TRANSLATIONAL RESEARCH FOR PRACTICE & POPULATIONS
- The Nursing Practice Requiring Change
The relationship between the safety of the patients and the care they receive from the nurses is undoubtedly significant. Evidence suggests that most patients are likely to shorten their stay at the hospital as a result of receiving increased care from the nurses. In addition, increased care facilitates proper transition of patients from the hospital setting to the home setting as the patient is discharged, thus ensuring that the patient is able to uphold the required levels of self-care. This reduces the number of deaths that occur among patients after discharge and cases of rehospitalisation. Nevertheless, nurses in the hospital setting are faced with a heavy workload that reduces their capability to provide each patient with adequate nursing care. One of the major factors contributing to such a reduction in the amount of care that the patients receive is the number of hours that nurses work in a day. As a result of an increase in the number of hours worked each day, the nurses experience a burnout, thus reducing their productivity, exposing them to stress, and even contributing to increased absenteeism and turnover. This leads to a further shortage of nurses within the hospital, thus resulting in more fatigue among nurses due to the need of overtime and coverage for the missing nurses.
It is important for proper measures to be put in place in order to reduce the amount of hours that nurses work each day, considering the magnitude of the work that they are required to do in such a period. The health care organization should consider improving the quality of life of the nurses in order to facilitate an improvement in the quality of care that they give to the patients. The workload that nurses are given each day contributes to the mental workload that they are expected to carry out with each patient. In a bid to provide each patient with adequate care, the nurses experience fatigue and hence contribute majorly to the amount of medical errors that occur within the healthcare environment including poor diagnosis of some of the patients, inadequate recording and passing on of information regarding the patient, and errors in medication administration. A sufficient nurse-patient ratio would allow the nurses reduced working hours and hence improve their quality of life. This would in turn ensure that the nurses provide adequate care to each of their patients and eliminate medical errors, thus improving the health status and safety of the patients.
- Key Stakeholders
The issue of staffing within the health care environment is majorly determined by various stakeholders including the Medical Director, Chief Nursing Officer (CNO), Financial Manager, Human Resource Manager (HRM) and the Nurse. Each of these stakeholders has a role to play in ensuring that the nurse-patient ratio is adequate enough to reduce the chances of nurse burnout and hence reduced quality of care. The Medical Director is a major decision maker when it comes to issues of recruitment and budgetary decisions within the health care environment. As such, he would be consulted in view of determining if the hospital has the resources required to employ more nurses in order to reduce the current deficit. On the other hand, the CNO is a representative of the nurses as she has a better understanding of their needs and their experience. As such, she is an important individual in determining the measures that should be taken including the number of nurses that need to be employed in order to reduce the number of hours that each nurse has to work in a day. The CNO also has a role to consult with the nurses and understand their grievances, which may be shared with the top management to promote a better experience of the nurses in the work environment and facilitate quality care.
On the other hand, the Financial Manager is in charge of financial resources of the organization and hence an important decision maker in determining whether the health care organization has the resources to support the required addition in the employed personnel. As much as changes are required in the number of nurses that are employed in the hospital, a negative change in their compensation would still have a detrimental effect on the quality of care that they provide. As such, the Financial Manager should be consulted to determine the number of nurses that could be additionally employed without straining the organization’s financial resources. The Human Resource Manager is in charge of managing the employees and carrying pout the recruitment process, including the advertisement of any vacant positions. In addition, they are in charge of determining the work schedule, hence would be important determinant of the number of nurses that should be employed in order to facilitate the desired reduction in the number of working hours among the nurses. Last but not least, the nurses are key stakeholders as they understand their experience and what is required to effect positive change. As such, they ought to be consulted in determining the number of hours that would prefer working in order to reduce their burnout each day and the areas that strain them in order to consider employing more nurses in such areas.
- Evidence Critique Table
|Source||Evidence Strength and Hierarchy|
|Twigg, D., Duffield, C., Bremner, A., Rapley, P., & Finn, J. (2011). The impact of the nursing hours per patient day (NHPPD) staffing method on patient outcomes: a retrospective analysis of patient and staffing data. International Journal of Nursing Studies, 48(5), 540-548.||Evidence Strength – Level IV Evidence Hierarchy – Retrospective Analysis|
|Arkin, N., Lee, P. H., McDonald, K., & Hernandez-Boussard, T. (2014). The Association of Nurse-to-Patient Ratio with Mortality and Preventable Complications Following Aortic Valve Replacement. Journal of Cardiac Surgery, 29(2), 141-148.||Evidence Strength – Level V Evidence Hierarchy – Meta-Synthesis|
|Shekelle, P. G. (2013). Nurse–patient ratios as a patient safety strategy: a systematic review. Annals of internal medicine, 158(5_Part_2), 404-409.||Evidence Strength – Level V Evidence Hierarchy – Qualitative Systematic Review|
|Holden, R. J., Scanlon, M. C., Patel, N. R., Kaushal, R., Escoto, K. H., Brown, R. L. & Karsh, B. T. (2011). A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life. BMJ quality & safety, 20(1), 15-24.||Evidence Strength – Level IV Evidence Hierarchy – Cross-Sectional Study|
|Duffield, C., Diers, D., O’Brien-Pallas, L., Aisbett, C., Roche, M., King, M., & Aisbett, K. (2011). Nursing staffing, nursing workload, the work environment and patient outcomes. Applied Nursing Research, 24(4), 244-255.||Evidence Strength – level IV Evidence Hierarchy – A Combination of Longitudinal Retrospective and Concurrent Cross-Sectional Methods|
- Evidence Summary
Different authors have engaged in studies to explore the impact that nurse staffing levels have on patient outcomes in the hospital setting. In their researches, different authors have established that a reduced nurse to patient ratio positively contributes to the quality of patient care and facilitates a reduced stay of the patients in the hospital.
In a study conducted by Twigg, Duffield, Bremner, Rapley, and Finn (2011), the authors engaged in a retrospective review of staffing administrative and patient data in order to determine the impact of the nursing hours per patient day (NHPPD) staffing method proposed by the Australian Industrial relations Commissions back in 2002. The NHPPD staffing is a “bottom-up” method that allows for the classification of different hospital wards into seven different categories in view of various characteristics including intervention levels, patient complexity, the availability of high dependency beds, patient turnover, and the elective/emergency patient mix (Twigg, Duffield, Bremner, Rapley, & Finn, 2011). It is upon such classification that NHPPD are allocated for the wards. The objective of the researchers was to determine the effectiveness of this method in view of 14 outcomes that are sensitive to nursing including: wound infections, complications of the central nervous system, urinary tract infections, pulmonary failure, pressure ulcer, gastritis/ulcer/upper gastrointestinal bleed, pneumonia, sepsis, cardiac arrest/shock, deep vein thrombosis, metabolic/physiological derangement, length of stay, failure to rescue, and mortality. According to the findings of the study, there were reductions in complications of the central nervous system, mortality, pressure ulcers, sepsis, cardiac arrest/shock, deep vein thrombosis, upper gastrointestinal bleed/ gastritis/ ulcer, average length of stay, and pneumonia (Twigg, Duffield, Bremner, Rapley, & Finn, 2011). As such, this staffing methods, which ensures that the number of hours that the patients work in a day is reduced and more concentration is given to each patient, reduces nurse burnout, hence promoting positive patient outcomes.
In the study conducted by Arkin, Lee, McDonald, and Hernandez-Boussard (2014), the authors established that there is a clear relationship between the rate of mortality among patients who have undergone Aortic Valve Replacement (AVR) and the ratio of nurses to patients. It is clear that most of the deaths associated with AVR as a result of preventable complications, which can be rectified if identified in time (Arkin, Lee, McDonald, & Hernandez-Boussard, 2014). Nevertheless, with a reduced number of nurses, it is difficult to identify such cases and hence most patients succumb to the effects of such complications. This study’s findings are in line with other studies carried out on nurse staffing, which reveal that adequate nurse staffing allows the nurses to effectively spend more time with the patients, hence providing them with patient-centred and evidence-based care. This allows such nurses to engage the patient in the care process, hence identifying any complications that may arise in the course of recovery and using evidence to respond to such cases. The authors used discharge data from the Healthcare Cost and Utilization Project (HCUP), Nationwide Inpatient Sample (NIS), and the Agency for Healthcare Research and Quality. Out of the 82,430 patients who identified to have undergone AVR surgery, the authors identified a low risk-adjusted mortality among patients from hospitals that had a low nurse to patient ratio (Arkin, Lee, McDonald, & Hernandez-Boussard, 2014). On the other hand, it was clear that patients from hospitals with a high nurse to patient ratio were associated with an increased rate of risk-adjusted mortality.
In addition, in a study conducted by Shekelle (2013), the author engaged in a systematic review of evidence to establish the relationship between in-hospital deaths and nursing staffing ratios through the month of September 2012. The author was driven by the indication that some patients die shortly after being discharged from hospital or during their hospitalization as a result of inadequate nursing. The author reviewed 87 articles from 550 titles and selected 15 new studies which strengthened the existing reviews (Shekelle, 2013). Out of all the reviewed articles, the author identified a longitudinal study that was conducted in one hospital as a source of strong evidence to support the existing relationship between nursing ratio and patient mortality. The longitudinal study accounted for patient comorbid conditions and nurse staffing and involved a meta-analysis, which established a causal relationship between staffing of nurses and death of patients. Out of all the studies included in the review, the author did not identify any study that show a negative impact of increased nurse staffing in a hospital (Shekelle, 2013). It is clear from the author’s findings that there is a general relationship between the number of nurses in an organization and patient deaths, such that decreased staffing contributes to increased patent mortality. This is because the few nurses within a hospital are overwhelmed with the increased workload and are unable to meet the patient needs or identify any symptoms or complications that may aggravate the patient’s condition.
The workload that nurses are exposed to in the health care setting is a major contributor to their output. Like in any other work environment, exposure to increased workload among nurses causes work pressure and results in stress and fatigue. As a result, the nurses are unable to deliver their services to their full capacity in terms of quality. In a study conducted by Holden, Scanlon, Patel, Kaushal, Escoto, Brown, and Karsh (2011), the authors carried out a cross-sectional survey in order to establish the relationship between nurse workload and patient outcomes. It is clear that increase nurse workload is as a result of reduced nurse staffing. As a result, the small number of nurses available in the hospital are expected to handle a large number of patients. The authors studied nurses from six units in two hospitals. From the findings of the study, it was clear that inadequate staffing at the unit level contributed to burnout and job dissatisfaction among the nurses (Holden, et al., 2011). As a result, nurses exposed to increased workload were identified as having the highest likelihood of making medication errors.
Likewise, in a different study conducted by Duffield, Diers, O’Brien-Pallas, Aisbett, Roche, King and Aisbett (2011), the authors established a clear relationship between patient outcomes, nurse workload, and nurse staffing. The researchers embraced a mixed method approach to the study, which included a cross sectional collection of data from patients and nurses at the primary ward level and a longitudinal retrospective review of administrative data from the NSW authorities. In their findings, the authors established that lower nurse staffing levels contributed to increased rates of potential nursing sensitive outcomes (Duffield, et al., 2011). Such outcomes included cardiac arrest and shock, pneumonia, length of hospital stay, failure to rescue, and upper gastrointestinal bleeding. The authors also established that shortages in nursed staffing led to an increased nurse workload, an aspect that led to reduced nurse acuity and increased chances of medication errors.
- Best Practice Recommendation
In view of the provided evidence in the research conducted, this paper recommends increased investment in nurse staffing in order to reduce the nurse to patient ration and in turn to reduce the number of hours that nurses work in a day. This would ensure that nurses have enough time with their patients and hence develop a better understanding of the patients’ needs including arising needs, hence meet them adequately. In turn, patients would experience positive outcomes from such quality care. In addition, reduced nurse workload would reduce nurse burnout and improve the quality of life among nurses. Such improvements would promote increased quality of care for patients among nurses and reduce cases of medication among other medical errors and nursing sensitive outcomes that are associated with nurse fatigue and stress.
- Change Model
To effect the reduction of nursing hours per day in clinical practice, this paper recommends the adoption of the Iowa Model of change (Brown, 2014). The first step of this model involves identification of the knowledge –focused trigger or the problem-focused trigger. In this case, the issues of the increased number of nursing hours and understaffing is problem focused. This step involves asking the question: Is the issue of nursing one of concern? Enough evidence should be searched to identify the problem, with view of showing the implications of a high nurse to patient ration with regards to the safety of both the patients and the nurses, and the general performance of the hospital. It is clear that there is need for change in order to promote positive patient outcomes. Upon identification of the problem and the need for change, the second step of this model involves a critique and review of relevant literature to establish if there is enough evidence to support change (Brown, 2014). To uphold evidence-based practice, it is important to research evidence from other studies that suggest the relationship between nurse staffing and both nurse and patient outcomes. Based on such evidence, one would be able to determine the significance of the issue and to defend it against any barriers that may arise such as reduced management support. The next step involves isolation of evidence that supports increased nurse staffing and reduced nursing hours in clinical practice (Brown, 2014). After finding evidence that links nurse staffing to patient safety, it is practical to find evidence that provides a solution to the problem, of nurse understaffing. In this case, such evidence would provide a framework based on which one can establish a solution to both the immediate and underlying factors that contribute towards understaffing. This model would allow for proper establishment of evidence that would facilitate the implementation of a strategy through which more nurses can be employed in order to reduce nursing workload and the number of hours that nurses work in a day.
- Barriers To Successful Implementation
The implementation of this change is mainly dependent of the managements need to see the sense in addition of nurses to the current workforce and the resource capability of the hospital to employ more nurses. As such, one of the major barriers of the implementing the change is the inability of the administration to see the sense in employing more employees in efforts to cut costs. In addition, the lack of adequate resources including financial resources to allocate to addition of more nurses may impede any efforts to reduce the nurses’ workload and their nursing hours per day.
- Ethical Implications
are no direct ethical issues that may be related to increasing nursing
staffing. Nevertheless, it is important to note that nurses have ethical obligations
to patients and that there is need to provide them with enough time with the patients
to ensure that they fulfil this obligation. By employing more nurses, the hospital
will reduce the workload of nurses and allow them to provide quality care for
the patients, thus meeting their moral obligation.
Arkin, N., Lee, P. H., McDonald, K., & Hernandez-Boussard, T. (2014). The Association of Nurse-to-Patient Ratio with Mortality and Preventable Complications Following Aortic Valve Replacement. Journal of Cardiac Surgery, 29(2), 141-148.
Brown, C. G. (2014). The Iowa Model of Evidence-Based Practice to Promote Quality Care: An Illustrated Example in Oncology Nursing. Clinical journal of oncology nursing, 18(2).
Duffield, C., Diers, D., O’Brien-Pallas, L., Aisbett, C., Roche, M., King, M., & Aisbett, K. (2011). Nursing staffing, nursing workload, the work environment and patient outcomes. Applied Nursing Research, 24(4), 244-255.
Holden, R. J., Scanlon, M. C., Patel, N. R., Kaushal, R., Escoto, K. H., Brown, R. L., & Karsh, B. T. (2011). A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life. BMJ quality & safety, 20(1), 15-24.
Shekelle, P. G. (2013). Nurse–patient ratios as a patient safety strategy: a systematic review. Annals of internal medicine, 158((5_Part_2)), 404-409.
Twigg, D., Duffield, C., Bremner, A., Rapley, P., & Finn, J. (2011). The impact of the nursing hours per patient day (NHPPD) staffing method on patient outcomes: a retrospective analysis of patient and staffing data. International Journal of Nursing Studies, 48(5), 540-548.