Safe Staffing Levels
Where there is little disagreement is around the relationship between nurse staffing levels and patient outcomes. Nurses are the front line of patient surveillance — monitoring patients’ conditions, detecting problems, ready for rescue. Spread too thinly or lacking the appropriate skill set, the nurse is at risk of missing early signs of a problem, or missing the problem altogether.
One recent study found that higher nurse staffing levels, particularly with a greater number of R.N.s in the staffing mix, correlated with a 3-to-12 percent reduction in certain adverse outcomes, including urinary tract infection, pneumonia, shock, and upper gastrointestinal bleeding.
Several studies have examined the relation-ship between nurse staffing levels and the risk of patient complications. One study, examining intensive care unit (ICU) nurse staffing and complications after abdominal aortic surgery, found that patients in hospitals with fewer ICU nurses were more likely to have longer lengths of stay and postoperative complications.
A study of the impact of ICU nurse-to-patient ratios on patients who had undergone hepatectomy (liver excision) found that fewer nurses on the night shift resulted in an increased risk of complications, increased costs to the organization, and longer lengths of stay.
Several other studies have found positive associations between nurse staffing levels and patient outcomes, including lower catheter-related infections of the bloodstream, lower nosocomial infection rates in a pediatric cardiac ICU, and lower rates of decubitus ulcers, complaints and mortality.
And another recent study provides evidence that nurse-to-patient ratios matter. A lower number of deaths were associated with a nurse ratio of one R.N. to six patients versus a ratio of one R.N. to ten patients.
When nurses were asked to report their perceptions of the staffing levels in their hospitals, only 34 percent said they had enough R.N.s to provide quality care; and still fewer, 33 percent, had enough staff to get their work done. Of these nurses, 83 percent had experienced an increase in the number of patients assigned to them.
Not surprisingly, nurses have also reported dissatisfaction with the outcomes of their work and have real concerns about the risks to patients: only 36 percent describe the quality of care in their hospital as excellent; while 45 percent report that the quality of care has deteriorated in the last year; and 49 percent report receiving frequent complaints from patients and families.
Insufficient staffing not only adversely impacts health care quality and patient safety, it also compromises the safety of nurses themselves. The risk of having a needle stick injury is two-to-three times higher for nurses in hospitals with low staffing levels and/or poor working climates.
Current mandated ratios, related legislative proposals, and other nurse staffing initiatives are aimed primarily at adding to the supply of nurses. However, these efforts do not address other critical issues, such as nurse competency, skill mix in relation to patient acuity, and ancillary staff support.
Because of the mounting evidence of the impact of staffing on health care outcomes, the Joint Commission has recently introduced new standards that will require health care organizations to assess their staffing effectiveness by continually screening for potential issues that can arise from inadequate or ineffective staffing.
These standards, the result of a two-year project that involved a panel of more than 100 experts in nursing and related disciplines, are designed to help health care organizations monitor and assess whether their staffing – both by nurses and by other health care practitioners and technical staff – includes the right numbers of caregivers of the requisite competency and skill mix to provide safe, high quality care.
In assessing nurse staffing effectiveness, the standards require organizations to use data from the use of nursing-sensitive clinical and human resources indicators, such as adverse drug events, patient falls, use of overtime, staff turnover rate, patient and family complaints, and staff injuries on the job.
Organizations are required to select two each of human resources and clinical indicators, half of which must be taken from a list of 21 established indicators in these two areas. Although not mandating specific staffing levels or ratios, the Joint Commission standards do, in essence, require organizations to determine their own staffing ratios based on their own evidence and experience.