The quality of patient care, as well as the underlying tenets of timely, safe, effective, efficient and patient-centred health care, is inherently threatened by the increasingly difficult workload on the falling number of nursing staffers. However, while reduced patient loads are necessarily a desirable outcome, it has immense cost implications on struggling health care systems across the world. This review includes empirical literature drawn from across the world (China, Australia, and the US) on the effect of nurse staffing levels and the quality of care.
The adjusted regression analysis showed that nurse staffing levels had a statistically significant, and positive effect on the nurses’ quality of care reports, care quality, adverse patient events, patient satisfaction and the nurses’ confidence on whether the patients could take care of themselves once discharged. At least 35% of the nurse respondents reported that adequate patient/family preparation and patient surveillance was impossible for want of time, while a further 21% reported that required pain and skin management was never provided for the same reason. Between 30% and 43% of the nurse respondents believed that that poor or fair quality of services offered, low confidence in self-care, while 50% and 7% of patients reported dissatisfaction with the manner nurses communicated medication instructions and responsiveness to emergency calls respectively. When the nurse-to-patient ratio was raised to 0.6 from 0.5, all quality outcomes improved.
While Zhu, et al. (2012) found a nurse-to-patient ratio of more than 0.6 important, Duffield et al. (2011) finds that the exact ratio depends on a number of environmental/organizational factors. The difference could be due to the technological and human capital development differences between the US and China. Drawing on five-year longitudinal data and separate primary data, Duffield, et al. (2011) sought to determine the effect of nurse staffing, unstable nursing units and higher workloads on patient outcomes in Mew South Wales, Australia. The longitudinal data (nursing scheduling/payroll and patient discharge) was drawn from the Health Information Exchange (HIE) and the Area Health Services (AHS) databases between 2001 and 2006, while primary data was obtained from a random sample of 80 patient nursing units across 19 hospitals in 2004-2005. Chi-square tests were applied to the estimated unit-months of data countable as a unit increase/decline in variables while linear regressions linked staffing levels to patient outcomes.
The results indicated that RNs and ENs represented 68% and 20.4% of nursing staff respectively. The length of hospital stay (LOS) reduced to 3.23(SD=1.51) from 3.26(SD=1.44) days over the five years, but the number of time spent on one unit was under 75% of the total LOS, which effectively points to patients visiting different units. The demand for nurses stood at 124 (as against 100 required), with only 25% of the units having a balance between the number of work hours and the number of hours required by the patients. Further resource adequacy and control over the practice was positively related to supply/demand for nurses. Increased number of CNS/RN staff (or work hours) was linked with statistically significant reductions in pneumonia, sepsis, decubiti, GI bleeding, pulmonary failure, physiological derangement, and shock. Cross-sectional study results showed a reduction in medication errors (18.4%), adverse patient events (15.8%) and increased comforting to, and communication with the patients. Improvements in patient/family education, oral hygiene, distress and vital signs responsiveness, PRN administration and medication mobilization.
On the other hand, Cook, Gaynor, Stephens Jr, M., & Taylor (2012) evaluated the effect of California’s Assembly Bill 394, which imposed maximum patient levels per nurse in the state’s hospital settings. It utilized data from the state’s Office if Statewide Health Planning & Development (including financial and patient discharge records. A balanced panel data between 2000 and 2006 is constructed and analyzed using linear regression analysis. Patient safety indicators with proven validity are employed in measuring adverse outcomes. The study suffers from possible omitted variable bias due to the high variation in the level of resources committed to patient care per hospital, including nurse staffing practices. Further, the endogenous variable sorting is such that more resources are committed to severely ill patients.
This study finds statistically significant evidence of that mandated increases in the nurse-to-patient ratios led to increased care outcomes. The sample averaged a patient to nurse (PNR) of 6, with only 51 hospitals having a patient load of less than 4, which was reflected in proportionately worse care outcomes (including high Failure to Rescue (FTR)/death). The adjustment of patient loads, in part, led to the substitution of high skilled RNs with licensed vocational nurses, coupled with adjustments in the use of orderlies/aides. The worsening of skills mix was relatively small compared to the increased number of nurses. The regression results indicate an increased number of nurse staffers following AB394, but the increased number of nurses did not result in statistically significant improvements in the measured indicators of patient safety. Despite its methodological limitations, Cook, Gaynor, Stephens Jr, & Taylor (2012) shows the dangers of increases in patient-to-patient ratios as found by studies such as Zhu, et al. (2012) and Duffield, et al. (2011), because of the cost implications, especially in the wake of the on-going health care financing/insurance reforms in the US.
However, contrary to Cook, Gaynor, Stephens Jr, & Taylor (2012)’s findings, McHugh, Berez, & Small (2013) find that cost savings from improved quality of care (due to lower patient loads on nurses), may just be sufficient to offset the costs involved in increasing the staff levels. With the implementation of the Affordable Care Act (2010), which imposes penalties on hospitals for high readmission rates among Medicare beneficiaries, it is imperative that evidence-based initiatives such as better discharge preparation, patient education, and care coordination are emphasized. Fines were expected to reduce hospitals’ earnings by 0.3% in 2013 alone. McHugh, Berez, & Small (2013) investigated the relationship between RN staff levels and readmission rates’ penalizations under the Hospital Readmissions Reduction Program (HRRP). It used data from the American Hospital Association Annual Survey and CMS HRRP Supplemental Data File (2013). The results reveal that higher nurse staffing resulted in 25% (95%, CI) lower odds of financial sanctions, relative to hospitals with heavier nurse workloads. Of the 2976 hospitals studies, 28% escaped penalties, 9% attracted the maximum possible penalty, and 63% attracted at least some penalty. In common with Zhu, et al. (2012) and the majority of studies in this area, McHugh, Berez, & Small (2013) also found improvements in the quality of care (reduced failure to rescue, patient satisfaction, mortality, etc.).
McHugh, Berez, & Small (2013) is supported by Hariharan (2015), which is not an empirical research report, but an analytical research article that explores possible solution to meeting the challenges caused by nursing staff shortages. Its importance is underscored by shortages are not only because of cost implications but also because of supply side issues (e.g. training and nursing programs’ uptake in college). Effectively, solutions do not necessarily have to be conditioned on increased nurse/physician-to-patient ratios. According to Hariharan (2015), asserts that increased utilization of primary care, provision of graduate training to primary care physicians, coupled with the possible utilization of non-physician/nursing providers to ease the burden. Highly qualified nursing practitioners (advance practice registered nurses-APRN) are more productive/efficient, and thus their inclusion in medical teams has important implications for quality outcomes. These benefits should result in similar outcomes as anticipated by McHugh, Berez, & Small (2013).
References
Cook, A., Gaynor, M., Stephens_Jr, M., & Taylor, L. (2012). The effect of a hospital nurse staffing mandate on patient health outcomes: Evidence from California's minimum staffing regulation. Journal of Health Economics, 31(2), 340-348.
Duffield, C.,., O'Brien-Pallas, L., Aisbett, C., Roche, M., & al., e. (2011). Nursing staffing, nursing workload, the work environment and patient outcomes. Applied Nursing Research, 24(4), 244-255. .
Hariharan, S. (2015). Hariharan, S. (2015). USING ADVANCE PRACTICE REGISTERED NURSES AND PHYSICIAN ASSISTANTS TO EASE PHYSICIAN SHORTAGE. Physician Leadership Journal, 2(3), 46-51.
McHugh, M., Berez, J., & Small, D. (2013). Hospitals with higher nurse staffing had lower odds of readmissions penalties than hospitals with lower staffing. Health Affairs, 32(10), 1740-1747.
Zhu, X., You, L., Zheng, J., Liu, K., Fang, J., Hou, S., et al. (2012). Nurse Staffing Levels Make a Difference on Patient Outcomes: A Multisite Study in Chinese Hospitals. Journal Of Nursing Scholarship, 44(3), 266-273.
