Nurse staffing levels and patient outcomes in healthcare organizations

Nurse Patient Ratios and Quality of Care

This study reviews the broad level of issues that surround the nurse/patient ratio: a critical shortage of trained and experienced nurses; increased political and fiscal demands from all sectors of society; rising costs internally and externally combined with a rising number of under-insured; and the conundrum of nursing ethics and the ability to foster excellence in care and patient advocacy. We note that there remains an issue about hiring more nurses -- where will these nurses come from if the nursing schools do not increase their recruitment efforts and broaden their curriculum. In addition, we note that the large majority of patients and stakeholders primarily want two things when admitted to a healthcare facility: better paid nurses and more highly-trained professionals who are satisfied with their vocation.

Introduction

Modern nursing is, by necessity, a mixture of complex balance: patient care vs. staffing; procedures vs. patient load; ego and personality vs. patient need; and even fiscal budgeting vs. appropriate care. The contemporary nurse manager has a succession of evolving multiple horizontal priorities that are never-ending. To compound matters, each of these priorities has a significant impact on patient care, both short- and long-term. Healthcare, even in the digital age, is extraordinarily labor intensive. (Fabre, 2005, 180-2).

Background

There is a tangible relationship between the nurse patient ratio -- nurse staffing, patient acuity, and performance within the healthcare organization. This makes logical sense if we think of small hospital with low levels of nursing staff that sometimes have higher rates of patient outcome. It is not as one-dimensional as this suggests, though. Simply adding more nursing staff to the schedule has some benefit, but does not really solve or go to the heart of the issue. Additionally, factors in the equation of nurse-patient ratio need to consider the management style of the individual nurse and the charge nurse, as well as interaction with physicians, specialists, support staff, and patient stakeholders. Trends in the field show that there are several areas in which the issues of leadership, staffing, patient acuity, and budgets converge to become critical "tipping points" in the improvement of patient care (More Nurses, 2012).

Lower levels of nurse staffing are clearly associated with adverse outcomes -- There is a direct relationship between understaffed organization and an increase in adverse outcomes. In almost every case the reason for the staffing situation was budgetary -- there simply were not enough bodies to handle the patient load. Adding staff as appropriate, however, results in an up to 25% decrease in adverse reactions. Thus, it is not productive for the hospital to save money in one area (short-term employee hours) and pay it out, usually at a higher rate, in other areas (adverse outcomes, reduction in market share, insurance claims) (Unruh, 2003).

Objectives

Research shows that patients continue to have higher acuity in most developed countries, but skill levels for medical personnel have declined in the past decade. The objectives of this paper are to understand some of the reasons for these trends:

The shortage of highly trained, RN level, nurses often results in wards using a single nurse manager to handle a large patient load without adequate staff. How prevalent is this and what are some solutions?

Discussion of the role of job satisfaction on nurses and patient acuity. This is a vicious circle - the fewer staff the harder those remaining work, yet the harder they work, the more dissatisfied with quality of care and their own internal ethics and values.

The issue of nurse/patient ratio is but the tip of the iceberg regarding the needs of the modern professional nurse. Nursing school curriculum, advanced training, and a rethinking of philosophies and job descriptions is also necessary in order to put the right person in the right position to handle patients for the best possible outcome (Aiken, et.al., 2001).

Rationale

Patient acuity is up, in many cases dramatically due to a combination of demographics (aging population living longer) and cultural related expectations. Costs for hospitals have also increased, especially for staff, and cutbacks occur. This combination increases the individual nurse manager's role within the department, and their ability to perform adequately given the constraints imposed upon them (Stanton, 2005). Cross-sectional studies continue to show that there is an association between lower levels of RN staffing and patient mortality; association because one cannot link direct causation but only statistical probability. Nevertheless, mortality is but one issue: studies show increase complications after surgery, heart attacks, and even some hospital acquired infections in areas of low nurse/patio ratios (Needleman, et.al., 2011).

Literature Review

We know there is a shortage of trained nurses and sometimes even physicians; we know that there are rising costs both internally and externally for healthcare organizations; and we know that a great number of Americans are under insured, or not insured at all. In fact, the issue is so complex that it has become a public health issue that affects the nation. The Nursing supply Model contains three major components: 1) modeling new graduates from nursing programs, 2) modeling location and the employment patterns on a national base, and 3) modeling separations from the nurse workforce. As noted, the trends in demographics combined with economic issues tend to exacerbate the nursing shortages; resulting in a situation in which there is a supply problem from schools because of various economic issues that dominoes into a demand problem for healthcare institutions (Glazer & Alexandre, 2009).

Partnerships between schools of nursing and healthcare agencies are critical for providing nursing students with the opportunity to build upon a sound clinical care basis. In addition, working closely with healthcare organizations can help schools tailor the curriculum to what is needed within the nursing field. Healthcare in the 21st century is extremely labor intensive, even with the advent of more and more technological solutions (Delunas & Rooda, 2009). However, it is not just increases in funding and synergism with healthcare institutions that may solve the situation. For nursing to be effective, it is not just quantity, but quality and new ability (Glazer & Alexandre). There is a very real and quantitative relationship between nurse staffing, patient acuity, and performance within a healthcare system. Certainly, it makes sense that hospitals with low levels of nurse staff have higher rates of poor patient outcomes. However, it is not easy, with modern budgets and fiscal demands to simply add more staff -- rather like adding a Band-Aid to a serious injury -- there is some benefit, but it doesn't solve the issue. (Dickson & Flynn, 2008, p. 311).

Conclusions

Patients, politicians, and community leaders are almost unanimous in their desire for more highly trained and satisfied nurses within the healthcare system (Fitzgerald, 2001). The data is quite clear, the lower the level of qualified nurse staffing, the more there associated negative consequences for the patient -- a direct relationship between understaffed organization and an increase in adverse outcomes. In almost every case the reason for the staffing situation was budgetary -- there simply were not enough bodies to handle the patient load. Patient satisfaction studies, in fact, are higher in hospitals in which RNs have better working conditions and nurse/patient ratios (Kutney-Lee, et.al., 2009). Adding staff as appropriate, however, results in an up to 25% decrease in adverse reactions. Thus, it is not productive for the hospital to save money in one area (short-term employee hours) and pay it out, usually at a higher rate, in other areas (adverse outcomes, reduction in market share, insurance claims) (Unruh).

In many cases, there are nurses, but not enough RN or those with Advanced Practice Certification, which sometimes results in a ward using a single nurse manager to handle a large patient load with understaffed and minimally qualified individuals. Job dissatisfaction plays a heavy role in this, and yet is a vicious circle -- the fewer staff the harder those remaining work, yet the harder they work, the more dissatisfied with quality of care and their own internal ethics and values (Moore and Waters, 2012). In fact, three decades of data show us that the lower the staffing level of qualified nurses, the more there are potential issues for a decline in patient care -- thus, a direct relationship between understaffed organization and an increase in adverse outcomes. Healthcare managers need to see the human resource paradigm of staffing as an investment in their organization; a way to increase patient satisfaction, care levels, and most certainly to improve the image of the organization within the community. In tandem, then, greater respect for nurses will not only increase their job satisfaction, but may draw more qualified candidates into the field (Ekmekci & Turley, 2008).