Running Head: NURSE STAFFING AND ITS EFFECT ON PATIENT OUTCOMES 1

Nursing Staffing and Its Effect on Patient Outcomes

Kelley Baird, Morgan Clark, Lauren Haynes, Michael Johnson, Katie McGraw

Nursing Inquiry: Group 12

James Madison University

NURSE STAFFING AND ITS IMPACT ON PATIENT OUTCOMES 2

Introduction

Every year, seven million patients acquire infections while in the hospital (Cimiotti,

Aiken, Sloane & Wu, 2014). More specifically, approximately 6-7% of deaths are attributable to

an increase in nurse caseload (Kane, Shamliyan, Mueller, Duvall & Wilt, 2007). Nurse staffing

has been shown to be associated with the spread of infection and other adverse patient outcomes,

yet little additional information is available to support or explain this association (Cimiotti et al.,

2014). According to a study conducted by McGahan, Kucharski & Coyer (2012), adequate nurse

staffing is inherently related to positive patient outcomes in both high acuity units and general

acute care units. The importance of this study is to emphasize that nurse staffing directly

influences the quality of patient care and has a significant impact on patients. This research

illustrates the growing need for smaller nurse-to-patient ratios and seeks to further explain the

impact nurse staffing has on patient outcomes during hospitalization.

Study Commonalities

The articles gathered in this research all focused on how decreased nurse staffing is

attributed to adverse patient outcomes. Mortality and hospital acquired infections were the most

common adverse patient outcome examined within each of our articles. Since all articles

included within the literature review were observational studies conducted within the last ten

years and were found using similar search terms, many yielded similar results. Three of the

articles whose purpose was to examine the relationship between staffing levels and patient

outcomes within an acute care setting found a trend/association between increased staffing and

decreased risk of adverse events (McGahan et al., 2012, Kane et al., 2007 & Cimiotti et al.,

2014). In addition, one study found higher staffing levels were associated with a more than thirty

percent infection risk reduction (McGahan et al., 2012). More specifically, McGahan et al.

NURSE STAFFING AND ITS IMPACT ON PATIENT OUTCOMES 3

(2012) and Wilcox et al. (2013) both found that hospital models consisting of high-staffing levels

resulted in decreased mortality and other adverse outcomes within the ICU setting. Building on

this idea, Cimiotti et al. (2014) determined that fewer infections were seen when nurses had a

smaller case load. While each of the interventions studied within these articles varied slightly,

these studies clearly show the importance of increased nurse staffing and its significant impact

on patient outcomes.

Study Differences

While our articles yielded similar findings, there was a degree of differences in the

articles that are considered notable to our research. Van den Heede, Simoens, Diya, Lesaffre,

Vleugels & Sermeus (2010) considered overall hospital costs in relation to nurse staffing and

patient outcomes. That is, if they were to increase nurse staffing in their hospitals, would it really

be worth the extra time and money that would be required to fulfill such a task? Ultimately, it

was found that increasing nurse staffing levels to the 75th percentile in Belgian general cardiac

postoperative nursing units was a cost-effective intervention and appeared to give better value

for money than other cardiovascular interventions (Van den Heede et al., 2010). Another article

looked at how nurse burnout was also a factor in reduced staffing and its relation to hospital

acquired infections. It was found that every 10% increase in burned-out nurses in a hospital

increased the rate of urinary tract infections by nearly 1 per 1,000 patients and the rate of surgical

site infections by more than 2 per 1,000 patients (Cimiotti et al., 2014). While neither of these

viewpoints were examined in other articles, they each provided profound insight and helped in

determining our suggested recommendations for practice.

On a fundamental level, each study included consisted of a varying amount of

observational studies. McGahan et al. (2012) was the smallest review, comprised of nineteen

NURSE STAFFING AND ITS IMPACT ON PATIENT OUTCOMES 4

observational studies, whereas Cimiotti et al. (2014) was the largest with over 161 studies

included. Additionally, while the articles used in these studies all related to reduced staffing and

adverse patient outcomes, some focused on different levels of care and types of patients. For

example, McGahan et al. (2012) focused on adult ICU patients whereas Van den Heede et al.

(2010) narrowed in on cardiac surgery patients. Though the articles used all depict that decreased

nurse staffing results in poor patient outcomes, these slight differences provide alternative

outcomes to the issue and ways in which it could be addressed.

Inconsistencies/Gaps in the Literature

Although the research utilized has provided helpful knowledge about the likelihood of

better patient outcomes with increased nurse staffing, there are some other incidences within the

studies that could have influenced patient outcomes. Infection rates, mortality rates, disease

prognosis, invasive procedures, and exposure to harmful substances are just a few of the many

other contributing factors that often come into plays. The articles used glanced over many of

these issues but did not greatly highlight their immense contributions to recovery time,

readmission rates, and overall health of the patient. Instead, the research focused more on how

increasing nurse-to-patient ratios would help to combat negative patient outcomes. However,

many logistical views were left out of the research. For example, there was very little mention of

the financial aspect of increasing staffing. In the Van den Heede et. al (2010) study, finances are

discussed but they are strictly limited to that of Belgium rather than examining the financial

impact that increased staffing could have on hospital systems within other countries. In addition,

nurses available to work additional shifts, federal working laws, overtime pay, and hospital

standards, among others are all significant logistical factors which affect the realistic application

of increasing staffing and patient ratios. Although there is a plethora of evidence supporting

NURSE STAFFING AND ITS IMPACT ON PATIENT OUTCOMES 5

increased staffing and better patient outcomes, failing to include a comprehensive review of

these other factors results in a major gap within the practical application of these findings.

Furthermore, the studies reviewed mainly focused on immediate outcomes associated with

changing staffing protocols. To combat these inconsistencies, a revised longitudinal study may

warrant examination to determine the long-term effects of decreased nurse-to-patient ratios.

Limitations and Threats to Validity

Despite the reliability of all studies used in this research, each individual study had its

own limitations that influenced results. A major threat to validity was that while these studies

were published within the last decade, some of the articles referenced research that was

conducted more than ten years ago. In fact, data used in the Wilcox et al. (2013) study dated as

far back as mid 1990s and early 2000s. Due to constantly changing medical practices, some of

these results could be viewed as inconsistent due to a lack of current, evidence based practice.

Another significant limitation seen within this study is that results were narrowed to include

adult patients within high-acuity or intensive care units. Data regarding pediatric or neonatal

demographics were not considered. Additionally, the studies included contained specific

inclusion criteria. Therefore, studies that included details on nursing errors, readmission rates,

increased length of stay, specific organ dysfunction and many other factors contributing to

patient wellbeing were excluded. Neglecting to include such factors threatens the validity of this

study as it pertains to only the strictest definitions of adverse patient outcomes. By having done

so, the reach of this study was severely limited along with its practical application.

Van den Heede et al. (2010), was the only study included in this research that considered

differences among nurse education and its relation to patient outcomes. By considering pay grade

and level of education, it is suggested that patient outcomes may be linked to the degree level of

NURSE STAFFING AND ITS IMPACT ON PATIENT OUTCOMES 6

practicing nurses. However, the study does not further examine this idea and fails to determine if

there is any true link, which limits the validity of its findings as another possible contributing

factor was abandoned. A similar flaw existed in Kane et al. (2007) as post-treatment

requirements amongst patients and specific nursing interventions were excluded. Without this

information, one cannot determine if hospital protocols, nursing education, skill level or patient

specific needs have any bearing on adverse outcomes.

Among the various articles used, reporting of data was inconsistent. While some studies

reported morbidity and mortality data, others, such as Cimiotti et al. (2014), merely focused on

infection rates without examining other adverse patient outcomes or factors that influence patient

recovery. Additionally, data collection locations varied greatly which further inhibits ones

ability to determine conclusive data. For example, McGahan et al. (2012) considered data from a

single unit rather than hospital-wide whereas Wilcox et al. (2013) included data across various

ICU settings. Including unit-specific and hospital wide data is inherently important in helping to

determine which areas may be most affected by understaffing or limited resources.

Lastly, each of the articles included within the study failed to determine a safe or

appropriate nurse-to-patient ratio. Although all studies concluded smaller ratios would result in

fewer adverse outcomes, a suggested nurse-to-patient ratio was not offered. Thus, the validity of

the research could be questioned in terms of its numerical accuracy. Without having a

recommended nurse-to-patio ratio, one cannot determine what constitutes low or high intensity

staffing. By failing to determine this important aspect, the studys relevance could be questioned.

To increase the likelihood that the research will make an impact within acute care settings,

consistency and reliability need to be established to prove its importance across the healthcare

continuum.

 NURSE STAFFING AND ITS IMPACT ON PATIENT OUTCOMES
Recommendation
Implement mandatory
nurse-to-patient ratios in all
50 states
Ensure the presence of
skilled charge nurses/nurse
managers on each unit
(McGahan et al., 2012).
Utilize float pool
nurses/supplemental
staffing
Utilize unlicensed assistive
personnel (UAPs) and
nursing technicians
Implement support
interventions as strategies
to improve retention and
satisfaction while reducing
job-related burnout
(Cimiotti et al., 2014).
Encourage hospitals to
increase investments in
nurse staffing (Van den
Heede et al., 2010).
7
Recommendations/Linkages to Practice
Link to Practice/Benefits
Legislation would ensure fair mandates and require all institutions to
comply
Nursing case-load would be universal and job enticement/reduced retention
from other hospitals with lower nurse-to-patient ratios would be reduced
Helps maintain safe nursing assignments based on skill level of nurses and
individual patient acuity and fair allocation of tasks
Could reduce nurse burnout, job-related stress and adverse patient outcomes
Help to maintain safe nurse-to-patient ratios in situations where there is a
late call-out or no-show for a shift by having additional staff to pull from
If acuity is high, additional staffing could be drawn from a float pool for a
designated time to ensure safe working conditions for both the nurse and
patient
Allowing assistance with fundamental care (baths, linen changes, etc.)
would give licensed staff more time to dedicate to skill-intensive care
Could help to reduce nurse workload and associated adverse patient
outcomes
Supportive services could help improve retention rates, thereby reducing
nurse shorting, hiring turnover and understaffed units resulting in improve
nurse-to-patient ratios
Reduce burnout could result in fewer errors, more accurate care
coordination, higher patient satisfaction and lower incidence of adverse
patient outcomes
Could help to foster more-skilled nurses and create an environment that is
team oriented with a focus on both nurse and patient safety
Lower nurse-to-patient ratios could result in less hospital expenditure going
towards lost reimbursement from Medicare/Medicaid due to readmissions
and hospital-acquired infections
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Summary of Studies Evidence Table

PICO: Are adult intensive care units who have inadequate staffing at increased risk for adverse patient outcomes
compared with units who maintain 1:1 nurse-to-patient ratios?
Group 12: Kelley Baird, Morgan Clark, Lauren Haynes, Michael Johnson, Katie McGraw

Author, Purpose Sample Intervention Instruments Results/Statistical Summary/

Yr. Description with Validity Evidence Conclusion
& Size & Reliability

McGahan, Examine 19 Nurse to N/A Increased staffing reduced Studies

M. et al. relationship observational patient ratios, (article is mortality; 1 study found demonstrated a
(2012). between studies hours per recent) higher staffing levels were trend between
nurse patient day & assoc. with a >30% increased nurse
LOE: I staffing workload, com infection risk reduction (RR staffing levels
levels & the pared to 0.69, 95% CI 0.50-0.95); and decreased
incidence of incidence of ICU with more RN hours adverse patient
mortality & infections, per patient day had lower outcomes in
morbidity in pressure incidence of pressure ulcers ICU
adult ICU ulcers, & (OR 0.69, 95% CR 0.49 -
patients mortality 0.98)

Wilcox, M. Determine 52 Models of high N/A 18 studies reported (35%) Trend showing
E., et al. effect of observational vs. low (article is ICU mortality, that high-
(2013). difference studies intensity recent) demonstrating lower intensity
staffing staffing numbers with w/ high staffing
LOE: I models on intensity staffing (pooled correlated with
outcomes of RR, 0.81; 91% CI, 0.68- improved
critically ill 0.96) patient
patient outcomes and
reduced ICU
mortality

Kane, R. Examine 96 RN to patient Tested 28 studies reported adjusted Studies show

L., et al. assoc. observational ratio, heterogeneity odds ratios of patient association
(2007). between RN studies commitment to and outcomes; ICU RN staffing between RN
staffing and quality of care, sensitivity averaged 3.0 +/- 1.8 patient staffing and
LOE: I patient incident of analysis per shift; greater RN lower risk of
outcomes in infection, (article is staffing was associated with mortality and
acute care mortality and recent) reduction of hospital related adverse related
several adverse mortality & lower odds of events; patient
patient events adverse patient events and hospital
characteristics
contributed to
causal pathway

Van den Examine 28 RN staffing to Sensitivity 12 studies reported a high Study shows
Heede, K., overall observational patient care analysis association between higher association

 NURSE STAFFING AND ITS IMPACT ON PATIENT OUTCOMES 9

et al. hospital studies received; (article is mortality rates and lower between
(2010) costs in calculated cost recent) nursing staffing (between increased
relation to to bring nurse 15% and 5% depending on staffing and
LOE: IV nurse staffing to a severity of illness). Higher decreased
staffing & 75% nurse staff numbers were mortality.
patient ratio and associated with decreased Factors
outcomes implement mortality contributing to
after staffing mortality were
elective patient
cardiac demographics,
surgery lifestyle, and
hospital related
events

Cimiotti, J. Observe 161 Burnout due to N/A There was a significant Findings
P., et al. correlation observational understaffing, (article is assoc. between patient-to- confirm an
(2014). between studies incidence of recent) nurse ratios, UTI (P = .02) association
understaffin infection, & surgical site infections (P between nurse
LOE: I g of nurses acquired cost = .04); hospitals in which staffing and
and increase to hospital burnout was reduced by infections, with
in hospital 30% had a total of 6,239 fewer seen
acquired fewer infections, for an when nurses
infections annual cost saving of up to care for less
$68 million patient; high
rates of
infection appear
to be associated
with nurse
burnout due to
heavier patient
loads

References

NURSE STAFFING AND ITS IMPACT ON PATIENT OUTCOMES 10

Cimiotti, J. P., Aiken, L. H., Sloane, D. M., Wu, E. S., (2014). Nurse staffing, burnout, and

health careassociated infection. American Journal of Infection Control, 40(6), 486-490.

doi: 10.1016/j.ajic.2012.02.029

Kane, R.L., Shamliyan, T. A., Mueller, C., Duval, S., Wilt, T. J., (2007). The association of

registered nurse staffing levels and patient outcomes. Medical Care, 45(12), 1195- 1204.

doi: 10.1097/MLR.0b013e3181468ca3

McGahan M., Kucharski G., Coyer F. (2012). Nurse staffing levels and the incidence of

mortality and morbidity in the adult intensive care unit: a literature review. Australian

Critical Care, 25(2), 64-77. doi 10.1016/j.aucc.2012.03

Van den Heede, K., Simoens, S., Diya, L., Lesaffre, E., Vleugels, A., Sermeus, W., (2010).

Increasing nurse staffing levels in Belgian cardiac surgery centres; a cost-effective patient

safety intervention? Journal of Advanced Nursing. 66(6). 1291-1296. doi:

10.1111/j.1365-2648.2010.50307.x

Wilcox, M.E., Chong, C. A., Niven, D. J., Rubenfield, G. D., Rowan, K. M., Wunsch, H., Fan,

E., (2013). Do intensivist staffing patterns influence hospital mortality following ICU

admission? Critical Care Medicine. 41(10) 2253-2274. doi:

10.1097/CCM.0b013e318292313a