Nursing Literature Review: understaffing in primary care institutions
Nursing Literature Review
One of the significant nursing challenges in primary care institutions is understaffing, leading to a high nurse to patient ratio. Many states in the United States have tried to recommend the required nurse to patient ratios with the intention to improve the quality and safety of care. For instance, after the State of California mandated the lowest registered nurse to patient ratio, twelve other American states followed suit by creating nurse staffing policies to reduce workloads in healthcare organizations and improve care safety (He, Staggs, Bergquist-Beringer, & Dunton, 2016). The struggle by these and many other states reveals that there is a substantial relationship between nurse to patient ratio and patient safety. According to Carlesi, Padilha, Toffoletto, Henriquez-Roldán, and Juan (2017) explain that nurse a high nurse to patient ratio contributes to role overload, which is associated with adverse safety outcomes that comprise nosocomial conditions such as hospital-acquired infections. By seeking to answer the question on whether an increase in the nurse to patient ratio reduces patient safety, five research articles will be reviewed to confirm or reject the hypothesis: an increase in the nurse to patient ratios has a link with the decrease in patient safety.
Information from secondary sources ascertains that a high nurse to patient ratio increases the occurrence of negative, patient safety outcomes. For instance, Carlesi et al. (2017) conducted a quantitative cross-sectional study by reviewing medical records to determine any associated between workloads in nurses and the occurrence of patient safety outcomes in a Chilean public hospital. They estimated workloads in intensive care units (ICUs) through the completion of the Therapeutic Interventions Scoring System while using the nursing assistant to patient and nurse to patient ratios. These researchers analyzed their data using Pearson correlation, multivariate, and univariate analysis. After analyzing data from the workload of 157 nursing assistants, 85 nurses, and 879 post-discharge records, Carlesi et al. (2017) found a positive correlation between nurses’ workloads and patient fall rates. As a result, these researchers of this secondary source concluded that a high nurse to patient ratio, which results in role overload has an inverse relationship with adverse patient safety outcomes such as falls.
Similarly, Hall, Johnson, Watt, Tsipa, and O’Connor (2016) conducted a systematic review with the principal goal of exploring the link between the levels of burnout, which is attributed to understaffing of caregivers such as nurses and the safety of patients. They reviewed article sources that were accessed through a myriad of databases comprising Medline, Scopus, Embase, and PsychInfo. Out of the 27 studies, 16 established a significant correlation between worse patient safety and poor wellbeing of caregivers while 21 out of 30 studies found a substantial relationship between burnout attributed to understaffing and poor patient safety outcomes that comprise medical errors and patient morbidities and mortalities (Hall et al., 2016). Further, these researchers found that the wellbeing of nurses and other health professionals was worse in places with massive workloads due to understaffing. A similar trend was realized in situations associated with high levels of burnout. Therefore, this study concluded that understaffing was associated with poor wellbeing and high levels of burnout, all of which had a direct associated with the occurrence of adverse safety outcomes in patients such as medical errors.
Further, primary research provides sufficient evidence to confirm that nurse to patient ratios influence patient safety in healthcare organizations. For example, Magalhães et al. (2017) conducted a cross-sectional study to assess the influence of workloads and nursing team staffing levels on patient safety outcomes in different surgical and clinical units of a large university hospital in South Brazil. This study was conducted from 2013 to 2015 where the investigated factor was workload, which was expressed as the mean number of patients to that of nursing clinicians in day shifts and 24 hours. These researchers selected a sample of 502 nursing clinicians and 157,481 patients where they made 264 observations to determine safety outcomes. From the results, Magalhães et al. (2017) found that the ratios of patients per nursing technician and per nurse in days shifts were five to six and 14 to 15 per professional respectively. A significant associated was found between the workloads in the inpatient units and average satisfaction rates of patients, the rates of urinary tract infections associated with invasive procedures, and the length of hospital stay with nursing care. As a result, this study concluded that a rise in nursing team team workloads is an outcome of high nurse to patient ratios that significantly impact the safety and quality of patient care before recommending for adequate staffing.
Driscoll et al. (2018) found that the number of nurses in acute hospitals was lower to match the heightened demand of patients for quality care to meet different healthcare needs. As a result, they decided to conduct a systematic review and meta-analysis through which they examined the associated between the staffing levels of these clinicians and the nurse-sensitive patient outcomes in different acute specialist units. To access relevant secondary sources published within the English language between 2006 and 2017, nine electronic databases were used with the principal outcomes being nurse-sensitive patient outcomes. Out of the 3,429 unique articles that were found after the search process, only 35 met the inclusion criteria. All these articles were cross-sectional with most of them using large administrative databases. From the secondary data, Driscoll et al. (2018) found that the higher levels of staffing resulted in reduced medication errors, hospital-acquired infections, mortalities, restraint use, ulcers, and a greater number of patients on percutaneous coronary intervention and aspirin. Before recommending optimal staffing to improve nurse to patient ratios in acute care units, the study concluded that nurse to patient ratios have a massive influence on patient safety outcomes, such as mortalities and patient-acquired diseases.
Moreover, data from the renowned National Database of Nursing Quality Indicators reveals a strong inverse relationship between the different levels of nurse professional staffing and positive outcomes of patient safety. He et al. (2016) conducted a study to determine the longitudinal relationship between these levels of staffing for nurses and safety outcomes that comprise not only nosocomial infections but also falls. In this study, patient safety outcomes comprised the rates of hospital-acquired infections and inpatient falls while the staffing variables were the registered nurse skill-mix and the total nursing hours per patient days. He et al. (2016) found that the staffing variables had an inverse association with all the patient safety outcomes, which means that the higher the staffing levels, the lower the occurrence of adverse patient outcomes. As a result of these findings, this secondary source concludes that in different healthcare units, the levels of nurse staffing are indirectly associated with the occurrence of adverse patient safety outcomes.
Conclusion
Overall, high nurse to patient ratios results in massive nurse workloads, burnout, and dissatisfaction, all of which result in stress leading to a reduction in the quality and safety of care. The best strategy to reduce these ratios is by improving the staffing levels to have more nurses per a certain number of patients. When understaffing is prevalent, these ratios are high, which translates to few nurses taking care of many patients, hence role overload. Based on the review of the literature, an increase in the nurse to patient ratios due to understaffing in the presence of massive workloads, there is a likelihood of patients experiencing a decrease in the safety of care, which manifests through the occurrence of adverse safety outcomes.
References
Carlesi, K. C., Padilha, K. G., Toffoletto, M. C., Henriquez-Roldán, C., & Juan, M. A. C. (2017). Patient safety incidents and nursing workload. Revista Latino-Americana de Enfermagem, 25, e2841. http://doi.org/10.1590/1518-8345.1280.2841
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%2F1474515117721561
Hall, L. H., Johnson, J., Watt, I., Tsipa, A., & O’Connor, D. B. (2016). Healthcare staff wellbeing, burnout, and patient safety: A systematic review. PLoS ONE, 11(7), e0159015. http://doi.org/10.1371/journal.pone.0159015
He, J., Staggs, V. S., Bergquist-Beringer, S., & Dunton, N. (2016). Nurse staffing and patient outcomes: A longitudinal study on trend and seasonality. BMC Nursing, 15(1), 60. https://doi.org/10.1186/s12912-016-0181-3
Magalhães, A. M. M. D., Costa, D. G. D., Riboldi, C. D. O., Mergen, T., Barbosa, A. D. S., & Moura, G. M. S. S. D. (2017). Association between workload of the nursing staff and patient safety outcomes. Revista da Escola de Enfermagem da USP, 51. http://dx.doi.org/10.1590/s1980-220×2016021203255
