Evidence Builds for Better Hospital Staffing Saves Lives
For more than a decade, nurse researchers have recognized that low registered nurse staffing presents risks for patient outcomes and death. Now, a new study confirms the relationship between poor nurse staffing and mortality but also found the danger if the unit has low nurse support staffing.
“Staffing matters,” said Jack Needleman, PhD, FAAN, chair of the Department of Health Policy and Management at the University of California Los Angeles Fielding School of Public Health. “The study reinforces that. It adds to the literature that deals with the concern that high-staffed hospitals are different than low-staffed hospitals, and it raises issues about the work of nursing support staff and the role of nursing support staff as complementary to the RNs and ways in which shortages of nursing support staff affect the ability of the unit to keep patients safe.”
A different approach to staffing studies
Needleman and colleagues at Columbia University in New York analyzed data for more than 133,000 shifts from a three-campus academic medical center and considered shifts with less than 75 percent of the annual median staffing as being low staffed. The facilities were not in California, which has minimum nurse to patient ratios. Exceedingly low staffing as determine by nursing administrators at the facilities studied were excluded, as were surgical and mental health patients, those with community-acquired infections, and patients with a length of stay of less than three days.
The methodology used in this latest study differs from some earlier nurse staffing research, which tended to compare high- and low-staffed hospitals or reports from nurses about their last shifts. Needleman and colleagues controlled for factors beyond staffing, such as equipment or technology, by including only one hospital system.
“What is differing here is the shift-to-shift ability of the hospital to meet the expected, usual or target staffing,” Needleman said. “These studies provide strong indications that it is the staffing that makes the difference.”
Additionally, the recent Needleman study analyzed nurse support staffing levels, which included licensed practical nurses and nurse’s aides. The study also looked at the effect of patient turnover on mortality but did not find an affect.
Results show staffing matters
Overall, RN staffing was low on 10 percent of the day shifts and 9 percent at night. Intensive care units had more shifts with low RN staffing than other units. For nursing support staff, 22 percent were considered low on day shifts and 23 percent for night shifts. ICUs also were more likely to be short on support staff than other units. Forty-four percent of shifts with low RN staffing also had low nurse support staffing.
“When we just analyzed the RN staffing, we saw a clear association between nurse staffing and patient outcomes,” Needleman said.
During the course of the six-year study, mortality declined from 4.2 percent in 2007 to 3.6 percent in 2012. The researchers found mortality associated with low RN staffing, low support staffing and during instances in which both RNs and support staff members were low.
The researchers hypothesize that when nurse support staff levels are low it means fewer eyes on the patient. Support staff might pick up on a change in condition and call it to the nurses’ attention. Additionally, it could be due to RNs taking responsibility for support staff duties, such as delivering food trays, gathering supplies or transporting patients, leaving RNs with less time to properly care for patients.
“They are competing [theories] and potentially complementary,” Needleman said. “Additional research will be needed to differentiate.”
Interestingly, a British study published in the August 2019 issue of BMJ Quality & Safety found that while high nursing assistant staffing was associated with increased mortality as was low nursing assistant staffing. Needleman suggested several factors could be at play, such as when a ward has poor nurse staffing, administration might bring in more assistants. That British study found low RN staffing was associated with worse patient safety than when RN staff is satisfactory. Additionally, nursing assistants may complete different tasks in the United Kingdom.
More research is needed to determine reasons for nursing support staffing’s influence on patient outcomes, how the work of RNs and nursing support staff are integrated, and how the work changes when one or the other or both are below the level needed.
“Our finding that the risk is intensified when support staffing for nurses is low, and the effect may be intensified when both RN and nursing support staffing are low is a new finding,” the authors wrote in a BMJ Quality and Staffing article. “Whatever the staffing model at an institution, our results suggest that shortfalls from typical or targeted staffing in both RN and nursing support staffing can have negative consequences for patients.”