Impact of Understaffing Nurses and Impacts on Patient Safety

Nurse staffing ratios and shorthanded staff in both day and night shifts effect not only nurse satisfaction but also has a big impact in patient experience, safety, and outcomes. Despite the amount of research supporting appropriate and safe nurse staffing it is still a big problem for hospitals to manage. This paper will explore the influence of understaffing nurses and the negative effects on patient safety measured through the patient’s health, wellbeing and outcomes. Depending on the department (ICU/CCU, cardiac unit, medsurg, etc) understaffing has an affect in various ways compared to that of a less acute patient versus that of a higher acuity. Regardless, these patients are vulnerable to a lack of surveillance, medication errors and lack of basic care. These are direct examples of the effects of shorthanded staffing. Indirect consequences may include erroneous documentation, lack of managing important nursing tasks such as obtaining vital signs and overall lack of nurse wellbeing due to not having a break nurse or charge nurse or both. With the appropriate number of nursing staff and ratio will result in better patient experiences, outcomes, and decreased hospital acquired infections and mortality.

 In the past few decades there has been many changes in the nursing community, specifically, in what dictates an appropriate level of nurse staffing and ratio. Although on paper it may seem easy to accommodate each patient with the appropriate number of nurses but as Driscoll, Grant, Carroll, et al (2018) stated managers try to “understand the influence of the multiple factors that make up each individual care”. These factors include managers understanding the patient acuity and dependency nature, patient throughput and the current nurse skills and scheduled staff for the day and night shift. Halm (2019) iterates “in order to fully incorporate assessment of patient risk, a multitude of factors should be considered when planning the number of staff and skill mix needed on a given shift”. These factors were previously stated, in addition, to teamwork with supportive services and interprofessional collaboration. In conjugation of determining these factors three staffing models are utilized by hospitals. The first is a budget-based model. In the budget-based model nursing staff is allocated according to nursing hours per patient day. Nursing hours refers to the total number of hours worked by all nurses on the unit for a given time period, which is usually a twenty-four-hour period. Total patient days reflects the average number of patients in a day. The second model is the nurse-patient ratio. This model is calculated through the number of nurses per number of patients or patient days. A pure nurse-patient ratio will not consider individual patient needs or nursing judgement. This model will usually be used in combination with the budget-based staffing. Lastly, the patient acuity is utilized when the patient characteristics are used to determine a shift staffing need. This model considers the complexity of care needed by certain patient diagnosis, comorbidities and severity of illness. Managers who are responsible for staffing using this model should consider more than just how long it takes to do certain nursing tasks such as performing initial assessments, taking vitals and administering medications. Those responsible need to consider the full scope of nursing practice. The scope of nursing practice according to the American Nurses Association (ANA) include: assessment, nursing diagnosis, identifying outcomes, planning, implementation, coordination of care, health promotion and teaching, consultation, evaluation and prescriptive authority and treatment for those of advanced practice registered nurses. Some patient characteristics considered for their acuity include: age, diagnosis, severity of illness, comorbidities, socioeconomic status, ability to provide self-care, anticipated length of stay, family and/or other caregivers that are included in patient education and plan of care. Most organizations will use a combination of models and tailor them to the nursing culture and specific needs.

 Another factor for scheduling and staffing is reimbursement. Since the 1980s the hospitals nurse staffing was based on the number of beds, even if the beds were not being used. Since the reimbursement change, hospitals have been trying to control costs by matching nursing resources to the average census. Two types of variability is utilized and are as follows: artificial and natural. Artificial variability is controlled by surgical schedules. Natural variability results from factors we cannot control, such as, the flow of Emergency Department (ED) patients, natural disasters or mass-casualty events. Artificial variability is easily managed by involving surgeons to work on elective and nonemergency surgeries over a course of a week or two. This will better manage the needs of the unit(s) and appropriate hospital staffing in accordance to type of surgeries, account of average emergent surgeries from previous year statistics, and hospital throughput. Natural variability includes clinical variability and professional variability. Clinical variability is characterized by the differences among the patient’s diseases, signs and symptoms, and socioeconomic factors. Direct-care nurses are affected the most and can be managed in several ways. Depending on the hospital processing organization and available resources a Registered Nurse (RN) patient assignment may have patients who are either all diabetic, all having heart failure, or all with pneumonia. The other option would to mix the type of patient characteristics where one is diabetic, one pneumonia and one with heart failure assigned to one RN and the other RNs to have similar assignments. Professional variability related to how physicians, nurses and others practice along with their schedule. This type of variability affects the patient’s progress, census and length of unnecessary delays. Staff skills, motivation, mentoring nursing students and variations in beliefs are main factors that influence staffing and scheduling with professional variability. Regardless, a unit needs to properly staffed and with doing so “studies do report the higher the level of nurse staffing, the greater the reduction in inhospital mortality” (Driscoll, Grant, Carroll, et al. 2018).

 To decrease the healthcare costs direct-care nurse, or bedside nurse, have been pressured to show an impact on patient outcomes using nursing-sensitive indicators. A lot of this data is collected and analyzed to accommodate and properly staff specific units based on these indicators. Some indicators may include: catheter-associated urinary tract infections, thirty-day mortality, patient falls, longer lengths of stay, pressure injuries, failure to rescue, intravenous infiltrations, upper gastrointestinal bleeding, nosocomial infections, shock, patient restraint use, pneumonia, and pain management, etc. With these considered managers, staffers and direct-care nurses can provide their input and improve the patient care, quality and processing with proper staff levels. Although managers and staffers try to consider staff calling off sick or floating to another unit there are other factors that go unforeseen, such as direct admissions, number of expected discharges and delays of discharging. Bedside nurses are then looked upon for their input because they are at the point of providing care and can make suggestions to improve the process. With this we will dive into nursing delivery models and care delivery models.

 Every unit and each hospital have a specific model or combination of models for nursing care. There are five different nursing delivery models which include: primary nursing, float nursing, team-based nursing, functional nursing and modular nursing. Some care delivery models are as followed. Primary care team models have a nurse care manager partnered with another nurse in which they are responsible for a specific group of patients. A twelve-bed hospital model has a registered nurse who acts as a patient-care facilitator for a small group of patients, about twelve, and coordinates all care and serves as a liaison for the other healthcare team members involved in each patient care. A transitional care model has a registered nurse assigned to a patient at admission, who coordinates the patient’s care throughout the hospital stay and follows the patient through discharge for up to three months after. In a planetree patient centered model all staff members are considered as caregivers and patients are partners in their care. In a hospital at home an acute hospital-level are is given at home with registered nurses visiting once to twice daily to assess the patient, assess and administer infusions and provide education/evaluations. Whichever, the hospital or unit a registered nurse is working a consistent model should be followed and implemented with clear roles and responsibilities. Without this proper staffing will be insufficient and confusion will disorientate the health care team resulting in inconsistent patient outcomes and “adverse events” (Glette, Aase and Wiig, 2017).

 Appropriate nurse staffing and ratios are difficult to achieve. Although there are some guidelines and models a hospital and unit specific variabilities the staffing and ratios will not be perfect. Managers strive to achieve and better staff each unit based on calculated and collected data from previous years and research-based practices from within itself or by observing other hospitals current practices. Many factors come into play when deciding the right amount of staff to assign to a floor and ratios to follow depending on the state. With the help of direct care nurses or previously known as bedside nurses, staffers and managers can improve predictions, patient throughput, experience and outcomes. There will always be room for improvement for a policy and/or practice especially when it involves nurse staffing.

References

• Driscoll, A., Grant, M. J., Carroll, D., Dalton, S., Deaton, C., Jones, I., … Astin, F. (2018). The effect of nurse-to-patient ratios on nurse-sensitive patient outcomes in acute specialist units: a systematic review and meta-analysis. European Journal of Cardiovascular Nursing, 17(1), 6–22. https://doi.org/10.1177/1474515117721561
• Glette, M. , Aase, K. and Wiig, S. (2017) The Relationship between Understaffing of Nurses and Patient Safety in Hospitals—A Literature Review with Thematic Analysis. Open Journal of Nursing, 7, 1387-1429. doi: 10.4236/ojn.2017.712100.
• Halm, M. (2019). The influence of Appropriate Staffing and Healthy Work Environments on Patient and Nurse Outcomes. American Journal of Critical Care, 28(20), 152-156. https://doi-org.summit.csuci.edu/10.4037/ajcc2019938.