Impact of nurse staffing levels on patient outcomes and mortality

Staffing in Nursing

Staffing and Other Nursing Issues

The main topic of this paper is staffing related to the field of nursing, here it is very important to realize a correct balance between the demand of nurses and available nurses at any medical facility. Since the duty of any medical professional like a doctor requires much assistance from a subordinate such as nurse therefore it is vital for any organization to fulfill this requirement in a way that best suits all parties involved especially the patients. This paper will focus on many different aspects related to the issues of staffing and will also shed some light on some of the difficulties of keeping a low or high number of required nurses.

The emphasis here would also be on many different aspects related to staffing such as the economical perspective, the quality perspective of any medical organization and so on. The paper is divided into three main sections, in the first section the focus would be given on introduction as well as some of the negative aspects of patient outcomes or care due to insufficient nurse staffing, this would also look at the losses that the medical organization may suffer from because of these mentioned aspects. The second section will identify much of the positive aspects related to the outcomes with sufficient nurse staffing, this may include some of the benefits as well which the medical organization could attain if it maintains the appropriate level of nursing standards in itself.

Finally, the third section will address the Californian law related to patient or nurse ratio alongside the conclusion page which will summarize all of the information that we have discussed in the paper and would also give the reader an idea regarding the overall importance safety of patients in the field of healthcare.

1.2 Negative aspects related to irregular staffing and other facts

Hospitals currently in the United States are under extreme pressure to control the overall cost of its medical care while improving patient health outcomes at the same time especially with respect to a proper reduction in medical errors that might be damaging for some cases or even fatal for others. These and many more concerns including irregular staffing are on the agenda of the top decision makers of hospitals. Intuitively, anyone would expect that a higher ratio of nurses associated with patients could lead towards better patient outcomes and if this is correct then various patient benefits must be deemed as an important consideration in the overall determination of levels of nurse staffing.

It is ideal for hospitals to make their decisions regarding nurse staffing guided by proper empirical evidence, here different studies have properly examined this issue and by analyzing some of the data from more than one hundred and fifty hospitals in the state of Pennsylvania, it was determined that a cross-sectional variation related to nurse staffing levels is correlated negatively with the patient morality, this is measured as risk adjusted thirty day failure and mortality to the rescue rates.

Another analysis of different sorts of administrative data from more than seven hundred and fifty hospitals in eleven states that took over an year span concluded in finding out higher levels of staffing of nurses being directly associated with lower than average failure to rescue rates, this analysis also reported better patient outcomes alongside a variety of different specific facts such as reduction in upper gastrointestinal bleeding, rates related to urinary tract infection, cardiac arrest, pneumonia and shock cases at hospitals.

The regression analysis in the above mentioned cases gave important evidence related to cross-sectional correlations, but there are still some concerns that remain about casual relationships in all of these mentioned cases. With regard to this, there are many potential problems, two of which are as follows. The first is related to a specific type of omitted variable bias. "There is a relative amount of variation across various hospitals at the level of resources which are devoted to patient care" (Cimiotti, 2012).

The mentioned variation exists at primarily the nurse staffing but it is also found at different other aspects such as the quality and quantity of medical equipment, the proper adoption of educational efforts in order to keep the current medical staff on best practices, the efficiency related to the management practices and so on. The cross-sectional regression analysis attempts to take control of the mentioned factors but the researches in this regard have a very limited set of covariates in the beginning to work with. Therefore it is easy to assume that those hospitals which possess a relatively higher level of nursing staff also have above average level of various different positive and negative factors that are associated with patient care. Cross-sectional regression analysis tends to state the effect of high patient or nurse ratio on the health outcomes of patients.

Second problem is related with endogenous sorting. Generally it is expected that medical providers would devote relatively high resources towards patients who are statistically much more likely to show the highest effect for that attention, this includes those patients as well who are at much greater risk with regards to the adverse outcomes. Example here includes the expectation of high mortality rates on those medical units which have high nurse or patient ratios.

A researcher could attempt to take control over the severity of the medical conditions of patients but this practice is extremely difficult to do considering what is available as data. Here, the researchers would usually underestimate the vital beneficial impact related to higher nurse-to-patient ratios at the patient outcomes. Concerns somewhat related to these belong to the evaluations which are based upon hospital-level paned data, therefore the hospitals which experience improved and better nurse staffing levels may well be increasing their resources alongside other factors which are unobserved. Converse to this, those hospitals which increase their levels of nurse staffing may well be doing that because of an increase in the levels of their patient's general acuity levels which might also show signs of improvement in the overall health of patients.

An appropriate response towards these mentioned concerns is for researchers to do a search for shifts to nurse staffing that are exogenous and then use that variation for the exploration of the affect on patient outcomes. Though true exogenous variation might not be available for this procedure but there are various other ways to figure out the so called natural experiments for the purpose of generating plausibly exogenous changes at the nurse-per-patient ratios.

A good example here is related to the identification strategy, which is used to utilize natural variation that occurs at hospital admissions, this in turn create variations at patient loads. Using this approach, it is found out that those patients who are admitted when their patient load is high have a greater mortality, but effects are calculated to be relatively small and therefore are not significant statistically in different specifications.

It is acknowledged that the mentioned interpretation is very difficult since it has no independent data which deals on how hospitals might deal with situations where a sudden influx of patients occurs, therefore if the hospitals respond by providing overtime shifts to its nursing staff then the ratio of nurse to patient might not change much in case where there is any sort of surge in the hospital for admissions.

This paper will also provide an analysis which exploits a sort of exogenous shock for the nurse staffing so that the relationship between patient outcomes and nurse staffing is studied in more detail, here the California Assembly bill 394 will also be analyzed which mandated the optimum amount of patients per nurse at any given hospital setting. When this law was passed, some of the hospitals had the appropriate staffing figures as related to nursing whereas others did not have their nurse staffing according to the mandated standards proposed by the bill. Therefore changes in staffing ratios at the hospitals from pre-mandate to post mandate time is partially because of this legislation.

Here are some of the other facts associated with nurse to patient ratios, according to federal law the nurse to patient ratio at any given health facility should be 1:1 at the main operating room, at intensive care, neonatal intensive care units, critical care, labor and delivery units and at post-anesthesia recovery departments it should be 1:2, at general medical-surgical units it should be 1:5. The main factor which makes the law hard and controversial to implement for hospitals is that it requires those facilities to be in a state of continuous compliance with the ratios.

This means that the amount of patients designated to each nurse must not exceed the ratio during any given time interval of the nurse' duty or any of its shift. This also means that if the nurse has to take a break for the restroom then even in that scenario it has to reassign its patient to any other nurse available on duty at that time. Since the year 2004, eleven states which are namely Nevada, Maine, Illinois, Connecticut, Oregon, Ohio, New Jersey, Nevada, Washington, Vermont, Texas and Rhode Island alongside District of Columbia have adopted regulations or enacted legislation that addresses nurse staffing although many of them chose less rigid approaches as compared to the California law.

After some five years of the placement of California law, nurses were very optimistic regarding their ratios. According to an analyst, the ratio law was a success and it was commonly witnessed that there was an increment in the total amount of RNs licensed in the state of California after the implementation of the law, also there was a decrement in the rate of turnover because of a gain in patient satisfaction towards the hospital management. The law also improved patient safety greatly as well as saved the lives of many patients, made nurses to be a much stronger advocate for their respective patient and also towards the overall career of nursing.

Hospitals, though are not yet convinced especially since there exists no conclusive evidence regarding if the ratios have really reduced errors or improved care. A study in this regard suggested that if a nurse is to be designated to more than for patients at the same time then the risk of fatality towards the patients goes up by seven percent for every additional patient involved.

This means that if the risk for fatality for every patient goes up seven percent when a single nurse is looking after five patients at the same time then it goes to forty two percent for every patient when that same nurse is looking after ten patients at the same time. This shows the extreme amount of risks involved in the field of nursing and also that if a single nurse is dedicated towards more than its respective share of work then it is bound to do more mistakes than usual and some of these might result as fatal for the patients.

Common mishaps related to the nurses when they are assigned more patients at the same time include giving the wrong medicine to the patient, this sort of action could worsen the condition of the patient greatly and could determine if it will live or die, also the nurses might not be present for the patient in times of emergency when the patient needs help, this could also be a fatal error from the side of nurses and can be easily the cause of death for the patient.

Some other mishaps done by the nurses are as follows, the patient may fall very easily since it requires getting up on its own for restroom and if the nurse is not there for help. "Nurses are commonly known to reply to the patients that they don't want to bother them just so they can avoid their duty of service" (Blegen, 2011).

It is recommended that checking on the patient must be done every hour during daytime and after every two hours during night, If the nurse asks the patient if it wants to go to the restroom or if it makes sure that the television remote or tissues are within the reach of the patient then this simple factor could reduce the amount of patient falls by fifty percent.

This is the reason many of the hospitals have implemented the concept of hourly rounding. According to data some thirty percent decrease was recorded in patient falls inside two months at various different hospitals after the implementation of hourly rounding at the oncology and medical surgical unit. Some hospitals even recorded a sixty five percent decrement in fall rate mainly due to the rounding done by nurses at regular intervals.

Spread of infections is also a vital mishap which could be done on behalf of the nurse who is assigned more duty than what it is supposed to handle, this error is also very common in overcrowded hospitals and were the nurses often don't bother taking proper care of the patients therefore it is regarded as one of the major negative factors which can be associated with shortage of nurses at any given hospital or medical centre.

Here, hand hygiene is very important for the prevention of infectious diseases, as a guideline nurses must disinfect all of the equipment as well as other important items at their disposal in order to ensure that there is no spread of disease. Nurses are also told to wear proper personal protective equipment during surgery or when performing patient care, this practice is even more important to perform when the nurse is operating on a patient who is diagnosed with any fatal virus or disease such as HIV.

There are various different best-practices interventions that can be applied by nurses so that they can reduce the chances of any spread in infection at the hospital, this includes keeping appropriate hand hygiene, usage of chlorhexidine for the purpose of skin preparation and so on.

The nurses should also ensure that full barrier precautions are done and a proper sterile field is maintained at insertion. In order to prevent pneumonia, nurses should always keep the bed's head elevated and do daily oral care by using chlorexidine. According to various clinicians, a better success rate in regards to safety can be achieved if the nurses on duty could identify hazardous elements on the spot and properly address those risks so that they may not infect anyone in its premises.

On their behalf, the nurses should also take more time in assisting their subordinates so that they can properly learn from their experiences, this could greatly benefit the new recruits in the field of nursing and could also help them handle tough situations in a rather easy manner. Nurses should also give guidelines to their apprentices on how to handle more than one patient at the same time and what are the important techniques and tips that may save lives at critical moments. It is commonly found that the gravest of problems arise from the simplest of mistakes on behalf of the nurses or doctors and therefore it is very important for all the medical personnel to be good in their basics and learn to identify the problem early on before it is exaggerated to a certain level.

For nurses, it is very important to be properly dressed, used sterilized equipments, give proper time to their patients, be more helpful not only to their subordinates but to their respective seniors, be vigilant in case of any outbreak, emergency or any other catastrophic event and this is why so much importance is given to them at all levels in the hospital.

3.1 Californian assembly bill

In the year 1999, the legislature in California passed the bill named AB394, this started a procedure according to which the maximum amount of patient-to-nurse ratios were determined for the state's hospitals. When the bill was initially passed, the health department service in California (DHS) spend some two years just holding hearings where various stakeholders related to the field of healthcare industry were invited to make different recommendations which were associated with appropriate nurse staffing levels at hospitals.

As a response towards this invitation, the top nurse unions in the state of California namely the Service Employees International Union and California Nurses Association alongside California Healthcare Association which was a firm that represented many of the hospitals in the state of California proposed various ratios which they thought were appropriate. In addition to all of this, the DHS also presented its own ratios regarding draft nurse staffing but this was done in January of the year 2002. The main idea here was exchange of information regarding different organizations and to know their viewpoint regarding the changes in healthcare industry, also to find out if they agree or disagree to the bill that was previously passed.

In the mid of 2002, DHS made a formal announcement regarding its final standards that was supposed to be implemented in around mid-2003 by the month of July. This mentioned mandate was implemented after many hurdles on the start of year 2004 in the month of January. The hope here was that an increment in the levels of nurse staffing could translate as an overall beneficial factor towards patient outcomes at hospitals all across California.

But some of the nursing unions noted two important concerns regarding the legislation which according to them could have undermined their main objective. The first point was regarding enforcement, since under current guidelines, the department of health and safety was only permitted to have a defined action plan which was to be created by the hospital, this would address any sort of violations that might have occurred in hospital as well as how those deficiencies would be properly rectified but this also assessed any set period of time according to which the main plan had to get implemented.

The second point was that in the overall procedure of accordance with the requirements related to patient-to-nurse ratio, hospitals might had to reduce the employment of its non-nursing personnel, this would enable them to ask their nurses to do tasks that were previously done by those employees. Any such action would greatly reduce the overall effectiveness of the legislation itself in the promotion of better patient outcomes. However, according to various analyses suggested that there were no proper evidence of any sort of casual impact of law at patient safety.

Analysis also suggested that any mandate reducing the nurse or patient ratios on its own doesn't have to lead towards better patient safety. It was found out that the hospitals which are known to be more effective at ensuring patient safety usually find it common to employ more nurses as per patient. Therefore improved nurse staffing may be the key point in improving the overall patient safety but this is only when done in collaboration with various different elements. It is extremely important for policy-makers as well as healthcare providers to properly sort out all of the important issues together.

3.2 Conclusion

This paper mainly focuses on proper staffing related to the field of nursing, for this purpose there have been many examples provided which clearly shows the importance of an appropriate balance between patients and nurses at any given hospital. The first part emphasizes on the negative aspects which could result mainly from keeping low numbers of nurses in a hospital, here different stats also help in explaining the accurate ratio which the hospital must maintain at its various departments. It also discusses some of the incidents or mishaps which might take place because of inadequate staffing or error from the side of nursing while performing their duty.

The second part defines the importance as well as benefits of keeping a good ratio of nurses as compared to patients, it mentions several different facts which are associated with various hospitals that indicate how much can be gained if the management is serious regarding staffing techniques. It also describes various techniques which can be adapted by the management of a hospital in order to ensure that the best is delivered by its staff especially the nurses and the benefits which the hospital could provide to its nurses so they stay dedicated towards their respective field.

The third portion deals with a Californian assembly bill related to healthcare and briefly details in on the impact it has caused in the state of California. It mentions about all the stakeholders who were involved with the field of healthcare and how they acted in response to this bill, besides the usual facts there is also the mention of how this has changed the field of healthcare for good.