Shortage in the staffing of nurses is a significant challenge for healthcare systems all over the world. Although most studies associated with inadequacies in nurse staffing have been conducted in the USA, other studies in the same area have also been done in other parts of the world with similar findings; New Zealand (North et al., 2013), Malawi (Bradley et al., 2015) and Hong Kong (Chau et al., 2015).
Nursing shortages have been associated with poor medical services, poor patient outcome, high stress levels and burnout among nurses, low retention rates and high turnover of nurses. Evidence from numerous studies has associated adequate nurses’ staffing with positive patient outcomes (decreased mortality rates, improved patient safety), improved quality of care, job satisfaction and high retention rates (Chau et al., 2015; Bradley et al., 2015; Hairr et al., 2014).
Additionally, hospitals and other healthcare organization can save money by retaining nurses and maintaining the recommended nurse-patient ratio. Administrative efforts towards retaining nurses are rewarded by financial savings by avoiding recruitment and retraining costs associated with high nurses’ turnover,
The shortage of nurses in healthcare facilities has become a global concern. In the United States, nurses’ shortages have been reported regularly since the late 1980s (Grumbach et al., 2001). In Malawi, a shortage in Human Resources for health particularly the inadequate staffing in nurses negatively affects the maternal outcomes as well as the preparedness of healthcare facilities to offer maternity services at any given time (Bradley et al., 2015). This inadequacy in human resources makes it difficult for this African Country to attain the fifth Millennium Development Goal (MDG) that aims at decreasing the maternal mortality rate while increasing the number of births attended by qualified medical workers (Bradley et al., 2015). In New Zealand, the nursing shortages and persistent poor working conditions have been long standing (North et al., 2013).
Delivery of quality services and enhancement of patient outcomes are essential goals for healthcare workers. However, these goals cannot be realized without having an adequate staffing of competent nurses. According to Chau et al. (2015), manpower shortages and high levels of turnover in the past decade have resulted in job dissatisfaction, high stress levels and burn outs. As a result, delivery of healthcare has been affected negatively leading to poor patient outcomes. The quantity and quality of the nursing workforce have a direct relationship with the quality of nursing care given. Hence, the adequacy of nurses plays a significant role in determining patient safety and outcomes. Inadequate number and skill mix in the nursing department results in the reduced time that a nurse dedicates to a patient, affects the quality of care, interferes with patient safety, and deters early detection of complications in patients (Blegen et al., 2008).
Staffing levels in the nursing manpower are usually measured using the nurse-patient ratio, nursing hours per patient, nurses’ skill mix (number of nurses of different grades), educational qualifications and practice experience in years. Studies carried out in the USA indicate that a high nurse-patient ratio is associated with increased mortality and failed rescue rates (Chau et al., 2015). Also, increasing the number of nurses and the number of hours a nurse attends to a patient is associated with shorter hospital stays (Chau et al., 2015). It has been noted that increased time of care by nurses lead to reduced occurrences of urinary tract infections (UTI), pressure ulcers, bloodstream infections (catheter associated), and upper gastrointestinal bleeding. Facilities that are associated with rich nurse staffing (proper quality and adequate quantity of the workforce) have a lower-failure-to rescue rate, lower mortality rates, and reduced hospital stays among inpatient clients.
According to Hairr et al. (2014), positive patient outcomes are not the only benefits of enriching the nursing workforce. Additional benefits of adequate nurses in a health care facility include improved job satisfaction and high retention rates. Nurses who work in environments that have staff shortages and high workloads tend to leave their positions. The high turnover of nurses has therefore become a fiscal challenge for many health care systems due to recruitment and retraining costs. Medical organizations can achieve savings of up to $140, 000 annually by retaining one nurse and implementing the recommended nurse-patient ratio of 1:4 (Hairr et al., 2014). These findings indicate that the cost challenges cited by most medical facilities in regards to increases the number of nurses are unreasonable. There is a tremendous potential for healthcare facilities to make financial savings as well as improve service delivery by implementing the evidence-based recommendation maintaining a 4:1 patient to nurse ratio and reducing the turnover of nurses.
References
Blegen, M. A., Vaughn, T., & Vojir, C. P. (2008). Nurse staffing levels: impact of organizational characteristics and registered nurse supply. Health services research, 43(1 Pt 1), 154-173.
Abstract
Objective: To assess the impact of nurse supply in the geographic areas surrounding
hospitals on staffing levels in hospital units, while taking into account other factors that
influence nurse staffing.
Data Sources: Data regarding 279 patient care units, in 47 randomly selected community hospitals located in 11 clusters in the United States, were obtained directly from
the hospitals from the U.S. Census report, National Council of State Boards of Nursing,
and The Centers for Medicare and Medicaid Services.
Study Design: Cross-sectional analyses with linear mixed modeling to control for
nesting of units in hospitals were conducted. For each patient care unit, the hours of care
per patient day from registered nurses (RNs), LPNs, nursing assistants, and the skill-mix
levels were calculated. These measures of staffing were then regressed on type of unit
(intensive care, medical/surgical, telemetry/stepdown), unit size, hospital complexity,
and RN supply.
Principal Findings: RN hours per patient day and RN skill mix were positively
related to intensity of patient care, hospital complexity, and the supply of RNs in the
geographic area surrounding the hospital. LPN hours, and licensed skill mix were
predicted less reliably but appear to be used as substitutes for RNs. Overtime hours
increased in areas with a lower RN supply. Vacancy and turnover rates and the use of
contract nurses were not affected by nurse supply.
Conclusions: This study is the first to show that hospital RN staffing levels on both
intensive care and nonintensive care units decrease as the supply of RNs in the sur-
rounding geographic area decreases. We also show that LPN hours rise in areas where
RN supply is lower. Further research to describe the quality of hospital care in relation to
the supply of nurses in the area is needed.
Bradley, S., Kamwendo, F., Chipeta, E., Chimwaza, W., de Pinho, H., & McAuliffe, E. (2015). Too few staff, too many patients: a qualitative study of the impact on obstetric care providers and on quality of care in Malawi. BMC pregnancy and childbirth, 15(1), 1.
Abstract
Background: Shortages of staff have a significant and negative impact on maternal outcomes in low-income countries, but the impact on obstetric care providers in these contexts is less well documented. Despite the government of Malawi’s efforts to increase the number of human resources for health, maternal mortality rates remain persistently high. Health workers’ perceptions of insufficient staff or time to carry out their work can predict key variables concerning motivation and attrition, while the resulting sub-standard care and poor attitudes towards women dissuade women from facility-based delivery. Understanding the situation from the health worker perspective can inform policy options that may contribute to a better working environment for staff and improved quality of care for Malawi’s women.
Methods: A qualitative research design, using critical incident interviews, was used to generate a deep and textured understanding of participants’ experiences. Eligible participants had performed at least one of the emergency obstetric care signal functions a in the previous three months and had experienced a demotivating critical incident within the same timeframe. Data were analysed using NVivo software.
Results: Eighty-four interviews were conducted. Concerns about staff shortages and workload were key factors for over 40% of staff who stated their intention to leave their current post and for nearly two-thirds of the remaining health workers who were interviewed. The main themes emerging were: too few staff, too many patients; lack of clinical officers/doctors; inadequate obstetric skills; undermining performance and professionalism; and physical and psychological consequences for staff. Underlying factors were inflexible scheduling and staff allocations that made it impossible to deliver quality care.
Conclusion: This study revealed the difficult circumstances under which maternity staff are operating and the professional and emotional toll this exacts. Systems failures and inadequate human resource management are key contributors to the gaps in provision of obstetric care and need to be addressed. Thoughtful strategies that match supply to demand, coupled with targeted efforts to support health workers, are necessary to mitigate the effects of working in this context and to improve the quality of obstetric care for women in Malawi.
Chau, J. P., Lo, S. H., Choi, K. C., Chan, E. L., McHugh, M. D., Tong, D. W., & Lee, D. T. (2015). A longitudinal examination of the association between nurse staffing levels, the practice environment and nurse-sensitive patient outcomes in hospitals. BMC health services research, 15(1), 1.
Abstract
Background: The level of patient safety and outcomes accomplished depends on the quality of care provided. Previous studies found that nurse-to-patient ratio, practice environment, and nursing education were significant predictors of patient outcomes. However, the outcomes measured in previous studies were mainly inpatient mortality and failure-to-rescue rates. Few nurse-sensitive patient outcomes have been measured that quantify nurses’ contribution to patient care. Selecting appropriate outcomes that reflect the clinically relevant effect of nursing care is important. Moreover previous studies were largely cross-sectional and retrospective. These research designs are limited in their ability to explain the casual links between the variables examined. This study is aimed at determining the associations among staffing levels, skill mix of baccalaureate-prepared registered nurses, and practice environment on nurse-sensitive outcomes for medical and surgical patients in public hospitals in Hong Kong.
Method/designs: A multi-method research design will be adopted. The sample includes all medical and surgical wards of four major public hospitals that offer 24-h accident and emergency services. Multiple responses from registered nurses who work in the study wards will be collected over 12 months to examine their individual characteristics and perceptions of the practice environment. A 12-month prospective observational study will be performed to determine the association between nurse staffing levels, the practice environment, and nurse-sensitive patient outcomes including pressure ulcers, falls and restraint prevalence, urinary catheter-associated urinary tract infections, and central line catheter-associated bloodstream infections. Multilevel Cox proportional hazards models will be employed to examine the association between these patient outcomes and the explanatory nursing factors of primary interest (nurse staffing levels, education composition, and practice environment), with adjustment for all patient-, ward- and hospital-level potential confounders (age, sex, diagnosis, comorbidities, level of surgical invasiveness, mortality, length of stay, and type of admission).
Discussion: It is anticipated that knowledge of the association between nurse staffing levels, the practice environment, and nurse-sensitive outcomes will inform the provision of quality and timely patient care. This study will provide a landmark report that is of relevance and importance to patients and to hospital stakeholders and managers, health policy makers, nurses, and educators who advocate patient benefits.
Grumbach, K., Ash, M., Seago, J. A., Spetz, J., & Coffman, J. (2001). Measuring shortages of hospital nurses: How do you know a hospital with a nursing shortage when you see one?. Medical Care Research and Review, 58(4), 387-403.
Abstract
Lack of clarity in definitions of shortages of hospital registered nurses may cause problems for effective policy making, particularly if different measures for identifying a nurse shortage lead to different conclusions about which hospitals and regions are experiencing a shortage. The authors compared different methods of identifying hospitals and regions with a shortage of registered nurses, including both relatively subjective measures (e.g., a hospital administrator’s report of a nurse shortage) and more objective measures (e.g., number of registered nurses per inpatient year). Associations were strongest between self-reported shortage status and nursing vacancy rates and weaker for self-reported shortage status and registered nurses per inpatient year and overall regional supply of nurses. Different definitions of nursing shortage are not equally reliable in discriminating between hospitals and regions with and without nursing shortages. When faced with reports sounding an alarm about a hospital nursing shortage, policy makers should carefully consider the definition of shortage being used
Hairr, D. C., Salisbury, H., Johannsson, M., & Redfern-Vance, N. (2014). Nurse staffing and the relationship to job satisfaction and retention. Nursing Economics, 32(3), 142.
Abstract
The purpose of this quantitative, correlational research study was to examine the relationships between nurse staffing, job satisfaction, and nurse retention in an acute care hospital environment. Results indicated a moderately strong, inverse relationship between job satisfaction and nurse retention. A weak positive relationship between job satisfaction and nurse staffing was identified. Nurses reported experiencing job dissatisfaction in the past 6months specifically related to the number of patients assigned. Analysis suggested nurses are staying with their current employer because of the current economic environment. Improving nurse staffing will be necessary when the economy improves to prevent the departure of discontented nurses from acute care facilities.
North, N., Leung, W., Ashton, T., Rasmussen, E., Hughes, F., & Finlayson, M. (2013). Nurse turnover in New Zealand: costs and relationships with staffing practises and patient outcomes. Journal of nursing management, 21(3), 419-428.
Abstract
Aims: To determine the rates and costs of nurse turnover, the relationships with
staffing practises, and the impacts on outcomes for nurses and patients.
Background: In the context of nursing shortages, information on the rates and costs
of nursing turnover can improve nursing staff management and quality of care.
Methods: Quantitative and qualitative data were collected prospectively for
12 months. A re-analysis of these data used descriptive statistics and correlational
analysis techniques.
Results: The cost per registered nurse turnover represents half an average salary.
The highest costs were related to temporary cover, followed by productivity loss.
Both are associated with adverse patient events. Flexible management of nursing
resources (staffing below budgeted levels and reliance on temporary cover), and a
reliance on new graduates and international recruitment to replace nurses who left,
contributed to turnover and costs.
Conclusions: Nurse turnover is embedded in staffing levels and practises, with costs
attributable to both. A culture of turnover was found that is inconsistent with
nursing as a knowledge workforce.
Implications for nursing management: Nurse managers did not challenge flexible
staffing practices and high turnover rates. Information on turnover and costs is
needed to develop strategies that retain nurses as knowledge-based workers.
