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Grading Rubric
Module C
NURS4342
Incorporation of Evidence into Practice
Evidence Based Practice Aspects
Content/Criteria
PICOT Question. One PICOT question based on a
current issue (Joint Commission and/or IOM) will
be developed.
Research Article Review. Complete the provided
grid with information concerning three research
articles addressing the PICOT question.
Summary of Findings. The group will provide a
summary related to the strengths and weaknesses
found from all three articles reviewed.
Application of Findings to Policies and
Procedures. What policies and procedure should
be reviewed based on what was learned from the
review of articles.
Individual discussion of Application of Evidence
to Own Practice. In one page discuss how you are
going to use the information learned during this
course in your own practice and how you can
initiate a policy or procedure change within your
practice setting based on what you have learned in
this class.
Scholarly Presentation
Writing style allows for clear communication of
thoughts through logical presentation of ideas
with correct spelling, grammar, and punctuation.
APA Style Citations/References
A title page is required for this assignment.
Assignment is to be submitted as one document.
Narratives are supported by proper citation and
use of references following APA guidelines.
Total:
Expert
Proficient
Competent
Substantial Areas for
Improvement
Unsatisfactory
The PICOT question does
not identify key parts of
the question.
(1 points)
Discussion of the
research articles
demonstrated more
than 6 omitted parts
requested within the
grid.
(43 points)
Information given does
not provide descriptions
of the strengths and
weaknesses of all 3
articles.
(2points)
No discussion of policies
and procedures related
to the topic are
provided.
(2 points)
Minimal and nonspecific discussion
related to using the
information learned was
provided.
(10 points)
The PICOT question
effectively and clearly
identifies all relevant parts of
the question. (5 points)
Three research articles were
discussed in depth with clear
and concise information
provided with all of the
information requested
included within the grid.
(53 points)
Summary discussion results
exceed objectives with clear
and concise information
descriptions of the strengths
and weaknesses of all 3
articles. (6 points)
Specific policies and
procedures related to the
topic that need review are
identified.
(6 points)
Clear, individualized detailed
discussion provided. Specific
examples of using the
information learned was
provided. (15 points)
The PICOT question identifies
all relevant parts of the
question.
(4 points)
Discussion of the three
research articles met
assignment objectives related
to the information requested
included within the grid.
The PICOT question minimally
identifies all relevant parts of the
question.
(3 points)
Discussion of the research articles
demonstrated 2 to 3 omitted parts
requested within the grid.
The PICOT question does
not identifies all relevant
parts of the question.
(2 points)
Discussion of the research
articles demonstrated 4 to
5 omitted parts requested
within the grid.
(51 points)
Summary discussion results
met objectives with
descriptions of the strengths
and weaknesses of all 3
articles.
5 points)
General discussion of policies
and procedures related to the
topic that need review are
provided.
(5 points)
Individualized discussion
provided on utilization of
information learned was
provided.
(46 points)
Summary discussion results provide
minimal descriptions of the
strengths and weaknesses of all 3
articles.
(4 points)
Less than one page of individualized
discussion was provided on the
utilization of EBP material into own
practice.
(45 points)
Summary discussion
results do not address
both the strengths and
weaknesses of all 3
articles.
(3 points)
Vague discussion of
policies and procedures
related to the topic are
provided.
(3 points)
No individualization of
how the learned content
would be integrated into
practice was provided.
(13 points)
(12 points)
(11 points)
Thoughts are logically
organized without errors in
spelling, grammar, or
punctuation. (5 points)
Thoughts are logically
organized with no more than 3
errors in spelling, grammar, or
punctuation. (4 points)
Thoughts are logically organized
with no more than 4 errors in
spelling, grammar, or punctuation.
(3 points)
Thoughts show no
logical organization.
APA format used for all
citations and reference
listings with no errors.
No more than 3 APA
formatting errors noted.
4 to 5 APA formatting errors noted.
Thoughts are logically
organized with no more
than 5 errors in spelling,
grammar, or punctuation.
(2 points)
6 to 7 APA formatting
errors noted.
(10 points)
(8 points)
(6 points)
(4 points)
(2 points)
(4 points)
Minimal discussion of policies and
procedures related to the topic are
provided.
(0 points)
More than 7 APA errors
noted in both citations
and reference listings.
Comments:
PLAGIARISM: Plagiarism is considered cheating and is a violation of academic integrity as outlined in the Student Handbook. Any student who plagiarizes any portion of the assignment may receive a grade of zero on the
assignment.
LATE ASSIGNMENTS: Unless prior faculty notification and negotiation of an extended deadline, ten points will be deducted per day if submitted late. Assignment will not be accepted if submitted more than 3 days late
and assigned grade will be 0 (zero).
HEALTH POLICY AND SYSTEMS
Impact of Nurse Work Environment and Staffing on Hospital
Nurse and Quality of Care in Thailand
Apiradee Nantsupawat, PhD1 , Wichit Srisuphan, DrPH2 , Wipada Kunaviktikul, DNS3 ,
Orn-Anong Wichaikhum, PhD4 , Yupin Aungsuroch, PhD5 , & Linda H. Aiken, PhD6
1 Lecturer, Chiang Mai University, Faculty of Nursing, Chiang Mai, Thailand
2 Professor, Chiang Mai University, Faculty of Nursing, Chiang Mai, Thailand
3 Professor, Chiang Mai University, Faculty of Nursing, Chiang Mai, Thailand
4 Lecturer, Chiang Mai University, Faculty of Nursing, Chiang Mai, Thailand
5 Associate Professor, Chulalongkorn University, Faculty of Nursing, Bangkok, Thailand
6 Professor, Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, PA, USA.
Key words
Nurse work environment, staffing, nurse
burnout, job dissatisfaction, quality of care,
Thailand
Correspondence
Wichit Srisuphan, Chiang Mai University, Faculty
of Nursing 110 Inthawarorot Road, Chiang Mai,
50200, Thailand. E-mail:
wichit@mail.chiangmai.ac.th
Accepted June 29, 2011
doi: 10.1111/j.1547-5069.2011.01419.x
Abstract
Purpose: To determine the impact of nurse work environment and staffing
on nurse outcomes, including job satisfaction and burnout, and on quality of
nursing care.
Design: Secondary data analysis of the 2007 Thai Nurse Survey.
Methods: The sample consisted of 5,247 nurses who provided direct care for
patients across 39 public hospitals in Thailand. Multivariate logistic regression
was used to estimate the impact of nurse work environment and staffing on
nurse outcomes and quality of care.
Findings: Nurses cared for an average of 10 patients each. Forty-one percent
of nurses had a high burnout score as measured by the Maslach Burnout Inventory; 28% of nurses were dissatisfied with their job; and 27% rated quality
of nursing care as fair or poor. At the hospital level, after controlling for nurse
characteristics (age, years in unit), the addition of each patient to a nurse’s
workload was associated with a 2% increase in the odds on nurses reporting high emotional exhaustion (odds ratio [OR] 1.02; 95% confidence interval
[CI] 1.00–1.03; p < .05). Nurses who reported favorable work environments
were about 30% less likely to report fair to poor care quality (OR 0.69; 95% CI
0.48–0.98; p < .05) compared with nurses who reported unfavorable work environments. The addition of each patient to a nurse’s workload was associated
with a 4% increase in the odds on nurses reporting quality of nursing care as
fair or poor (OR 1.04; 95% CI 1.02–1.05; p < .001).
Conclusions: Improving nurse work environments and nurse staffing in Thai
hospitals holds promise for reducing nurse burnout, thus improving nurse retention at the hospital bedside as well as potentially improving the quality of
care.
Clinical Relevance: Nurses should work with management and policymakers to achieve safe staffing levels and good work environments in hospitals
throughout the world.
The nursing shortage is a global problem. Major concerns about the nursing shortage have been compounded
by evidence of undesirable outcomes such as job dissatisfaction and burnout, which are major contributory
426
factors of intention to leave, absenteeism, turnover
(Hayes et al., 2006), and adverse outcomes in hospital
care (Aiken, Clarke, & Sloane, 2002; Estabrooks, Midodzi,
Cummings, Ricker, & Giovannettii, 2005; Needleman,
Journal of Nursing Scholarship, 2011; 43:4, 426–433.
C 2011 Sigma Theta Tau International
Work Environment and Staffing on Outcomes
Nantsupawat et al.
Buerhaus, Mattke, Stewart, & Zelevinsky, 2002). Previous studies have indicated that nurses in hospitals with
supportive nurse work environments and adequate nurse
staffing are more satisfied in their jobs (Aiken, Clarke,
Sloane, Lake, & Cheney, 2008; Laschinger, Almost,
& Tuer-Hodes, 2003), experience less nurse burnout
(Vahey, Aiken, Sloane, Clarke, & Vargas, 2004), and report better quality of nursing care (Aiken, Clarke, &
Sloane, 2002). Most of the research has been undertaken in North America and Western Europe. This is one
of the first studies to examine factors associated with
nurse retention and quality of care in Southeast Asia. If
there are similarities in research findings in other parts of
the world, the possibility of global approaches to solving
nursing shortage may be suggested.
Thailand is a developing country, categorized as “lower
middle income” by the World Bank, located in Southeast
Asia. Nurses and midwifery personnel comprise 70% of
all the health personnel of Thailand’s healthcare system.
Thailand is a leader in nursing education attainment in
the region. Most registered nurses have a bachelor’s degree education, signifying the generally high regard with
which nursing is viewed. Public hospitals under the jurisdiction of the Ministry of Public Health are the mainstay of health care in Thailand. They provide health services that include health promotion, disease prevention,
and management of acute and chronic health. Citizens
of Thailand have universal access to public sector health
facilities and services. Private healthcare facilities play a
significant role in providing health services in urban areas, especially to higher income patients. Globalization,
international trade, and medical hubs policy are leading
to more international clients and the expansion of private hospitals (Bureau of Policy and Strategy, Ministry of
Public Health, 2007).
Thai hospitals have been experiencing nurse shortages
(Thailand Nursing and Midwifery Council [TNC], 2009).
An analysis of the nursing workforce based on a geographic information system survey and overtime paid revealed a shortage of nurses with vacancies of 15% to
26% of all nursing positions in public hospitals (TNC,
2008). The issues of undesirable patient outcomes such
as mistakes in patients’ identification, patient falls, medication errors, pressure ulcers, and urinary tract infections
were found in Thai public hospitals (Asavaroengchai,
2003; Kessomboon, Panarunothai, & Chongsuvivatwong,
2003; Nantsupawat, Akkadechanunt, Ketlertnapa, &
Padungsak, 2010; Padungsak, 2007).
The model that guided the study was adapted from
the Quality Health Outcomes Model (QHOM; Mitchell,
Ferketich, & Jennings, 1998). The QHOM was adapted
from Donabedian’s (1966) conceptualization of quality
as a linear relationship between structure, process, and
outcomes to include multiple-level analysis among system, client characteristics, interventions, and outcomes.
The QHOM is particularly pertinent to this research because it posits that nursing interventions are mediated by
the organizational context in which care takes place. One
of the innovations of this study is an empirical measure
of the quality of nurses’ work environments that permits
a direct test of the QHOM. A literature review shows
that the QHOM is useful to theoretically guide studies
that evaluate system interventions such as nurse staffing,
improved patient care, and outcomes (Borglund, 2008;
Gerolamo, 2006; Mayberry & Gennaro, 2001; Newhouse,
Johantgen, Pronovost, & Johnson, 2005; Vahey et al.,
2004). Nursing can be thought of as a healthcare organization’s surveillance system for the early detection of adverse events (Clarke & Aiken, 2003). Nurse staffing levels
influence the timing of problem identification, and timing is important in patient rescue. More supportive work
environments and better staffing facilitate a high quality of nursing care, resulting in more favorable nurse and
patient outcomes (Aiken, Clarke, & Sloane, 2002; Aiken
et al., 2008).
Although a few international studies have documented
an association between nurse work environment and
nurse staffing for nurse outcomes and quality of care
(Aiken, Clarke, & Sloane, 2002; Aiken et al., 2008), little is known about this relationship in Asian countries.
This study aims to determine the impact of nurse work
environment and nurse staffing on nurse outcomes, including job dissatisfaction and burnout, and on quality of
care in public hospitals in Thailand. The results will provide evidence of relationships that will help create strategies to promote desirable outcomes in public hospitals in
Thailand and elsewhere around the world.
Methods
This study is a predictive correlational design using secondary data analysis of the 2007 Thai nurse survey directed by Dr. Yupin Aungsuroch of Chulalongkorn University in Bangkok and made available to this investigator. The instrument was adapted from an instrument used
in the International Hospital Outcomes Study (IHOS;
Aiken, Clarke, & Sloane, 2002). The survey was conducted at 13 general and 26 regional hospitals for a total
of 39 out of 94 general and regional hospitals in Thailand
selected by multistage sampling to achieve geographic
representation from every public health region and to
include both general and regional hospitals. All nurses
within participating hospitals were requested to complete
the questionnaire, which was accompanied by a cover letter explaining the purpose of the survey, its voluntary
nature, and the strict protection of anonymity. The final
427
Work Environment and Staffing on Outcomes
response rate for the nurse survey was 92%, for a total of
8,222 registered nurses (Aungsuroch & Wanant, 2007).
This study was approved by the Graduate School at Chiang Mai University and the Research Ethical Committees
of the Faculty of Nursing, Chiang Mai University.
Sample for the Study
The hospital sample included 13 general and 26 regional hospitals in the 2007 Thai nurse survey. Nurses
included in the study were limited to those who provided direct care for patients in the study hospitals and reported having responsibility for at least 1 but fewer than
21 patients on their last shift. We were primarily interested in nurses providing direct care at the bedside and
thus eliminated nurses without a patient assignment and
nurses who provided partial care to large numbers of patients. There were 5,247 nurses in the final sample.
Measures
Nurses were asked general demographic questions
about themselves and their backgrounds, including age,
gender, years as a registered nurse, years as a registered
nurse on the current unit, highest degree of education attained, and employment status. The IHOS questionnaire
was translated into Thai. The face validity of the Thai version was verified and back-translated by qualified academic experts who determined that the Thai version and
English version did not differ in meaning.
Nurse work environment. Nurse work environment was assessed by the Practice Environment Scale
of the Nursing Work Index (PES-NWI; Lake, 2002),
the most widely reported measure used to gauge the
quality of nursing practice environment (Warshawsky &
Havens, 2011). The PES-NWI is composed of 29 items
that have been organized into five subscales: nurse participation in hospital affairs; nursing foundations for quality
of care; nurse manager ability, leadership, and support
for nurses; staffing and resource adequacy; and collegial
nurse-physician relations. The potential scores ranged
from 1 (strongly disagree) to 4 (strongly agree) on a 4-point
Likert scale. Higher scores indicated more agreement that
the subscale items were present in the current job. Nurse
responses in each item were aggregated for each subscale
to create a hospital-level mean of the subscales (Verran,
Gerber, & Milton, 1995).
In multivariate models the resource adequacy subscale
was excluded because a direct measure of nurse staffing
that is highly correlated with the resource adequacy scale
was included in the analytic modeling. A categorical variable of the four remaining subscales was created, adapting the method of Aiken et al. (2008): hospitals above
the median on all four subscales; on one, two, or three
428
Nantsupawat et al.
subscales; and on none of the subscales were classified
as having “favorable”, “mixed”, “unfavorable” results, indicating the most supportive environment; a moderately
supportive environment; and the least supportive environment, respectively.
Reliability of the PES-NWI subscales was 0.64 to 0.72
(Lake, 2002). Based on 2007 Thai Nurse Dataset, the
Cronbach’s α coefficient of the PES-NWI in subscales 1
to 5 was 0.87, 0.90, 0.87, 0.91, and 0.85. Its discriminant
validity has been shown in its ability to detect differences
in the nurse practice environments of hospitals (Lake &
Friese, 2006).
Nurse staffing. Nurse staffing was measured based
on nurse reports of the number of patients assigned to
each nurse. Nurses were asked to indicate how many patients were assigned on their last shift. Nurse responses
were calculated as the mean patient load across all nurses
in a hospital who reported having responsibility for at
least 1 but fewer than 21 patients. The mean number of
patients cared for was aggregated to the hospital level.
Analyses of nurse staffing levels were conducted with
a continuous measure. The predictive validity of using
nurse reports in this manner to assess staffing levels has
been shown previously (Aiken, Clarke, Slone, Sochalski,
& Silber, 2002). Because the nurse sample is large and individual nurses’ responses to the staffing questions were
aggregated to the hospital level, nontypical staffing for individual nurses was unlikely to affect the overall hospital
mean.
Job dissatisfaction. Job dissatisfaction was measured by a single item that asked nurses’ perception about
their satisfaction with their present job. The response categories ranged from 1 (very satisfied) to 4 (very dissatisfied)
on a Likert scale. Higher scores indicated that nurses were
dissatisfied with their current job. Reliability of published
tests for a single item of nurse job satisfaction was in the
range of 0.70 (Wanous, Reichers, & Hudy, 1997).
Burnout. Burnout was measured using the Maslach
Burnout Inventory–Human Services Survey (MBI-HSS),
a standardized instrument with published norms for medical personnel that has been used previously in international research (Aiken et al., 2001; Poghosyan, Aiken,
& Sloane, 2009; Poghosyan, Clarke, Finlayson, & Aiken,
2010). Nurses with a total score of 27 or above on
the nine-item emotional exhaustion subscale exceeded
norms for healthcare workers published by Maslach and
were considered to have high burnout. The reliability coefficients were 0.89 for the emotional exhaustion subscale (Maslach & Jackson, 1981), and the Cronbach’s α
coefficient of the emotional exhaustion based on 2007
Thai Nurse dataset was 0.87.
Quality of care. Quality of care was measured by
a single item that asked nurses’ perception about the
Work Environment and Staffing on Outcomes
Nantsupawat et al.
quality of nursing care delivered on the last shift. The response categories ranged from 1 (excellent) to 4 (poor) on a
Likert-scale, with higher scores indicating poorer levels of
quality. The Cronbach’s coefficients for previous quality
of nursing care were in the range of 0.92 to 0.94 (Pearson
et al., 2000). This single-item measure has been used extensively in international work and has established predictive validity (Aiken, Clarke, & Sloane, 2002; Bruyneel,
Van den Heede, Diya, Sermeus, & Aiken, 2009).
Data Analysis
Categorical variables were examined by frequency,
percentage, and range. Mean and standard deviation
were used to assess distribution and central tendency
of continuous variables. Multivariate logistic regression
analysis controlling for nurse characteristics (age and
years in unit), was performed to assess the impact of
nurse work environment and nurse staffing for nurse
outcomes and quality of care. STATA version 10 was used
to analyze the data, and p < .05 was considered statistically significant in all analyses.
Results
Table 1 provides characteristics of sample nurses and
reported outcomes. The majority of study nurses were
34 years old on average, 98% were female, they had
nearly 8 years of nursing experience and 6 years of
experience in their current hospital position, and they
were almost totally full-time. All the nurses in the study
had earned a bachelor’s of science in nursing or higher.
Twenty-eight percent of nurses were dissatisfied with
their jobs, 41% experienced high burnout, and 27% reported quality of care as fair or poor.
Table 2 describes nurse staffing and the nurse work
environment in study hospitals. The average number of
patients per nurse was 10, with significant variation from
7 to 13 patients. The study nurses rated collegial nursephysician relationships to be the most positive of the five
PES-NWI subscales and staffing and resource adequacy to
be the lowest or of greatest concern.
Table 3 presents logistic regression odd ratios indicating the impact of nurse work environment and nurse
staffing on job dissatisfaction, high emotional exhaustion, and fair or poor quality of care. After controlling for
nurse characteristics, nurse burnout (measured by emotional exhaustion) was found to be associated with nurse
staffing levels. The addition of each patient to a nurse’s
workload was associated with an increase of 1.02 times
in the odds on nurses reporting high emotional exhaustion (odds ratio [OR] 1.02; 95% confidence interval [CI]
1.00–1.03; p < .05). Given the range in workloads in
the study hospitals from roughly 7 to 13 patients per
Table 1. Characteristics of Sample Nurses and Reported Outcomes
Variables
Mean
SD
Range
Age (yr)
Years as RN
Years as RN on current unit
Gender
Male
Female
Highest degree
Bachelor’s degree or
equivalent in nursing
Master’s degree in
nursing
Master’s degree in other
fields
Employment status
Full-time
Part-time
Job satisfaction
Very satisfied
Moderately satisfied
A little unsatisfied
Very dissatisfied
Quality of nursing care
Excellent
Good
Fair
Poor
Emotional exhaustion
High
Average
Low
33.57
8.43
6.12
6.51
5.96
4.69
22–58
1–33
1–29
Frequency (%)
92(1.75)
5, 141(97.98)
5, 019(95.65)
140(2.67)
86(1.64)
5, 211(99.31)
36(0.69)
466(8.88)
3, 330(63.46)
343(6.54)
1, 108(21.12)
140(2.67)
3, 709(70.84)
1, 356(25.90)
32(0.59)
2, 166(41.28)
1, 406(26.80)
1, 675(31.92)
nurse, this OR of 1.02 implies that nurses in hospitals
with the highest ratios of patients to nurse are roughly
12% ([(1.02 – 1.00) × 100] × [13 – 7]) more likely to
be emotionally exhausted than nurses in hospitals with
the lowest ratios. The quality of nursing care was also significantly associated with the hospitals’ nurse work environments and staffing levels. After controlling for nurse
characteristics, nurses in hospitals with favorable work
environments were roughly 30% less likely than nurses
in hospitals with poor environments to report that the
quality of care was only poor or fair as opposed to good
or excellent (OR 0.69; 95% CI 0.48–0.98; p < .05). Here
too, the addition of each patient to nurses’ workloads was
associated with an increase of 1.04 times in the odds of
nurses reporting that the quality of nursing care on their
unit was only fair or poor (OR 1.04; 95% CI, 1.02–1.05;
p < .001), which implies that nurses in the hospitals with
the highest ratios of patients to nurse were roughly 24%
([(1.04 – 1.00) × 100] × [13 – 7]) more likely to report
only poor or fair quality care than nurses in hospitals with
the lowest ratios.
429
Work Environment and Staffing on Outcomes
Nantsupawat et al.
Table 2. Characteristics of Nurses’ Work Environment and Nurse Staffing
Levels in Study Hospitals
Characteristics
Nurse staffing levels
Patient-to-nurse ratio
Nurses’ work environment
Nurse participation in
hospital affairs
Nursing foundation for
quality of care
Nurse manager ability,
leadership, and support
of nurse
Staffing and resource
adequacy
Collegial nurse-physician
relationship
Composite
Mean (SD)
Range
10:1
7:1–13:1
2.81 (0.10)
2.94 (0.11)
2.80 (0.11)
2.70 (0.14)
3.09 (0.11)
2.87 (0.11)
Table 3. Logistic Regression Odd Ratios Indicating the Impact of Nurse
Work Environment and Nurse Staffing Levels on Job Dissatisfaction, High
Emotional Exhaustion, and Fair or Poor Quality of Care
Fair or
Job
High emotional poor quality
dissatisfaction dxhaustion
of care
Nurses’ work environment
Unfavorable (as reference)
Mixed
Favorable
Nurse staffing levels
0.79
(0.48–1.29)
1.34
(0.88–2.05)
1.01
(0.98–1.03)
0.99
(0.76–1.27)
1.06
(0.81–1.38)
1.02∗
(1.00–1.03)
0.87
(0.61–1.22)
0.69∗
(0.48–0.98)
1.04∗∗
(1.02–1.05)
Note. Model was adjusted for nurse characteristics (age and years in unit).
∗
p < .05; ∗∗ p < .001.
Discussion
This study investigates nurse work environment,
patient-to-nurse staffing ratios, nurse outcomes, and
quality of nursing care in public hospitals in Thailand.
Nurses, on average, cared for 10 patients each, which
is higher than the recommended ratio from the TNC
(2005). The quality of the nurse work environment in
Thailand varies across hospitals. Inadequate staffing and
resources were nurses’ major concerns, while nursephysician relationships were generally positive.
This study indicates that almost one out of four
nurses was dissatisfied with their job and close to 40%
of study nurses experienced high burnout. This is notable because prior research has demonstrated an as430
sociation between job dissatisfaction and nurses’ intent to leave and turnover (Coomber & Barriball, 2007;
Hayes et al., 2006); nurses’ intent to leave was also negatively associated with patient satisfaction (Leiter, Harvie,
& Frizzell, 1998). Moreover, prior studies have shown
that high nurse burnout is associated with lower levels of
patient satisfaction (Poghosyan et al., 2010; Vahey et al.,
2004), quality of care (Kutney et al., 2009), and nurse
turnover and absenteeism (Maslach, Jackson, & Leiter,
1996). Additionally, almost one out of four study nurses
reported quality of care as fair or poor, suggesting that
many patients may be at significant risk for preventable
adverse outcomes.
The empirical evidence from this study supports the
QHOM in that the impact of nurse work environment
and nurse staffing, both features of the organizational system in which nursing care is delivered, is shown to be
associated with outcomes– job dissatisfaction, high emotional exhaustion, and fair or poor quality of care. This
finding verifies the usefulness of the QHOM in explaining variations in hospital nurse outcomes as mediated by
the organizational context of care, and points to the potential for improving nursing outcomes by improving the
organizational context in which nursing care is delivered.
Our findings show that hospitals with favorable work environments and nurse staffing had lower likelihoods of
having lower nurse-assessed quality of care. Also, nurses
practicing in hospitals with a favorable work environment had lower burnout. This result is consistent with
previous studies which found that organizational support
for nursing, as an indicator of a supportive work environment, was positively correlated with nurse-assessed
quality of care (Aiken, Clarke, & Sloane, 2002; Aiken
et al., 2008; Bogaert, Clarke, Vermeyen, Meulemans,
& Heyning, 2009; Laschinger, Shamian, & Thomson,
2001; Patrician, Shang, & Lake, 2010) and negatively
associated with burnout (Aiken et al., 2008; Aiken,
Clarke, Sloane, Sochalski, et al., 2002) and nurses in
hospitals with lower nursing staff were higher in reporting quality of nursing care as fair or poor (Aiken,
Clarke, & Sloane, 2002; Aiken et al, 2008; Solchalski,
2004).
The main conclusions from this study are that modifying organizational characteristics to improve nurse work
environments and improving nurse staffing constitute
promising strategies for enhancing nurse retention and
quality of care. The American Nurses Credentialing Center’s magnet application represents a blueprint for how
hospitals could improve their nurse work environments
(www.nursecredentialing.org). The nurse work environment measure used in this study suggests that the areas that managers could improve to create better work
environments include improving nurse participation in
Work Environment and Staffing on Outcomes
Nantsupawat et al.
hospital affairs; developing ongoing programs to support
nursing foundations for quality of care; investing in the
expertise of nurse managers; and promoting collegial
nurse-physician relations and teamwork.
Several limitations of the study should be noted. Generalizability, which is the extension of research findings
and conclusions from a study conducted on a sample
population to the population at large, may be limited
because all data were collected at public regional and
general hospitals; thus, we cannot generalize to private
hospitals. Also, the study uses cross-sectional data at a
single point in time, thus limiting our ability to assert a
causal link between more favorable staffing and work environments and nurse outcomes and quality of nursing
care. Additionally, the nurse staffing measure is a general
measure of average hospital staffing that should not be
interpreted as an actual patient-to-nurse ratio in a clinical
sense because the staffing on the shift requested may not
be typical for any given nurse, but the measure has nevertheless shown very good predictive validity in relation
to nurse and patient outcomes in many published studies. Similarly, while job satisfaction and quality of nursing
care were measured with single items, both have established predictive validity in international research (Aiken,
Clarke, & Sloane, 2002; Bruyneel et al., 2009).
Conclusions
This study found remarkable similarities in Thailand
and a number of other previously studied countries
showing a significant association between more favorable nurse staffing and work environments and more favorable outcomes for nurses and better quality of care.
These findings add to the growing nursing outcomes
research evidence showing the importance of adequate
staffing and work environment to reduce nurse burnout
and improve the quality of nursing care. Results suggest
that evidence-based “best practices” like magnet hospital recognition that have been shown to improve work
environments in countries with similar problems of high
nurse dissatisfaction and burnout might have a positive
effect if implemented in Thailand. The findings suggest
that, at the very least, support of efforts to improve
staffing and work environments in hospitals that currently fall below average by Thai standards may bring important benefits to Thai patients in terms of better quality of care and help retain a qualified nurse workforce in
public hospitals.
Acknowledgments
We thank and express our appreciation to Dr. Yupin
Aungsuroch of Chulalongkorn University Faculty of
Nursing and Dr. Wanida Wanant of Shenandoah University School of Health Professions for their permission to
use the 2007 Thai Nurse Dataset.
Clinical Resources
r To learn more about
r
how to implement safe
nurse staffing, see www.safestaffingsaveslives.org/
WhatisSafeStaffing/UtilizationGuide.aspx
To learn more about how to improve nurse
work environments, see information provided by
the American Nurses Credentialing Center’s Magnet Recognition Program:www.nursecredentialing.
org/Magnet/ProgramOverview.aspx
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Expression of Concern
The following article from the Journal of Nursing Scholarship, “Development and Evaluation of an Undergraduate Training Course for Developing International Council of Nurses Disaster Nursing Competencies in China,” by S.S.S. Chan
et al., published online on September 9, 2010 in Wiley Online Library (www.wileyonlinelibrary.com) has raised concerns among the authors, the journal Editor-in-Chief and Wiley Periodicals, Inc. This expression of concern is being
provided due to significant overlap between the above-named article and Pang et al., “Pilot training program for developing disaster nursing competencies among undergraduate students in China,” published in Nursing & Health Sciences,
Volume 11, Issue 4, December 2009, pp 367–373, which was first published online October 27, 2009, as was noted in
the article by S.S.S. Chan et al.
433
The Effect of Nurse Staffing
Patterns on Medical Errors
and Nurse Burnout
CONNIE GARRETT, RN, BSN, CNOR
L
ittle disagreement exists about
the relationship between nurse
staffing levels and patient outcomes in health care settings. Higher
staffing levels have been shown to result
in better patient outcomes compared
with lower nurse staffing levels.1-15
Various measures such as managed
health care and reduced reimbursement from insurance companies have
combined with the nursing shortage to
lead hospital administrators to rely on
voluntary and mandatory overtime to
solve their nurse staffing problems.
According to a 2007 report published by
the Agency for Healthcare Research and
Quality (AHRQ),16 chronic fatigue and
poor global sleep quality (ie, a measure
of sleep quality that includes indicators
such as time needed to fall asleep, sleep
duration, waking up during the night,
use of sleeping medication, and difficulty staying awake during the day17) are
common among health care personnel.
Voluntary overtime requests may be
made too often of nurses who do not
have families or who suffer financially
because of low salaries in nursing,18 and
working overtime can lead to dangerous levels of fatigue.
On July 4, 2006, Julie Thao, RN, a
veteran obstetrical nurse in Wisconsin,
worked two eight-hour shifts back to
back. Thao slept on a cot at the hospital
overnight and was near the end of her
shift on July 5 when she administered
the wrong medication to a patient,
which resulted in a fatal medication
error. She was charged with a felony,
“criminal neglect of a patient causing
great bodily harm,” the sentence for
which is three years on probation and
mandatory exclusion from working in a
critical care setting. She ultimately pled
© AORN, Inc, 2008
no contest to two misdemeanors.19 This
was the first time a nurse in Wisconsin
had been criminally charged for a medical error.20
The human error component of medical errors18 may be affected by staffing
patterns. Although few studies on the
topic have been conducted with hospital
personnel, studies outside the field of
health care demonstrate a relationship
between fatigue and degradation in performance. Fatigue has been shown to
result in slowed reaction time and lapses
of attention to detail that can result in
errors of omission, which are known to
compromise problem solving, reduce
motivation, and decrease energy for successful completion of required tasks.21
Fatigue has been implicated in disasters such as the Exxon Valdez, Bhopal,
Chernobyl, and Three Mile Island.22 The
working hours for airline pilots and air
traffic controllers are regulated to reduce
ABSTRACT
HOSPITAL ADMINISTRATORS frequently rely
on the use of mandatory or voluntary overtime to
cover staff nurse vacancies. This practice is common in the perioperative setting, but it can lead
to staff-member fatigue that may adversely affect
patient safety.
THIS LITERATURE REVIEW explores the effect
that nurse staffing patterns have on the frequency
of medical errors, fatigue, and nurse burnout.
THE EVIDENCE INDICATES that inadequate
nurse staffing leads to adverse patient outcomes
and increased nurse burnout. Hospital administrators should invest in adequate nurse staffing to
improve patient safety and increase nurse retention. AORN J 87 (June 2008) 1191-1204. © AORN,
Inc, 2008.
JUNE 2008, VOL 87, NO 6 • AORN JOURNAL • 1191
Garrett
JUNE 2008, VOL 87, NO 6
The perioperative setting is unique in
that nurses not only consider it
normal to work more than 40 hours a
week but also are required to take
call, which may result in fatigue.
The effects of extreme fatigue can
be compared to being under the
influence of alcohol.
the possibility of human error brought on by
fatigue. To improve patient outcomes and
reduce medical errors, nurse staffing patterns
also should be reviewed to ensure that direct
patient care is not compromised by the use of
mandatory overtime to cover staffing shortfalls.23 This literature review explores the effect
that nurse staffing patterns have on the frequency of medical errors, fatigue, and nurse
burnout.
OVERTIME
In many perioperative settings, mandatory
overtime is used daily to staff the OR for elective, unplanned, and emergent procedures or
to cover staff nurse vacancies.1 There seems to
be a double standard in some ORs when the
first day shift is relieved of duty and the shift
change occurs. Staffing is usually at the highest
level in the morning and decreases as the day
progresses to the second shift, possibly as the
result of a belief that the perioperative area is
not as busy in the afternoon and therefore
staffing can be decreased for the second shift.
This situation creates a problem of voluntary
overtime at the shift change resulting from
delayed start times, underestimation for the
length of a procedure, and changes in patient
status or the complexity of a procedure. Periop-
1192 • AORN JOURNAL
erative personnel sometimes refer to staffing in
the surgical suite as “Russian roulette” regarding who will have to stay late to act as the circulating nurse in a procedure that has not finished by the shift change. Often, a circulating
nurse expects a request to stay late to finish the
procedure when there is no available relief. If
the nurse objects to staying late, the situation
becomes one of mandatory overtime because
the nurse’s preferences do not change the fact
that no relief is available.
Unrealistic workload may result in chronic
fatigue and poor global sleep quality. The literature provides examples of overtime use resulting in fatigue, burnout, absenteeism, and
job dissatisfaction among hospital nurses.2,24 In
addition, working overtime has been shown to
increase the odds of nurses making at least one
medication-related error, and the risk of making errors increased for nurses who worked
overtime after long shifts.17
FATIGUE
Fatigue is a contributing factor for nurse
absenteeism, burnout, and job dissatisfaction.2,24 In addition, rotating shifts and extended work hours of 12.5 hours or more have
been shown to increase injuries and automobile accidents among nurses,25 and chronic
fatigue has been found to result in depression
and poor global sleep quality.18 Minimal data,
however, are available in the perioperative setting related to fatigue and increased errors.
The perioperative specialty is unique in that
nurses not only consider it normal to work
more than 40 hours a week but also are required to take call, which may be abused to
the extent that the effects of a nurse’s fatigue
can be compared to being under the influence
of alcohol. Research has shown that after 17
hours without sleep, performance degrades to
the equivalent of having a blood alcohol concentration of 0.05%,21 and after 24 hours without sleep, the effect on performance is equivalent to a blood alcohol level of 0.10%.26
Call hours may vary from four hours to 72
hours or more, though actual hours worked
during the call period are unpredictable and can
range from 30 minutes to the entire length of the
call period.27 A normal day for a perioperative
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JUNE 2008, VOL 87, NO 6
nurse who is on call consists of an eight-, 10-, or
12-hour shift. Nurses on call then may have to
work call hours to complete or relieve for elective procedures that are scheduled to start when
there are no other available RNs to fill the role
of circulating nurse. It is not unusual for the oncall nurse to complete elective cases and continue working for up to 16 hours without rest or
relief. That same nurse must then hope that he
or she is not called back for an emergency procedure in the middle of the night, which interrupts the sleep cycle and circadian rhythms.
The cycle of fatigue starts when the nurse,
whether called in the middle of the night to
work an emergency procedure or not, is expected to be back at work the next morning at the
start of his or her daily shift.
ed 6% increase in the number of nurses by the
year 2020 will not keep up with the 40%
expected growth in demand. In addition, the
elimination of perioperative curriculum in
nursing schools has contributed to the shortage of available perioperative nurses in the
OR.30 Health care facilities cannot afford to
have their perioperative nurses burn out and
leave the perioperative setting, so hospital
administrators should look for ways to increase nurse retention.
STAFFING PATTERNS
AND
MEDICAL ERRORS
A study by Rogers et al1 examined the relationship between medical errors and both staff
work patterns and hours worked by nurses.
The researchers found that
mandatory overtime was
NURSE BURNOUT
used frequently to cover hosUnrealistic workloads in
pital nurse staffing vacancies.
the perioperative setting,
This policy produces fatigue
Mandatory overtime
including call, are the result of
and nurse burnout, which
a shortage of nurses and can
ultimately results in more
frequently is used to
lead to increased absenteeism
mandatory overtime to solve
and high rates of nurse burnstaffing issues, a practice that
cover staff vacancies.
out that exceed the norm for
is both controversial and
health care workers.28 Job dispotentially dangerous.31-33
This results in fatigue
satisfaction for nurses is four
The study by Rogers et al
times higher than the average
included 393 RNs—most of
and nurse burnout and,
rate for all US workers, and
whom were women—who
ultimately, in more
one in five nurses have
worked full time. More than
reported that they intend to
half worked in hospitals with
mandatory overtime to
leave their current jobs within
300 beds or more, 56%
a year.28 Nurses often cope
worked in urban areas, 19%
solve staffing issues.
worked in suburban areas,
with increased stress and
18% worked in small town
burnout by calling in sick, and
hospitals, and 17% worked in
patient safety is compromised
rural areas.1 The nurses were
by the effect of high nursing
18
turnover rates. Perioperative
given logbooks to track their
nurse turnover rates increase when nurses
scheduled work hours, overtime, days off,
burn out and leave the OR to work in other
sleep and wake cycles, and errors and near
nursing specialties where call is not required
errors for 28 days; the logbooks also provided
or used as a staffing solution.
the opportunity to describe the errors. AlAccording to the American Hospital Assothough the response rate was lower than usual
ciation, the current nursing shortage reflects
for this type of nurse survey, the lower re“fundamental changes in population demosponse rate was attributed to the increased
graphics, career expectations, work attitudes,
effort required for the nurses to record 17 to 40
and worker dissatisfaction.”29(p80) Hospital
items each day for 28 days. The researchers
nursing vacancies are expected to reach
took care in the collection of data to ensure
800,000 (ie, 29%) by the year 2020. An expectthat participants’ identities were protected and
1194 • AORN JOURNAL
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JUNE 2008, VOL 87, NO 6
to alleviate fears related to reporting errors.
The nurses in the study generally worked
more than 40 hours per week and longer than
their scheduled shifts: 39% of the shifts worked
lasted 12.5 or more consecutive hours, 14% of
the nurses reported working 16 or more hours
at least once during the study period, and the
longest shift reported was 23.6 hours. The nurses reported working 360 shifts of mandatory
overtime, and nurses were coerced to work
voluntary overtime for 143 shifts.
Health care facilities can avoid
preventable patient mortality and
low nurse retention rates by
investing in RN staffing.
During the data-gathering period, 199 errors
and 213 near errors were reported, with medication errors accounting for more than half of the
total errors. Other errors included procedural,
charting, and transcription errors, as well as 6%
of errors and 29% of near errors that could not
be categorized. Of the respondents, 30% reported making at least one error and 32% reported
making at least one near error.
Analysis of the data indicated that work
duration, overtime, and number of hours
worked per week had significant effects on
errors, with the likelihood of making an error
increasing with longer work hours. Nurses
were three times more likely to make an error
when working shifts that lasted 12.5 hours or
more. Regardless of how long the shift was
originally scheduled to last, working overtime
increased the odds of making at least one
error. The data also indicated a trend of increased risk for errors when nurses worked
overtime after longer shifts, with the risks
being significantly elevated for overtime
worked after a 12-hour shift.
1196 • AORN JOURNAL
PATIENT-TO-NURSE RATIOS, ADVERSE
OUTCOMES, AND NURSE RETENTION
A study by Aiken et al2 examined the association between patient-to-nurse ratios and
patient mortality, failure to rescue among surgical patients, and factors related to nurse
retention. A cross-sectional analysis was performed on linked data from nurses surveyed
(N = 10,184) and patients discharged from the
hospital (N = 232,342) between April 1, 1998,
and November 30, 1999.
The researchers found that after adjusting for
patient characteristics and hospital characteristics such as size, teaching status, and availability of advanced technology, each additional
patient per nurse was associated with a 7%
increase in the odds of failure to rescue and a
7% increase in the likelihood of 30-day mortality. Furthermore, each additional patient per
nurse was associated with a 23% increase in the
odds of nurse burnout and a 15% increase in
the odds of job dissatisfaction. This study provides evidence that a high patient-to-nurse ratio
is directly responsible for nurses’ job-related
burnout and job dissatisfaction.
Aiken et al suggest that hospitals can avoid
low nurse retention rates and preventable
patient mortality by investing in RN staffing.
This study provides the necessary evidence that
nurse staffing ratios are major indicators when
hospital mortality is used as a variable. The
authors suggest that the approach California
has taken in legislating nurse staffing to reduce
patient mortality is credible, and they agree
with government officials’ decisions to reject
hospital stakeholders’ support of up to 10
patients to each nurse. The ratios mandated in
the legislation were five or six patients per
nurse on medical and surgical units, depending
on the phase of implementation.34
NURSES’ ASSESSMENTS
OF
QUALITY
OF
CARE
Sochalski3 studied the effects of nurse
staffing and indicators of nursing care processes on nurses’ assessments of the quality of
nursing care delivered. A mail and telephone
survey was designed to collect information
including patient load, quality of care, and
work environment for nurses in acute care hospitals in Pennsylvania. The nine-page survey
Garrett
captured information on nurses’ work environments and the nurses’ perceptions of the quality of care delivered. The survey included variables on patient load; tasks left undone during
the previous shift; and patient safety problems
(eg, frequency of medication errors, patient
falls with injuries) during the previous year.
Of the nurses who responded to the survey,
a total of 8,670 were included in the data
analysis. Nurses reported caring for an average of 6.3 patients on general inpatient units
and 1.2 patients on intensive care units (ICUs),
with an overall average of 5.3 patients across
all respondents. An average of 2.1 tasks were
left undone at the completion of the last shift,
with 40% of nurses reporting three or more
tasks left incomplete. Sixteen percent of the
nurses reported that medication errors
occurred more than rarely in a period of one
year, and more than 20% of nurses reported
that patient falls with injuries occurred occasionally or frequently during the same period.
Regarding quality of care assessments, 25%
of respondents rated the care delivered as
excellent, and slightly more than 20% rated the
care delivered as poor or fair. Analysis of the
data showed that as the number of patients
assigned to nurses dropped, quality assessments increased and reports of unfinished
tasks and patient safety problems decreased,
indicating that nurses with lower numbers of
patients assigned to them felt that they were
providing a higher level of care.
This study demonstrates the relationship
between workload versus quality of care and
how increased workload results in compromised patient safety and unfinished tasks.
More importantly, Sochalski asserted that the
results of this study indicate that nurses’
assessments of quality could provide a critical
overview of the process of care (ie, the clinical
interventions that comprise the nursing care
that patients receive).
The author discusses several limitations to
the study, including that the cross-sectional
data do not permit inference of causality and
that the analyses suggest associations between
workload changes and patient outcomes but
are not equipped to provide definitive links.
The data are based on self-reports, which
JUNE 2008, VOL 87, NO 6
could be biased because of the associated factors of self-reporting and fear of punitive
action. In addition, the subjective variable of
“excellent” quality of nursing care also could
result in unmeasured bias.
UNIT STAFFING
AND
ADVERSE PATIENT OUTCOMES
The question of what effect nurse staffing
patterns have on patient care has stimulated a
number of studies that report links between
staffing levels on specific units and adverse
patient outcomes.4-8 Central line infections
(CLIs), pressure ulcers, medication errors, falls,
urinary tract infections (UTIs), and respiratory
infections are all examples of negative outcomes associated with low staffing levels.
Whitman et al9 attempted to identify which
units should increase nursing hours based on
patient outcomes. The researchers collected
data across several different types of hospital
units (ie, cardiac and noncardiac ICUs, cardiac
and noncardiac intermediate care, medicalsurgical) and then analyzed the data separately for each unit.
This study was a secondary analysis of observational data that included 95 patient care units
from 10 adult acute care hospitals. Variables
included total staff member work hours and
nurse-sensitive outcome rates for CLIs, pressure
ulcers, medication errors, falls, and restraint
application duration rates (ie, duration for use of
mechanical restraints). Descriptive statistics
were used to summarize all variables, and average monthly rates were calculated.
The researchers found no significant relationship between CLI and pressure ulcer rates
and staffing hours worked for any of the specialty units. There was, however, an inverse
relationship between falls in cardiac intermediate care units and staff hours worked. Medication errors also were inversely related to staff
hours worked in the cardiac ICU and noncardiac intermediate care units. The restraint
application duration rate was significantly
inversely related to staff hours worked only in
medical-surgical units.
Overall, the results of the Whitman et al
study suggest that the effect of staffing on
patient outcomes is highly variable across specialty units but, when present, the relationships
AORN JOURNAL •
1197
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JUNE 2008, VOL 87, NO 6
Excerpt from “AORN position statement:
Safe work/on-call practices”
ecognizing the potential negative consequences of sleep deprivation and sustained work hours and
further recognizing that adequate rest and recuperation periods are essential to patient and perioperative personnel safety, AORN suggests the following strategies.
• Perioperative registered nurses should not be required to work in direct patient care more than 12
consecutive hours in a 24-hour period and not more than 60 hours in a seven-day period. Sufficient
transition time is required for appropriate patient handoff and staff relief. Under extreme conditions
exceptions to the 12-hour limit may be required (eg, disasters). Organization policy should outline
exceptions to the 12-hour limitation. All worked hours (ie, regular hours and call hours worked) should
be included in calculating total hours worked.1-3
continu• Off-duty periods should be inclusive of an uninterrupted eight-hour sleep cycle, a break from
ous professional responsibilities, and time to perform individual activities of daily living.4-6
• Arrangements should be made, in relation to the hours worked, to relieve a perioperative registered
nurse who has worked on-call during his or her off shift and who is scheduled to work the following
shift to accommodate an adequate off-duty recuperation period.
• The number of on-call shifts assigned in a seven-day period depends on the type of facility and should be
coordinated with the number of sustained work hours and adequate recuperation periods mentioned above.
• An individual’s ability to meet the anticipated work demand should be considered for on-call assignments. Limited research indicates older people are more likely than younger people to be adversely
affected by sleep deprivation; however, there is no research specific to the effects of on-call assignment and a person’s age.
• Orientation to on-call should be included in the orientation process and should be accomplished using
the preceptor system (ie, having an experienced nurse serve as an immediate resource for the orientee). The time frame depends on the type of procedures and the scope of services.
responsibility to patients and themselves to
• Perioperative registered nurses should uphold their ethical
arrive at work adequately rested and prepared for duty.2,7
• Health care organizations should support perioperative RNs in changing cultural attitudes so that
fatigue is recognized as an unacceptable risk to patient and worker safety rather than a sign of a
worker’s dedication to the job.2
R
DEFINITIONS
On-call: A designated period of time, outside of designated hours of operation, during which perioperative RNs and other perioperative personnel are available to respond to patient care needs for unplanned
circumstances or urgent or emergent procedures.
Call hours worked: This is the actual time the on-call perioperative registered nurse or other perioperative personnel are called into the facility for a procedure.
Extended work period: Work schedules having a longer than normal workday; however, there is no
clear consensus nor are there regulations about the length of the extended workday. Some sources regard
time worked in excess of eight hours to be extended work periods, while others consider shifts longer
than 12 hours to be extended shifts.8,9
Sustained work hours: Work periods of 12 or more hours with limited opportunity for rest and no
opportunity for sleep.10
1198 • AORN JOURNAL
Garrett
JUNE 2008, VOL 87, NO 6
Excerpt from “AORN position statement:
Safe work/on-call practices” (continued)
Off duty: A period of uninterrupted time during which an individual is free from work-related duties.6
Fatigue: A response to predefined conditions that has physiological and performance consequences.
Fatigue is identified as deterioration in human performance arising as a consequence of changes in the
physiological condition. Factors contributing to fatigue include, but may not be limited to, time on task,
time and duty period duration, time since awake when beginning the duty period, acute and chronic
sleep debt, circadian disruption, multiple time zones, and shift work.11
Circadian rhythms: Twenty-four-hour cycles of behavior and physiology generated by an internal biological clock located in the suprachiasmatic nuclei of the hypothalamus. It regulates the daily cyclical
patterns of sleep and wakefulness. It compels the body to fall asleep and wake up and regulates hour-tohour waking behavior reflected in fatigue, alertness, and cognitive performance.12
REFERENCES
1. Rosekind M, Gander PH, Gregory KB, et al. Managing fatigue in operational settings 2: an integrated approach.
Hosp Top. 1997;75(3):31-35.
2. Gaba DM, Howard SK. Patient safety: fatigue among clinicians and the safety of patients. New Engl J Med.
2002;347(16):1249-1255.
3. Page A. Work and workspace design to prevent and mitigate errors. In: Keeping Patients Safe: Transforming
the Work Environment of Nurses. Washington, DC: National Academies Press; 2004:237.
4. Page A. Appendix C: Work hour regulation in safety-sensitive industries. In: Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academies Press; 2004:384-435.
5. Rogers AE, Hwang WT, Scott LD, Aiken LH, Dinges DF. The working hours of hospital staff nurses and patient
safety. Health Aff (Millwood). 2004;23(4):202-212.
6. Dinges DF, Graeber RC, Rosekind MR, Samuel A, Wegmann MH. Principles and Guidelines for Duty and
Rest Scheduling in Commercial Aviation. Moffett Field, CA: National Aeronautics and Space Administration;
1996. http://humanfactors.arc.nasa.gov/zteam/fcp/pubs/p.and.g.intro.html. Accessed March 8, 2008.
7. AORN explications for perioperative nursing. In: Standards, Recommended Practices, and Guidelines.
Denver, CO: AORN, Inc; 2004:53-83.
8. Extended unusual work shifts. US Department of Labor, Occupational Safety and Health Administration.
http://www.osha.gov/OshDoc/data_Hurricane_Facts/faq_longhours.html. Accessed March 6, 2008.
9. OSH answers. Canadian Centre for Occupational Health and Safety. http://www.ccohs.ca/oshanswers/work_
schedules/workday.html. Accessed March 6, 2008.
10. Kruger GP. Sustained work, fatigue, sleep loss and performance: a review of the issues. Work Stress. 1989;3(2):
129-141.
11. Battelle Memorial Institute, JIL Information Systems. An overview of the scientific literature concerning fatigue,
sleep, and the circadian cycle. January 1998. Federal Aviation Administration. http://cf.alpa.org/internet/projects
/ftdt/backgr/batelle.htm. Accessed March 6, 2008.
12. Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine. 3rd ed. Philadelphia, PA:
W B Saunders Co; 2000:319, 334.
Reprinted with permission from “AORN position statement: Safe work/on-call practices.” In: Standards, Recommended Practices, and Guidelines. Denver, CO: AORN, Inc; 2007:409-412. http://www.aorn.org/Practice
Resources/AORNPositionStatements/Position_SafeWorkOnCallPractices/. Accessed March 6, 2008.
AORN JOURNAL •
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JUNE 2008, VOL 87, NO 6
Garrett
are inversely related, with lower staffing levels
reviewed, the dependent variables of shock,
resulting in higher rates of all negative outcardiac arrest, UTIs, and pneumonia were all
comes. In this study, there was a lack of signifinegative outcomes associated with low nurse
cance between CLIs and nurse staffing and pres- staffing levels.
sure ulcers and nurse staffing, which differs
ADVERSE OUTCOMES. An AHRQ-funded report
from other reports4,5 but may be explained by
titled The Effect of Health Care Working Conditions
methodological differences in determining
on Patient Safety35 reviewed 26 studies on nurse
staffing hours. This study is consistent with oth- staffing levels and patient safety measures.
Many of the studies reviewed found an associaers when variables of fall rates and nurse
staffing levels are observed.7,8 In this study, actu- tion between lower nurse staffing levels and
al negative outcomes (ie, CLIs, pressure ulcers)
various adverse patient outcomes. The largest
were not associated with staffing levels, but
study of nurse staffing examined the records of
staffing was consistently, statis5 million medical patients and
tically, and inversely associated
1.1 million surgical patients
with falls, medication errors,
who had been treated in 1993
and restraint application duraat 799 hospitals.11 The principal
tion rates. The small sample
findings included that in hosA vast amount of
size could explain the lack of
pitals with high rates of RN
research has found a
relationship in those variables
staffing, medical patients had
that were different from other
lower rates of five adverse
relationship between
studies.
patient outcomes (ie, UTIs,
Results from this study
pneumonia, shock, upper gaslower nurse staffing
have a commonality with the
trointestinal bleeding, longer
others presented in this literahospital stay) than patients
rates and higher rates
ture review in the finding that
in hospitals with low RN
staffing can have an impact on
staffing. Higher RN staffing
of adverse patient
nurse-sensitive outcomes. This
was associated with a 3% to
study is unique, however, in
12% reduction in patients’
outcomes.
that most studies have identiadverse outcomes, depending
fied a relationship between
on the outcome. Higher
staffing patterns and adverse
staffing at all levels of nursing
outcomes at the hospital level
(ie, RNs, licensed practical
or on a specific unit, whereas this one reviewed nurses [LPNs], and nurses’ aides) was associatthe issue across multiple units and then
ed with a 2% to 25% reduction in adverse outapplied the data to individual units. The data
comes, depending on the outcome. For surgical
from this study may help hospital administrapatients, higher rates of RN staffing were associtors anticipate which units need higher levels
ated with a 5% to 6% reduction in rates of UTIs,
of staffing and at what time of day these higher a 4% to 6% reduction in rates of failure to rescue,
levels of staffing are needed, and the data may
and an 11% reduction in rates of pneumonia
be useful in developing staffing patterns that
compared to facilities with low RN staffing.
are linked to quality.
A study by Unruh12 of acute care hospitals
in Pennsylvania found that hospitals with
AHRQ REPORTS
more licensed nurses had a lower incidence of
The AHRQ reports that a vast amount of
nearly all of the adverse outcomes studied. A
research has shown a relationship between
10% increase in the number of RNs and LPNs
lower nurse staffing and higher rates of
decreased
adverse patient outcomes,10 with two research
• lung collapse by 1.5%,
reports from the AHRQ10,35 presenting evi• pressure ulcers by 2%,
dence that shows hospital staffing is directly
• falls by 3%, and
related to patient outcomes. In the studies
• UTIs by less than 1%.12
1200 • AORN JOURNAL
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JUNE 2008, VOL 87, NO 6
PNEUMONIA. Three studies found that lower
nurse staffing is directly related to increased
rates of pneumonia in particular.13-15 A study
by Kovner et al13 found that adding half an
hour of RN staffing per patient day could
reduce pneumonia in surgical patients by
more than 4%. Another study by Kovner et al14
revealed that fewer RN hours per patient were
significantly correlated with a higher incidence of pneumonia.
Instead of placing blame on nurses
for lapses in patient care, hospital
administrators should ensure patient
safety by examining how health
care is provided in their facilities
and changing nurses’ working
conditions so that they are able to
more safely care for patients.
A study by Cho et al15 of nurse staffing and
adverse outcomes in California found an 8.9%
decrease in the odds of a surgical patient
acquiring pneumonia when RNs were available for one additional hour per patient day.
This study also showed a 9.5% decrease in the
odds of a patient acquiring pneumonia when
the proportion of RNs was increased by 10%.
The researchers suggested that heavy responsibilities placed on RNs for respiratory care of
surgical patients is directly related to rates of
RN staffing and pneumonia. Unlike many
other studies, these researchers examined only
adverse outcomes that were not present at the
time of admission.15
1202 • AORN JOURNAL
ENSURING PATIENT SAFETY THROUGH
ADEQUATE NURSE STAFFING
This literature review included various
studies that compared staffing patterns with
patient outcomes and explored the relationship of fatigue and nursing errors. The evidence indicates that nurse staffing patterns can
have positive and negative effects on patient
care, and low levels of nurse staffing can result
in medical errors and adverse outcomes.
Rather than placing blame on nurses for lapses
in patient care, hospital administrators should
ensure the safety of patients by examining
how health care is provided in their facilities
and changing nurses’ working conditions so
that they are able to more safely care for patients. Nurses who suffer fatigue as a result of
working mandatory overtime or call are set up
for the potential to make medical mistakes,
which not only have a negative effect on nurses and their coworkers but also may result in
adverse outcomes for patients.
Inadequate staffing and unrealistic workloads place an unnecessary burden on nursing
staff members, reduce the quality of care that
nurses are able to provide, lead to fatigue and
unachievable expectations, and result in uncompleted tasks. Physicians also agree with
hospital nurses who report that nurse staffing
levels are inadequate for safe and effective
care and that inadequate nurse staffing is a
major impediment to providing high-quality
hospital care.36
An AHRQ report10 reveals the financial burden of adverse events, which can raise the cost
of total treatment by 84%; for example, this
translates to an increase of $22,390 to $28,505 to
treat pneumonia. Adverse events also were
shown to increase length of stay by 5.1 to 5.4
days and probability of death by 4.67% to 5.5%.10
When adverse outcomes occur as a result of
low nurse staffing, placing blame on nurses
provides no solution to the problems that
managed care and budget cuts have caused.
Ensuring an adequate number of nurses to
provide good quality patient care is a challenge for many hospitals, but the rewards can
be more positive outcomes, higher nurse
retention, less nurse burnout, and higher quality patient care.
Garrett
REFERENCES
1. Rogers AE, Hwang WT, Scott LD, Aiken LH,
Dinges DF. The working hours of hospital staff
nurses and patient safety. Health Aff (Millwood).
2004;23(4):202-212.
2. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber
JH. Hospital nurse staffing and patient mortality, nurse
burnout, and job dissatisfaction. JAMA. 2002;288(16):1
987-1993.
3. Sochalski J. Is more better? The relationship
between nurse staffing and the quality of nursing care
in hospitals. Med Care. 2004;42(2 Suppl):II67-II73.
4. Archibald LK, Manning ML, Bell LM, Banerjee S,
Jarvis WR. Patient density, nurse-to-patient ratio
and nosocomial infection risk in a pediatric cardiac
intensive care unit. Pediatr Infect Dis J. 1997;16(11):
1045-1048.
5. Fridkin SK, Pear SM, Williamson TH, Galgiani
JN, Jarvis WR. The role of understaffing in central
venous catheter-associated bloodstream infections.
Infect Control Hosp Epidemiol. 1996;17(3):150-158.
6. Blegen MA, Vaughn T. A multisite study of nurse
staffing and patient occurrences. Nurs Econ. 1998;
16(4):196-203.
7. Blegen MA, Goode CJ, Reed L. Nurse staffing
and patient outcomes. Nurs Res. 1998;47(1):43-50.
8. Sovie MD, Jawad AF. Hospital restructuring and
its impact on outcomes: nursing staff regulations are
premature. J Nurs Adm. 2001;31(12):588-600.
9. Whitman GR, Kim Y, Davidson LJ, Wolf GA,
Wang SL. The impact of staffing on patient outcomes across specialty units. J Nurs Adm. 2002;32
(12):633-639.
10. Stanton MW. Hospital nurse staffing and quality
of care. Res In Action. March 2004;14:1-10. http://
www.ahrq.gov/research/nursestaffing/nursestaff
.pdf. Accessed March 1, 2008.
11. Needleman J, Buerhaus P, Mattke S, et al.
Nurse-staffing levels and patient outcomes in hospitals.
Final report for Health Resources and Services Administration. Boston, MA: Harvard School of Public
Health; 2001.
12. Unruh L. Licensed nurse staffing and adverse
events in hospitals. Med Care. 2003;41(1):142-152.
13. Kovner C, Mezey M, Harrington C. Research
priorities for staffing, case mix, and quality of care
in US nursing homes. J Nurs Scholarsh. 2000;32(1):
77-80.
14. Kovner C, Jones C, Zhan C, Gergen PJ, Basu J.
Nurse staffing and postsurgical adverse outcomes:
an analysis of administrative data from a sample of
US hospitals, 1990-1996. Health Serv Res. 2002;37(3):
611-629.
15. Cho SH, Ketefian S, Barkauskas VH, Smith DG.
The effects of nurse staffing on adverse events,
morbidity, mortality, and medical costs. Nurs Res.
2003;52(2):71-79.
16. Making Health Care Safer: A Critical Analysis of
Patient Safety Practices. Rockville, MD: Agency for
Healthcare Research and Quality; July 2001. http://
JUNE 2008, VOL 87, NO 6
www.ahrq.gov/clinic/ptsafety/pdf/ptsafety.pdf.
Accessed March 1, 2008.
17. Mystakidou K, Parpa E, Tsilika E, et al. The
relationship of subjective sleep quality, pain, and
quality of life in advanced cancer patients. Sleep.
2007;30(6):737-742.
18. Kane RL, Shamliyan T, Mueller C, Duval S,
Wilt TJ. Nurse Staffing and Quality of Patient Care.
Rockville, MD: Agency for Healthcare Research and
Quality; March 2007. http://www.ahrq.gov/down
loads/pub/evidence/pdf/nursestaff/nursestaff.pdf.
Accessed March 1, 2008.
19. Mason DJ. Good nurse—bad nurse [Editorial].
Am J Nurs. 2007;107(3):11.
20. Wahlberg D, Treleven E. Nurse is charged in
death of patient. Wisconsin State Journal. November
3, 2006:A1. http://www.madison.com/archives
/read.php?ref=/wsj/2006/11/03/0611030019.php.
Accessed March 1, 2008.
21. Committee on the Work Environment for Nurses
and Patient Safety; Board on Health Care Services;
Page A, ed. Keeping Patients Safe: Transforming the
Work Environment of Nurses. Washington, DC:
National Academies Press; 2004. http://www.nap
.edu/openbook/0309090679/html/1.html. Accessed
March 2, 2008.
22. Mitler MM, Carskadon MA, Czeisler CA, Dement
WC, Dinges DF, Graeber RC. Catastrophes, sleep,
and public policy: consensus report. Sleep. 1988;11
(1):100-109.
23. Beyea SC. Too tired to work safely? AORN J.
2004;80(3):559-562.
24. Zboril-Benson LR. Why nurses are calling in
sick: the impact of health-care restructuring. Can J
Nurs Res. 2002;33(4):89-107.
25. Gold DR, Rogacz S, Bock N, et al. Rotating shift
work, sleep, and accidents related to sleepiness in hospital nurses. Am J Public Health. 1992;82(7):1011-1014.
26. Rosekind M, Gander PH, Gregory KB, et al.
Managing fatigue in operational settings 2: an integrated approach. Hosp Top. 1997;75(3):31-35.
27. AORN position statement: Safe work/on-call
practices. In: AORN Standards, Recommended Practices, and Guidelines. Denver, CO: AORN, Inc; 2007:
409-412. http://www.aorn.org/PracticeResources
/AORNPositionStatements/Position_SafeWork
OnCallPractices/. Accessed March 6, 2008.
28. Aiken LH, Clarke SP, Sloane DM, et al. Nurses’
reports on hospital care in five countries. Health Aff
(Millwood). 2001;20(3):43-53.
29. AHA Commission on Workforce for Hospitals
and Health Systems. In Our Hands: How Hospital
Leaders Can Build a Thriving Workforce. Chicago, IL:
American Hospital Association: April 2002. http://
www.aha.org/aha/resource-center/Statistics-andStudies/ioh.html. Accessed March 1, 2008.
30. Girard NJ. Perioperative education—perspective
from the think tank. AORN J. 2004;80(5):827-838.
31. Bosek MS. Mandatory overtime: professional
duty, harms, and justice. JONAS Healthc Law Ethics
AORN JOURNAL •
1203
Garrett
JUNE 2008, VOL 87, NO 6
Regul. 2001;3(4):99-102.
32. Capitulo KL, Ankner ML, Miller J. Professional
responsibility versus mandatory overtime. J Nur
Adm. 2001;31(6):290-292.
33. Curtin LL. The case against mandatory overtime. Semin Nurse Manag. 2002;10(4):274-278.
34. Governor Davis announces nurse workforce initiative [news release]. Sacramento, CA: Office of the
Governor; January 23, 2002. http://psychtechs.net
/idx/PSYCH-HEALTH1/nurse02.htm. Accessed
March 1, 2008.
35. Hickam DH, Severance S, Feldstein A, et al. The
Effect of Health Care Working Conditions on Patient
Safety. Rockville, MD: Agency for Healthcare
Research and Quality: May 2003. http://www
.ahrq.gov/downloads/pub/evidence/pdf/work
/work.pdf. Accessed March 1, 2008.
36. Doctors in five countries see decline in health
care quality. Commonw Fund Q. 2000;6(3):1-4.
Connie Garrett, RN, BSN, CNOR, is an
OR nurse educator at James A. Haley Veterans Hospital, Tampa, FL.
DASH Diet May Prevent Strokes in Women
T
he Dietary Approaches to Stop Hypertension
(DASH) diet was found to lower the risk of coronary heart disease (CHD) and stroke in middle-aged
women, according to a study in the April 14, 2008,
Archives of Internal Medicine. The prospective cohort
study included 88,517 female nurses, ages 34 to 59
years, with no history of cardiovascular disease or
diabetes in 1980. After seven dietary assessments
during 24 years of follow up, researchers recorded
the following:
• 2,129 cases of incident nonfatal myocardial
infarction,
• 976 CHD deaths, and
• 3,105 cases of stroke.
After adjusting for cardiovascular risk factors
(eg, age, smoking), researchers found that DASH
scores were associated with a significantly reduced
risk of stroke in women. The DASH score, based on
consumption of certain foods and nutrients (eg,
whole grains, low-fat dairy, sodium), was also significantly associated with lower plasma levels of Creactive protein (ie, an indicator of inflammation
and stroke risk).
Fung TT, Chiuve SE, McCullough ML, Rexrode KM, Logroscino G, Hu FB. Adherence to a DASH-style diet and risk of
coronary heart disease and stroke in women. Arch Intern
Med. 2008;168(7):713-720.
US Pharmacopeia Revises Glycerin Monograph
A
revised glycerin monograph is scheduled for publication in the United States Pharmacopeia as a
means to increase consumer safety and prevent fatalities associated with adulteration of the sweetener,
according to a March 17, 2008, news release from
the US Pharmacopeia (USP). The revised monograph
includes an updated procedure for quantifying impurities in glycerin and a new procedure for identifying
the presence of diethylene glycol.
Diethylene glycol, a poisonous chemical used in
industrial solvents and antifreeze, has been found as
an adulterant in glycerin, which is used as a sweetener in pharmaceutical syrups and various consumer
products. In 1938, more than 100 US citizens died
of poisoning from diethylene glycol. Since then, the
1204 • AORN JOURNAL
USP has worked with the US Food and Drug Administration (FDA) to increase consumer safety.
The FDA issued a “Guidance for Industry Testing of Glycerin for Diethylene Glycol” in May 2007,
emphasizing the importance of screening for the
chemical. The revised monograph and FDA guidelines
require any medication manufacturer using glycerin to
prove diethylene glycol is not present in its product.
The revised monograph goes into effect on May
15, 2008. The USP currently is working to update
additional monographs for ingredients that may also
be susceptible to diethylene glycol contamination.
USP announces revised glycerin monograph [news release].
Rockville, MD: US Pharmacopeia; March 17, 2008.
Spring 2018
Module C
Page 1 of 2
NURS4342
Incorporation of Evidence into Practice
Critique Process
Introduction
For this module, the synthesizing of evidence-based practice will be the focus. Following the
completion of this module, the student is expected to be able to function as a competent
consumer of evidence in nursing demanding an understanding and application of evidence and
basic reserach principles to advance the practice of safe and competent nursing care.
Objectives
2.
Summarize the essential components of evaluating evidence, such as determining
the PICOT, assessing research aspects, ethical considerations and assessing other
forms of evidence.
5. Apply evidence with a partner for clinical decision making to promote patient safety
and quality.
Learning Activities
1. Actively participate in the appropriate discussion board per the class schedule.
2. Read appropriate areas within selected research text.
3. Access and view a narrative PowerPoint file related to how to develop a PICOT question
effectively. The file is located at: http://www.ttuhsc.edu/son/ceebp/. It is entitled: PICOT
Development. Within the Center of Excellence in Evidence-Based Practice, it is located
under the “Learning Resources” found on the right-hand side of the page.
4. Completion of the assignment entitled: Documenting Evidence-based Practice Aspects.
Practical rationale for Module C assignment: This assignment provides a full
look at how to complete an evidence-based practice project. Within this
assignment, the group has to determine a PICOT question then access and
evaluate articles to find out the evidence available for that topic. The final part of
this assignment is individual work to help the student to implement EBP into their
own practice in a functional manner. ONLY ONE MEMBER OF THE GROUP
NEEDS TO SUBMIT THE ASSIGNMENT. THE ASSIGNMENT SHOULD BE
SUBMITTED AS ONE DOCUMENT NOT MULTIPLE FILES.
Please save the assignment as: NURS4342_ModuleC_ last name & last
name
Group work: The team will select a current health topic to concentrate on for this
assignment. You could find suggested topics from your agency, Institute of
Medicine (IOM), or Joint Commission. Confirm with the course facilitator the team
members and the selected priority area. It is strongly advised that the team
submits a draft of the PICOT question to the faculty member for review prior to
working with the research articles. The team will locate 3 research articles for use
within this assignment. The team will summarize these articles using the grading
criteria and document the findings on the form provided.
Individual work: After completing the EBP grid with the PICOT question, EBP
grid, and two questions included on the grid, each member of the group will
Spring 2018
Module C
Page 2 of 2
NURS4342
Incorporation of Evidence into Practice
prepare a ONE page discussion about how they are using the material learned
within this course in their unique practice of nursing and how you can initiate a
policy or procedure change within your practice setting based on what you have
learned in this class.
A grading rubric is provided for use with this assignment.
"All papers will be automatically scanned for evidence of plagiarism. A paper
containing any plagiarism will receive a grade of zero and a complaint for
academic misconduct may be submitted to the Assistant Dean of Student Affairs.
Other reporting requirements may also apply."
Resources
Boswell and Cannon; appropriate chapters as needed.
Resources from the Boswell and Cannon (2017) textbook for use with the Documenting
Evidence-Based Practice Aspect form:
Examples of the form completed: Pages 470-475
Writing a PICOT: Pages 14-19
Level of evidence: Page 53
Strength of evidence: Page 54
Sampling: Pages 282-287
Quantitative aspects: Pages 111-124
Qualitative aspects: Pages 136-159
Validity: Pages 359-365
Qualitative control: Pages 145-146
Kevin M. Shimp
Systematic Review
Of Turnover/Retention and Staff
Perception of Staffing and Resource
Adequacy Related to Staffing
EXECUTIVE SUMMARY
Strategies identified in the literature that support the impact of
staffing on registered nurse (RN)
turnover/retention and RN staff
perceptions of staffing and
resource adequacy are summarized and reviewed.
Staffing and environment that
impacts the resources of RNs
directly impacts RNs’ intent to
leave their current institution as
well as their perception of
staffing and resource adequacy.
Organizational leadership needs
to be innovative and creative in
their approach to staffing, allowing for education, empowerment, professional development,
and equitable assignments that
foster a better perception of the
individual RN’s ability to provide
high-quality care.
KEVIN M. SHIMP, MSN, RN, CCRN, is
DNP Student, James Madison University
School of Nursing, Harrisonburg, VA.
ACKNOWLEDGMENT: The author wishes
to thank Professor Linda Hulton for her
feedback on an early draft of this paper.
A
nurse-to-patient
ratio is a national challenge. Finding the correct
ratio without addressing
acuity should not be overlooked
even though there is a lack of literature existing to address this aspect
of the overall concern of inadequate
resources to meet patient needs.
According to the American Nurses
Association (ANA, 2015), adequate
staffing levels have shown reduced
medical and medication errors,
decreased patient complications,
decreased mortality, improved
patient satisfaction, reduced nurse
fatigue, decreased nurse burnout,
and improved nurse retention and
job satisfaction.
In July 2002, The Joint Commission stated that staffing effectiveness is the appropriate level
of nurse staffing that will provide
for the best possible outcome of
individual patients throughout a
particular facility (Health Leaders
Media, 2010). This requires hospital
administration to track two patient
outcome indicators such as falls and
hospital-acquired pressure ulcers
and determine the variation in
performance caused by the number,
skill mix, or competency of the staff.
In June 2009, this standard was suspended due to the debate that
N OPTIMAL
NURSING ECONOMIC$/September-October 2017/Vol. 35/No. 5
nurse staffing impacted patient
outcomes. As a result, interim
staffing effectiveness standards
came into effect July 1, 2010 and
will remain in effect while further
research is conducted on staffing’s
impact on patient outcomes (Health
Leaders Media, 2010). Healthcare
leaders have been creative in
developing strategies to build a safer
environment for patients and registered nurses (RNs). Any optimal
staffing model must include patient
acuity, unlicensed assistive personnel, and the skills, education,
and training of the workforce within
specific unit settings to be effective.
Appropriate staffing is imperative to
provide safe and quality patient care
(ANA, 2015).
There is a lack of evidence
that addresses the influence of
staffing and scheduling committees on RN turnover, retention,
and their perception of staffing
and resource adequacy. A systematic review of the current
literature was conducted to add to
the overall literature, developing a
baseline for RN turnover, retention, and RN perception of staffing
and resources adequacy. The
purpose of this systematic review
was to identify common themes
that can be used to evaluate the
239
author’s future descriptive study
on staffing and scheduling committees’ influence on turnover,
retention, and staff perception of
staffing and resource adequacy at
the institutional level when the
committee utilizes staff RNs in
their decision process.
Background
Since California mandated the
ratio between nurses and patients,
seven states (Oregon, Washington,
Ohio, Illinois, Connecticut, Rhode
Island, and Texas) enacted laws or
adopted regulations regarding
nurse staffing. These states did not
follow California’s lead in mandating specific nurse-to-patient ratios.
Most of these states modeled legislation from the ANA Safe Staffing
Principles which address the
problem by requiring hospitals to
create nurse staffing committees
comprising at least 50% clinical
nurses. These committees are
responsible for developing staffing
plans tailored to the institution
(Shullanberger, 2000).
Identifying and maintaining
the number and mix of nursing
staff to patients while considering
patient acuity is critical to the
delivery of safe and quality care.
Frequent studies have revealed an
association between higher levels
of experienced RN staffing and
lower rates of adverse patient
outcomes including mortality. The
literature shows the number of
RNs at the bedside impacts the
safety of both patient and nurse
(ANA, 2015).
Some authors suggest legislation and regulation is the only
way to achieve adequate staffing,
but in reality regulation is already
in place. At the federal level, legislation was created in 2008 to
amend or introduce new staffing
guidelines for the healthcare
industry. In the 114th Congress,
House Bill 2083 and Senate Bill
1132 sought to amend Title XVIII
(Medicare) of the Social Security
Act which requires Medicare-participating hospitals to implement
a hospital-wide staffing plan for
240
nursing services within their
organization. The amendment
called for a plan that would
require an appropriate number of
RNs providing direct patient care
in each unit of the hospital to
ensure staffing levels that: (a)
address the unique characteristics
of the patients and hospital units,
and (b) result in the delivery of
safe, quality patient care consistent with specified requirements.
The proposals also sought to
require each participating hospital
to establish a hospital nurse
staffing committee to implement
such a plan. Nationally, efforts
continue to amend or introduce
new legislation.
State staffing laws have three
general approaches (ANA, 2015).
The first requires hospitals to have
a nurse-driven staffing committee
to create staffing plans that reflect
the needs of the patient population and match the skills and
experience of the staff. The second
approach is for legislators to
mandate specific nurse-to-patient
ratios in legislation or regulation.
The third approach requires
facilities to disclose staffing levels
to the public and/or a regulatory
body.
The ANA platform for safe
staffing calls for a legislative model that requires nurses to be
empowered to create staffing
plans that meet specific unit demands. This approach establishes
staffing levels that are flexible and
allows for changes in intensity of
patients’ needs; number of admissions, discharges, and transfers during a shift; level of
experience of nursing staff; unit
layout; and availability of resources (ancillary staff, technology, etc.)
(ANA, 2015).
The development of staffing
and scheduling committees has
occurred throughout the nation
because of ANA’s platform, the
desire for Magnet® recognition by
the institution, and legislation and
regulation. The American Nurses
Credentialing Center (ANCC,
2015) Magnet Recognition Pro-
gram® is viewed around the world
as the ultimate seal of quality and
confidence. Magnet organizations
are recognized for superior nursing processes and quality patient
care, which lead to the highest
levels of safety, quality, and
patient satisfaction (ANCC, 2015).
Little is known on how to develop
these committees. However, Dawson
(2014) provided recommendations
for staffing and scheduling committees.
1. Involve nurses in the design of
work schedules using a regular and predictable schedule,
so nurses can plan for work
and personal responsibilities.
2. Limit work weeks to 40 hours
within 7 days and work shifts
to 12 hours in duration.
3. Establish at least 10 consecutive hours per day of protected
time off duty for nurses to
obtain 7 to 9 hours of sleep.
4. Eliminate the use of mandatory overtime as a “staffing solution.”
5. Promote frequent, uninterrupted rest breaks during
work shifts and facilitate the
use of naps during scheduled
breaks.
To promote staff recruitment
and retention, nurses on a 13-bed
medical oncology unit proposed
the following goals for their
staffing committee: increase staff
morale; increase staff control over
their work environment through
self-governance activities; and
offer flexible scheduling options.
The committee goals to address
these concerns were to examine
and evaluate scheduling options
for the unit on an ongoing basis,
promote and maintain staff input
into decision making, and educate
staff and provide hands-on scheduling experiences for committee
members (Dearholt & Feathers,
1997).
In another study, a nursing productivity committee was formed to
analyze productive and nonproductive hours and seek improvements in staffing models and
scheduling processes, which re-
NURSING ECONOMIC$/September-October 2017/Vol. 35/No. 5
sulted in lower nurse-to-patient
ratios, better control of labor costs,
elimination of agency staff, greater
staff satisfaction, and introduction
of new technologies (McKenna et
al., 2011). The goals of this committee were:
1. Review/revise staffing formulas for budgeted full-time
equivalent requirements.
2. Understand hours per patient
day (HPPD), productive and
nonproductive hours, how the
standards are determined, and
how variances occur.
3. Establish standards for productive and nonproductive
time.
4. Discuss staffing strategies to
reach target HPPD on all nursing units.
5. Analyze computerized staffing
reports to ensure accuracy and
determine opportunities for
improvement.
6. Collaborate with nursing councils to address staff morale
related to turnover and workload.
7. Seek opportunities to make
cost savings without adversely affecting patient care.
Methods
A literature search was undertaken in October 2015 of the major healthcare-related databases:
CINAHL, Medline, and ProQuest.
The keywords “nurs* AND practice AND environment AND committee* and governance” were
used initially. Additional keywords “retention strategies” were
also searched. Abstracts were
reviewed and articles which
included a purpose to improve the
practice environment of nurses in
relation to RN turnover, retention,
and RN’s perception of staffing
and resource adequacy were identified. Reference lists of selected
articles were reviewed for other
potential articles. Articles were
excluded if not written in English.
The initial search located 79
articles and all abstracts were
reviewed. Ten papers were reviewed for reported processes
aimed at assessing turnover and
retention and 12 papers were
identified that looked at staffing
perception and resource adequacy. All articles were published
within the last 5 years, allowing
for the most recent literature to be
reviewed.
After screening, one acrossmethod triangulation study, one
literature review, one triangulated
methodology study, nine crosssectional surveys, one cross-sectional correlational design, three
surveys, one retrospective study
of data, one mixed-method survey,
one survey with focus groups, one
survey with focus groups, one
qualitative descriptive study, and
one secondary analysis were
included in the systematic review.
The years of publication ranged
from 2009-2015 and the level of
evidence included six Level 6, one
Level 5, and 15 Level 3.
Results
See Tables 1 and 2.
Discussion
The literature supports the
cost...