Running head: NURSE STAFFING 1

Nurse Staffing and the Impact on Quality of Patient Care

Allison B. Hensley, RN

James Madison University

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Abstract

The aim of this paper is to bring light to the potential consequences patients may face when

nurses are understaffed. Patients may experience both direct and indirect repercussions, ranging

in severity from patient dissatisfaction to patient mortality. Less than ideal working

environments have pushed nurses away from the practice, exacerbating the nursing shortage

(Carayon & Gurses, 2008). Low staffing among nurses and it’s adverse effect on patients has

generated many studies, in which findings have been used in support of new staffing laws and

regulations. Improved patient outcomes have been correlated to increased staffing (Mitchell et

al., 2018). Nurses are encouraged to be an advocate for this issue, voicing their concerns through

committees and state legislators.

Keywords: patient safety, understaffing, adverse patient outcomes, missed care, mortality
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Nurse Staffing and the Impact on Quality of Patient Care

Increased patient to nurse ratios compromise the quality of patient care due to excessive

workloads that force nurses to postpone or omit duties, creating an environment that has the

potential to produce negative patient outcomes. In some cases, rationing care may lead only to a

disgruntled patient. However, all too frequently, missed care has resulted in patient mortality. In

many focused studies, limitations in the quality of care provided for patients has been closely

correlated to understaffed units (Glette et al., 2017). The focus of this paper will revolve around

the specific threats an understaffed nursing unit can pose towards the quality of patient care,

patient safety, patient satisfaction, and patient outcomes. In conclusion, a course of action will be

highlighted in which nurses can find a voice in the matter and advocate, in turn contributing to

increased awareness across the nation.

Nurse Staffing

Background

The overwhelming reports of understaffed nursing units is not a new concern. For

decades, the issue of low staffing has been on a steady rise. Many studies have been done to

bring to light the cause, effect, and potential consequences of this matter. The cause has been

found to have multiple variables, including lower retention rates and a higher demand for nurses

(Carayon & Gurses, 2008). Within pinpointing the direct effect this has on patients, numerous

factors must be considered. Dissimilar methods in research have shown to produce divergent

outcomes due to variables such as patient health status, units or hospitals involved, and location

of the study (Glette et al., 2017). More research on this issue is essential to understanding the

underlying mechanism associated between low staffing and quality of patient care. Evidence
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based findings that have proven a perilous correlation have been used to advocate for mandatory

minimums among staffing (Griffiths et al., 2018).

Adverse Effects

Direct

In situations where the patient to nurse ratio is high, patients may experience negative

consequences with varying degrees of severity (Glette et al., 2017). We can categorize the results

into both direct and indirect outcomes of missed care among patients. A literature review was

conducted in 2017 in which 33 studies were incorporated in attempts to directly link the

understaffing of nurses to increased risk factors in patient safety (Glette et al., 2017). Of the 33

studies, 23 were found to tie severe patient consequences directly to low staffing levels (Glette et

al., 2017). These consequences included direct patient harm, involving hospital acquired

infections (HAI’s), hospital acquired pressure ulcers, patient falls, medication errors and patient

mortality (Glette et al,. 2017). Another literature review completed in 2015 focused more closely

on the occurrence of hospital acquired infections alone. The results were posted within The Joint

Commission Journal on Quality and Patient Safety, suggesting that an increase in nursing staff

was positively correlated to a decrease in HAI’s (Mitchell et al., 2018).

Indirect

The outcomes listed above are grievous, although indirect consequences on the patient

can cause just as much of an issue. According to Glette, Aase and Wiig (2017), “Six studies

found understaffing to affect patient safety, not by causing direct patient harm but by increasing

the risk for direct harm later on” (p.1400). When a short staffed unit causes a heavier workload,

the nurse may take part in “implicit rationing”, in which certain tasks are postponed or left out

(Griffiths et al., 2018). Within this, the nurse may find providing quality patient care to be quite
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unattainable. Lack of documentation, vital signs, patient communication, and poor basic care

including oral hygiene and skin care were all found to cause an indirect threat to the patient’s

safety (Glette et al., 2017). As mentioned previously, indirect risks to the patient have the

potential to escalate into a critical situation. For example, the nurse may postpone applying

sequential compression devices to her patient, which may result in the patient developing a deep

vein thrombosis later on.

When a person becomes a patient, he or she is fully reliant on healthcare professionals for

a desired result. When the patient is harmed within the place they came to seek care, mistrust

occurs, causing a domino effect. Not only does the patient suffer, but now his or her family,

friends and even community obtain doubts aimed towards the hospital’s ability to properly care

for its patients. This is only one of the many reasons that advocating for staffing standards is

necessary within the healthcare system.

Bring to Light

According to the US Department of Health and Human Services, patient safety is

defined as, “the freedom of accidental or preventable injuries produced by medical care.” (Glette

et al,. 2017) From the moment we decided to become a nurse, the importance of patient safety is

engraved within our minds. In fact, the very code of ethics we base our practice on promotes the

protection of patient rights, health and safety within provision number three (Lachman et al.,

2015). According to law, the nurse has a shared responsibility within the healthcare system to

conduct actions in a professional manner, within an environment created in support of the nurse

(Glette et al., 2017). Issues arise when the nurse feels as if he/she is incapable of providing

quality care, not due to lack of skill, but related to issues which are not within the nurse’s power

to change. According to the American Nurses Association, an increasing nursing shortage, as

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well as massive budget cuts have created an environment in which less nurses are working

longer hours, in turn placing patients at risk (“Safe staffing”, 2019).

Taking Action

Fully implemented in 2004, California became the first state to pass a law in which a

legal maximum patient to nurse ratio was enforced (“Safe staffing”, 2019) Shortly thereafter,

California reported an overwhelming number of registered nurse applicants from other states

(“Safe staffing”, 2019). After notable success in achieving its main goal of improving quality

patient care, many other states followed in California’s footsteps, placing new laws or

regulations addressing nurse staffing levels (“Safe staffing”, 2019). It is encouraging to see the

changes being made. However, the issue of short staffing has not been eradicated. As nurses, it is

important to make our voices heard. Ways in which we can make a change include speaking up.

Joining workplace committees, being familiar with legislation in our state, and documenting the

challenges faced are all ways in which we can help.

Conclusion

Patient safety and quality of care is of utmost importance. Nurses strive to maintain a safe

and therapeutic environment, but oftentimes find themselves fighting against the odds.

Understaffed units pose threats to patients through both direct and indirect consequences of

rationed care. For decades this issue has been linked to unfavorable patient outcomes. New

regulations and laws are on the rise, which through implementation have shown positive results.

However, only 14 states possess laws directly obtaining to staffing levels (“Safe staffing”, 2019).

Nurses must continue advocating for safe staffing levels by staying informed and getting

involved.
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References

Carayon, P., & Gurses, A. (2008). Nursing workload and patient safety - A human factors

engineering perspective. In R. Hughes (Ed.), Patient safety and quality: An evidence-

based handbook for nurses (Ch. 30). Retrieved from

https://www.ncbi.nlm.nih.gov/books/NBK2657/

Glette, M. K., Aase, K., & Wiig, S. (2017). The relationship between understaffing of nurses and

patient safety in hospitals - A literature review with thematic analysis. Scientific

Research An Academic Publisher, 7(12), 1387-1429. Retrieved from https://m.scirp.org/

Griffiths, P., Recio-Saucedo, A., Dall'Ora, C., Briggs, J., Maruotti, A., Meredith, P., Ball, J.

(2018, April 23). The association between nurse staffing and omissions in nursing care: A

systematic review. Journal of Advanced Nursing, 74, 1474-1487.

http://dx.doi.org/10.1111/jan.13564

Lachman, V.D., Swanson, E.O., & Windland-Brown, J. (2015). The new ‘code of ethics for

nurses with interpretive statements’ (2015): Practical clinical application, part ll,

MEDSURG Nursing, 24(5), 363-36, 368

Mitchell, B. G., Gardner, A., Stone, P. W., Hall, L., & Pogorzelska-Maziarz, M. (2018). Hospital

staffing and healthcare-associated infections: A systematic review of the literature. The

Joint Commission Journal on Quality and Patient Safety , 44, 613-622. http://dx.doi.org/

https://doi.org/10.1016/j.jcjq.2018.02.002
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Safe staffing: Critical for patients and nurses. (2019). Retrieved from

https://dpeaflcio.org/programs-publications/issue-fact-sheets/safe-staffing-ratios-

benefiting-nurses-and-patients/