Understaffing Nurses in the Hospital Setting, How Bad Can it Really Be?

PATIENT OUTCOMES WITH UNDERSTAFFED NURSES 2

UnderstaffingNurses in the Hospital Setting, How Bad Can it Really Be?

MarieBarthelemy

MaryBuskirk

LucyKoroma

DanVaillancourt

JannaWieland

GrandCanyon NURS 504

March11, 2015

UnderstaffingNurses in the Hospital Setting, How Bad Can it Really Be?

Adequatenurse staffing has continued to be a disputed and difficult issuewithin healthcare. Controversy tends to exist in regards to what isconsidered adequate staffing, what defines “understaffing”, andhow this can be remedied in an affordable fashion. However, with therecent government shift towards quality of care, patient perceptionof quality, and hospital reimbursement, the focus is beginning toturn back towards what is really important, patient safety. Whatshould be done in order to meet the needs of the patients andcultivate a culture of high quality care and safety? That question isoften met with answers from governing hospital administration in theforms of audits, increased charting, and scripted nursing dialogue.What do nurses call for when faced with this increased workload? Thesimple answer is more staff. One of the most sought after resourcesis adequate staffing, and yet it remains one of the most limited andis considered to be the most expensive. In order to support the needfor more of this resource, we have to look at literature and researchregarding the perpetual issue of nurse staffing.

ProblemStatement

Doesinadequate nurse staffing adversely affect the quality of patientcare within the hospital setting?

Reviewof Literature

Table 1: Synthesis of Nurse Staffing Levels and Patient Outcomes

Diya et. al.

2011

Frith et. al.

2012

Bae et. al.

2014

Unruh

2012

Curtin

2003

Fittail

2004

Welton

2007

Needleman et. al.

2009

Brooks et. al

2012

Yia-Wun et. al

2012

Levels of Evidence

IV

IV

IV

IV

VII

IV

II

IV

Study Design

Systematic review

RCS

RQ

RQ

QDS

QDS

Systematic Review

Quantitative Study

Cross-sectional study

Longitudinal Panel Study

Evidence shows decrease in patient falls

X

X

X

Evidence shows decrease in decubitus ulcers

X

X

Evidence shows decrease in Medication Errors

X

X

Evidence shows decrease in hospital readmission or hospital days

X

X

X

Evidence shows increased nurse staffing in prevention of PSIs

X

X

X

X

X

Evidence shows decrease in patient mortality with increased staffing

X

X

RCS=RetrospectiveCorrelational Study RQ=Retrospective Quantitative QDS=QualitativeDescriptive Study

Table 2: Table of Evidence

Study 1

Study 2

Study 3

Study 4

Study 5

Curtin, Leah

Fittail, Jeannette

Diya, Luwis et. al.

Frith et. al.

Yia-Wun et. al.

Study title

An integrated analysis of nurse staffing and related variables effects on patient outcomes.

Can we measure how changes in the workforce affect patient care?

The relationship between in-hospital mortality, readmission into the intensive care nursing unit and/or operating theatre and nurse staffing levels

Nurse Staffing is an Important Strategy to Prevent Medication Errors in Community Hospitals

Nursing Staffing in Taiwan and its Effect on the Health of Patients

Research Questions

Are patient outcomes affected by staffing of nurses?

Does changes in the workforce affect patient care

To study the relationship between in-hospital mortality, hospital readmission, and/or operating room readmission of cardiac surgery patients and nurse staffing variables.

To examine the relationship between nurse staffing and the occurrence of medication errors on medical-surgical units.

Nurse staffing and patient mortality

Design

Descriptive study

Descriptive study

Systematic Review

Retrospective correlational study

Longitudinal Panel Study

Setting/Sample

All hospital settings

Acute care hospital setting

Acute care hospital in Belgium

Cardiac surgery patients

Acute Care hospitals

Medical-surgical nursing units

108 selected nursing wards

Methods: intervention/instruments

Compiled evidence from hospital deaths and found the outcomes

2000 audit by the Commission which is being repeated by the Health Care Commission

Retrospective analysis of cross-sectionally collected multi-level data. Data taken from Belgium hospital and National Database

Medication error data collected from 9 medical-surgical nursing units in one hospital. The hospital’s incident reporting database was used.

Mixed effect logic model: Questionnaires were handed to different individuals in the participating wards

Analysis

10 % increase of proportion RN’s , 5 deaths per 1000 patients

Analyzed audits by the Commission and now by the Heath Care Commission

3-level statistically logistic modeling (patient, nursing, hospital level)

Hierarchical Linear Modeling and the Logit model

Mixed Effect Logic model

Key findings

Fewer deaths when there are more RN’s in the skill mix

Changes in the workforce like inadequate staffing affects patient outcomes

Patient safety concerns can be identified through different proxies of patient safety at various stages of the patient’s hospital stay.

Most common errors were due to dose omission, failure to follow protocol, and improper dose. As RN staffing increased, medication errors decreased. As LPN staffing increased, medication errors increased.

Patient mortality was higher in places where nursing workload was high.

Recommendations

4-6 patients to each

Nurse look at acuity

4-6 patients per

Nurse look at acuity

Consideration of different nursing units is key in consideration of staffing issues. Blanket proposals will not benefit units (like ICU) that are already staffed appropriately.

Increase number of RN hours per patient day in all nursing units, or substitute RN hours for LPN hours.

Improve nurse staffing in health institutions in Taiwan to reduce patient mortality.

How this supports EBP/Capstone

EBP standards for highest quality care

EBP standards for highest quality care

National patient safety goals, reduction of readmission post-cardiac surgery.

National patient safety goals, reduction of medication errors.

Demonstrates the relationship between nursing workload and patient outcome.

Table 2 continued:

Study 6

Study 7

Study 8

Study 9

Study 10

Brooks et. al.

Unruh &amp Shang

Bae et. al.

Welton

2007

Needleman et. al.

2009

Study title

.Nurse Staffing and Postsurgical Outcomes in Black Adults

Nurse Staffing and Patient Safety in Hospitals: New Variable and Longitudinal Approaches

Analysis of Nurse Staffing and Patient Outcomes Using Comprehensive Nurse Staffing Characteristics in Acute Care Nursing Units

Mandatory hospital nurse to patient staffing ratios: Time to take a different approach

Nurse-staffing levels and the quality of care in hospitals

Research Questions

Does nurse staffing effect surgical outcomes for black patients?

Examination of the relationship between changes in RN staffing and patient safety events.

Examination of the relationship of nurse staffing to quality of patient care outcomes by including nursing turnover and temporary nursing staff, nurse staffing levels, and skill mix.

The feasibility of mandatory nurse-to-patient staffing ratios in modern American healthcare institutions

The relationship between nurse-staffing levels at hospitals and the risk that patients have complications or die

Design

Cross-sectional study

Retrospective Quantitative

Retrospective Quantitative

Qualitative research study

Quantitative research study

Setting/Sample

Acute care hospitals in California

Post-surgical African American patients

Acute care hospitals in Florida

Acute care hospital

50 research reports

799 U.S. hospitals

Methods: intervention/instruments

Odds ratio for the different variables established to assess the relationship

Retrospective data analysis from nine years, measuring patient safety indicators

A convenience sample was collected, looking at injury falls and decubitus ulcers

Critical assessment of previously presented research findings

Statistical analysis of published and unpublished hospital materials

Analysis

30-day mortality and failure to rescue

Latent growth curve models were used to assess the impact on patient safety of RN staffing changes in hospitals.

Negative binomial regression modeling with hospital and time-fixed effects.

Mandatory nurse to patient staffing ratio will increase medical expense in terms of health insurance

Greater number of licensed nurse-hours per day is associated with reduced length of hospital stay:

Regression coefficient -0.08 percent confidence interval -0.12 yo 0.05 P&lt0.001

Key findings

Post-op mortality for black patients was higher in areas where nurse staffing was lower

A negative relationship between RN staffing and patient safety indicators was strongly supported with failure to rescue and weakly supported with decubitus ulcers, selected infections and postoperative sepsis.

Greater use of LPNs was related to a decrease in patient falls, and increased use of temporary RNs was related to increased patient falls and falls with injury.

The implication of mandatory nurse-to-patient staffing ratios in U.S. hospitals is not a perfect option in terms of costs and quality of services provided to patients.

A higher proportion of hours of care per day provided by RNs is associated with shorter length of stay lower rates of urinary tract infections and gastrointestinal bleeding lower rates of pneumonia, shock and ‘failure to rescue.’ There is no association between increased level of staffing by RNs and the rate of in-hospital death.

Recommendations

The number of nurses should be increased to reduce mortality for the black population

Patient safety indicators should be retested in an expanded change model study using multistate or national sample Healthcare Cost and Utilization Project data.

Nurse managers should look at not just the number of nurses, but also the skill mix when evaluating staffing needs.

In order to provide high quality medical services, U.S. healthcare institutions are offered to consider intensity billing that could balance staffing and economic issues

It is important to increase the number of hours of care per day provided by RNs to ensure improved patient outcomes.

How this supports EBP/Capstone

Demonstrating the relationship between nursing workload and patient outcome.

National patient safety goals and reduction of hospital acquired injury.

National patient safety goals and reduction of hospital acquired injury.

The study suggests that understaffing in U.S hospitals affects the quality of provided services

The study demonstrates the direct relationship between the number of hours of care per day provided by nurses (depends on staffing policy) and patient outcomes.

Table 3: Evidence-Based Project Evaluation

Citation

Purpose

Design

Subject/Setting

Findings/Results

Independent Variable

Dependent Variable

Implication for Practice

Methods

Data Analysis

Stats

Level &amp Quality of Evidence (Strength &amp Confidence to Act)

Fittail, J,

Can we measure how changes in workforce affect patient outcomes? Nov. 2004 vol. 12 issue 6.

clarify the need for adequate staffing

Descriptive study

Nurse staffing in an acute hospital

Dependent variable nurse staffing or workforce

Need staff to take care of patients or the care will be poor

Collected stats from acute care hospitals systematic review

Audit commission in 2000 which is being repeated by Health Care Commission on staffing, patient outcomes and research already available

Level 1 Quality of evidence is strong and there is confidence to act

Curtin, Leah (2003)

An integrated analysis of nurse staffing and related variables affects in patient outcomes

Online Journal of Nursing 8 (3)

Clarify the need for adequate staffing

Descriptive study

Nurse staffing in an acute hospital

Patient outcome dependent variable

Need adequate staff to give good quality care

Analyzed info from hospitals and looked at mortality cross sectional analysis

10% increase in the proportion of RNs across all hospital types were associated with 5 fewer deaths per 1000 patients

Level 1 Quality of evidence is strong and there is confidence to act

Unruh &amp Shang (2012)

Examination of the relationship between changed in RN staffing and patient safety events.

Retrospective quantitative

124 hospitals in Florida between 1996 and 2004

A negative relationship between RN staffing and PSIs was strongly supported with failure to rescue and weakly supported with decubitus ulcers, selected infections, and postoperative sepsis.

PSIs should be retested in an expanded change model study using multistate or national sample Healthcare Cost and Utilization Project data

Latent growth curve models were used to assess the impact

Latent growth curve models were used to assess the impact

IV

Bae et al. (2014)

Examination of the relationship of nurse staffing to quality of patient care outcomes by including nursing turnover and temp nursing staff, nurse staffing levels and skill mix.

Retrospective quantitative

35 nursing units in 3 hospitals

Greater use of LPNs was related to a decrease in patient falls, and increased use of temporary RNS was related to increased patient falls and falls with injuries. Patient variables: Falls with injuries, pressure ulcers. Nurse staffing variables: Nursing hours per day, skills mix, nursing turnover and temp staff.

Nurse managers should look at not just the number of nurses, but also the skill mix when evaluating staffing needs

Negative binomial regression modeling with hospital and time-fixed effects.

Negative binomial regression modeling with hospital and time-fixed effects.

IV

Welton,&nbspJ.&nbspM. (2007). Mandatory hospital nurse to patient staffing ratios: Time to take a different approach. The Online Journal of Issues in Nursing, 12(3). DOI:&nbsp10.3912/OJIN.Vol12No03Man01

To identify the feasibility of mandatory nurse to patient staffing ratios in U.S. hospital

Qualitative study

Critical assessment of 50 reports and peer-reviewed article

In U.S. hospitals, the mandatory implication of nurse to patient staffing ratios is economically infeasible. There are also no guarantees that mandatory staffing will improve the quality of services provided to patients.

IV: nurse to patient staffing ratios

DVs: quality of healthcare services costs

U.S hospital should look for alternatives, including intensity billing

References to panel of experts

Mandatory nurse to patient staffing ratio will increase medical expense in terms of health insurance

Welton utilizes credible and updated sources that add expert value to the conclusions that he makes

Needleman,&nbspJ., Buerhaus,&nbspP., Mattke, S., Stewart,&nbspM., &amp Zelevinsky,&nbspK. (2009). Nurse-staffing levels and the quality of care in hospitals. The New England Journal of Medicine, 346, 1715-1722.

To identify how levels of staffing by nurses at hospitals impact patient outcomes

Quantitative research

799 U.S, hospitals

There is a relationship between proportion of hours of care per day provided by RNs and patient outcomes.

IV: hours of care per day

DVs: patient outcomes length of hospital stay mortality rates

Increased number of hours of care per day improves reduces the lengths of stay and improves patient outcomes

Statistical assessment of hospital reports

Greater number of licensed-nurse-hours per day is associated with reduced length of hospital stay:

Regression coefficient -0.08 percent confidence interval -0.12 yo 0.05 P&lt0.001

The study has a solid research base research methods are in line with purpose.

Diya, L., Van den Heede, K., Sermeus, W., &amp Lesaffre, E. (2012). The relationship between in-hospital mortality, readmission into the intensive care nursing unit and/or operating theatre and nurse staffing levels. Journal Of Advanced Nursing, 68(5), 1073-1081.

To study the relationship between in-hospital mortality, hospital readmission, and/or operating room readmission of cardiac surgery patients and nurse staffing variables.

Systematic Review

Cardiac surgery patients in Acute care hospitals in Belgium

Patient safety concerns can be identified through different proxies of patient safety at various stages of the patient’s hospital stay.

Consideration of different nursing units is key in consideration of staffing issues. Blanket proposals will not benefit units (like ICU) that are already staffed appropriately.

Retrospective analysis of cross-sectionally collected multi-level data. Data taken from Belgium hospital and National Database

3-level statistically logistic modeling (patient, nursing, hospital level)

Level IV:

Evidence is relevant to population, but needs more research in order to apply to larger patient populations.

Frith, K. H., Anderson, E. F., Fan, T., &amp Fong, E. A. (2012). Nurse Staffing Is an Important Strategy to Prevent Medication Errors in Community Hospitals. Nursing Economic$, 30(5), 288-294.

To examine the relationship between nurse staffing and the occurrence of medication errors on medical-surgical units

Retrospective correlational study

Acute Care hospitals

Medical-surgical nursing units

Most common errors were due to dose omission, failure to follow protocol, and improper dose. As RN staffing increased, medication errors decreased. As LPN staffing increased, medication errors increased.

Increase number of RN hours per patient day in all nursing units, or substitute RN hours for LPN hours.

Medication error data collected from 9 medical-surgical nursing units in one hospital. The hospital’s incident reporting database was used.

Hierarchical Linear Modeling and the Logit model

Level IV: research is non-randomized, therefore causal inferences are difficult to support.

Brooks Carthon, J. M., Kutney-Lee, A., Jarrín, O., Sloane, D., &amp Aiken, L. H. (2012). Nurse Staffing and Postsurgical Outcomes in Black Adults. Journal Of The American Geriatrics Society, 60(6), 1078-1084. doi:10.1111/j.1532-5415.2012.03990.x

To determine the link between nursing staffing and the outcomes for older black patients after theater

A cross-sectional Study using patient discharge data at a University Hospital

The study used data from 599 Pennsylvanian acute care hospitals. 548,397 individuals over 64 years participated in the study. These individuals had different types of surgeries.

The 30-day mortality rate was higher for backs compared to their white counterparts. A higher odds ratio for the mortality of these patients was recorded in black patients managed in institutions with higher nursing workloads. Blacks had higher odds of death in the increase of the ratio when the patient-per-nurse ratio increased.

Dependent variable: mortality post surgery

Independent variable: Nurses workload and staffing.

The increase in nursing workload may adversely affect the outcomes of black surgical patients.

Cross-sectional study. The researchers measured the 30-day mortality for post-op patients and the prevalence of death as a complication in patients where the nursing workload was high as a result of inappropriate staffing.

A higher odds ratio for and a 30-day mortality was experienced. An increase in odds ratio of 1.10 was observed with each rise.

Level II the study strongly supported the question.

Yia-Wun, L., Wen-Yi, C., wo-Leun, L. &amp Li-C. (2012). Nurse staffing, direct nursing care hours and patient mortality in Taiwan: the longitudinal analysis of hospital nurse staffing and patient outcome study. BMC Health Services Research,&nbsp12(1), 44-51. doi:10.1186/1472-6963-12-44

To establish interaction between mortality and nursing staffing in Taiwan

A longitudinal panel survey. The study sought to define the relationship between nursing staffing and patient outcomes in Taiwan using this study design

108 wards participated after sampling through random stratified sampling techniques. These were selected from a total of 32 hospitals with the selection taking place over a seven month period in Taiwan. The researchers sough to establish the link between mortality and the number of nurses at these wards.

Patient mortality was higher in institutions with lower nurse staffing and nurse manpower. The researchers assessed the odds ratio for death in patients that were above or below the direct-nursing-care-hour with the result of a higher odds ratio for patients below this ratio.

Dependent Variable: Patient mortality

Independent variable:

Nursing Workload

The implication for practice in Taiwan is that the mortality associated with reduction in the nursing workforce is significant. The nation should have improved nursing staffing to ensure that this high mortality is reduced. Consequently, nursing workload proportionately affects the mortality outcomes in patients receiving care.

After sampling was done using the stratified random sampling method, the researchers used the mixed effect logic model to assess the link between the mortality of patients and the number of nurses giving them care (Yia-Wun, Wen-Yi, wo-Leun, &amp Li 2012). The researchers also established the relationship between the nursing workload with their performance for patients in the Taiwanese hospitals.

The researcher calculated the nurse manpower as 378.. Those above the DNCH had an odds ratio of 0.393 with those below being 0.589. This finding means that the number of patients that died from the high nursing workload increased with the increase in workload.

Level IV: this research uses available data and data gathered from the hospitals to assess the relationship between patient outcomes and the nursing workload in Taiwan.

Synthesisof Data

Theliterature review and synthesis of data looked at the effects ofnurse staffing in various acute care hospital units throughoutmultiple countries in an attempt to explain patient safety,mortality, and hospital readmission. Patient safety indicators thatwere looked at included occurrence of decubitus ulcers, patientfalls, and medication administration errors. Patient mortality wasalso examined with an association to nurse staffing levels. Articlesby Diya et. al. (2012) and Yia-Wun et. al. (2012) both supported apositive correlation between increased nursing staff in unit and adecrease in patient mortality. Research conducted by Bae et. al.(2014) implied that staffing of more Licensed Practical Nurses (LPNs)on the floor improved patient safety by reducing patient falls.However, Frith et. al. (2012) found that an increase in LPNs on thefloor actually increased the occurrence of medication errors due tointerruptions from LPN staff while RNs are administering medications.This shows that the use of LPNs, as they are a more affordable optionto RNs, does not necessarily result in safer patient outcomes.However, the use of more healthcare providers in unit in general mayreduce certain patient injuries, such as falls and decubitus ulcersthat do not necessarily fall primarily within the realm of nursingpractice.

Allof the research that shows an increase in nurses at the bedsidedecreases patient safety issues are not only relevant to the nursingprofession, but to the hospital as a whole. The 2015 National PatientSafety Goals from the Joint Commission for nursing focus directly onreduction of falls, reduction of decubitus pressure ulcers, and safeuse of medication. Hospital reimbursement is also dependent upon theachievement of these goals as well as reduction in readmission to thehospital within 30 days for the same illness or disease process. Inorder to achieve these goals, more educated staff needs to beaccessible. Although nurses are often considered the most expensive,and most easily disposed of, commodity, the cost of adding one or twonurses to the staff would greatly reduce the overall cost thathospitals incur from the occurrence of patient safety events.

References

Bae,S., Kelly, M., Brewer, C., Spencer, A. (2014). Analysis of NurseStaffing and Patient Outcomes Using Comprehensive Nurse StaffingCharacteristics in Acute Care Nursing Units. Journalof Nursing Care Quality. 29(4):318-326.

BrooksCarthon, J. M., Kutney-Lee, A., Jarrín, O., Sloane, D., &amp Aiken,L. H. (2012). Nurse Staffing and Postsurgical Outcomes in BlackAdults. Journalof the American Geriatrics Society, 60(6),1078-1084. doi:10.1111/j.1532-5415.2012.03990.x

Curtin,L. (2003). An Integrated Analysis of Nurse Staffing and RelatedVariable: Effects on Patient Outcomes. OnlineJournal of Issues in Nursing, 8(3).Retrieved fromwww.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/KeynotesofNote/StaffingandVariablesAnalysis.aspx

Diya,L., Van den Heede, K., Sermeus, W., &amp Lesaffre, E. (2012). Therelationship between in-hospital mortality, readmission into theintensive care nursing unit and/or operating theatre and nursestaffing levels.&nbspJournalOf Advanced Nursing,&nbsp68(5),1073-1081. doi:10.1111/j.1365-2648.2011.05812.x

Fittail,B. (2004). Can We Measure How Changes in the Workforce Affect PatientCare? Journalof Nursing Management, 12(6),277-492.

Frith,K. H., Anderson, E. F., Fan, T., &amp Fong, E. A. (2012). NurseStaffing Is an Important Strategy to Prevent Medication Errors inCommunity Hospitals.&nbspNursingEconomic$,&nbsp30(5),288-294.

Needleman,J., Buerhaus, P., Mattke, S., Stewart, M., &amp Zelevinsky, K.(2009). Nurse-staffing levels and the quality of care inhospitals.&nbspNewEngland Journal of Medicine, 346,&nbsp1715-1722.

Unruh,L., Zhang, N. (2012). Nurse Staffing and Patient Safety I nHospitals: New Variable and Longitudinal Approaches. NursingResearch.61(1): 3-12, January/February 2012.

Welton,J. (2007). Mandatory Hospital Nurse to Patient Staffing Ratios: Timeto Take a Different Approach. OJIN:&nbspTheOnline Journal of Issues in&nbspNursing,12(3),Manuscript 1. doi: 10.3912/OJIN.Vol12No03Man01

Yia-Wun,L., Wen-Yi, C., wo-Leun, L., &amp Li-C. (2012). Nurse staffing,direct nursing care hours and patient mortality in Taiwan: thelongitudinal analysis of hospital nurse staffing and patient outcomestudy.BMCHealth Services Research,&nbsp12(1),44-51. doi:10.1186/1472-6963-12-44