Nurse-Staffing Levels and the Quality of Care in Hospitals

Needleman, Jack; Buerhaus, Peter I.; Mattke, Soeren; Stewart, Maureen; Zelevinsky, Katya

doi:10.1056/nejmsa012247

Cited by 1,901 publications

(1,514 citation statements)

References 35 publications

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“…Our findings resonate with research that highlights the associations of staffing levels of different nursing staff with patient outcomes and quality of nursing care services (Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002). This indicates the potential significance of missed care as a consequence of inadequate nurse staffing resources, although the relationship between missed nursing care and mortality is as yet uncertain.…”

Section: Discussionsupporting

confidence: 87%

What impact does nursing care left undone have on patient outcomes? Review of the literature

Recio‐Saucedo

Dall’Ora

Maruotti

et al. 2017

Journal of Clinical Nursing

327

304

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Aims and objectivesSystematic review of the impact of missed nursing care on outcomes in adults, on acute hospital wards and in nursing homes.BackgroundA considerable body of evidence supports the hypothesis that lower levels of registered nurses on duty increase the likelihood of patients dying on hospital wards, and the risk of many aspects of care being either delayed or left undone (missed). However, the direct consequence of missed care remains unclear.DesignSystematic review.MethodsWe searched Medline (via Ovid), CINAHL (EBSCOhost) and Scopus for studies examining the association of missed nursing care and at least one patient outcome. Studies regarding registered nurses, healthcare assistants/support workers/nurses’ aides were retained. Only adult settings were included. Because of the nature of the review, qualitative studies, editorials, letters and commentaries were excluded. PRISMA guidelines were followed in reporting the review.ResultsFourteen studies reported associations between missed care and patient outcomes. Some studies were secondary analyses of a large parent study. Most of the studies used nurse or patient reports to capture outcomes, with some using administrative data. Four studies found significantly decreased patient satisfaction associated with missed care. Seven studies reported associations with one or more patient outcomes including medication errors, urinary tract infections, patient falls, pressure ulcers, critical incidents, quality of care and patient readmissions. Three studies investigated whether there was a link between missed care and mortality and from these results no clear associations emerged.ConclusionsThe review shows the modest evidence base of studies exploring missed care and patient outcomes generated mostly from nurse and patient self‐reported data. To support the assertion that nurse staffing levels and skill mix are associated with adverse outcomes as a result of missed care, more research that uses objective staffing and outcome measures is required.Relevance to clinical practiceAlthough nurses may exercise judgements in rationing care in the face of pressure, there are nonetheless adverse consequences for patients (ranging from poor experience of care to increased risk of infection, readmissions and complications due to critical incidents from undetected physiological deterioration). Hospitals should pay attention to nurses’ reports of missed care and consider routine monitoring as a quality and safety indicator.

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Section: Discussionsupporting

confidence: 87%

What impact does nursing care left undone have on patient outcomes? Review of the literature

Recio‐Saucedo

Dall’Ora

Maruotti

et al. 2017

Journal of Clinical Nursing

327

304

View full text Add to dashboard Cite

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“…Secondly, the medical subset of patients (medical patients) was examined and finally the surgical subset of patients (surgical patients) was examined. For the second data file, these analyses were repeated for each of the four ward categories A, B, C and D. These groupings were used as previous studies suggest differences between medical and surgical patients or the studies were limited to only one type of patient ([Aiken et al, 2002], [Needleman et al, 2002] and [Tourangeau et al, 2006]). …”

Section: Resultsmentioning

confidence: 99%

The impact of the nursing hours per patient day (NHPPD) staffing method on patient outcomes: A retrospective analysis of patient and staffing data

Twigg

Duffield

Bremner

et al. 2011

International Journal of Nursing Studies

114

112

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BackgroundIn March 2002 the Australian Industrial Relations Commission ordered the introduction of a new staffing method -nursing hours per patient day (NHPPD) -for implementation in Western Australia public hospitals. This method used a "bottom up" approach to classify each hospital ward into one of seven categories using characteristics such as patient complexity, intervention levels, the presence of high dependency beds, the emergency/elective patient mix and patient turnover. Once classified, NHPPD were allocated for each ward. ObjectivesThe objective of this study was to determine the impact of implementing the NHPPD staffing method on 14 nursing-sensitive outcomes: central nervous system complications, wound infections, pulmonary failure, urinary tract infection, pressure ulcer, pneumonia, deep vein thrombosis, ulcer/gastritis/upper gastrointestinal bleed, sepsis, physiologic/metabolic derangement, shock/cardiac arrest, mortality, failure to rescue and length of stay. Design and settingThe research design was an interrupted time series using retrospective analysis of patient and staffing administrative data from three adult tertiary hospitals in metropolitan Perth over a 4-year period. SampleAll patient records (N = 236,454) and nurse staffing records (N = 150,925) from NHPPD wards were included. ResultsThe study found significant decreases in the rates of nine nursing-sensitive outcomes when examining hospital-level data following implementation of NHPPD; mortality, central nervous system complications, pressure ulcers, deep vein thrombosis, sepsis, ulcer/gastritis/upper gastrointestinal bleed shock/cardiac arrest, pneumonia and average length of stay. At the ward level, significant decreases in the rates of five nursing-sensitive outcomes; mortality, shock/cardiac arrest, ulcer/gastritis/upper gastrointestinal bleed, length of stay and urinary tract infections occurred. ConclusionsThe findings provide evidence to support the continuation of the NHPPD staffing method. They also add to evidence about the importance of nurse staffing to patient safety; evidence that must influence policy. This study is one of the first to empirically review a specific nurse staffing method, based on an individual assessment of each ward to determine staffing requirements, rather than a "one-size-fits-all" approach.What is already known about the topic?• Higher nurse staffing levels have been linked with improved patient outcomes.• This evidence has resulted in some states and jurisdictions legislating or mandating nurse staffing.• The available evidence does not provide specific guidelines for nurse staffing, either in terms of the amount of care required or skill mix of the nurses providing care at a unit level. What this paper adds• This study empirically reviews a specific nurse staffing method, based on an individual assessment of each ward to determine staffing requirements, rather than a "one-size-fits-all" approach.• It provides evidence that implementation of the NHPPD staffing method decreased nursingsensi...

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“…It can be seen that help with feeding, and staffing levels, are factors that can be modified with a view to improving nutritional status. The relationship between staffing levels and other quality indicators have been documented in the USA (Needleman et al, 2002) and Australia (Braithwaite, 2001). It is not surprising that a relationship between staffing levels and nutritional status is also observed in the residential care setting.…”

Section: Discussionmentioning

confidence: 98%

Low staffing level is associated with malnutrition in long-term residential care homes

et al. 2005

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Objective: To determine if staffing level is associated with poor nutrition in the long-term residential care setting, adjusting for other confounding factors. Design: Cross-sectional survey. Setting: In total, 14 residential care facilities in Hong Kong, stratified by nature (government subvention or for-profit) to reflect the overall proportion in Hong Kong. Subjects: A total of 1914 subjects were assessed, using the Resident Assessment Instrument (RAI) 2.0. The response rate was 95% (1820 subjects), of which 1699 subjects had complete nutritional information. Intervention: Body mass index (BMI) was calculated by weighing and height measurement, and arm span was used if the subject could not stand. Subjects who were receiving parenteral or enteral nutrition via nasogastric of enterostomy tubes were excluded. A history of weight loss of 5% in the past month or 10% in the past 6 months, leaving 25% of food uneaten, and BMI o18.5 kg/m 2 were examined as nutritional indicators. Association with age, gender, functional disability, oral problems, taste problems, presence of physical diseases and psychological well-being was examined using w 2 -test, and multiple logistic regression. Results: In all, 26% of residents had a BMI o18.5 kg/m 2 , with a higher prevalence in the for-profit homes. History of weight loss and the record that 25% of food was left uneaten were poor indicators of low BMI. Multivariate analysis showed that having chronic obstructive airways disease, requiring help with feeding, being female, older age, were factors associated with an increased risk of poor nutrition, while being independent in activities of daily living and higher staff levels were associated with a reduced risk. Conclusion: Poor nutrition is a persistent problem in the long-term care setting, and inadequate staffing levels may be a reversible cause. However, resource limitations may render efforts at improvement difficult. Sponsorship: SK Yee Memorial Fund.

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Nurse-Staffing Levels and the Quality of Care in Hospitals

Abstract: A higher proportion of hours of nursing care provided by registered nurses and a greater number of hours of care by registered nurses per day are associated with better care for hospitalized patients.

Cited by 1,901 publications

References 35 publications

What impact does nursing care left undone have on patient outcomes? Review of the literature

What impact does nursing care left undone have on patient outcomes? Review of the literature

The impact of the nursing hours per patient day (NHPPD) staffing method on patient outcomes: A retrospective analysis of patient and staffing data

Low staffing level is associated with malnutrition in long-term residential care homes

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