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How Improvement of Nursing Staffing Helps in Enhancing Patients Safety


HowImprovement of Nursing Staffing Helps in Enhancing Patients Safety

andEmployee Retention


Researchindicates that issues of workload and staffing ratio in healthcareare rampant. Nurses have been reporting that they lose patience withfailure of the management to act regarding the issues of safestaffing and positive patient outcomes. According to most nurses, thesolutions to their problems must be implemented to limit the numberof nurses that a nurse can administer at a given day. However,innovation and transformation are high agendas for both provincialand national healthcare quality. It is clear that nurses affect thepatients’ outcomes. Quality nursing care reduces patient’scomplications and length of stay in hospital. It is evident thatnurses are usually overworked. Their work environment is full of roleconfusion and interruptions, lack of human support and limitedtechnical coordination. Nurses have been aware of this intuitivelythroughout their practice.

Thispaper investigates how improved staffing encourages employeeretention and improves patients’ safety.

Appropriatestaffing in healthcare is critical to the well-being and safety ofthe patient. Inadequate staffing levels influence the rates ofmedical errors, heart attacks and overall mortality. According to astudy by surgical survey, the risk of dying for patients within thefirst 30 days increases by 7 percent as a result of increasedworkload among the nurses at certain points(Marks, 2007).

Asurvey by American Nurses Association (ANA) found out that 54 percentof the nurses within the adult emergency and medical units spentinsufficient times with the patients. Results indicated that 43percent of the nurses worked extra hours because of excessively busyunits or short-staffing. From the 20 percent of the cases examinedinsufficient staffing affected unit admissions, discharges andtransfers while understaffing depleted morale of the nursesincreasing the levels of absenteeism and turnover ratio.

Staffingin healthcare is affected by various external factors, as cynicalshortages for registered nurses (RNs), immigration policies, nursingschool capacities, changing expectation and need of the patients,general economic state and increased competition for the healthcaredollars. For instance, recession mitigates staffing problems forhealthcare organizations and some hospitals by decreasing demand forthe elective treatment as well as motivating the older nurses toreturn to the full-time practice. Nevertheless, organizations mustnot be lulled into complacency. The industry analysts caution thatthe long-term projections have probability of widening in the futuredue to improvement of the economy and as older nurses reach theretirement age(Aiken &amp Clarke, 2006).

Thelegislative efforts to address adequate staffing range from themandated nurse-patient ratios to the state reporting programs. Giventhe healthcare diversity and complexity of the staffing issues, theone-size-fits-all solutions may be unlikely. Therefore, effectivestaffing model must consider variables like the acuity of thepatients, ancillary support and unit layout in determination of theappropriate number, skills, specialized trainings and experience ofthe nurses for a given unit(Rogers, 2008).

Appropriatestaffing involves more than just increasing the numbers. The processrequires long term commitment by an organization towards empoweringand appreciating the nurses. This involves examination of the issuesaffecting nurses staffing and gives strategies to help organizationswithstand the periodic shortages, reduce liability exposure andimprove the patients’ outcomes(Cho, 2003).

Standardsand requirements of staffing

Incrafting the staffing plans, an organization must consider thepertinent standards and regulations. Staffing ratios are designed toensure safety of employees and patients. This also requiresadministrators and nurse executives to consult the ANA principles.Some organizations like American Hospital Organization and otherprofessional nursing associations have also formulated their staffingrecommendations. Therefore, healthcare administrators must create astaffing program which incorporates various inputs and tailoredtowards meeting the specific mission of the organization aligned tothe enterprise wide-goals.

Challengesexperienced in formulating the nurse staffing strategies(El-Jardali &amp Lagace, 2005).

Manyorganizations experience the challenge of reconciling the resourceswith external staffing standards and mandates. Among the majorapproaches is to create a nurse-management committee to handlestaffing issues. The committee should directly report to thegoverning board and must develop practical, safe and patient-centredpolicies on staffing. After convening, the committee can then embarkon design process of the policies that maximizes the contribution ofthe nurses while minimizing the risks at the same time.

Advantagesof improved staffing(Hugonnet, 2007).

Formalstaffing plan allows flexibility in fixing the nurse-patient ratios.The written plans must extend beyond the raw numbers to ensure thatall patients are taken care of appropriately. Organizations caneasily address the shortages in nursing through use of spredetermined strategy as well as ensuring that staffing decisionsincorporate acuity, special needs and patient diagnoses. Whenestablishing the staffing mix, coordinators must take into accountthe ability of the various nurses in solving the problems, effectivecommunication and solving problems(Duffield, 2008).

Thestaffing levels should be routinely analyzed in relation to theadverse occurrences. The nursing-sensitive outcomes decline orimprove based on changes in quality and quantity of the nursing care.Such outcomes do not solely convey impact of staffing on thepatient’s safety. Hospital type, patient’s acuity, staffavailable and other factors must be included when making dailydecisions on staffing needs for different units. To thrive andachieve high competitive advantage, the healthcare organizations mustfocus their efforts on staff retention strategies. For instance, whena hospital employs 600 nurses with an average annual salary of$46,000 and a turnover rate of 20 percent, then the organization willbe compelled to spend $5.5 million dollars for replacement costs(Aiken &amp Clarke, 2006).

Lowwages and poor working conditions have been the major causes ofnurses seeking employment elsewhere. Some of the interventions thatcan enhance nurses’ retention include minimizing the paperworkburden which distracts the patient care, limiting mandatory overtimefor the emergency situations, diversifying the nursing workforce,adopting effective ergonomic technologies and offering faircompensation and benefit package to commensurate with experience andeducation(Marks, 2007).

Focuson valuing and empowering nurses

Nursestend to perform better when allowed to fully utilize their skills andexpertise in exercising their judgment on patients’ assignment. Theempowerment can be achieved in transformational leadership and otherassociated practices like shared governance, professional autonomy,continuous learning and career advancement tracks. This must alsoinvolve retaliatory actions against the nurses who disclose unsafe orunlawful practices that weaken the relationship of the managementwith staff as well as creating a demoralized and passive workforce(Marks, 2007).

Accordingto experts, effective empowerment of nurses requires currentreimbursement system overhaul which perpetuates consideration of thenursing as the fixed cost instead of valuable asset. Reimbursinghospitals at higher level for the high acuity healthcare based ondiagnosis, the additional revenue can necessitate hiring additionaland highly experienced nurses. There is a high likelihood of thenumber of nurses decreasing by 2020. The state staffing mandates maynot be able to resolve the looming crisis that threatens the patientcare and increases the liability exposure. The individual hospitalsand healthcare systems must work collaboratively with the nurses toenhance the creation of and implementation of policies on staffingand employment to meet the patients` needs as well as to leverage theexpertise of nurses as well as minimizing the risks(El-Jardali &amp Lagace, 2005).

Creatinga culture of retention

Virtuallyall people in healthcare require the contribution of the registerednurse. All care is attended by knowledge, comfort and support of thenurses. There have been few professionals who have been able to offersuch care. Availability of few nurses is an indication of threatenedpatient`s safety. This severely affects the ability of the healthsystem in responding to the effects of mass casualty. Impendingcrisis for the staffing in healthcare has potential of impacting thesecurity of the society and health of the patient. The increasedshortage of healthcare is affecting the healthcare system in UnitedStates. About 90 percent of the long-term organizations dealing withthe healthcare lack sufficient nursing staffing to provide for thebasic care(Rogers, 2008).

Thehealthcare agencies are compelled to prevent new admissions inhealthcare. Currently, there are over 126, 000 unfilled nursingpositions in the country. However, the American public is currentlyaware of the shortages. There is a shortage of 93 percent shortageof nurses that is threatening delivery of quality healthcare. Thisstaffing shortage has been a major problem since the demand forservices exceeds the capacity. This is threatening to worsen as babyboom generation is getting old. Given this, the anticipated demandfor the services in healthcare is estimated at 400,000 fewer nursesby 2020. Aging along the baby boomers are the nurses themselves(Aiken &amp Clarke, 2006).

Average age of working for registered nurses is 43.3 years. This isincreasing at a rate twice that of other workforces countrywide.There are only 12 percent of the registered nurses from the totalworkforce who are aged below 30 years of age. This is a decline of 41percent of the total occupation. By 2010, the working age was 50percent. At this rate, more nurses are reaching retirement than thenurses who are joining the occupation. The higher acuity patients andincreasingly low level of nurses is a prescription for danger.According to research, staffing levels have been relatively lowresulting to increased number of deaths for the patients andpermanent loss of the function. Conversely, various studies haveindicated positive impacts on costs, health outcomes and quality. Theoptimization of the staffing levels can help in reducingcomplications, shortening the length of stay in hospitals andreducing the number of adverse effects(Marks, 2007).

Inaddition to the safety of the patients, nursing the shortage has beendiminishing and this affects the capacity of many hospitals intreating patients. Recent studies indicate that the nursing shortagehas caused overcrowding even in emergency departments. This causeddiversion of patients, reduced number of beds, discontinuation ofservices and programs and cancellation of some elective surgeries. Asa result, most nurses feel that providing quality care is relativelymore complex due to the shortages. This has made the institute ofmedicine to substantially reduce the frequency of the preventablemedical errors and adverse events. The healthcare organizations arerallying around on safety issues and introducing various measures inorder to reduce errors. There have been constant efforts to addressthe issue on the nursing shortage and to frame the solutions for theproblem(El-Jardali &amp Lagace, 2005).

Recommendationsfor improved staffing in healthcare

Createorganizational retention cultures

The‘magnet` hospitals should be adopted to produce a workplace thatempowers the nurses and is respectful to all people. This must beaccompanied by management training and support for the executives innursing institutions. The nursing work should be positivelytransformed using ergonomic and information technologies. Thestaffing levels should be set in such a way to enhance the competencyand skill mix for the nurses to acuity and patient mix.Zero-tolerance policies for the abusive behaviours by thepractitioners in healthcare should be adopted. This diversifies thenursing workforce in order to broaden the base for the potentialworkers. Throughout the time, the cost constraints driven by reducedMedicare, reimbursement(Duffield, 2008).

Bolsteringnursing educational infrastructure

Thefunding for nursing education must be increased. This includesscholarships, endowments and federal appropriations. This may alsoinclude the establishment of standardized residency program forpostgraduate. Team training must be emphasized in nursing education. Nursing career ladders should be created commensurate witheducational experience and educational level(El-Jardali &amp Lagace, 2005).

Establishmentof financial incentives for nursing investment

Newfederal monies should be made available for the healthcareorganizations to enable them invest in nursing services. The privatepayer may be aligned and federal reimbursement incentives used toreward the effective nursing staffing(Aiken &amp Clarke, 2006).

Safestaffing levels

Therehas been disagreement on relationship between patient outcomes andsafe staffing levels. Nurses have been in the forefront towardspatient surveillance in order to monitor the conditions of thepatients and detect any problem regarding the health of the patients.Lack of any skill set or slow response by the nurses can result toseverity of the condition of the patient. Recent studies indicatedthat high staffing needs reduce adverse outcomes in the life of thepatients. Many studies have succeeded in examining relationshipbetween risk of the patient complications and staffing levels. Forinstance, studies have indicated that few nurses during the nightshift increases the complications, length of stay in hospital andconsequent increment in costs(Duffield, 2008).

Insufficientstaffing adversely affects quality healthcare and the safety of thepatients. This also compromises safety of the nurses. There isincreased of needle stick injuries for nurses in low-staffedhospitals than those in other areas. The current staffing ratios areobjected at adding to the number of nurses. Healthcare organizationsshould assess their effectiveness in terms of staffing by screeningcontinually any potential issues that may arise from insufficient orinadequate staffing. In the assessment of the effectiveness ofstaffing, organizations must use data from human resources andnurse-sensitive indicators like patient falls and drug events amongothers. Healthcare organizations must select human resources andrelated clinical indicators in an effort to determine the staffingratios and related effectiveness(Marks, 2007).

Thestaffing levels have demonstrable and obvious effects on the abilityto provide quality and safe care by the nurses that enhances positivepatients` outcomes. The increased and improved staffing results toimproved patient care with higher employee satisfaction.

Improvedstaffing in healthcare settings is critical in enhancing healthcareoutcomes. It is estimated that five people die on a daily basis and145 sustain permanent injuries because of delayed healthcaredelivery. Nurses have been intrinsic on this goal. There have beenmany more nurses who have outlined the impact of staffing on safetyof patients and associated individual costs for the healthcareprovided. Linda Aiken, a US nurse academic, documented the effects ofstaffing in healthcare on the mortality levels of the patients.According to Aiken, the positive work environments on patientoutcomes may not be possible in cases where there is inadequatestaffing, which in most cases cause burnout and dissatisfaction amongthe nurses. The study simply demonstrated that more nurses areequivalent to the reduced number of deaths(Aiken &amp Clarke, 2006).

Researchindicates that nurses and patients in hospitals having a high numberof nurse-to-patient ratio have constantly reported positive outcomesthan those with the reduced number of staff. Improved staffing alsoreduces the mortality rate. According to Hugonnet (2007),availability of enough number of nurses acts as the key determinantof the infections in health care. Researchers also argue that themaintenance of appropriate nurse-to-patient ratios could reduce thenumber of infections and people in intensive care units(Hugonnet, 2007).

Theimproved care for fragile infants needs the high level of expertiseand skills. Nurses must be available and the organization shouldprovide all the resources necessary as well as delivering therequired care. Failure to these risks the lives of people andincreases vulnerability of patients. The impact of failing staff anddecreased retention rates has been rampant in US. Research shows thatadmissions to paediatric intensive care unit indicated that theoccurrence of the unplanned extubations was the most frequent adverseevent within those units. This was propelled by the reduced number ofnurse staffing and increased workloads for the available nurses.Unplanned extubation involves the infant removing the breathing tubeand this increases the risk of respiratory complications andincreases the duration of ventilation required. This is a risk factorfor the respiratory complications, increases the length of stay of aninfant in hospitals and may at other time die. The study indicated anincrease of unplanned extubations by four times with the acuity levelof the patient per nurse(Hugonnet, 2007).

Anotherstudy found out that the patient ratio was considerably higher andrelated to in-hospital mortality. Ratio of total nursing staff topatients acted as the best predictor of the in-house mortality. Inhis study, Cho et al. (2003) found out statistically significantcorrelations between patients’ outcomes and the nurse staffinglevels. An increased one hour, more than the normal working hours,led to 8.9 percent decrease in pneumonia casualties, while anincrease in the number of nurses by 10 percent resulted in 9.5percent decrease, in pneumonia cases. In relation to the costs, thefindings concluded that the adverse effects resulting from increasedlength of hospital stay as well an increased severity of thedisorder. Pneumonia was also associated with an increase of 220percent death and 84 percent increased costs due to delayed length ofstay. This relationship is a clear indication that pneumonia andregistered number of nurses underscore importance of increasedexpertise and knowledge for the registered nurses in order to providefor improved health care to the patients. The availability of enoughnumber of nurses ensures good infection control as well as preventsthe retained secretions that provide economic benefits and increasethe retention of the healthcare staffs(Cho, 2003).

Astudy in US, by Mark (2007), investigating the relationship betweenthe patients’ safety and nursing staffing in child care showed thata large number of working by registered nurses reduced significantlythe postoperative pulmonary infections. The magnitude of theinfections indicates that increased number of nurse staffing at arate on one hour per patient could avoid complications among thepatients at a considerable percentage(Marks, 2007).

Stone(2007) supported various studies on nurse staffing when he showedthat the increased rate of staffing reduced the incident ofpneumonia, blood infections and decubitus ulcers. In the study, stoneused the postoperative patient having severe psychological andphysical conditions. Such patients were vulnerable to all kinds ofinfections, but he noted that increased number of staffs couldprevent complications that can increase the length of stay inhospital and increased human and economic costs.

Anurse must ensure that the patient has a planned length of stay. Thisinvolves navigating through all admission and discharge.Nevertheless, this is prone to many variables that may prevent theprovision of healthcare as planned. Nursing must involve dealing withunpredictable, and involves care plans created by the nurses andconstant assessment of the activities of the nurses. The potentialproblems must be identified and actions taken quickly before theybecome severe. This requires experience, humanity and skills by thenurses.

Nursingworkload and patient outcomes(Hugonnet, 2007).

Thestaffing and workloads in nursing are intrinsically linked. Lack ofenough nurses increases the workload for the nurses available. Thisis equivalent to reduced time that is needed by a nurse to attend toother routine observations, wound care, patient education, paperwork,nutrition, counselling among others. Inadequate staffing andincreased workloads reduce the ability of a nurse to deliver thenecessary care and predispose them to increased fatigue and erroneousservice delivery. In consideration of the contribution of theincreased workloads to the outcomes of the patients, the care notdelivered by the nurses as they rush between the increased numbers ofpatients must be factored in(Rogers, 2008).

Atother times, nurses are compelled to leave some tasks undone as aresult of increased workloads. A study by El-Jardali and Lagace(2005) show that such unfinished tasks increase the frequency of theadverse effects on patient’s safety. Aiken (2006) demonstrated howthe increased workload among the nurses increased the likelihood ofdeath of the patients. Each additional patient for a given nurse wasassociated with an increased mortality rate of 7 percent andincreased the likelihood of dying by 30 days after admission. Thisshowed that the additional patients increased burnout of the nurse by23 percent and job dissatisfaction by 15 percent. According to thefindings, increased staffing for the registered nurses decreasedsubstantially the patients’ mortality and increased retention ratedue to reduced burnout and stress(Aiken &amp Clarke, 2006).

Anotherfactor affecting workload in nursing is churn, which is rarely takeninto consideration when doing the staffing allocations. Churn refersto constant and unpredictable nursing work aspect, especially whennurses are needed to accompany the patients to and from various areaswithin the healthcare institution. The patients may be suicidal,frail, on oxygen or even bleeding, hence requiring high levelclinical interventions. Moving the nurses away from the patients forindefinite periods exposes other patients to risks and increases theworking loads and stress among the nurses. Studies indicate thepatient’s acuity and severity of the injuries or illness of thepatient may also increase the nursing workload(El-Jardali &amp Lagace, 2005).

Rogers(2008) pointed out that the work duration number of hours worked andovertime affects the severity of the effects to the patients. Thestudy indicates that nurses that work more than recommended hourshave the high likelihood of making errors. The study depictsincreased nursing workload as a powerful predictor of the nosocomialinfections while hours devoted for healthcare were best predictor foradverse outcome indices. This is supported by Hugonnet (2004) whobelieved that understaffing and imbalance between the resources andworkload determined the nosocomial infections.

Themanagement of nursing workloads through provision of adequatestaffing is critical in improving quality and safety of the servicesoffered. Nurses allocated too many patients are not able to provideappropriate care. This usually risks the safety of the patients andincreases likelihood of nurses leaving the profession for other jobs(Rogers, 2008).Nurses experience high rates of exhaustion and increaseddissatisfaction rates. The high job burnout and dissatisfactionresult due to increased number of patients per nurse. Nurses cannotprovide the care required in the time allocated and the number ofpatients allocated.

Workloadis among the major concerns with constant reports on job stress anddeteriorating morale. Most of the healthcare professionals believethat their experience and skills are underpaid. Nurses often complainof the working being intense with reduced resources. Most of theextra hours worked normally go unpaid despite the work beingphysically demanding, emotionally challenging and dangerous at othertimes(Duffield, 2008).

Thestudy in Duffield (2007) nurses reported of undergoing emotional andphysical threats. Other nurses experience actual physical abuse withoccupational injuries being very common. Therefore, morale is low anddeteriorates consistently. The pay rates remain relatively low,making them consider working hours as inconvenient(Duffield, 2008).

Benefitsof improved staffing in healthcare

Aikenstudied the importance of improved staffing in health careinstitutions. He gave the example of magnet hospitals that recognisethe importance of nurses in all levels of hospital management andadministration hospital. According to this study, when nurses havethe autonomy and control of the practise settings, favourablerelationships with the patients, colleagues, families and anothersupport staff are guaranteed. The analysis by Aiken on magnethospitals and the effects of such environments on stability ofnursing workforce and quality of healthcare identified increasedautonomy for the nurses that allowed them control their work in abetter way. This improves care and enhances the nursing morale(Aiken &amp Clarke, 2006).

Theimproved staffing increased the job security for the nurses. Whenthey work in safe settings, nurses tend to be stronger, hence reducesinstances of injuries and severity of patients’ conditions. Theimproved work environment for the nurses also reduces errors andhelps in addressing underlying difficulties in retaining andrecruiting the nurses. Magnet hospitals are normally effective costwise as they reduce the staff turnover rates and the average cost perpatient through prevention of expensive complications. Such hospitalshave low mortality rates, low average length of stay, few intensivecare unit requirements, less pharmaceutical utilization fewer testsare carried out. Conversely, poor staffing potentially increases thenumber of errors that can increase the adversity of the patients`conditions(Marks, 2007).

Asurvey by department of health in 2012 summarised the evidence ofimpacts of the working conditions on the safety of the patient. Thereport indicated that working conditions affected the patientoutcomes, especially staffing level among licensed and unlicensednurses. Therefore, improved staffing can be an appropriate avenue toreduce stress and fatigue among the professionals in healthcare andreduce the risks of making the patients’ conditions become fatal.At least, this will reduce the number of errors made at work. Whethersuch errors result from poor administration of medication or failurein detecting the critical signs, the errors can be avoided andefforts should be made towards improvement of the safety of thepatient and delivery of quality care(Rogers, 2008).


Itis clear from the research that nurses play a major role inhealthcare surveillance, with one of the roles being identificationand correction of mistakes. Therefore, nurses should be extremelycautious in correcting such errors. However, due to unavoidablecircumstances, errors may occur while at work. This may be due todifferences in shift length or patterns. Such errors are normallyprofound and subsequent efforts must be emphasized to improve thequality of services and safety of the patient.

Therefore,improvement of staffing by the organization is an important factorthat reduces such errors that often stress the nurses and affects thehealth of the patients. Various studies indicate that appropriatestaffing is a predictor of satisfaction with the nursing profession.This is a reflection of increased autonomy for the nursingprofessionals for attracting and retaining the nursing practitionersas well as delivering quality services to the patients.


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Duffield,C. (2008). Glueingit together: nurses, their work environment and patient safety.Sydney: the University of Technology.

El-Jardali,F., &amp Lagace, M. (2005). Making hospital care safer and better:the structure process connection leading to adverse events.HealthcareQuarterly 8(2),40-48.

Hugonnet,S. (2007). The effect of workload on infection risk in critically illpatients. CriticalCare Medicine 35(1),76-81.

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