn’t helpful to a nurse manager challenged to determine what risk the unit’s current skill mix and available staff levels pose to achieving patient outcome targets. Without knowing the risk a priori, it’s impossible to identify possible solutions. Furthermore, the lack of unit-level data for use by researchers is reflective of the lack of real-time data for decision support on units where staffing decisions are taking place.

The use of large databases also presents a second challenge: Preexisting, aggregated data are generally limited to cross-sectional research designs. The large dataset studies indicate that nurse staffing factors correlate with patient outcomes, which allows us to conclude that nurse staffing plays a role in producing those outcomes, yet causal claims can’t be drawn from correlational studies.34 Future research needs to study unit-level data using more complex statistical operations.The Effect Of Inadequate Nurse Staffing To Patient Care Essay Paper

For example, studies could control for moderator and mediator variables, such as Magnet® recognition or turnover rate, or use hierarchical linear modeling to study nested data.35 Even better would be using experimental or quasi-experimental study designs to determine which staffing factors or decisions are best for producing target outcomes.34 Different acuity systems could be studied on the same unit or similar units using a quasi-experimental design. Another example is testing which skill mix and staff-patient ratio combinations produce the best patient results over a period of time.

A third problem is that the best ways to measure unit-level nurse staffing aren’t yet known through research. Few studies have tried to determine the best measure of nurse staffing, whereas measures have been selected more for convenience or availability than from any underlying construct supporting their use.35,36 A construct is the abstract theme that a researcher is attempting to measure by using variables that are indicators of that theme.37 For example, nursing HPPD is commonly used as a variable indicative of the level or adequacy of nurse staffing. Although nursing HPPD was found to be a reliable measure in three studies, the studies’ small sample sizes limited generalization of the reliability findings to other populations, thus falling short of supporting a claim that nursing HPPD is the best measure.38-41

A systematic review of 29 nurse staffing literature reviews and systematic reviews further highlighted the extent of this problem: It found that the three most common variables used as measures of nurse staffing levels were HPPD, skill mix, and nurse-patient ratio, and that they were calculated 82 different ways across multiple studies.35 For example, HPPD was calculated using midnight census and average census over 24 hours, and using RN-HPPD and total HPPD, which includes RNs, LPNs, and unlicensed assistive personnel (UAP). Skill mix was also calculated in a variety of ways, including combining LPNs with RNs or LPNs with UAP.

Two studies stand out as offering possible paths forward through the cluttered field of nurse staffing measures. One study sought to discover which staffing measure was best for determining the effect on patient quality outcomes by correlating HPPD, RN-HPPD, perceived adequacy of nurse staffing as gathered from nurses via the PES-NWI, having enough assistive personnel, and case mix index (CMI)—a DRG-related weight indicative of the hospital resources a patient required that’s often used as a proxy for acuity.42,43 Both HPPD and perceived adequacy of staffing correlated with CMI, but perceived adequacy wasn’t correlated with HPPD; rather, it was strongly associated with whether enough assistive personnel were available, which isn’t included in RN-HPPD. The author concluded that HPPD was likely a better measure than RN-HPPD, but also recommended that researchers conducting quality-of-care studies choose nurse staffing measures based on a conceptual framework and not by availability.The Effect Of Inadequate Nurse Staffing To Patient Care Essay Paper

Another group of researchers proposed two composite staffing measures seated within a conceptual framework called “nurse dose.”44 Years of direct nursing experience, levels of nursing education, and skill mix were combined to create a composite measure of nurse qualities called “active ingredient,” whereas total nursing HPPD, RN-HPPD, and average nurse-patient ratio were combined to represent the intensity of nursing applied to patients.44 Both of the composite nurse dose measures were found to be significant predictors of hospital-acquired methicillin-resistant Staphylococcus aureus infections and patient falls.45 Use of composite measures or other means of considering the interactions of multiple staffing variables at once holds merit for use in future research to improve our understanding of how variables combine to affect outcomes.

Nursing is a critical factor in determining the quality of care in hospitals and the nature of patient outcomes. Twenty-four hour nursing care is one of the distinctive hallmarks of inpatient care in hospitals. Historically, hospitals have been at the core of the U.S. health care system, and nursing services are central to the provision of hospital care. They have also functioned as the traditional place of work for nursing personnel and especially for registered nurses (RN). Nursing personnel comprise the largest proportion of patient care givers in a hospital. Nursing care in hospitals takes on added importance today because increase in acuity of patients requires intensive nursing care.

In recent years, the nursing profession has been especially concerned about the nature of the transformation taking place in the health care sector. Reports of hiring freezes and layoffs of RNs in hospitals have led to increasing apprehension among them and their supporting organizations about the potential threat to the quality of patient care in hospitals as well as their physical and economic well-being. RNs have expressed concerns that hospitals are implementing a variety of nursing care delivery systems involving major staff substitutions, reducing the proportion of RNs to other nursing personnel by replacing them with lesser-trained (and at times untrained), and lower-salaried, personnel at a time when the increasing complexity of hospital inpatient caseloads calls for more skilled nursing care.

At the same time, the aggregate quantity of RNs is at a high level, creating uncertainties about job security. Much health care is moving to ambulatory settings, the community, and the home through home health services. The nursing profession also has concerns about the training needs to accommodate these

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Suggested Citation:”5 Staffing and Quality of Care in Hospitals.” Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151. ×
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shifts in work settings. With respect to the hospital setting, a rapidly changing health care environment, continuing pressures to contain costs, and the rising levels of severity of illness and comorbidity of inpatients all make it imperative for hospitals to explore innovative ways to redesign delivery of care without compromising quality.

Throughout the decade of the 1980s, hospital expansion, scientific advances, and technological development led to the use of an increasing number of nursing personnel, particularly the RN. As discussed in Chapter 4, employment of RNs in hospitals has increased steadily for the past several decades. In 1993, RN employment in hospitals continued to increase, but the rate of growth over the previous year showed a slight decline for the first time in many years (AHA, 1995b). However, a comparison of first-quarter 1994 data with preliminary data for the first quarter of 1995, shows that while total hospital employment was down; RN employment increased by 3.5 percent, and licensed practical nurse (LPN) employment declined by 1.2 percent (see Table 4.3). These figures may represent a 1-year artifact or an indication of an underlying shift in the health care delivery system.The Effect Of Inadequate Nurse Staffing To Patient Care Essay Paper

Information about trends in employment levels of RNs and other nursing personnel needs to be understood in the context of the changing health care system, as elaborated in Chapters 3 and 4. In particular, hospital inpatient lengths of stay continued to decline, along with inpatient days; admissions increased in 1995 after remaining relatively level in 1994. The increasing acuity of patients requiring intense nursing care, the large increase in hospital outpatient services, and the relative increase in beds dedicated to intensive care units also may account for at least part of the continued increase in hospital employment of RNs.

In sum, although the committee heard reports of widespread layoffs of RNs and other nursing personnel, national statistics suggest that in the aggregate these employment losses appear to have been more than offset by hires. (This generalization does not hold for licensed practical nurses [LPN], whose employment by hospitals has been declining for some years.) The continued growth in RN employment appears to run counter to many assertions the committee heard from nurses during site visits, testimony and numerous written and oral communications throughout the study. Aggregate trends, of course, obscure local and regional variations that respond to local market conditions and other factors, and anecdotal information cannot be discounted totally as it often is a warning indicator of changes that are not yet reflected in national statistics.

This chapter examines the relationship of staffing patterns of nursing personnel in hospitals and quality of patient care. The chapter begins with a discussion of the restructuring of hospital care and the changing roles of nursing personnel in hospitals. It then provides a brief overview of the elements of quality of care, measurement issues, and the status of quality in hospitals. Next, it proceeds to assess whether there is any reliable evidence linking nurse staffing to the quality  The Effect Of Inadequate Nurse Staffing To Patient Care Essay Paper

The Pros and Cons of Required Minimum Nurse-to-Patient Ratios
What with hospital downsizing, budget cuts, and a nursing shortage in the United States, it’s no wonder that an American Nurses Association survey found that 54% of their nurse respondents didn’t have sufficient time to spend on each patient.[1] The past two decades have seen overcrowding and understaffing that has led to longer hours and more stressful shifts for nurses, and as a result, higher burnout rates and lower retention rates. To combat this serious problem, in 2004, California became the first state to implement a law requiring all of its hospitals to limit the number of patients its nurses could treat at any given time.[2] Since then, many other states have been looking to follow suit, or at least regulate staffing ratios more closely, so it’s crucial to study not only the specific benefits of such laws, but also the detriments they can pose. Below is a list of those advantages and disadvantages to help enlighten you on this important issue:

Benefits of Required Minimum Nurse-to-Patient Ratios:

Published studies have shown that appropriate nurse staffing helps decrease nurse fatigue, thus promoting increased safety as well as job satisfaction.[3] Lowering nurse-to-patient ratios decreases nurse burnout, including chronic fatigue, irritability, insomnia, depression, weight gain, and other potential health risks that come from being overworked in a stressful environment.[4] One study found that a lower percentage of California nurses experienced both high burnout and dissatisfaction when compared with nurses in states without minimum staffing ratios.[5] Regulated ratios allow nurses to give better value-based care while also maintaining their own health.
Retention and recruitment rates also improve drastically with minimum nurse-to-patient ratios. The year California’s law went into effect, the California Board of Nursing reported that applications for nursing licenses increased by more than 60%, and by 2008, vacancies for registered nurses in the state’s hospitals plummeted by 69%.[6]
Patient mortality and the number of preventable mistakes – including patient falls, pressure ulcers, central line infections, and healthcare-associated infections – are all proven to decrease after minimum nurse-to-patient ratios are instigated.[7] After enacting its law, California hospitals saw procedural mistakes decline as well as outcomes improve – fewer patients got sick in hospitals, more recovered, and fewer suffered post-treatment complications that required them to return.[8]

Drawbacks of Required Minimum Nurse-to-Patient Ratios:

The largest concern that accompanies this change is that of its cost. Minimum nurse-to-patient ratio laws impose steep fiscal costs on hospitals and allow them little say in regards to staffing decisions.[9] Funding for nursing programs would need to be increased, and hospitals would be required to hire more nurses and increase their salaries and benefits so as to attract enough employees to fill the positions required. California’s transformation was certainly an investment, and not all states have the ability to spend the money required to enact such a law.[10]The Effect Of Inadequate Nurse Staffing To Patient Care Essay Paper
Ratio laws might cause patients to wait longer for treatment. For patients waiting for admission into a ward, even if a bed is available and there isn’t much activity in the ward, nurses wouldn’t be able to see them due to the ratio requirement law.[11] Additionally, such laws don’t account for larger emergency situations happening within the hospital or the city that might require drastic action and changes in staff assignments.[12]
Though some studies have shown that lower nurse-patient ratios improve patient outcomes, others show that the California minimum law has had a limited impact on adverse events in hospitals and mixed effects on quality.[13] Though there is little doubt that nurses are benefited by this law, it is less clear how a patient may benefit.

Though everyone may not agree on the extent to which nursing-to-patient ratios should be turned into law, it’s clear that this topic is one that isn’t going away. As healthcare needs morph in this constantly shifting political, economic, and social climate, finding ways to provide better care for both nurses and patients will always be a relevant discussion.

[1] “Health experts debate the merits of nurse-staffing ratio law,”, n.d.

[2] Ibid

[3] “Optimal Nurse Staffing to Improve Quality of Care and Patient Outcomes: Executive Summary,” Avalere Health LLC, Sept. 2015,

[4] Safe Staffing Ratios: Benefiting Nurses and Patients,” Department for Professional Employees AFL-CIO, May 2016,

Improved Safety
The National Campaign for Safe RN-to-Patient Staffing Ratios is a nationwide effort to ensure safe staffing for nurses and patients across the country.

Studies have shown that appropriate nurse staffing helps achieve clinical and economic improvements in patient care, including:

Enhancement of patient satisfaction and HCAHPS scores
Reduction in medication errors, patient mortality, hospital readmissions, and length of stay
Improved safety outcomes by reducing incidents of falls, pressure ulcers, and healthcare-associated infections (HAIs)
Reduced patient care costs through avoidance of unplanned readmissions
Prevention of nurse fatigue.
In addition to supporting models where nurses themselves are empowered to create staffing plans and promoting flexible staffing plans, the ANA and like-minded organizations support public reporting of staffing data to promote transparency, and penalizing institutions that fail to comply with minimal safe staffing standards.

Optimal staffing is essential to providing the best care possible and getting the maximum value from RNs. Greater benefit can be derived from staffing models that consider the number of nurses and/or the nurse-to-patient ratios and can be adjusted to account for unit and shift level factors.

One strategy to meeting the need for additional nursing staff is opening up the path to a degree for aspiring nurses and encourage more people into the field. Companies such as Wolters Kluwer are working closely with healthcare industry partners, nursing programs and individual educators throughout the country to build world-class nursing education solutions that meet the demands of today’s healthcare field.The Effect Of Inadequate Nurse Staffing To Patient Care Essay Paper

But as the transformation of the American healthcare system continues apace, many healthcare professionals are being asked to develop a more holistic approach to addressing the increasing complexity of patients’ health needs. Today’s nurses are now expected to acquire knowledge from several non-nursing disciplines in order to treat patients.

In her new whitepaper, “Effective Interprofessional Education and Collaborative Practice in Nursing Education,” Elizabeth Speakman, EdD, RN, ANEF, FNAP, notes that experts argue that the delivery of high-quality care requires an interprofessional approach, where representatives from multiple departments work together to provide care. Recent studies, however, question whether nurses can adapt, given the shortage of nurse faculty and mentors, as well as research indicating the prevalence of poor communication and collaborative practices across the healthcare professional spectrum.

From a research tradition in which nurse staffing factors were primarily background variables, the study of nurse staffing and patient outcomes has emerged as a legitimate and strategically crucial field of inquiry. However, despite significant growth in the number and sophistication of studies responding to public policy and provider demand for these findings, results have been inconsistent. This chapter highlights the methodologic challenges inherent in this area of inquiry and explicates how the diversity in measures and units of analyses confound literature synthesis. In the face of myriad pressures to adopt a position for or against mandated nurse-to-patient ratios, the state of the young science does not permit precision in prescribing safe ratios. In fact, it may be concluded that further research is crucial to tease out the nuances in the staffing-outcomes equation. It is essential to advancing the field that future studies replicate, extend, and refine the current body of knowledge, making explicit how characteristics of the workforce, now barely considered (for example, years of experience or professional certification), in addition to the “dose” of the nurse, are linked to processes of care that ultimately result in clinical outcomes (both desirable and adverse). Until then, selected better practices have been noted, with the potential to contribute to pragmatic efforts to improve patient care quality and safety in hospitals.

Controlling health system expenditure has been an important policy goal in the UK National Health Service (NHS) and many similar publicly funded health systems.1–3 The tension between the need for greater efficiency and the impact on quality and safety has been compounded by shortages of registered nurses (RNs). In the UK, these shortages have been created by reduced intakes to RN training coupled with severe RN recruitment and retention difficulties.4 5 Service managers have been driven to consider reducing RN staffing levels and diluting the skill mix of nursing teams, substituting RN posts with healthcare assistants (HCAs) who are unregistered and for whom no formal training is required.6–9 Wide variations in staffing policies and practices persist across the NHS, and there is a lack of consensus in many countries on the value of mandated staffing levels and appropriate nursing skill mix.10–12 In the NHS, a number of concerns have been raised about the ability of HCAs to deliver complex compassionate care, although at the same time the relational abilities of RNs have also been widely questioned The Effect Of Inadequate Nurse Staffing To Patient Care Essay Paper

Many studies report a relationship between low nurse staffing levels and adverse outcomes, particularly higher mortality rates. These findings are reported in studies across the globe including the UK and wider Europe, Australia, China, Thailand and USA.6 A smaller number of studies have reported associations between low staffing levels and low quality of care or patient satisfaction.17–19 The National Institute for Health and Social Care Excellence (NICE), the body which provides guidance and sets standards of care for the NHS called for more evidence considering skill mix and outcomes related to patient satisfaction to guide policy and practice on hospital nurse staffing.6 9

Research on nurse staffing levels and skill mix, while international and large scale, has relied on retrospective methods and rarely examines the staffing experienced by individual patients, which hampers the weight of subsequent staffing recommendations and thus impact on policy and practice. Most studies use hospital administrative data to gather staffing information, linking staffing to patients as a hospital average over a period of time, which does not reflect the care received by an individual on a particular ward on a specific day.6 7

Qualitative studies of RN views report that a lack of nursing time interferes with RNs building relationships with patients in hospital.20 However, the extent to which hospital nurse staffing levels or skill mix actually impact on the quality of interaction with patients has not been reported before. Quality of interaction between staff and hospital patients is an important determinant of patient experience and wider quality of care, especially for older patients with complex needs related to dementia or communication impairments.20–24 The study reported here aimed to explore association between nurse staffing levels, skill mix and the quality and quantity of daytime interactions with patients in hospital wards.

This is a secondary analysis of observational data collected as part of a feasibility study of a compassionate care intervention for hospital nursing teams.25 The study took place in two NHS hospital Trusts in England that collectively employ an estimated 13 800 staff members. Six wards, across the two sites, with high proportions of patients aged over 65 participated: medicine for older people (four wards), urology (one ward) and orthopaedics (one ward). Each study ward had between 28 and 32 beds and almost 100% bed occupancy, with an average of 44 full-time equivalent nursing staff (RNs and HCAs) employed.

We used the Quality of Interaction Schedule (QuIS),26 an observational, time sampling tool that gives a measure of the length and quality of interactions between staff and patients on the ward. It has been used in a number of studies in NHS acute care settings for service improvement and evaluation.27–30 Interactions are rated as positive social, positive care, neutral, negative protective or negative restrictive. In this paper, we focus on interactions classified as ‘negative’ (negative protective or negative restrictive), an approach taken by other researchers using QuIS.29 In feasibility testing, we found close agreement between pairs of observers in relation to the number of interactions observed and moderate to substantial agreement on the QuIS rating.31 32 We also found reasonable correlation between QuIS and patients’ ratings.The Effect Of Inadequate Nurse Staffing To Patient Care Essay Paper


Observations took place between March 2015 and March 2016 and were undertaken by one of 12 trained observers during each of 120 2-hour sessions. Timing of sessions was balanced between wards, day of week and time of day (Monday–Friday, 08:00–22:00). Within each observation session, an index patient was chosen at random from all eligible patients on the ward in question and invited to take part in the study. Patients were excluded if they were unable to communicate their choices about taking part in the research and a consultee (as defined by the Mental Capacity Act 2005 Code of Practice)33 could not be consulted. Patients who indicated either verbally or non-verbally that they did not wish to take part were excluded, as were patients who were unconscious or those for whom there were clinical concerns that precluded them from being approached. Patients excluded for clinical reasons included people who were critically ill, at the end of life or isolated because of a high risk of infection. If the index patient approached consented to take part, up to three other patients in their vicinity were also approached and invited. If the patient declined to take part, a new index patient was selected. This process continued until an index patient was consented.

We developed a protocol to guide the observers in making their QuIS ratings.31 Characteristics of the selected patients (gender, age, cognitive impairment) were recorded, along with session characteristics (number of patients, RNs and HCAs on the ward at the start of the session). During the 2-hour observation session, the observer would find a discrete location on the ward where they were able to observe the social interactions between staff of any discipline and the index and other recruited patients. Observations were recorded in real time using tablet-based software (QI Tool).25 For each interaction, the following data were recorded: its start and finish time; the quality of the interaction; staff type and number of staff involved; whether or not the patient was agitated and whether or not visitors were present.The Effect Of Inadequate Nurse Staffing To Patient Care Essay Paper

For analysis purposes, RN staffing was categorised as low (eight or more patients per RN, reflecting the threshold for low NHS staffing recognised by NICE),9 medium (6.1–7.9 patients per RN) and high (six or fewer patients per RN).9 Because there is no equivalent guidance defining low HCA staffing, we divided HCA staffing levels into tertiles based on observation sessions reflecting low (over eight patients per HCA), medium (7–8 per HCA) and high staffing (fewer than seven patients per HCA). Descriptive statistics (means and SD) for patient, observation session and interaction characteristics were calculated.

A three-level mixed logistic regression model was estimated using the command xtmelogit in Stata V.11.0,34 to investigate the impact of staffing levels on the chance of an interaction being rated negatively: the lowest level being the individual interaction and the higher two levels represented by random effects for the patient and observation session involved. The three-category variables for RN and HCA staffing level were included as fixed factors along with the following controlling variables: patient age, gender and cognitive impairment; presence of visitors, patient agitation and staff type and the ward involved. We explored the impact of each fixed effect alone (including only patient and session-level random effects in the variance structure) and in the presence of all others. Finally, because the influence of one staff group may be related to that of another, specific combinations of RN and HCA staffing were examined by including an interaction term in the model. Analysis was repeated for the subset of interactions involving at least one member of nursing staff (ie, an RN, an HCA, a student nurse or nursing staff not specified).

Association with a negative QuIS rating is presented as an odds ratio (OR) or adjusted OR (aOR) with 95% CIs. The significance of staffing level variables was tested postestimation using Wald tests at the 5% two-sided level. The Wald test for interaction (the need for combinations of RN and HCA staffing to be included in the model) was done in the presence of RN and HCA staffing main effects. The significance of other variables can be judged from the exclusion of the value 1.0 (representing equality) from the 95% CI around an OR/aOR.The Effect Of Inadequate Nurse Staffing To Patient Care Essay Paper

The rate at which patients experienced interactions with staff per observed hour was explored in a negative binomial model at the patient level using command nbreg in Stata. Staffing level variables (and their combination) were examined on their own and after controlling for patient characteristics and the ward involved. Association is estimated from the model as incidence rate ratios (IRR) or adjusted IRRs along with 95% CIs. Statistical significance was judged as described above. The number of interactions experienced by each patient was the dependent variable in the negative binomial model, and the logarithm of their observed time was included as an offset. The median and IQR of the rate (number of interactions per observed hour) across patients are presented.

The amount of time a patient spent interacting with staff per observed hour was examined in normal-based models using command mixed in Stata, including observation session as a random effect, and the staffing level variables, patient characteristics and ward as fixed effects. Models were also examined for the logarithm of the percentage of time spent interacting per observed hour and estimates were back transformed to yield multiplicative effects.

Patients gave informed consent before taking part. The study took an inclusive approach to people with cognitive impairment, in order to properly reflect the relevant patient population. Procedures used were informed by requirements of the Mental Capacity Act and process consent.33 35 Process consent assumes residual capacity exists and then uses knowledge about how the person makes and communicates their choices and preferences in everyday situations as a basis for negotiating participation or not in the research. As required by the Mental Capacity Act, where capacity to decide to participate could not be established, a personal consultee was consulted. The Effect Of Inadequate Nurse Staffing To Patient Care Essay Paper