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Key Findings From Research Studies on Safe Nurse Staffing

Safe Staffing Impacts Patient Safety and Quality of Care

• Evidence suggests that improving nurse work environments in hospitals could result in improved patient outcomes, including better patient experiences and higher satisfaction ratings. Patient-to-nurse ratios in hospitals does affect patient satisfaction ratings and recommendation of the hospital to others.

Kutney-Lee, A, McHugh, M.D., Sloane, D.M., Cimiotti, J.P., Flynn, L., Felber Neff, D., and Aiken, L.H. (2009). Nursing: A Key to Patient Satisfaction. Health Affairs 28 (4), 669-677.

• Consistent evidence from observational studies suggests that an increase in Registered Nurse (RN) to patient ratios was associated with a reduction in hospital-related mortality, failure to rescue, and other nurse-sensitive outcomes, as well as reduced length of stay. An increase in total nurse hours per patient day was associated with reduced hospital mortality, failure to rescue, and other adverse events.

Kane, R.L., Shamliyan, T., Mueller, C., Duval, S., and Wilt, T.J. (2007). Nurse Staffing and Quality of Patient Care. Agency for Healthcare Research and Quality. AHRQ Publication 07-E005.

• Research suggests that improved registered nurse staffing has a beneficial effect on patient outcomes. Conversely, research shows that the likelihood of both overall patient mortality (i.e., in-hospital death) and mortality following a complication (failure to rescue) increases by 7% for each additional patient added to the average registered nurse workload.

 Aiken, L.H., Clark S.P., Sloan D.M., Sochalski J.& Silber J.H. (2002).     Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction. Journal of the American Medical Association, 288(16), 1987-93.

• Evidence shows that both a higher proportion of RNs in the nurse staffing mix and more RN hours per patient day are associated with decreased length of stay. Authors found that fewer nurses per patient resulted in greater rates of urinary tract infections, upper gastrointestinal bleeding, pneumonia, and cardiac arrest.

  Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinsky, K.(2002). Nurse Staffing Levels and the Quality of Care in Hospitals. New England Journal of Medicine, 346(22), 1715-22.

• Results from a sample of Pennsylvania hospitals indicates that increased nurse staffing is associated with reductions in atelectasis (lung collapse), decubitus ulcers, falls, and urinary tract infections.

  Unruh, L. (2003). Licensed Nurse Staffing and Adverse Events in Hospitals. Medical Care, 41(1), 142-52.

• Savings from shortened length of stay improve the cost-effectiveness of increased staffing, although the savings only offset half of the increased labor costs. Savings resulting from decreased length of stay would largely accrue to payers, such as health insurers, while hospitals would incur the costs of additional staffing.

  Rothberg, M.B., Abraham, I., Lindenauer, P.K.& Rose, D.N. (2005). Improving Nurse to Patient Staffing Ratios as a Cost Effective Safety Intervention. Medical Care, 43(8), 785-91.

Safe Staffing and Medical Errors

• Hospital nurses reporting higher workloads in a survey were more likely to report more frequent medical errors and patient falls occurring in their units over the previous year.

  Sochalski, J. (2004). Is More Better? The Relationship Between Hospital Staffing and the Quality of Nursing Care in Hospitals. Medical Care, 42(2 Suppl.) 1167-73.

•  The number of hours worked by RNs is an important factor in the rate of medical errors. Odds of making an error during a shift of 12.5 hours or longer is over three times as great as during a shift of 8.5 hours or less.

  Rogers, A.E., Hwang, W., Scott, L.D., Aiken, L.H., Dinges, D.F. (2004). The Working Hours of Hospital Staff Nurses and Patient Safety. Health Affairs, 23(4), 202-12.

• The Institute of Medicine, in a study of the nursing work environment, recommends that the length of nursing shifts be limited to 12 hours in any 24 hour period, whether mandatory or voluntary.

  Institute of Medicine (2004) Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, D.C., National Academies Press, p.237.

Safe Staffing Affects the Retention of Experienced RNs

• Patient workload is one of the working conditions that affect the job satisfaction of RNs. Researchers found that 43% of surveyed RNs had high scores on burnout measures, and that 41% reported they were dissatisfied with their jobs. These negative feelings foreshadowed a retention problem: Almost 23% of the nurses surveyed reported they were planning to quit their current jobs within the next year.

  Aiken, L.H., Clarke, S.P., Sochalski, J., Busse, R., Clarke, H., Giovannetti, P., Hunt, J., Rafferty, A., & Shamian, J. (2001). Nurses’ Report on Hospital Care in Five Countries. Health Affairs, 20(3), 43-53.

• A statistically significant relationship exists between lower nurse-to-patient ratios and higher levels of reported dissatisfaction and burnout among RNs.

  Aiken, L.H., Clark S.P., Sloan D.M., Sochalski J.& Silber J.H.(2002). Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction. Journal of the American Medical Association, 288(16), 1987-93.

• Preliminary evidence indicates a link between mandatory staffing plan legislation and the most positive nurse work environment perceptions among RNs when compared with either the implementation of mandatory staffing ratios or with no workforce regulation. These results are based on a study examining the variations in work environment perceptions of 4,000 RNs in 10 states.

  Cox, K.S., Anderson, S.C., Teasley, S.L., Sexton, K.A., & Carroll, C.A. (2005). Nurses’ Work Environment Perceptions When Employed in States With and Without Mandatory Staffing Ratios and/or Mandatory Staffing Plans. Policy, Politics, & Nursing Practice, 6(3), 191-197.