Nursing care impact on patient outcomes

This is the second article I have written about the size and reach of nurse shortages, focused on the US market. In April, I summarized my findings about the shortage itself - that earlier-than-normal retirements, young nurses changing careers, and an aging population combine to a current shortfall of 100,000-200,000 nurses vs what is demanded by the US system - and growing. Here, I go beyond this high-level summary to better understand the impact: what is the clinical impact of the shortage on patient care, specifically in US hospitals?

Measuring nursing adequacy

Over the past 2 decades, a significant body of research has established the link between nurse staffing and patient outcomes in the hospital setting. Staffing is defined either by the total full-time equivalents working in a hospital relative to the number of patients under its care, or the number of hours of nursing care per patient. Both measures have been inversely correlated with patient mortality and failure to rescue (FTR), which is defined as the failure to prevent a death resulting from a complication of medical care or from a complication of underlying illness or surgery. Similarly, lower nurse hours per patient correlated with longer length of stay. And when staffing targets weren’t met, mortality increased.

Nurses are trained medical personnel that spend most of the time with the patient, constantly monitoring the wellbeing of a patient from a medical and psycho - social perspective. They coordinate care, monitor and administer medications and treatments, and are the first to detect issues with patient health. Nurse staffing levels directly impact patient outcomes. For example - intensive care unit nurses (it is of course relevant for any nurse in any hospital setting) who are usually assigned one critical patient. Now they may be caring for three due to staffing shortages, increasing the chance that patients miss care or that medical errors occur.[1]. And having in mind the first article - it also can increase the chance that nurses feel overwhelmed, leading to burnout, continuing the cycle of staffing shortages.

Why appropriate staffing is crucial to patient safety

Nurse teams are the sentinels of healthcare safety, monitoring patients 24-hours a day and responding to their needs in real-time. Such responsibilities require constant vigilance from nurses who have the right skills and experience to handle their patients care and specific needs.

Appropriate nurse staffing is complicated and involves many variables, from nurse skill mix to patient acuity, but at its most basic, having enough nurses at the bedside to effectively monitor and respond to patients and their needs is imperative for quality management. Because of this, it makes sense that research has tied so many safety and quality indicators to nurse staffing. Nurse-to-patient ratios and overall nurse workload are linked to safety factors like medication errors and contracting pneumonia[2].

I think it's fair to say that the impact on patients can be broken down into two large areas:

• What had to be done and was not done at all (“Missed Tasks”).
• What had to be done and was done in the wrong manner (“Mistakes”).

The consequences of poor staffing: Missed tasks

No matter the industry, having fewer employees available to do the same amount of time-sensitive work will not only make the work take longer, but will cause the quality of that work to suffer. That, in turn, raises the alarm about safety for both patients and staff.

Numerous studies show the consequences of poor staffing on quality management and patient outcomes in healthcare settings.

Let's have a look at some examples of what had to be done and was not done at all:

• An article published in Patient Safety Network stated that the prevalence of missed nursing care appears to be high, both in the United States and internationally. In a systematic review of 42 studies, 55%–98% of nurse respondents reported missing one or more items of required care during the time of assessment (frequently the last shift worked). Investigators concluded the activities most frequently missed are those related to emotional and psychological needs, rather than those related to physiologic needs. For example, one measurement approach found that ambulation, turning, and mouth care were among the most frequently missed aspects of care. This resulted in pressure ulcers and bad mouth hygiene (potentially life-threatening conditions in elderly patients). Another approach found surveillance activities were most frequently missed[3].
• If we take a simple but basic item such as vitals charting, a retrospective observational study in the UK found that late and missed observations were frequent, particularly in high acuity patients when RN staffing was not met. Higher levels of RN staffing, measured in hours per patient per day (HPPD), were associated with a lower rate of missed observations in all and high acuity patients.
• It is also both interesting and important to view the patient perspective on missed activities. An article that performed scoping review of Missed Care from the Patient’s Perspective states the following: to begin with missed basic care, mouth care (missed 32.1–50.3% of the time), ambulation (missed 20.3–41.3% of the time), lifting to a chair (missed 38.8% of time), bathing (missed 26.9% of time), assistance with hand washing (missed 29.4% of time) and support for changing position (missed 17% of time) were recognized as missed. Moreover, activities categorized as missed communication included nurses providing necessary information to patients and families (missed 11.9–27% of the time), discussing the treatment plan with patients (missed 26.5% of time), considering patient’s opinions (missed 20.4% of time), patient knowing who their assigned nurse was (missed 11.2% of time), and listening to patient (missed 7.8% of time)[4].

The consequences of poor staffing: Mistakes

And here are some examples of what had to be done and was done in the wrong manner:

• O’Brien-Pallas et al. investigated the association of NPRs with nurse-sensitive patient outcomes. They calculated the NPR as the average number of patients cared for daily by a nurse on day shift during the data collection period. Their outcomes included: deep vein thrombosis, pressure ulcers, falls with injury, medical errors with consequences, pneumonia, catheter-associated urinary tract infection and wound infections. Researchers analyzed an administrative dataset of 1230 patients from 24 cardiac and cardiovascular units from six hospitals. They found that for every additional patient per nurse, patients were 22% less likely to experience ‘excellent or good quality care’ and 35% more likely to experience a longer than expected length of stay.
• An article in the IOSR Journal of Nursing and Health Science examined fluid balance monitoring accuracy in intensive care units. 65% of fluid balance recorded in patients’ folders were accurate and 35% were inaccurate. Major reasons for the errors were reported to be workload and time management (as a result of inadequate staffing).
• An article published in International Nursing Review found that the most common medication error was ‘inappropriate time (before/after meal) for administering drug’. The researchers’ experiences in different hospitals indicate that nursing shortages and high workloads result in increased work pressure. The consequences being mealtime-related medication orders are not considered when starting or finishing medications. In most cases, they do not follow the before/after meal order of the medications. The drug-drug, food-drug, and herb-drug interactions affect pharmacokinetics and pharmacodynamics. Drugs efficacy relies on administration in appropriate quantities with the appropriate combination of drugs and foods and at appropriate time.

Is anybody paying attention?

The problem is widespread and has gained the attention of leaders and policy shapers. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has added a new standard for accreditation requiring organizations to “use data on clinical/service screening indicators in combination with human resource screening indicators to assess staffing effectiveness”.

Some states have begun to pass legislation to limit patient-to-nurse ratios. Despite this, when staffing is short, ratios go up to meet the need.

As leaders in the healthcare industry begin asking the right questions: is the current staffing model correct? What can be done to improve the staffing models? The actions above are definitely a step in the right direction.

Yet, a workload management method is one way to ensure a proper fit between patient needs and nursing staff. A nursing workload management method needs to have the following characteristics: easy to interpret; limited additional registration; applicable to different types of hospital wards; supported by nurses; covers all activities of nurses and suitable for prospective planning of nursing staff. At present, no such method is available[5].

Conclusion

Nursing shortages are a widespread problem that impact patients’ outcomes (increased mortality being one example) in healthcare organizations. Shortages heavily impact nursing burnout and contribute to unnecessary spend of dollars. This is crucial for organizations that historically run on strict budgets. The problem has obviously caught policy shapers' attention and there are some steps being done to try and tackle the problem. But these changes are a passive reaction to an already existing problem. There are many ways to address the nursing shortages: more compensation (to improve retention), more nursing hires, better management support and so on. One thing seems to be lacking: technology. Technology can step in and do more for nurses by automating nursing tasks, shortening charting and documentation, and so on. And maybe, conditions are ready for the ability to develop algorithms to help in forward planning of nursing staffing according to workload intensity.

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References

[1] https://www.ahu.edu/blog/nurse-staffing-and-patient-outcomes

[2] Hooiveld J.

[3] https://psnet.ahrq.gov/primer/missed-nursing-care

[4] Gustafsson N., Leino-Kilpi H.,Prga I., Suhonen R., Stolt M

[5] van den Oetelaar et al.

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