Nursing Shortage in Canada Causes and Strategies to Solve Term Paper

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Nursing Staff Levels Affect Patient Mortality

Managing unnecessary variability in patient demand to reduce nursing stress and improve patient safety.

Litvak, E., Buerhaus, P.I., Davidoff, F., Long, M.C., McManus, M.L. & Berwick, D.M.

Date of publication: June 2005

Examination of the operational issues affecting health care delivery, including patient driven peaks in demand and effects of nursing shortages or inadequate staffing on clinical outcomes for patients.

Research question and/or hypothesis:

In this study the researchers propose that increases in adverse clinical outcomes occur when hospital nurse staffing is inadequate. Further the researchers suggest that increases in census rates increase the potential for serious stresses for patients and nurses working in the field. Lastly the researchers suggest that if hospitals reduce unnecessary variability of staff levels in a hospital, the hospital can reduce the probability of negative patient outcomes, improve safety for patients and improve the overall quality of care.

Sample and Sample Size:

In this study the researchers describe analysis of multiple data sets from varying examples but do not give specific details regarding their sample size and the population examined. This weakens the study compared with the other articles reviewed which give specifics related to sample size and selection.

Method of study and research tools used: The researchers employ investigational analysis surveying multiple previous studies which discuss adverse clinical outcomes occurring among patients being treated in facilities where staffing is not sufficient.


The results of the study confirm that all forms of "artificial variation" in demand and supply of nursing staff may lead to adverse outcomes. The study further finds that adverse outcomes are more likely when staffing shortages exist as opposed to when shortages do not exist.


The researchers conclude that pilot programs must be instituted which can test what operational changes will improve quality of patient care and reduce variance in hospital staffing levels as a means to improving patient outcomes. I would rate this article average as it does not provide sufficient details regarding the sample size and population examined.

Title of study: Nurse staffing and mortality for Medicare patients with acute myocardial infarction


Person, SD, Allison, JJ, Kiefe, CI, Weaver, MT, Williams, OD, Centor, RM & Weissman, NW.

Date of study: January 2004

Date of publication: Jan 2004

Aim of study: Assess the relationship that exists between nurse staffing and in hospital mortality with patients suffering from acute myocardial infarction (AMI).

Research Question:

Whether a relationship exists between nurse staffing levels in hospitals and patient mortality specifically from acute myocardial infarction.

Sample and Sample Size:

Data from 118,940 fee for service Medicare patients who were hospitalized for acute myocardial infarctions.

Method of Study and Research Tools:

Reviewed medical data from 1994-1995 Cooperative Cardiovascular project.


Results suggest from highest to lowest quartile of RN staffing hospital mortality rates ranged from 17.8% to 20.1%. Patients treated in environments with higher RN staffing were according to the study less likely to suffer mortality in house with 95% confidence intervals.

Conclusion of Study:

Even with adjustments, the study confirms that higher levels of staffing between RN's are positively correlated with lower mortality and better quality care. The authors suggest that the study results have important implications confirming that staffing levels do affect in hospital mortality rates for certain populations of patients. This study is satisfactory as it provides information regarding a specific population, patients on Medicare and patients suffering a specific adverse outcome. This article is average compared with the others analyzed.

Title of study: Nurse-Staffing Levels and The Quality of Care in Hospitals

Needleman, J. Buerhaus, P., Mattke, S., Stewart, M. & Zelevinsky, K.

Date of study: May 2002

Date of publication: May 30, 2002

Aim of study: The aim of this study is an investigation of nurse staffing levels in order to determine whether lower levels of staffing by nurses specifically at hospitals correlates with increased patient risk of complications or mortality rates.


Lower staff levels of registered nurses at hospitals correlates with increased patient risks and complications including patient mortality.

Sample and sample size: The researchers collected data from 799 hospitals in 11 states from 1997 including more than 5 million medical patients and one million surgical patients.

Method of study and research used:

The researchers examined the relationship between amount of care provided to patients by nurses at hospitals and patient outcomes by examining administrative data supplied from the 799 hospitals surveyed. A regression analysis was conducted with controls for patients' risks of adverse outcomes and differences in nursing care needs.


The results of the study show that the mea number of hours nurses spent with patients per day was roughly 11.4. With medical patients the results show a higher number of hours of care every day. The higher the average hours of care the shorter patients stay in the hospital. Lower rates of mortality are noted among patients with longer hours of care, as well as lower levels of urinary tract infections, cardiac arrest or other heart problems and pneumonia or other complications. With surgical patients the study reveals that a greater number of hours allocated to patient care was directly related to lower rates of patient mortality and adverse outcome, including the incidence of infections like urinary tract infections. The hospital was used as the unit of analysis in both cases with the length of stay, rates of adverse outcomes among patients, hours of care per patients and hours of care based on nursing staff all measures of statistical performance. This study provides the reader with a smaller population size but is very decent as it provides the rough amount of time that nursing staff may need to spend with patients to affect their care in a positive manner.


The researchers conclude that in a large sample of diverse patients an association or correlation does exist between the number of total hours of nursing care offered patients by registered nurses and patient outcomes for medical and surgical patients. Specifically the research found that more hours of patient care resulted in shorter hospital stays and subsequent reduced likelihood of urinary tract infections, GI problems, cardiac arrest, pneumonia and failure to rescue. The authors also conclude that additional research is necessary to refine the data measuring tools used and to determine other factors that may influence care or nursing staff levels. The authors also suggest that systems be developed that enable more routine monitoring to ensure better patient outcomes regardless of the levels of nursing staff available to work directly with patients. This study is superbly done and provides ample information regarding the relationship between staffing levels and patient outcome.

Title of study: Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction.

Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, R.N., Silber, J.H.

Date of study: 2000

Date of publication: 2002

Aim of study: The purpose of this study was to determine what association if any exists between patient to nurse ratios and patient mortality rates, failure to rescue (defined as deaths following complications) specifically among surgical patients. In addition the researchers investigate what factors impact nurse retention.

Research Question:

The researchers hypothesize that worsening hospital nurse shortages and recent legislation mandating minimum hospital patient to nurse ratios demand an understanding of how staffing levels among nurse affect nurse retention and patient outcomes.

Sample and Sample Size:

This study includes a sample of 10,184 staff nurses, 232,342 general, orthopedic and vascular patients discharged from the hospital between 1998 and 1999 as well as administrative data gathered from 168 nonfederal adult general hospitals located in PA.

Method of study and research tools used:

The researchers use a cross sectional analysis of linked data for this study. They use risk adjusted patient mortality and failure to rescue results within 30 days of patients admission to the hospital. A survey is also used to collect information regarding nurse reported instances of job burnout or dissatisfaction.

Results: The results of the study after adjustments for hospital characteristics suggest that every additional patient added to a nurses case load increased their risk of mortality within 30 days of admission by 7% or greater. An increase of 7% in the failure to rescue odds is also reported. With adjustment for nursing and hospital characteristics these ratios raised to 23% and 15% respectively and when associated with an increased risk of nurse burnout or job dissatisfaction.

Conclusion of Study:

The authors conclude that in cases where a high nurse to patient ratio exists the likelihood of patient mortality is greatly increased in the 30 days following surgical procedures, as is the risk for failure to rescue rates. The study also suggests that nurses are more likely to experience burnout and job dissatisfaction when additional patients are added to their already full plates. This study receives a high rating and provides ample evidence that extreme adverse outcomes are associated with inadequate staffing levels.

Title of study: Hospital nurse staffing and patient mortality, emotional exhaustion and job dissatisfaction.

Halm, M., Peterson, M., Kandels, M.,…[continue]

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