Evidence Based Nursing

Recommendations
for Best Practice:
Nurse staffing levels and patient outcomes

Group A:
Alejandro Dominguez, Cadence Williams, Daniel Hermosillo, Erin Krening
Heidi Kukahiko, Lauren King, Nicole Taylor, & Rebecca Hitchcock
 Introduction
Nurse staffing levels
Carondelet St. Josephs Hospital staffing levels
Introduction to implications for nursing
 PICOT Question
What is the best practice for nurse staffing levels in relation to patient
outcomes?

In hospitalized patients (P), what is the effect of increased nurse staffing

(I) on patient outcomes (O) compared to decreased nurse staffing (C)
within the last 5 years? (T)
 Current Practice
Given the complexity of nurse staffing issues and the immense diversity in
healthcare organizations, there exists no current national one-size-fits-all
solution that addresses fixed nurse-to-patient ratios.

The Registered Nurse Safe Staffing Act

This act gives hospitals and a committee comprised of at least 55% direct care
nurses establish unit-by-unit staffing plans

(American Nurses Association, 2017)

 Staffing Plans
Establish adjustable minimum number of RNs
Include input from direct care RNs
Be based on patient numbers and the variable intensity of care needed
Take into account education level, experience and training of the RNs
providing care
Take into account staffing levels of other healthcare personnel associated
with nursing care
Consider staffing levels recommended by specialty nursing organizations
Take into account unit and facility level staffing, quality and patient outcome
data and national comparisons as available
Take into account geography and available technology
ENSURE THAT RNs ARE NOT FORCED TO WORK IN UNITS WHERE
THEY ARE NOT TRAINED OR EXPERIENCED

(American Nurses Association, 2017)

 Local, State & National Results
Local, state and national nurse-to-patient ratios all vary depending on the
hospital, however, more recent data lists these as the typical ratios:

1:1 in operating room and trauma emergency units

1:2 in critical care areas, including emergency critical care, intensive
care, labor and delivery, and post-anesthesia units
1:3 in emergency rooms and in antepartum, pediatric, step-down
surgical and telemetry units
1:4 in intermediate care nursery, specialty care, medical, surgical and
acute care psychiatric units
1:5 in rehabilitation units
1:6 in postpartum and well-baby units

(American Nurses Association, 2017)

 Current Nurse-to-Patient Ratios
at St. Josephs Hospital
1:2 in the intensive care units (ICU)
For every 16 patients there is 1 PCT
For every 24 patients there are 2 PCTs
 Summary of Research
A higher number of RNs was associated with lower
readmission rates
Each additional patient added to the nurses
workload increased odds of 30-day mortality for all
patients.
Nurses' perceptions regarding staffing and
resource adequacy were significantly associated
with nosocomial infections.
Patient acuity, rather than patient volume or the
patient-nurse ratio, was viewed as being more
closely tied to the threshold of safety, which we are
characterizing as that point at which inadequate
staffing has the potential to result in or contribute to
suboptimal patient outcomes.
Shortage of competent and trained ICU nurses,
increased patient to nurse ratio, matching nurses
skills to patients acuity level, decreased level of
ICU experience, all brought about compromises in
patient care.
 Summary of Research
Researchers found that higher numbers of nurse per bed and higher numbers
of consultants were associated with higher survival rates of ICU patients.
A large patient-nurse ratio was associated with greater incidence of
administration of the wrong medication, wrong dose, pressure ulcers and
patient falls with injury.
Rationing of nursing care, nurse-reported quality of care, patient adverse
events, and patient satisfaction were improved with the nurse-to-patient ratio
0.6
Decreased patient to nurse ratios are associated with higher odds of patient
survival after a cardiac arrest.
When the LPN care hours are increased by one hour per patient day, patient
falls were decreased. When the use of temporary nurse staff increases, the
amount of patient falls are greater than units who do not use temporary nurse
staff.
 Research articles strengths and weaknesses
Type of study US Sample Disease Control Stat Consistency SR

Article 1 Retrospective Study

Article 2 Qualitative design

Article 3 Quantitative study:

Retrospective study

Article 4 Cross-sectional,
retrospective
observational study

Article 5 Cross-sectional
quantitative study

Article 6 Cross-sectional
quantitative study

Article 7 Quantitative study

Article 8 Cross-sectional
quantitative study

Article 9 Quantitative study:

exploratory design

Article Retrospective
10 longitudinal
Quantitative study

Us = conducted in the US. Sam = sample size. Dis = disease. Control = variable were controlled.
Sta = statistically significant findings. Consistency = consistent with other findings. SR = Self report
 Research articles strengths and weaknesses
1. Nurse Staffing and 30-day Readmission of
Chronic Obstructive Pulmonary Disease
Patients: A 10-year Retrospective Study of
Patient Hospitalization
Sample size: 300,000 male and female
participants from over 1,000 hospitals
Statistical significance
The study was held for a period over 10 years
No conflicts of interest were declared
Possibility of recall bias
High potential for selection bias and confounding
factors (only COPD patients were included in the
study; most patients were older)
The study was done in another country so the
hospital environment can vary greatly.
(Kim, Park, Han, Kim, & Kim, 2016)
2. Intensive care unit nurse managers
views regarding nurse staffing in their units
in South Africa
Consistency of themes emerged from the data.
Sample: Interviewees were ICU managers with
extensive experience and knowledge working in the
ICU setting
Eligibility criteria: RNs, ICU trained, permanent
nursing staff in the selected units; > six months
working in the unit as a unit manager.
Using individual interviews in this research was
beneficial in that it provided opportunities for the
researchers and the unit managers to discuss
staffing in the large ICUs in more detail.
Small sample size
Possible bias: all interviewees from ICU floors
Lack of generalizability: Study conducted in one
province of South Africa; sample size was small
(Matlakala & Botha, 2016)
 Research articles strengths and weaknesses
3. Analysis of nurse staffing and patient
outcomes using comprehensive nurse staffing
characteristics in acute care nursing units
Tightly controlled for all aspects of nursing staff
Statistical significance
Controlled for time-variant nursing unit
characteristics
Used a convenience sample
Other missing variables might have affected
patient quality of care
Did not control for unit case mix and individual
patient characteristics such as age or comorbid
conditions
(Bae, Kelly, Brewer, & Spencer, 2014)
4. Nurse staffing, medical staffing and mortality
in Intensive Care: An observational study
Large sample size
Controlled for patient characteristics and workload
Used statistical data to organize information such
as the use of multilevel logistic regression (a
mathematical formula) used to quantify the data
obtained from observation of patient outcomes.
Includes nurses, doctors, and support staff
The study only used information from 65 ICUs. It
would be ideal if they had more hospitals to gather
data from.
Lack of generalizability: Conducted in the UK and
may not reflect the same data from the US; more
than just nursing staff numbers were measured.
(West et al., 2014).
 Research articles strengths and weaknesses
5. Better Nurse Staffing and Nurse Work
Environments Associated With Increased
Survival of In-Hospital Cardiac Arrest Patients.
Large sample size of 11,160 patients
Data collected over a long period of time (2005-
2007)
Multiple states were involved in the study
Patients who were assessed did not have a wide
variety of disease
Could not establish causality of the study
because a cross-sectional design was used
Lack of generalizability: Hospitals that
participated were larger and more likely to be high-
technology hospitals compared with the full
population of hospitals.
(McHugh et al., 2016)
6. Nurse Staffing and Postsurgical
Outcomes in Black Adults
Utilized facilities from multiple states
Large sample (599 adult nonfederal acute care
hospitals).
Models were adjusted for sex, race, and age to
help determine discrepancies in mortality rates.
Adjusted for socioeconomic status, type of surgery,
and comorbidities in addition to hospital
characteristics.
Findings consistent with similar studies
Unable to determine causality (cross-sectional
design)
Administrative data may have skewed reliability of
racial designations which may have had an impact on
results.
Results may not solely be reliant on nurse staffing
but on other factors related to work environment and
institution type.
Lack of generalizability of patients socio economic
status
(Carthon, Kutney-Lee, Jarrn, Sloane, & Aiken, 2012)
 Research articles strengths and weaknesses
7. Nurse staffing levels make a difference on
patient outcomes: A multisite study in chinese
hospitals
Multistage sampling techniques
Large sample size
Use of logistic regression analyses
Adjustments were made for confounding factors
Lack of generalizability/subjective results:
obtained from nurse and patient reports.
High likelihood of bias due to self report
(Zhu et al., 2012)
8. The Relationships of Nurse Staffing Level and
Work Environment With Patient Adverse Events
Randomly selected data set with large sample
sizes and high response rate
Statistically significant findings obtained
Findings were consistent with results from other
studies
Controlled for nurse, hospital, and patient
characteristics
The cohort was representative of a population,
not a defined group
Cross sectional study
Self-report method used
High likelihood of recall bias
Lack of generalizability: surgical patients only
possibility of confounding effects by unmeasured
or unknown factors
(Cho, Chin, Kim, & Hong, 2016)
 Research articles strengths and weaknesses
9. On the Threshold of Safety: A Qualitative
Exploration of Nurses Perceptions of Factors
Involved in Safe Staffing Levels in Emergency
Departments
Study sample was demographically
representative of a self-selected group who were
interested in and able to attend a large conference
and volunteered to participate in the study.
There was some variety of professionals in the
sample which theoretically provided a multifaceted
perspective to the data collected.
Multiple levels of data collection and participant
interviews
This sample size may not be representative of the
United States emergency nursing workforce overall.
Small sample size: 26 emergency nurses
In regards to our purpose in reviewing this study it
could be seen as a limitation that the study focused
on safe staffing levels in the ED as opposed to the
ICU. However, both have intense workloads, and
fast paced environments.
(Wolf, Perhats, Delao, Clark, & Moon, 2016)
10. Use of temporary nursing staff and
nosocomial infections in intensive care units
Addressed possible confounding variables
regarding data collection
Consistency of study data collection
The data were collected monthly in 12 ICUs at
the six hospitals, resulting in a total of 144 data
collection points (unit-month points).
The study utilized controlled variables like RN
care hours per patient day, UAP care hours per
patient day and professional skill mix in an attempt
to maintain consistency in the hospital setting.
The unit size and work environment
characteristics were measured only once.
The work environment characteristics were
identified as critical confounding factors on the
relationship between the use of temporary nursing
staff and patient outcomes
(Bae, Brewer, Kelly, & Spencer, 2015)
 Evidence Based Nursing Recommendations

Accounting for acuity vs volume

Cap on patient:nurse ratios
Need for adequate support from other departments
Adequate resources
Availability of ancillary staff
Lower workloads for nurses
Adequate knowledge and skill set

(McHugh, 2017)
 Implementation
Two year plan implemented at Carondelet St. Josephs Hospital

Timeline:

1. Head of departments involved (ICU, NCCU, ED, etc. ) meet to

develop template based on current EBP research and create outline
within first month
2. Educate staff on importance of new EBP and reason for
implementation within first month
3. Three day training workshop for hospital personnel. Implemented in
one unit at a time. Have this completed within the first four months.
4. Quarterly meetings with staff involved to analyze success/ receive
feedback (eight total over two years)
 Implementation cont.
5. Pilot project on one unit by six months
6. Institutionalize project in all the high acuity units.
7. Bi weekly updates/review of progress by head of departments
8. Evaluate impact on patient care/outcomes at the end of two years
9. Revise plan and make changes to implementation. May need to add
an additional year in order to implement revised plan
 Cost Analysis

To implement this better practice

issue there is not a need to purchase
new equipment.
Also, the implementation of this better
practice issue does not involve much
training unless the facility must hire
more nurses to fulfill the increased
staffing on each unit.
Training new hires can take
week(s) to 12 months depending
on the unit, hospital, and nurse
experience. Also, the pay for
training depends on these factors
but on average a registered nurse
is paid $32.45 (National Average
2015).
 Cost At Other Facilities

The implementation of this

best practice issue has
cost other facilities
approximately $334.74 a
day (only 12 hrs) to add
one permanent RN for
8.47 hours and a
supplemental RN for the
remaining time to one unit.
The addition of these staff
members costed the
facility approximately
$122,180.10 a year to add
one nurse everyday onto
one unit.

Xue. Y., Chappel, A. R., Freund, D. A., Aiken, L. H., & Noyes, K. (2015).
 Cost Analysis (Cont.)
Once a facility has trained or
increased overtime hours for
nurses a detailed cost can be
analyzed. For example,
If one facility adds one nurse
to one unit for one shift a day
(12 hours) the yearly cost
would be approximately
$142,131.
This based off of paying a
nurse $32.45 an hour but once
a nurse reaches overtime,
hourly pay would increase to
approximately $48.68.
Research has shown that
increasing nurse staffing would be
important to implement despite the
cost.
It can decrease patient
readmission, bed sores, and
length of stay.
 Risk vs. Benefit
There are few risks to this research question and potential risks are mostly associated with
financial costs

Risks to Institution: Cost to hospital

Increased finances to pay for additional nurses, techs, cost of benefits/turnover, etc.
More education/meetings/orientations related to hiring more new grads
more orientation (lose $) , slows pace , and high turnover with new grads (lose $)

Risks from Research: Overall cost to hospital and potential costs to the nurse and patient

Risks to Nurse: Changes to salary/shifts with increased

costs
Decreased benefits and/or salary
Potential to affect shifts (shifts cut)
Per diem basis as more nurses are hired - shifts not
guaranteed

Risks to Patient: Insurance/other rates may rise

To help pay for nurses salaries and additional expenses to
hospital

(Xue, Chappel, Freund, Aiken, & Noyes, 2015)

(Department for Professional Employees (DPE), 2016)
 Risk vs. Benefit
There are many benefits to this research question, including, but not limited to:

Benefits to Institution:
Increased patient satisfaction
Decreased incidence of patient falls, bed sores, never events, HCAIs, etc.
Decreased mortality rates
Less days unpaid by Medicare for nosocomial infections

Benefits from Research: This topic has been well-researched and most studies show
substantial benefits with increased nurse staffing - with the potential in providing higher quality
healthcare

Benefits to Nurse:
Decreased workload, burnout, injuries, increased satisfaction
Higher retention rates/less nurse turnover
Less patients assigned to charge nurse more efficient management

Benefits to Patient:
Lower lengths of hospital stay
More competent/attentive care in the hospital
Decreased mortality rates, nosocomial infections, never events
Lower rates of readmission

(Department for Professional Employees (DPE), 2016)

 Evaluation

The desired outcome is to decrease patient mortality,

nosocomial infection rates, and failure to rescue events by
way of increasing the volume of nursing staff available in
a given unit.
This may be achieved by altering staffing matrix,
implementing an increase in fixed ratios, or altering the
billing model to create a market incentive for hospitals to
increase nursing staff.

(Zhu, X. et al, 2012)

 Summary
Summary of Introduction
Nurse staffing levels and how they affect patient
outcomes.
Experiences and observations from CSJ
Focused on areas of nursing concerning higher acuity
patients in gathering our articles.
In hospitalized patients (P), what is the effect of increased
nurse staffing (I) on patient outcomes (O) compared to
decreased nurse staffing (C) within the last 5 years? (T)
Description of issue
Lower nurse staffing levels negatively impact patient
outcomes
Lack of time spent per patient, allocation of resources,
distribution of assistive personnel.
Supportive studies
Variety of studies
Synthesize themes from each study
Focus: higher acuity areas of nursing care
 Summary
Current Practice
No legislation in place with fixed nurse-to-patient ratios.
Determined by individual states laws and hospital needs.
Registered Nurse Safe Staffing Act - hospitals establish their own nurse
staff needs.
ICU the ratio is 1 nurse to 2 patients.
Best Practice
Increase patient safety, satisfaction, care and overall outcome
Optimize the most effective nurse to patient ratios by, accounting for pt.
acuity vs. volume, availability of ancillary staff, nurse knowledge and skill
set, and support from other departments.
Application to facility
Redistribute assistive personnel in a more fair ratio to assist in better
managing the patient care workload between nursing staff.
 Summary
Cost analysis:
The exact cost of implementing this practice or intervention does vary on
facility, nursing experience, and overtime pay but the benefit of
implementing the intervention has shown to outweigh the cost.
Risk vs. Benefit:
Clinical benefits outweigh the financial costs
Increased patient satisfaction, decreased nurse burnout/workload,
and a decline in adverse patient outcomes
mortality, failure to rescue, pressure ulcers, falls, nosocomial
infections, etc.
Questions?
 References
American Nurses Association (2015). Safe staffing: The registered nurse safe acting act. Department of Government Affairs.
Retrieved from http://www.rnaction.org/site/DocServer/Registered_Nurse_Safe_Staffing_Act_of_2015.pdf?docID=2361

Bae, S. H., Brewer, C. S., Kelly, M., & Spencer, A. (2015). Use of temporary nursing staff and nosocomial infections in
intensive care units. Journal of Clinical Nursing, 24(7-8), 980-990. doi:10.1111/jocn.12718

Carthon, J. M., Kutney-Lee, A., Jarrn, O., Sloane, D., & Aiken, L. H. (2012). Nurse Staffing and Postsurgical Outcomes in
Black Adults. Journal of the American Geriatrics Society,60(6), 1078-1084. doi:10.1111/j.1532-5415.2012.03990.

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. doi:10.1111/jnu.12183

Department for Professional Employees. (2016). Safe-Staffing Ratios: Benefitting Nurses and Patients [Fact sheet]. Retrieved
from http://dpeaflcio.org/programs-publications/issue-fact-sheets/safe-staffing-ratios-benefiting-nurses-and-patients/

Kim, S.J., Park, E., Han, K., Kim, S. J., Kim, T. H. (2016). Nurse Staffing and 30-day Readmission of Chronic

Obstructive Pulmonary Disease Patients: A 10-year Retrospective Study of Patient Hospitalization.

Korean Society of Nursing Science, 10(4), 283-288. doi: 10.1016/j.anr.2016.09.003

Matlakala, M. C., & Botha, A. D. (2016). Intensive care unit nurse managers' views regarding nurse staffing in their units in
south africa. Intensive & Critical Care Nursing, 32, 49-57. doi:10.1016/j.iccn.2015.07.006 [doi]

McHugh, M. D., Rochman, M. F., Sloane, D. M., Berg, R. A., Mancini, M. E., Nadkarni, V. M., American Heart Associations
Get With The Guidelines-Resuscitation Investigators. (2016). Better Nurse Staffing and Nurse Work Environments Associated
With Increased Survival of In-Hospital Cardiac Arrest Patients. Medical Care, 54(1), 7480.
http://doi.org/10.1097/MLR.0000000000000456
 References
Nurse staffing levels make a difference on patient outcomes: A multisite study in chinese hospitals Journal of Nursing
Scholarship, 44(3), 266. doi:0.1111/j.1547-5069.2012.01454.

West, E., Barron, D. N., Harrison, D., Rafferty, A. M., Rowan, K., & Sanderson, C. (2014). Nurse staffing, medical staffing and
mortality in Intensive Care: An observational study. International Journal of Nursing Studies,51(5), 781-794.
doi:10.1016/j.ijnurstu.2014.02.007

Wolf, L. A., Perhats, C., Delao, A. M., Clark, P. R., & Moon, M. D. (2016). On the threshold of safety: A qualitative exploration
of nurses' perceptions of factors involved in safe staffing levels in emergency departments. Journal of Emergency Nursing: JEN
: Official Publication of the Emergency Department Nurses Association, doi:S0099-1767(16)30213-6 [pii]

Xue. Y., Chappel, A. R., Freund, D. A., Aiken, L. H., & Noyes, K. (2015). Cost outcomes of supplemental nurse staffing in a
large medical center. Journal of Nursing Care Quality, 30(2), 130-137. Doi: 10.1097/NCQ.0000000000000100

Zhu, X., You, L., Zheng, J., Liu, K., Fang, J., Hou, S., . . . Zhang, L. (2012).

Zhu, X., You, L., Zheng, J., Liu, K., Fang, J., Hou, S., . . . Zhang, L. (2012).
Nurse staffing levels make a difference on patient outcomes: A multisite study in chinese hospitals Journal of Nursing
Scholarship, 44(3), 266. doi:0.1111/j.1547-5069.2012.01454
The End