Pamela H. Mitchell and Jill K. Mount have written a comprehensive, well-referenced summary of current research, policy, and practice regarding nurse staffing and the effects of staffing on patients, nurses, and organizations. This Summary Report was commissioned by the Nurse Staffing Steering Committee of the William D. Ruckelshaus Center. The goal of the W. D. Ruckelshaus Center, a joint effort of the University of Washington and Washington State University, is to enhance the region’s capacity for effective policy making and sustainable problem solving.

The Executive Summary of the Report follows in this legislative column with a link to the full Report at the Ruckelshaus Center available at http://ruckelshauscenter.wsu.edu. I highly encourage you to read the entire Report because it clearly and succinctly describes what is known and what is not known about nurse staffing, and provides suggestions for future research.

While there is research evidence that fewer patients per nurse, or more direct nursing care hours per patient day is associated with fewer adverse outcomes in hospitals, particularly in surgical patients, the mechanisms of causality for this relationship are not established. Moreover, nurse staffing alone is not a reasonable approximation of workload. Rather working conditions and environments must be considered in assessing workload. Future research at single institutions and across institutions, in single states and across the nation, and in single countries and internationally must be prospective. Common definitions of variables and systematic data collection will be essential in establishing these mechanisms of causality.

A great strength of this report is that it is based on national and international (Australia, Canada, England, Finland, New Zealand, and Scotland) data. As health reform becomes a reality in the United States (US) this year and beyond, information from this report will be helpful in policy discussions both at the state and national levels.

Currently, twenty-two states in the US have either proposed or enacted legislation to regulate nurse staffing by mandating ratios, establishing staffing committees with input from staff nurses, or mandating public posting addressing staffing. We need to assure that any legislation in these states and others is based on fact, and not on emotion or political expediency. “Washington… can contribute by serving as an example to other states as it attempts to work from evidence to problem solve and innovate in an area of nurse staffing” (Mitchell & Mount, 2009, p.31). This Summary Report below is your opportunity to learn from the best.

Nurse Staffing – A Summary of Current Research, Opinion, and Policy

Executive Summary (Mitchell & Mount, 2009).

(NOTE: This report is reprinted with permission from the Ruckelshaus Center)

This paper was commissioned by the Nurse Staffing Steering Committee of the William D. Ruckelshaus Center, which is comprised of representatives of the Northwest Organization of Nurse Executives; SEIU Healthcare 1199 NW; United Staff Nurses, UFCW 141; the Washington State Hospital Association; and the Washington State Nurses Association.

In 2008, these organizations worked collaboratively for the successful passage of the Safe Nurse Staffing Legislation (Substitute House Bill 3123). The new law required each hospital, by September 1, 2008, to establish, where they do not exist, a nurse staffing committee with staff nurses composing at least half of the committee. This committee is charged with the development of unit and shift specific nurse staffing plans based on specific criteria and requires hospitals to post the staffing plan information in the hospital.

Additionally, the parties signed a memorandum of agreement to work together to address issues of nurse staffing and other nursing care issues in relation to implementation of Substitute House Bill 3123. The agreement requires collection of five nurse sensitive quality indicators from Washington hospitals, collection of nurse staffing committee information, modification of the state’s adverse events form to include nurse staffing information, an immediate staffing alert pilot project, and continued dialogue among the participating organizations on nurse staffing issues. The steering committee’s work is facilitated by the William D. Ruckelshaus Center of Washington State University and the University of Washington.

The purpose of this paper is to summarize the various schools of thought in research, policy, and current practice regarding nurse staffing and related issues of patient safety and outcomes, impact on quality of work life for nurses, and impact on hospital management and finances. We present current research, surveyed opinion, and prevailing policy views concerning the issues and approaches to hospital nurse staffing in the United States, and have summarized the applicability of some descriptions of current practices of interest.

The current concerns about the impact of nurse staffing on quality of care and patient safety stem from a convergence of recurring nursing shortages, cost-containment measures in the 1990s, and the upswing of public concerns about patient safety in the wake of the Institute of Medicine’s series on the Quality Chasm.  This literature asks four questions pertinent to this paper:

1. Does staffing matter -- is there a consistent relationship between higher ratios of patients to nurses (or fewer hours of direct nursing care per patient day) and adverse patient outcomes?
2. Do changes to nurse staffing improve patient care outcomes?
3. How does staffing matter -- what might account for this relationship? Are there other organizational and clinical structures or processes that logically link the numbers of nurses and the outcomes of patient?
4. What are the financial implications of various levels of nurse staffing?

Current systematic reviews point to a strong and consistent relationship between nurse staffing and specific adverse events, particularly in intensive care units and with surgical patients. Hospital acquired infections, urinary tract infections, blood stream infections, pneumonia, falls, medication errors, pressure ulcers, and longer than expected stays have been associated with poorer staffing (more patients per nurse or fewer hours of nursing care per patient day) in more than one study. However, the influence of organizational and other variables that mediate these relationships is still not clearly delineated, nor is there much data regarding changes in outcomes with changes in staffing or care delivery models. A different body of research suggests that some of these intermediate variables include work environment, type and quality of equipment, individual nurse experience, competency and education, clinical and organizational processes of care, and ability to communicate with team members.

The research is clear that having fewer patients per nurse or more direct nursing care hours per patient day is associated with fewer adverse outcomes, in particular mortality, failure to rescue and some specific adverse events, particularly among surgical patients. This association is no longer in dispute. There is, however, limited research to guide understanding of how to improve nurse staffing to reduce nursing workload and adverse patient outcomes. Health services researchers indicate an urgent need to examine facility level strategies to improve staffing and relate those efforts to both patient and organizational outcomes. In addition, evaluation of regulated strategies such as mandated nurse-patient ratios is needed. There is an equally urgent need for health care facilities to be conducting systematic and regular evaluations of the impact of staffing plans and models of care that are in place or about to be implemented. Just as clinicians are expected to be practicing evidence based care, health care organizations should be using the available research to practice evidence-based management.

This should not be read as a message of “more research is necessary before new attempts are made to improve the impact of staffing plans and policies on nurses and patients,” but as a message regarding interesting variables and tools that can be used to improve the results of staff planning, as well as important variables to measure. Further, recognizing the lack of such data and analysis in the present literature, these gaps suggests the value of measurement in assessing and learning from what is attempted in this important area.

The literature points to important variables that need to be measured and compared continuously in order to determine the effectiveness of any staffing plan. These include skill mix, patient acuity, nurse outcomes such as satisfaction and turnover, and patient outcomes such as mortality, pressure sore prevalence and falls incidence. The steering committee’s plan to collect some of these data before and after implementation will serve all parties well in evaluating the impact of the plans.

Many strategies are being used throughout the country to improve staffing and create innovative care delivery models. To date, few have included robust evaluation of the effects. Washington has the opportunity to evaluate the impact of particular innovations used at any given hospital, the extent of staff nurse involvement in the development of staffing plans, and to compare outcomes. For example, within the steering committee’s mandate, the state-wide measurement of nurse sensitive quality indicators has the potential to contribute to the existing body of research; the pilot project on staffing alerts may also result in useful findings; and work in both areas offers pre- and post-intervention data.

Legislative Column Author

Greer Glazer, RN, CNP, PhD, FAAN
Email: Greer.Glazer@umb.edu

Dr. Greer Glazer is Dean and Professor of Nursing and Health Sciences at University of Massachusetts Boston. She received her BSN from University of Michigan, and MSN and PhD from Frances Payne Bolton School of Nursing, Case Western Reserve University. She became particularly interested in collaboration and partnerships while serving as a Robert Wood Johnson Executive Nurse Fellow in 2001. Since then she has developed an interdisciplinary, PhD-level, leadership course; partnered with agencies in Israel to improve women's health; and engaged in  partnerships and collaborations with the following Massachusetts agencies and organizations: Partners Healthcare; Children's Hospital of Boston; The Massachusetts Board of Higher Education; Bunker Hill Community College; Roxbury Community College; and Dana Farber Harvard Cancer Center.