Running head: STRATEGIES TO IMPROVE STAFFING 1
Strategies to Improve Staffing on Inpatient Medical-Surgical Units
LaDonna D. Henderson
Frostburg State University
1
STRATEGIES TO IMPROVE STAFFING 2
Strategies to Improve Staffing on Inpatient Medical-Surgical Units
Nursing today has become more complex as nurses take on greater responsibilities in
caring for a more complicated patient population. This complexity is affected by the nurses
ability to safely carry out patient care. With patient safety at the core of the nursing profession,
identifying and establishing the appropriate nurse-patient ratio is critical in being able to provide
safe quality care and decrease poor patient outcomes. Establishing safe nurse-patient ratios has a
direct effect on the nursing profession, impacting the safety of both nurses and patients.
Clinical Problem
This paper will seek to identify strategies to improve staffing on inpatient medical-
surgical units by exploring the question of how nurse-patient ratios affect patient outcomes.
According to the Agency for Healthcare Research and Quality (AHRQ), Hospitals with low
nurse staffing levels tend to have higher rates of poor patient outcomes. (Stanton, 2004). While
increasing the nurse staffing seems an obvious response, there are actually many factors to
consider. Patient acuity and staffing mix are important aspects of determining nurse-patient
ratios, as well as considering how this ratio is defined and by whom.
Purpose Statement: The purpose of the study is to identify strategies to improve staffing
on inpatient medical-surgical units.
Research Question: How do nurse-patient ratios affect patient outcomes?
Hypothesis: Higher nurse-patient ratios negatively impact patient outcomes.
Independent Variable: Nurse-patient ratio.
Dependent Variable: Adverse patient outcomes.
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PICO Question
P (Patient/Population): Patients admitted on inpatient hospital medical-surgical units.
I (Intervention): Increase nurse-patient ratios on inpatient hospital medical-surgical units.
C (Comparison): Current 1:6 nurse-patient ratio.
O (Outcome): Smaller nurse-patient ratios than those currently established decrease adverse
patient outcomes.
Research was conducted using the Cinahl, Health Source: Nursing/Academic Edition,
MEDLINE, and Ovid databases. Search terms included (nurse AND ratios) AND (patient AND
outcomes), filtering by peer reviewed, English language, 2006-2016, academic Journals, and
USA. A review of the literature was compiled during the dates of September 25 October 5,
2016.
Literature Review
Seven articles were chosen from the literature review to examine the issue of nurse-
patient ratios and their impact on patient outcomes. There is a general consensus in the nursing
field that low nurse-patient ratios are dangerous for both nurses and patients, resulting in adverse
outcomes such as increased infection rates, increased fall rates, and even increased mortality
rates for patients, as well as increased job burnout and career dissatisfaction for nurses. The
literature review was undertaken to explore ways of improving nurse staffing levels and
decreasing adverse patient outcomes.
One attempt to resolve nurse-staffing concerns has been to federally mandate nurse-
patient ratios. In 1999, California because the first state to pass a law requiring specific nursing
ratios in an attempt to ensure patient safety. For medical-surgical units, this ratio was 1:6.
(Kasprak, 2004). By 2013, several studies had been conducted to discover what impact these
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federally established ratios had on patient outcomes. Research prior to the institution of
Californias federal regulations had previously demonstrated an inverse relationship between
patient-nurse ratio and adverse patient events. However, studies focusing in particular on
Californias nurse-patient ratio laws were at best inconclusive and failed to show a significant
correlation and suggested further research was necessary to explore the impact of ratios on
patient outcomes. (Serratt, 2013).
The main problem with comparing the findings from different research studies is in
determining how the nurse-patient ratio is defined. West, Patrician, and Loan cited inconsistent
definitions of staffing as a contributing factor to inconclusive research results. (2012, p. 24). As
was discovered in looking at the federally mandated ratios implemented in California, an across-
the-board hard-line approach does not adequately address the issue. Other factors must be at play
that influence the effects nursing ratios have on patient care, such as patient acuity, unit-level and
shift-level needs, and the staffing mix (RNs to LPNs, experience level, and education level).
Key to resolving the nurse-patient ratio issue is the level of involvement nurses have in
making staffing decisions. Staffing committees have been shown to be a successful approach in
developing staffing policies that take into account an organizations particular needs. This
alternative approach is flexible and can address multiple factors rather than adopting a fixed-ratio
mentality. Nurses who participate on these committees can bring more awareness of unit-level
needs to the table. Both bedside nurses and nurse managers have invaluable knowledge regarding
clinical care needs and can be extremely beneficial in determining a reasonable and effective
staffing plan.
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Practice Recommendations
Many factors must be considered when determining safe nurse-patient ratios. Based on
the literature reviewed, three practice recommendations are suggested. These recommendations
are discussed below.
1. Registered nurses need to take a more active role in decision-making regarding
determination of the nurse-staffing ratios that best promote safe patient care. Adequate staffing is
a complex nursing issue that is not easily solved by inflexible government-mandated staffing
ratios (Wallis, 2013, p. 22). Staffing committees that include both nurse managers and direct care
nurses are better equipped to determine safe nurse-patient ratios (Martin, 2015, p. 6) and allow
for unit-specific guidelines rather than a one-size-fits-all approach.
2. Staffing mix should be taken into consideration when determining safe nurse-patient
ratios. An effective model should take into account the amount of education, years of experience,
and professional knowledge and skills each nurse possesses when looking at safe staffing. More
adverse events occur during shifts staffed with fewer personnel overall and fewer RNs in
particular (Patrician et al., 2011, p. 67). A significant correlation was found between nurse skill
level and adverse patient outcomes with a decrease in nurse staffing levels being associated with
an increase in mortality among specific patient populations. (Schilling, Goulet, & Dougherty,
2011, p. 2937).
3. Total nursing care hours per patient per shift rather than specific nurse-to-patient ratios
should be used when determining safe staffing. A decrease in the number of nursing care hours
per shift increases the risk of adverse patient events. For example, on a unit with 20 patients and
10 nurses each working 8 hours per shift provides 80 nursing care hours. Dividing the number of
hours by the number of patients computes to 4 nursing care hours per shift. Changing the number
STRATEGIES TO IMPROVE STAFFING 6
of patients (either by admissions, transfers, or discharges) on any particular shift decreases the
nursing care hours available per patient thereby increasing the workload. (West, Patrician, &
Loan, 2012, p. 25).
Conclusion
Determining safe nurse-patient ratios is a complex issue facing todays healthcare world.
It will require a multi-factorial approach for successful resolution. While there is agreement that
lower nurse-patient ratios have unfavorable effects on safe patient care, traditional approaches no
longer sufficiently address this problem. Many have praised the efforts of government regulation
of staffing ratios, but this proposed solution has its flaws as well. More involvement of nurses,
rather than outside agencies, seems to be the direction with the most promise.
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References
Hinno, S., Partanen, P., & Vehvilinen-Julkunen, K. (2011). Nursing activities, nurse staffing
and adverse patient outcomes as perceived by hospital nurses. Journal of Clinical
Nursing, 21(11-12), 1584-1593. doi:10.1111/j.1365-2702.2011.03956.x
Kasprak, J. (2004). California RN staffing ratio law (2004-R-0212). Retrieved from
[Link]
Martin, C. (2015). The effects of nurse staffing on quality of care. Academy of Medical-Surgical
Nurses, 24(2), 4-6. Retrieved from [Link]
Patrician, P. A., Loan, L., McCarthy, M., Fridman, M., Donaldson, N., Bingham, M., &
Brosch, L. R. (2011). The association of shift-level nurse staffing with adverse patient
events. JONA: The Journal of Nursing Administration, 41(2), 64-70.
doi:10.1097/nna.0b013e31820594bf
Schilling, P., Goulet, J. A., & Dougherty, P. J. (2011). Do Higher Hospital-wide Nurse Staffing
Levels Reduce In-hospital Mortality in Elderly Patients with Hip Fractures: A Pilot
Study. Clinical Orthopaedics and Related Research, 469(10), 2932-2940.
doi:10.1007/s11999-011-1917-8
Serratt, T. (2013). Californias nurse-to-patient ratios, part 3. JONA: The Journal of Nursing
Administration, 43(11), 581-585. doi:10.1097/[Link]
Stanton, M. (2004). Hospital nurse staffing and quality of care (Publication No. 04-0029).
Retrieved from
[Link]
l#LowerStaffing
Wallis, L. (2013). Nurse-patient staffing ratios: Where are we headed and why? American
Journal of Nursing, 113(8), 21-22. Retrieved from ajn@[Link]
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West, G., Patrician, P. A., & Loan, L. (2012). Staffing MattersEvery Shift. AJN, American
Journal of Nursing, 112(12), 22-27. doi:10.1097/[Link].0000423501.15523.51
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Appendix A
Individual Evidence Summary
Databases Used: Cinahl, Search Terms Used: Filters Used:
Health Source: (nurse AND ratios) AND (patient AND Peer reviewed, English
Nursing/Academic outcomes) language, 2006-2016,
Edition, MEDLINE, Academic Journals,
Ovid USA
# Author Year Evidence Sample Results Limitations Strength/
Type Size Recommendation Quality
1 Serratt, T. 2013 Systematic Data Limited Level IV
review inconclusive number of Quality
regarding effects studies B
of nursing ratios
on patient level
outcomes.
2 Patrician, P., 2011 Cohort N=13 RN skill mix and Use of Level II
Loan, L., study/quasi hospitals experience and incident Quality
McCarthy M., experimental total nursing care reports as A
Fridman, M., hours associated basis for
Donaldson, with adverse evaluating
N., Bingham, patient events. adverse
M., Brosch, events.
L.
3 Wallis, L. 2013 Qualitative Success of the Level III
research Joyce-Capp bill Quality
over strict ratio B
mandates
4 Hinno, S., 2011 Research N=869 Significant Low Level II
Partanen, P., study/quasi RNs correlation found response Quality
& experimental between nurse rate, A
Vehvilainen- staffing and subjectivity
Julkunen, K., adverse patient in
outcomes questionnaire
5 Martin, C. 2015 Qualitative Safe nursing Level III
Research staffing has Quality
positive impact B
on nurses,
patients, and
hospitals
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6 West, G., 2012 Systematic Finding the Data Level IV
Patrician, P. review appropriate collected Quality
& Loan, L. number and mix from military B
of nursing staff hospitals
helps prevent only
adverse events
and errors.
7 Schilling, P., 2011 Cohort study N=13,343 Decreased nurse Staffing Level II
Goulet, J. & (pilot patients staffing levels levels not Quality
Dougherty, P. study)/quasi associated with measured at A
experimental increase in the patient
mortality among level but
patients with hip rather
fractures hospital
wide; only
looked at
specific
patient
population
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Appendix B
Overall Evidence Summation
Level of Number Summary of Findings Overall
Evidence of Quality
Studies
I 0 -- --
II 3 RN skill mix and experience and total nursing care hours A
associated with adverse patient events. A significant
correlation was found between nurse staffing and adverse
patient outcomes with a decrease in nurse staffing levels
being associated with an increase in mortality among
specific patient populations.
III 2 In determining safe staffing levels, staffing plans should B
be specific to each unit rather than a one-size-fits-all
approach with plans based on the number of patients on a
unit, the acuity level, the amount of RN experience and
that availability of support staff and other resources. As
well, such staffing plans should be nurse-driven.
Additionally, higher nurse-to-patient ratios have a
negative effect on nurses wellbeing and increase the
incidence of burn out.
IV 2 Finding the appropriate number and mix of nursing staff B
helps prevent adverse events and errors but further
research is needed to delineate specific benefits and risks.
Staffing ratios are affected by more than simply the
number of nurses working on a shift. Other variables
including amount of nursing experience and level of
education. When examining nursing care hours per shift
(rather than specific nurse-to-patient ratios), a decrease in
nursing care hours per shift increases the probability of
falls and medication errors. Future research needs to
focus on the impact of nursing care hours per shift on
adverse events from a shift level standpoint rather than
hospital and unit wide.
V 0 -- --
