The Effect of Increased Nurse-to-Patient Ratios in Hospitals and Skilled Nursing Facilities Related to Patient Falls and Pressure Injuries

Submitted by Joanna Hewett, RN, BSN

Tags: acute care falls Nurse-to-Patient Ratios Patient Falls patient outcomes Pressure Injuries work environment

The Effect of Increased Nurse-to-Patient Ratios in Hospitals and Skilled Nursing Facilities Related to Patient Falls and Pressure Injuries

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Abstract

There has long been a debate between healthcare administration, politicians, payers and nurses on the issue of safe staffing and the effect of nurse-to-patient ratios in hospitals and Skilled Nursing Facilities (SNF).  The purpose of this paper is to review research articles related to the effect of nurse-to-patient ratios at hospitals and SNFs on the fall rate and pressure injury rate of patients.  It is the hypothesis of this paper that there will be a positive effect for patients related to the improved nursing ratios.  Upon reviewing five solid research articles, as listed in the later part of this paper, the hypothesis is supported by solid evidence that both pressure injuries and fall rates of patients in the hospitals and SNF settings are directly improved by increased nurse staffing.  The recommendation made from this review is that states improve regulations for hospitals and SNFs to increase and maintain adequate nurse staffing as it has a direct positive effect on patient outcomes.

Introduction

There is an ongoing effort within the nursing community to address fall rates and pressure injury rates among inpatients at both SNFs and hospitals.  Overall fall rates decline in many hospitals but falls with injury continue to stay the same or increase.  Pressure injuries continue to be a problem in high acuity units such as stroke units and critical care.  Despite implementing bundle of care initiatives in both of these areas, hospitals are not making the indent they aspire to in reduction of harm to patients.  The purpose of this research review is to analyze research to maintain or discredit a link between increased nurse staffing and patient fall rates and pressure injury rates.  The importance of identifying a link between nurse staffing and these particular patient outcomes is that protocol for minimal staffing could be generated in SNFs and hospitals at the state regulation level.

PICO Question

In skilled nursing facilities and hospital populations, how does increasing nurse-to-patient ratio compared to usual standard of care affect fall rate and pressure injury rate among patients?

Hypothesis Statement

The direct positive effect of increasing nurse-to-patient ratios in hospitals and SNFs will be a decrease in patient falls and decrease pressure injuries.

Literature Review

This paper consists of and summarizes the review of five research studies related to the PICO question.  In review of the research article, Determinants of Hospital Fall Rate Trajectory Groups: A Longitudinal Assessment of Nurse Staffing and Organizational Characteristics in Health Care Management Review by Dr. Everhart, Dr. Schumacher, Dr. Duncan, Dr. Hall, Dr. Neff and Dr. Schorr (2014), a 54-month (July 2006 – December 2010) longitudinal study was conducted in 1,529 acute care general hospitals to compare the relationship between nurse staffing and hospital organizational characteristics associated with hospital fall rate as covariates.  The hospitals that were part of the study had to be participants in the National Database for Nursing Quality Indicators (NDNQI) from which the indicators for the study were selected.  Hospitals were classified into three groups according to fall rate trajectories.  The groups are classified as consistently high fall rates (4.96 per 1000 patient days), consistently medium fall rates (3.63 per 1000 patient days) and consistently low fall rates (2.50 per 1000 patient days).  The findings show that hospitals with higher total nurse staffing (more nurses to patients), Magnet status and larger bed size (greater than 300 beds) statistically were more likely to land in the low to medium fall rate category.  Along with increased nurse staffing leading to decreased falls, this study adds two additional factors to the findings of decreased patient falls in our assessment of the data.

Another research article, Nurse Staffing and Patient Outcomes: A Longitudinal Study on Trend and Seasonality found in BMC Nursing (2016) by He, Staggs, Bergquist-Beringer and Dunton, uses the same database (NDNQI) yet over a different time period while examining dissimilar aspects in the research.  The research uses longitudinal analysis of data from Hospital units in U.S. acute care hospitals participating in the NDNQI from 2004-2012 and was assessed to examine the longitudinal relationship between nurse staffing and patient outcomes of pressure injuries and falls in hospitals.  The sample size included 13,339 units from 1,622 hospitals which met the criteria to be included in the research related to nurse staffing in correlation with patient falls; and 12,435 units from 1,527 hospitals which were included to assess nurse staffing related to pressure injuries.  Using weighted linear mixed models results were analyzed to determine results.  It was found that increased nurse hours per patient day (HPPD) was related to lower event rate of pressure injuries and patient falls.

In agreement with the results above of increased nurse staffing and decreased pressure injury rate, the following article has similar findings but in the skilled nursing facility (SNF) setting.  The article, Nurse Staffing Impact on Quality of Care in Nursing Homes: A Systematic Review of Longitudinal Studies in The Journal of Post-Acute and Long-Term Care Medicine by Backhaus, Dr. Verbeek, Dr. Van Rossum, Dr. Capezuti and Dr. Hamers (2014), approaches the subject using a systematic review of longitudinal studies conducted of research articles related to nurse staffing and quality of care.  The authors systematically reviewed findings from recent longitudinal studies in the relationship between nurse staffing and quality of care (QoC) in SNFs.  After methodological analysis of articles from the databases PubMed, CINAHL, EMBASE and PsycINFO, 20 articles were selected of which two were excluded due to low quality.  The findings of the review was that there was no consistent relationship for increased QoC with increased nurse staffing.  However, a direct positive relationship was found between decreased pressure injuries and increased staffing.  The staffing looked at in this review includes RNs, LPNs and CNAs.  The writers of this article recommended further longitudinal studies to better understand the relationship between nurse staffing and QoC in nursing homes.

Also, looking at SNFs, the article, Improving Nursing Home Resident Outcomes: Time to Focus on More than Staffing? In The Journal of Nursing Home Research by Kimmey and Stearns (2015), looks at several factors related to patient outcomes in SNFs related to staffing.  Specifically, the researchers of this article looked at the effect of staffing at long-term care facilities on patient pain, pressure injuries, restraint use, falls, emergency department and hospital visits.  The sample was collected from nursing homes that participated in the 2004 National Nursing Home Survey (NNHS) and consisted of 14,017 residents at 1,500 facilities, after exclusions due to missing data final sample size was 10,043 residents at 954 facilities.  The authors did their analysis by reviewing the data collected from the 2004 NNHS conducted by the US National Center for Health Statistics.  The authors stated that although at the time of the article publication in 2015, the survey was over 10 years old, it was the most recent US national survey with appropriate data for determining correlations necessary for intended purpose of the research review.  To analyze results in the study models, they used logistic regression with sample weights calculated by the National Center for Health Statistics.  The results of the study found that moving from very poor staffing to very good staffing of CNAs led to improvement in outcomes of pain, pressure injuries and restraint use.  Greater RN oversight led to decrease in falls and ED / Hospital visits.

Finally, in review of the article, Associations Between Characteristics of the Nurse Work Environment and Five Nurse-Sensitive Patient Outcomes in Hospitals: A Systematic Review of Literature in International Journal of Nursing Studies (2016) by Stalpers, de Brouwer, Kaljouw and Schuurmans, a systematic review of literature was conducted to find the relationship between nurse work environment and patient outcomes (specifically delirium, malnutrition, pain, patient falls and pressure injuries) in hospitals.  The researchers conducted a systematic review of data sources PubMed, Cochrane, Embase and CINAHL.  Using the Dutch version of Cochrane’s critical appraisal instrument to assess quality of studies to include, 29 of the initial 1,120 articles were included in the final systematic review.  The review found that increased nurse staffing was directly related to decreased patient falls.  The results were mixed and inconclusive related to pressure injuries in this review.

Please note that a summary of the articles presented above are listed in the matrix table in the Appendix of this paper (Table 1).

Implications for Clinical Practice

According to the American Nurses Association (2019) currently only 14 states have nurse-to-patient hospital ratio regulation laws in place.  As far as staffing in skilled nursing facilities (SNFs), according to Wofford (2019), there are no set standards of nurse-to-patient ratios but simply the Nursing Home Reform Law of 1987 guidelines that a SNF must staff  “a registered nurse eight consecutive hours, seven days a week; licensed nurses 24 hours a day and otherwise ‘sufficient’ nursing staff to meet residents’ needs”. 

The implications of looking at the research review for this paper indicates strongly that increasing staffing will lead to improved patient outcomes related to pressure injuries and fall rates in both hospitals and SNFs.  In the SNF setting the staffing includes RNs, LPNs and CNAs.  In the hospital setting the improved staffing is related specifically to RNs.

Implementation Plan

Implementation for such a drastic all-encompassing change needs to happen either at the state or federal level through laws and regulations.  The nursing associations have long lobbied for such change and it is crucial for both nurses and patients to be involved in this cause.  Improving staffing to a set standard where both healthcare workers and patients feel safe is the goal.  However, there are many parties that will continue to oppose such change particularly among some administrators and payers.  If it can be shown through detailed research that increasing nurse staffing leads to decreased per patient cost because of improved health, the financial side of the equation may be solved.

Another barrier to executing the increase in nurse staffing is the shortage of nurses.  This needs to be addressed at the university level so that more educators are available and the wait-list for nursing school can be decreased.

Once bills are passed and nurse-to-patient ratios are improved in both SNFs and hospitals, the implementation will be well received by nurses and patients.  Currently, as of July 2020, New York State has a bill sponsored by Assemblywoman Gunther that is in the assembly committee.  The bill A2954, “Safe Staffing for Quality Care Act” could serve as a gold standard for other states.  The staffing ratios recommended by the law would improve and regulate nurse-to-patient ratios for both hospitals and SNFs. 

Bills such as A2954 is where implementation needs to start for improvement of nurse-to-patient ratios to be successful across states.  It is the hope of the author of this article that patient safety will come first and bill A2954 passes along with similar laws across the United States.  

The argument from hospitals and ANA against legislature is that no one staffing plan fits all patients.  Hospitals don't want to get locked into a fixed ratio but want to vary the staffing according to patients. Administrations argue that this will bankrupt hospitals however the amount of money paid for legal fees and suits could be a savings to the hospital, not to mention turnover.  Lastly, the environment of care needs to be explored.  Broken equipment, missing items for patient care, poor communication systems, minimal interdisciplinary teaming all contribute to patient care outcomes.  Perhaps if these were also fixed, patient outcomes would be better.  All in all, having one nurse to 20-40 nursing hospital patients is unacceptable for good outcomes.  We as a nursing community and society need to become more involved in the decision to staff our hospitals and nursing homes.

Appendix

Table 1 - Matrix Table

Author(s) Title of article Publication

Year Journal Problem/Purpose Design/Type of Study Data collection Instruments Setting Sample description Sample Size Analysis Findings

Everhart, Schumacher, Duncan, Hall, Neff and Shorr Determinants of Hospital Fall Rate Trajectory Groups: A Longitudinal Assessment of Nurse Staffing and Organizational Characteristics 2014 Heath Care Management Review To identify nurse staffing and hospital organizational characteristics associated with hospital fall rate as covariates 54-month longitudinal study Monthly retrospective data from the National Database for Nursing Quality Indicators (NDNQI) None U.S. acute care general hospitals U.S. acute care general hospitals participating in the NDNQI July 2006 – December 2010 1,529 Latent Class Growth Modeling with Means and C.I. Hospitals with higher nurse staffing were less likely to be characterized with higher fall rate

He, Staggs, Bergquist-Beringer and Dunton Nurse Staffing and Patient Outcomes: A Longitudinal Study on Trend and Seasonality 2016 BMC Nursing Examine the longitudinal relationship between nurse staffing and patient outcomes of pressure injurys and falls in hospitals. Longitudinal Study Monthly retrospective data from the National Database for Nursing Quality Indicators (NDNQI) None U.S. acute care general hospitals Hospital units in U.S. acute care hospitals participating in the NDNQI 2004-2012 13,339 units from 1,622 hospitals met criteria to be included for falls and 12,435 units from 1,527 hospitals were included for pressure injurys Weighted linear mixed models Higher nurse hours per patient day (HPPD) was related to lower event rate of pressure injurys and patient falls.

Backhaus, Verbeek, Van Rossum, Capezuti and  Hamers Nurse Staffing Impact on Quality of Care in Nursing Homes: A Systematic Review of Longitudinal Studies 2014 The Journal of Post-Acute and Long-Term Care Medicine To review findings from recent longitudinal studies in relationship between nurse staffing and quality of care (QoC) in nursing homes Systematic Review from recent longitudinal studies Systematic search of databases PubMed, CINAHL, EMBASE, PsycINFO The Newcastle-Ottawa scale Nursing homes Studies conducted in nursing homes, original study describing quantitative, longitudinal studies, written in English, Dutch or German 20 studies originally, 18 studies excluded for low-qualtiy Methodological Systematic analysis No consistent relationship found between nurse staffing and QoC however, more staff led to fewer pressure injurys.

Kimmey and Stearns Improving Nursing Home Resident Outcomes: Time to Focus on More than Staffing? 2015 The Journal of Nursing Home Research To estimate the effect of staffing at long-term care facilities on patient pain, pressure injurys, restraint use, falls, emergency department and hospital visits. Survey Review 2004 National Nursing Home Survey conducted by the US National Center for Health Statistics None Nursing homes in the United States Residents and facilities participating in the 2004 National Nursing Home Survey 14,017 residents at 1,500 facilities, after exclusions due to missing data final sample size was 10,043 residents at 954 facilities Models analyzed using logistic regression with sample weights calculated by the National Center for Health Statistics Moving from very poor staffing to very good staffing of CNAs led to improvement in outcomes of pain, pressure injurys, restraint use.  Greater RN oversight led to decrease in falls, ED / Hospital visits.

Stalpers, de Brouwer, Kaljouw and Schuurmans Associations Between Characteristics of the Nurse Work Environment and Five Nurse-Sensitive Patient Outcomes in Hospitals: A Systematic Review of Literature
2015 International Journal of Nursing Studies To find relationship between nurse work environment and patient outcomes (specifically delirium, malnutrition, pain, patient falls and pressure injurys). Systematic review of literature Systematic review of data sources PubMed, Cochrane, Embase and CINAHL Dutch version of Chochrane’s critical appraisal instrument to assess quality of studies to include Hospitals Quantitative studies published between 2004-2012 Initial 1,120 articles were identified of which 29 were included in the review Not listed in article Increased nurse staffing was directly related to decreased patient falls.  The results were mixed and inconclusive related to pressure injurys in this review.

References

  1. Backhaus, R., Verbeek, H., van Rossum, E., Capezuti, E., & Hamers, J. P. H. (2014). Nurse staffing impact on quality of care in nursing homes: A systematic review of longitudinal studies. Journal of the American Medical Directors Association (Vol. 15, Issue 6, pp. 383–393). Elsevier Inc. doi.org/10.1016/j.jamda.2013.12.080
  2. Everhart, D., Schumacher, J. R., Duncan, R. P., Hall, A. G., Neff, D. F., & Shorr, R. I. (2014). Determinants of hospital fall rate trajectory groups: A longitudinal assessment of nurse staffing and organizational characteristics. Health Care Management Review, 39(4), 352–360. doi.org/10.1097/HMR.0000000000000013
  3. He, J., Staggs, V. S., Bergquist-Beringer, S., & Dunton, N. (2016). Nurse staffing and patient outcomes: A longitudinal study on trend and seasonality. BMC Nursing, 15(1), 1–10. doi.org/10.1186/s12912-016-0181-3
    Kimmey, Stearns (2015). Improving Nursing Home Resident Outcomes: Time to Focus on More than Staffing?  The Journal of Nursing Home Research. Retrieved June 11, 2020, from jnursinghomeresearch.com/552-improving-nursing-home-resident-outcomes-time-to-focus-on-more-than-staffing.html
  4. Spilsbury, K., Hewitt, C., Stirk, L., & Bowman, C. (2011). The relationship between nurse staffing and quality of care in nursing homes: A systematic review. In International Journal of Nursing Studies (Vol. 48, Issue 6, pp. 732–750). Elsevier Ltd. doi.org/10.1016/j.ijnurstu.2011.02.014
  5. Stalpers, D., de Brouwer, B. J. M., Kaljouw, M. J., & Schuurmans, M. J. (2015). Associations between characteristics of the nurse work environment and five nurse-sensitive patient outcomes in hospitals: A systematic review of literature. In International Journal of Nursing Studies (Vol. 52, Issue 4, pp. 817–835). Elsevier Ltd. doi.org/10.1016/j.ijnurstu.2015.01.005
  6. Wofford, P. (2019). Nurses Say Staffing Ratios In Long Term Care Facilities Is Unsafe | Nurse.org. Retrieved June 19, 2020, from nurse.org/articles/nurse-staffing-unsafe-long-care-facilities/
    Nurse Staffing | Health Care Advocacy | American Nurses Association. (2019). Retrieved June 19, 2020, from nursingworld.org/practice-policy/nurse-staffing/nurse-staffing-advocacy/
    NY State Assembly Bill A2954. (n.d.). Retrieved June 19, 2020, from nysenate.gov/legislation/bills/2019/a2954