The Level of Nurse Staffing: Research Results

Introduction

Nurses constitute the largest group of clinical personnel who interact with patients and deliver direct care. Therefore, they play an essential role in the quality of care and patient safety. The level of nurse staffing significantly affects patient outcomes. The previous research findings suggest that improved patient-to-nurse staffing ratios are correlated with the decreased levels of hospital mortality, hospital-acquired infections, and other adverse events (Cho, Chin, Kim, & Hong, 2016). Consistent with previous research findings, in our study, we argued that better nurse staffing might lead to improved patient outcomes. In the given paper, we will present the data collected throughout the process of research, as well as the results of statistical analysis.

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Setting and Sample

For our research project, we selected the emergency departments (EDs) in three large randomly selected hospitals. The given type of hospital unit meets the goals of the study and allows the investigation of the problems associated with nurse staffing and related to the target patient population. Adults over 60-65 years of age constitute the largest group of ED users (about 40% of the total referrals) (Boltz et al., 2013). The ED is associated with the increasing number of older adults’ admissions because of a high prevalence of chronic illnesses in this patient group and the sensibility of older adults to frequent exacerbations of their health conditions (Boltz et al., 2013).

All nurses in the EDs of the selected settings were asked to participate in the study. We distributed the questionnaires among the staff members. They completed the surveys in private and then put them in the boxes placed in every unit.

The questionnaires were distributed among a total of 47 nurses, and 41 of them were returned. The surveys included the questions about nurse characteristics: job experience, education level, gender, age, and so on. The demographic information about nurse participants is summarized in Table 1. The average age of the participated RNs is 31, with a mean of 5.1 years of work experience. The majority of the interviewed nurses were female (n = 38). 79% of participants had a bachelor’s degree or higher degree in nursing science (n = 32). Additionally, we asked nurses to provide information regarding the last shift they worked: day shift prevailed among all other most recent work hours (n = 26).

Table 1. Nurse Characteristics.

Variables Mean
Age (years) 31
Years worked as a RN 5.1
Gender
Male
Female
3
38
Education level
Three years of college
Bachelor of Science in Nursing or higher
9
32
Last shift worked
Day shift
Evening shift
Night shift
26
10
5

The questionnaires were also distributed among all elderly patients in the selected hospitals, and 540 completed surveys were returned. The average age of patients was 62.1 years. The percentage of female patients was higher – 52% (n = 280).

Table 2. Patient Characteristics.

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Variables Mean
Age (years) 62.1
Gender
Male
Female
260
280

Lastly, data on hospital characteristics were obtained through questionnaires distributed among nurse participants. We focused primarily on the criteria of staffing level, overall work environment, and adverse events. The data is presented in Table 3. The estimated average nurse-to-patient ratio is 1-to-14. 54% of the respondents (n = 22) reported that they work in mixed practice environments combining both positive and negative aspects. The work environment was measured using the PES-NWI. The given tool is recognized as a validated measure for the examination of such environmental factors as managers’ support, RNs’ involvement in hospital affairs and decision making, doctor-nurse relationships, and the overall performance quality (Aiken et al., 2012). When speaking of adverse events, 8 study participants reported the administration of wrong medication dose to patients at least one time per month. Additionally, 21 nurses reported patient injuries to occur once or several times a year.

Table 3. Setting Characteristics.

Variables N
Nurse-to-patient ratio 14
Work environment
Poor
Mixed
Better
12
22
7
Adverse events
Wrong medication dose
Never
A few times a year
One or a few times a month
Every week
Every day
Patient injuries
Never
A few times a year
One or a few times a month
Every week
Every day
15
17
8
1
0

9
21
9
2
0

Personal Interviews: Measures

Along with surveys, we conducted personal interviews with every study participant. We inquired respondents about their perceptions of nursing staffing in the settings of their placement and asked them to provide the evaluation of hospital environments, as well as the observed patient outcomes.

After the records had been transcribed and the participants’ replies were categorized, we ran a few statistical analyses. A logistic regression approach was applied to investigate the links between staffing and measured patient outcomes. In this test, we used nurse-assessed measures, hospital characteristics as covariate variables. To analyze patient satisfaction, we used such variables as patients’ demographics, settings’ characteristics, and nurses’ skills. To administer the data analysis, we used Statistical Package for the Social Sciences, version 17.0. In our statistical model, a p-value <.05 was regarded as statistically significant.

Hospital Environment

Boltz et al. (2013) state that physical, social, and care environments of the settings cause reinforcing consequences for older patients’ conditions and, therefore, older person-hospital environment fit (i.e., the interplay of specific patients’ needs and interests with organizational climate, norms, and processes) is core to positive treatment outcomes. We asked patients to describe the setting environments. 131 respondents perceived their hospital environment as elderly-friendly, 34 patients tended to perceive it as poorly developed and unwelcome, while other 355 respondents described it as moderately friendly, combining both positive and negative aspects.

Patient Neglect and Communication

According to Reader and Gillespie (2013), high workloads and low levels of nurse staffing are the major proximal causes of patient neglect. We asked patient respondents about their experience of neglect by nursing staff during the stay at the ED. 103 of interviewed patients reported high levels of neglect, while 383 said that nurses were sufficiently attentive, and 54 – very attentive and responsive. At the same time, 136 patient respondents reported a decreased level of satisfaction in the area of nurse-patient communication. 20 nurses claimed that they do not have sufficient time to communicate with patients about medication and treatment procedures due to increased workloads.

Patient Outcomes

Researchers suggest that there are causal links between hospital mortality rates and staffing, and, moreover, the relationships between these two variables may be mediated by such environmental factors as RNs’ burnout, perceived support, a job satisfaction (Shekelle, 2013). During the interviews, we discussed with the nurses the issues of patient surveillance. Only 19 RNs reported adequate patient monitoring. 8 nurses claimed that they frequently do not have sufficient time for pain management, and 3 respondents were informed about the frequent cases of undone procedures due to limited time.

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Table 4. Effects of Nurse Staffing on Patient Outcomes (Nurse Assessed Quality Measures).

Nurse Staffing in the Emergency Units
N <0.4 0.4-<0.5 0.5-<0.6
Assessed quality of care (n = 41)
Adequate patient surveillance
Pain management
Treatment
22
8
3
1.20
1.31
1.45
1.03
1.14
1.12
0.79
1.16
1.20
Patient adverse events
Wrong medication dose
Hospital-acquired infections
1
2
1.21
1.53
1.64
1.53
1.13
1.21
Patient satisfaction (n = 540)
Dissatisfied with communication
Dissatisfied with responsiveness
20
3
1.87
2.04
2.21
1.67
1.45
0.73

The data represents odds ratios showing risks related to changes in staffing level (nurse-to-patient ratio =/> 0.6 was a referent category). “N” indicates the number of nurses who failed to perform a specific nursing activity due to the lack of time.

Strengths and Limitations

One of the major strengths of the study is the high rate of participants’ responses. Secondly, the applied sampling technique, as well as a large sample size, is associated with significant benefits as it allows the in-depth investigation of the issue, a high level of data representativeness, and generalization. However, when interpreting the results, one should consider that self-reports and interviews, which we used as the main data collection tools, are, to a large extent, subjective. In order to reduce risks of biasing and misinterpretation, further studies of objective data sources (e.g., clinical records and statistics) can be recommended. Lastly, to achieve a more profound understanding of the relations between staffing and patient outcomes, we will need to assess such RN’s characteristics as burnout, the level of perceived work-related stress, and so on. This information may be important in the investigation of confounding effects of hospital staffing.

References

Aiken, L. H., Sermeus, W., Heede, K. V., Sloane, D. M., Busse, R., Mckee, M.,… Kutney-Lee, A. (2012). Patient safety, satisfaction, and quality of hospital care: Cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ, 344(March). Web.

Boltz, M., Parke, B., Shuluk, J., Capezuti, E., Galvin, J. E. (2013). Care of the older adult in the emergency department: Nurses views of the pressing issues. Gerontologist, 53(3), 441-453. Web.

Cho, E., Chin, D. L., Kim, S., & Hong, O. (2016). The relationships of nurse staffing level and work environment with patient adverse events. Journal of Nursing Scholarship, 48(1), 74-82. Web.

Reader, T. W., & Gillespie, A. (2013). Patient neglect in healthcare institutions: A systematic review and conceptual model. BMC Health Services Research, 13(1). Web.

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Shekelle, P. G. (2013). Effect of nurse-to-patient staffing ratios on patient morbidity and mortality. In Agency for Healthcare Research and Quality (Ed.), Making health care safer II: An updated critical analysis of the evidence for patient safety practices (pp. 372-385). Rockville, MD: Agency for Healthcare Research and Quality (US).

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