Literature Review: Safe Nurse Staffing

Submitted by Shana Camphor

Tags: Competent Care float nurse float pool Floating floating nurse health ICU medication errors nurse Nurse and Burnout nursing ethics patient outcomes performance retention Staffing Issues stress Stress among Nurses work environment

Literature Review: Safe Nurse Staffing

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Abstract

OBJECTIVES: The purpose of this literature review is to exam nurse staffing and staffing related issue and its impact on the healthcare world. Safe nurse staffing poses substantial issues at the clinical level including its tremendous impact on patient mortality, patient satisfaction, increased incidence of medical errors, and nurse dissatisfaction and burnout.

DESIGN AND METHODS: A review of literature was conducted by narrowing the research for nursing staffing issues to the last five years. Majority of research findings were published from nursing journals and one research article was used from a journal of Health Services. In total 15, articles were reviewed and critiqued for the purpose of this literature research.

RESULTS: Issues related to nurse staffing are influenced by both physical and economic concerns, ranging from healthcare organization budget adjustments and federal legislation to aging patient population, perceived nursing shortages, and nursing skill mix.

CONCLUSION: A “one size fits all” solution to safe nurse staffing is doubtful. Political and socio-economic powers will have to merge to create a solution conducive to both financial and physical strain of nurse staffing issues.

Introduction

The debate on safe and adequate nurse staffing has remained a growing and controversial issue in the healthcare world. Studies have shown that inadequate nurse staffing has a direct correlation to patient mortality in addition to overall patient satisfaction. Numerous research studies and evidence-based practices have shown that poor quality of care related to limited nursing availability often results in adverse patient outcomes including urinary tract infections, upper gastrointestinal bleeding, shock, pneumonia, and increased hospital stay (Schmalenburg & Kramer, 2009). Evidence shows that patients recuperate quicker and suffer fewer complications when nursing care is readily available. When patient to nurse ratios increase to unsafe levels, there are higher incidences of medical errors, forced overtime, job dissatisfaction, and increased nurse turnover rates.

An appropriate research question for this topic is “How is safe nurse staffing defined and is it possible to achieve such a goal across all nursing settings?” The battle between nurse to patient ratios and quality nursing care has grown more complex from previous years. Many factors influence the legislative powers behind nurse to patient rations.

Factors contributing to this issue include perceived nursing shortages, aging population of both patients’ and experienced nurses, increased concerns about healthcare spending, and competing priorities for healthcare dollars. Few states have enacted state wide legislation on nurse staffing leaving the states within our nation; excluding California, to continue to choose cost benefit over cost effectiveness. Do the benefits outweigh the risks? The response to this question reveals differing opinions among state legislators, healthcare institutions, and practicing nursing professionals. Several research studies argue that if state legislators mandate minimum nurse staffing ratios, hospital revenue will suffer significantly due to the increased cost of employing more nursing personnel, resulting in organizational financial strain. Other research studies propose that when nurse staffing is inadequate to meet the needs of patient demands, patient mortality and medical errors increase leading to unwanted legal issues and increase cost to compensate for turnover rates.

Defining the Terms

As previously stated the topic of “safe nurse staffing” is a broad issue that carries different meanings to different people. For the purpose of this literature review, the topic of safe nurse staffing denotes a balance between the availability of nursing staff and the demand to meet patient needs. In addition to nurse to patient ratios, safe nurse staffing means that nurses should be competent in the care that they provide. For example, a float pool nurse should be cross-trained and deemed proficient in the skills necessary to perform caregiving tasks prior to being floated to unusual environments. For this review of literature the term “nurse” will be limited to only registered nurses (RN),  and all other nursing personnel will be identified by his/her role or tasks.

Methods

The method of data collection was very simplistic. A wide variety of nursing research studies was included in this literature review. Majority of studies came from nursing research, while one or two sources were retrieved from general health related studies. The goal of the literature search was to obtain as many quantitative studies that reflect current factors that contribute to, hinder, support, and influences safe nurse staffing. The design of the studies varied between quantitative and mixed method approaches. All research sources used for this review of literature were recent studies conducted within the past 5 years.

Inclusion criteria for the review must possess a link to nurse staffing. This yielded an abundance of study variables. A large number of the articles linked safe nurse staffing with patient outcomes, while other articles revealed several interesting perspectives to the issue. Some data indicate state and federal legislation as the main facilitators and barriers to adequate staffing. Much attention was also given to the availability of assistive personnel, managerial support, and patient conditions (acuity, patient needs). The review was not limited to United States, but also looked at other countries, as a way to compare trends in nursing practice related to ratios and outcomes across different countries. Various units were studied, including medical surgical, ICU, pediatrics, surgical care, and neurological rehabilitation centers to name a few.

Exclusion criteria limited nurse staffing to focus primarily on the registered nurse when considering nursing perspectives. For example, for data collection to be deemed valid for this review; surveys, questionnaire, and direct observational methods must be completed by or for nurses who possess an RN license. Though LPN/LVN and nursing assistants are also subjected to similar work conditions, the literature to support this population was very limited, thus excluded from study variables.    

Literature Review

Legislative Influences

There have been several efforts to correct this issue, ranging from healthcare organizations budget adjustments and federal legislation. There is a universal dilemma regarding strain between labor costs and competing healthcare dollars. To date there is no federal legislation enacted in Maryland for mandating any specific nurse to patient ratios. Most healthcare organizations within the state base their ratios on policies set forth by the institution and nurse union contracts.

To date California is the only state in the U.S. that has enacted minimum nurse staffing ratios. Regulations for minimum staffing ratios are determined by type of patient care unit, in addition to patient care needs and acuity (Reiter, Harless, Pink, and Mark, 2012). Research conducted by Reiter et al (2012), uses a conceptual framework to quantify benefits of mandating minimum nursing ratios. Conceptualization of staffing legislation shows that increasing total nursing hours raises the cost of staffing to supersede the value of quality-related cost offsets.

The influence of legislative powers on safe nurse staffing is relatively unpredictable. The longitudinal study conducted using California’s assembly bill (AB394), found increases of 20 percent in nursing hours of care per day, estimating a direct cost from $168,000 to $2.3 million over a five year period (Reiter, Harless, Pink, and Mark, 2012).

Other countries such as Taiwan have legislation mandating nurse to patient ratios for hospitals. However the minimum ratios do not seem to meet the expectation for favorable outcomes. For example, Taiwanese hospitals mandate a minimum ratio of 8 patients to 1 nurse on day shift, with an increase of up to 16 patients on second and third shifts (Liang, Chen, Huang, 2012). The study of minimum nurse ratios in Taiwan does not specify if these standards are set forth to every unit or if there are any exceptions to the rule. A nurse to patient ratio of 8:1 on a mother/baby unit may be suitable if infants are included in the patient ratio, however this ratio would be nearly impossible for a nurse working on an intensive care or critical care unit. Taiwanese organizations justify high nurse to patient ratios by stating that increased nursing skill mix will compensate for high patient demands (Liang, Chen, and Huang, 2012).

Staffing ratios are influenced most by standards set by state and federal policies, however the level of staffing varies based on organizational structure. Harrington et al (2012) explore the standards of nurse staffing in nursing homes across six countries. The study examines staffing regulations and policies in the United States, Canada, England, Germany, Norway, and Sweden. Findings of the study varied widely across the six countries. Research shows that standards set forth in countries without mandated ratios were not consistent with actual staffing. Actual staffing ratios were dependent on the size of nursing facility (number of beds), whether or not the facility was for profit, and number of residents. 

Cost Benefit vs. Cost Effectiveness

The struggle between cost effectiveness and cost benefit is an ongoing problem that causes healthcare organizations to weigh the benefits of safe staffing with the risks of increasing healthcare dollars. In response to patient demands, hospitals and healthcare organizations have incorporated nursing skill mix, overtime pay, and growth in number of employees to estimate labor costs. According to Reiter et al (2012), financial performance encompasses the direct cost of nursing care estimated at 80 percent worth of salaries and benefits, 44 percent is comprised of inpatient care costs, and 30 percent involves hospital expenditures. Given these figures it is no secret that the sum of financial expenditures weighs heavily on expected financial revenue.

 According to an article published by The Journal for Medical Care, the cost effectiveness of reducing nurse to patient ratios has not yet been proven (Rothenberg, Abraham, Lindenauer, and Rose, 2005). Rather, the article argues that nurse to patient ratios cost less than many other commonly accepted safety interventions. In order to test this assumption, further research was conducted calculating cost effectiveness in dollars per lives saved of various nurse to patient ratios. Expenses were calculated using national cost estimates and compared length of stay and patient mortality data (Rothberg, Abraham, Lindenauer, and Rose, 2005).

The results of the study showed that a nurse to patient ratio of 8:1 revealed to be most cost effective but was also associated with the highest patient mortality. As the ratio decreased per increment, labor cost increased while patient mortality decreased (Rothberg, Abraham, Lindenauer, and Rose, 2005). This research is a clear example of the battle between healthcare spending and patient care and safety. As a healthcare organization, where should priorities and limits be set? Is it ethical to jeopardize the welfare of patients and neglect the principles of beneficence and non-maleficence simply to save money?

Nurse Burnout and Turnover

Unsafe nurse to patient ratios has proven to pose significant implications on healthcare spending and budgeting, in addition to overall satisfaction of nursing staff. Guadine and Thorne (2012), convey the importance of ethical conflicts and emotional distress experienced by nurses and its association to nurse burnout. The study involves registered nurses as a convenience sample to explore ethical climate and job satisfaction in the hospital setting. Independent variables of the study include ethical conflict, stress, organizational commitment, and tenure, while the dependent variables include episodes of absences and turnover intent.

Using patient care values, staffing policy values, and value of nurses as a factor analysis, the study evaluates turnover intent. The Michigan Assessment Questionnaire is a three item scale given to nurses to assess how they feels about looking for a new job, possibility of quitting, and how soon they may consider changing jobs. Respondents acknowledge that ethical conflict contributes to work stress and emotional and physical burnout that drive nurses to work absence and intent to leave (Guadine and Thorne, 2012).

The Anticipate Turnover Scale (ATS) was created in 1987, to anticipate nurse turnover. Barlow and Zangaro (2010), use this tool as a Likert questionnaire for data collection on anticipated turnover of nurses, the study concludes that the instrument demonstrated great reliability in predicating unnecessary turnover. Nantsupawat et al (2011), sample 5,247 nurses in Thailand to observe contributory factors to job dissatisfaction and burnout. In this study, burnout was measured by using the Maslach Burnout Inventory-Human Service Survey (MBI-HSS), nurses scoring higher than 27 on an emotional exhaustion subscale were deemed to have high burnout (Nantsupawat, Srisuphan, Kunaviktikul, Wichaikhum, Aungsuroch, and Aiken, 2011). Burnout of nurses in ICU units of Korea show no direct link between patient to nurse ratios and nurse job satisfaction (Cho, June, Kim, Cho, Yoo, Yun, and Sung, 2009). The perception of staffing adequacy is reflective of different levels of patient care, thus burnout is influenced by the nursing unit, the nurses perception of workload, and work experience. 

Nursing Support

The adequacy of nurse staffing is dependent upon supportive personnel, including nursing care assistance, understanding nurse managers and availability of float and agency nurses. The flexibility of budget resources such as float pool and agency nurses assists hospital leaders to effectively staff nursing units. Float pool nurses are often used to compensate for shortages of regular staff nurses to contribute to improved patient care and limit stress on staff nurses. While agency nurses serve the same purpose, the cost associated with contracting an agency nurse inhibits economic and regulatory restraints.

Larson et al (2012) examine the relationship between staff nurses and float nurses relating to staffing dissatisfaction and quality of care. This mixed method study suggests that while staff nurses generally experience increased satisfaction due to low patient census and ability to provide safe patient care. On the contrast, float pool nurses are overwhelmed and unsatisfied with the work environment due to working in inconsistent environments and often receiving the most difficult patient assignment (Larson, Sendelbach, Missal, Fliss, and Gaillard, 2012).

Organizations seek to minimize budget cost of employing more registered nurses by ensuring that nurses have supportive personnel. Organizations justify that it costs less to staff two certified nursing assistances than to staff one nurse for any given shift (Kalisch, and Lee, 2011). Kalisch and Lee (2011), seek to better understand nursing workloads and teamwork in relation to actual levels of staffing. The study uses a nursing teamwork survey (NTS) to measure teamwork in inpatient settings, revealing that teamwork is strongly associated with patients safety; reducing patient falls, clinical errors, and improved end of life care (Kalisch and Lee, 2011).

Most nursing errors occur when the individual nurse is overwhelmed and lacking assistive support. Assistive personnel play a vital role in reducing nurse burnout and clinical errors; however the delegation of direct and indirect care to assistive nursing personnel can be a hefty task. The nurse is still held responsible to oversee and evaluate the tasks of the certified nursing assistant (CNA), patient care technician (PCT), and in some cases licensed practical nurses (LPN/LVN). The ability to practice in a safe and trustworthy manner is influenced by hours of care, technological advancements to healthcare, and availability of functional equipment. As a result, nurse staffing should be contingent upon the patient acuity, nursing skill mix, and prudent clinical environments.

The use of supportive staff is established by proper distribution of care activity. This means that nursing tasks should be separated into direct care, indirect care, unrelated tasks and personal time. These factors combined were assessed in a neurological rehabilitation setting in London to assess and quantify nursing care hours as a means to predicting staffing levels based on delegable tasks (Williams and Turner-Stokes, 2009). An example of indirect care tasks are team meetings, telephone calls, and documentation. Direct care tasks involve hands on interaction between healthcare professional and patient such as vital signs, administering meds, wound care and so forth. Unrelated tasks may involve ordering supplies management of a clean clinical environment, while personal time includes lunch breaks, professional development and staff appraisal. Often times, nurses are held responsible for managing all of these tasks which can be delegated to other personal, leaving the nurse more time to perform necessary patient care.

A quantitative comparison study by Paquay et al (2007), examines tasks performances of nurses and nursing care assistance in nursing homes. This study is limited to staffing regulations in regulations in Belgium and reports similar findings to that of Kalisch and Lee. Time spent on patient care tasks delegated to nursing assistance alleviates the RN from supportive tasks and allocates more time on practical nursing procedures (Paquay, Lepeleire, Milisen, Ylieff, Fountaine, and Buntix, 2007).

Technology and Medical Errors

Nursing staffing and advances in technology has a strong correlation to medical errors. A large number of hospitals and healthcare organizations have converted to electronic health records (EHR) and electronic documenting. To improve the safety of patients and effectiveness of care, organizations have implemented “computerized physician order entries, medication reconciliation, automated medication dispensing systems, bar code administration systems, and smart pumps” (Frith, Anderson, Tseng, and Fong, 2012). With implementation of such measures the prevalence of medical errors has declined significantly. However issues related to medical errors remains a struggle. Nurses play a vital role in ensuring that medical errors do not occur with calculating medication dosages, following unit protocols, and picking up on changes in patient conditions (Frith, Anderson, Tseng, and Fong, 2012).

Using technology to assess adequate nurse staffing is a new phenomenon lacking an abundance of research. Digitalized data recoding such as EHR can be used to establish and control nursing workloads. Medical database programs such as Micromedix, Centricity, and SMS provide nurses with quick data information to patient observation, pharmacologic interventions and lab values, saving time spent on indirect nursing tasks (Harper, 2012).

A pilot study by Harper (2012), attempts to utilize health information technology to predict nursing intensity. Nursing intensity is defined as the amount of direct nursing care demands including admissions, discharges, and transfers on any given nursing shift. Results of this study suggest that health information technology can be used to calculate nurse intensity, playing an active role in staffing and medical errors (Harper, 2012).

In addition to technology and nursing workloads as in medical errors, research has explored the idea of interruptions in the workplace to contribute to medical errors. Environmental interruptions in the nursing workplace are a result of workload demands, interruptions in continuity of care, and inconsistencies in nursing assignments. These interruptions in the work environment often lead to medication errors, delays in patient treatment and loss of communication among the nursing staff (McGillis, 2010). A large degree of environmental noise and activity is inevitable on most nursing units, thus distraction to some degree is unavoidable. Studies suggest that limiting interruptions can be achieved by creating areas of less-traffic used by nurses and other healthcare professionals to complete documentation and indirect care measures (McGillis, 2010).

Strengths and Weakness in Literature

Studies used to present data on safe nurse staffing poses many strengths as well as limitations to nursing practice. The research studies chosen for this literature search are all unanimous in detailing nurse to patient staffing as an ongoing issue to clinical practice and overall improvements to healthcare. The literature explores many perspectives to factors influencing a safe nursing environment and data collection methods were effective in capturing the perceptions of federal and state legislators as well as staff nurses. Many variables were studied and scrutinized to expose clinical outcomes that ensure safe, high-quality patient care.

Limitations of the research process are evident in the data collections methods. Specific sample sizes and participants are generalized to fit a broader population of nurses. Most research collected was studied over a limited amount of time and does not reflex findings over a long period of time. In addition, quality of patient outcomes and nursing support were examined using specific nursing settings only, such as ICU units, and nursing homes, thus the results of quality care and nurse satisfaction may be different in different settings. Measurement of certain variables were accomplished using study instruments when in fact direct observation would  have been a more appropriate technique to collect data.

Discussion

A comprehensive review of various studies examining safe nurse staffing presented a wide range of perspectives to factors that influence nurse to patient ratios. The findings suggest that standards governing nurse staffing are guided by state and federal regulations set forth to control budgeting constraints within the hospital infrastructure and other healthcare facilities. Few countries have legislation mandated to enforce nurse staffing, as a result there is little consistency in implementing policies to safe nurse staffing. The literature is clear in addressing the impact of unsafe nurse staffing on patient care and nursing viability.

Research demonstrates how adverse patient outcome and sentinel events are directly related to inadequate staffing levels. This includes increased nurse to patient ratios in addition to nursing assignments that lack consideration of patient acuity and nurse skill level. As a nurse who has experienced budget cuts and changes in nurse patient ratios, the issue of working short staffed and burnout is all too familiar. Budget cuts have resulted in loss of additional RN positions, limited reimbursement, and merging duties of support staff with nursing duties. The work environment such as noise pollution, ethical conflict, and support staff also play a critical role in minimizing stress that leads to burnout and increasing turnover rates.

Conclusion

There is no single solution to a problem such as this; however there are many factors that can contribute to making the issue better and tolerable. To ensure that nurses are able to successfully promote maintenance of health and restoration for illness, interventions for safe staffing must support safe working conditions. Introducing staffing plans and state regulations that mandate hospitals and other healthcare agencies to adhere to staffing guidelines is a beneficial way to ensure quality nursing care, decrease adverse patient outcomes, and nurse burnout. However, organizations must find a way to compensate for increase spending on additional nurse staffing. A possible solution to consider may involve exploring nursing care as a separate revenue generating activity to increase nursing budgets.

Annotated Bibliography

  1. Barlow, K. M., and Zangaro, G. A. (2010). Meta-analysis of the reliability and validity of the Anticipated Turnover Scale across studies of registered nurses in the United States. Journal of Nursing Management.Vol 18. 862-873. DOI: 10.1111/j.1365-2834.2010.01171.x
  2. This article seeks to anticipate factors related to nurse turnovers before they occur. The research uses a tool to collect data, the Anticipated Turnover Scale (ATS) to measure anticipated turnover. Within this study, the term turnover is described as a nurses’ intent to leave a current position. The purpose of the study is to critique the reliability and validity of the ATS instrument in predicting turnover.  
  3. Bae, Sung-Heui. (2011). Assessing the relationship between nurse working conditions and patient outcomes: systematic literature review. Journal of Nursing Management. Vol 19. 700-713. DOI: 10.1111/j.1365-2834.2011.01291.x.
  4. The article examines a systematic evaluation of nurse working conditions and its impact on patient outcomes. Domains of the work environment entails nurse autonomy, philosophy emphasizing quality of care, nurse participation, professional development, managerial support, and collaboration among multi-disciplinary healthcare professionals. Nurse staffing was evaluated based on the nurses’ individual perception of staffing adequacy and resources. The study suggests that when nurses have a positive perception of appropriate staffing there is a decrease in patient mortality.
  5. Cho, S., June, K., Kim, Y., Cho, Y., Yoo, C.,Y, S., and Sung, Y.  (2009). Nurse staffing, quality of nursing care and nurse job outcomes in intensive care units. Journal of Clinical Nursing. Vol18. 1729-1737. DOI: 10.1111/j.1365-2702.2008.02721.x.
  6. The article is a study that seeks to examine a relation between nurse staffing and quality of nursing care burnout, and job dissatisfaction in ICU units in Korea. Data for the study was collected by using a nursing survey targeting all ICU’s of 22 hospitals. Data was collected from staff nurses, charge nurses, and nurse mangers. Results of the study varied among the institution by which the nurse practices. Nurses employed at private institutions and non-for profit seemed to have better nurse to patient staffing ratios and thus were more satisfied in their work environments. The secondary and smaller hospital ICU units had higher dissatisfaction, burnout, and nurses with the intent to leave. Findings suggest that Korean ICU’s must establish a standard of minimum staffing policy and regulations to improve nurses’ perception of improving quality of care and job satisfaction.
  7. Frith, K., Anderson, E. F., Tseng, F., and Fong, E. (2012). Nurse Staffing is an Important Strategy to Prevent Medication Errors in community Hospitals. Nursing Economics. Vol 30 (5). 288-292.
  8. This study examines a relationship between adequate staffing and prevention of medication errors. The authors suggest that many nursing interventions have been instituted into clinical practice to prevent medical errors including, computerized order entries, medication reconciliation, and bar code administration systems. Even with preventive strategies in place to avoid medication errors, nurses play the most important role in preventing errors. Nurse availability, time pressures, and overall fatigue most often contribute to effectiveness of medication delivery and patient safety. This study is a retrospective correlational study examining factors associated with medication errors. Weekly staffing data is examined with medical errors to show that an increase number of RN staffing is directly related to decreased medication errors.
  9. Gaudine, A. and Thorne, L. (2012). Nurses’ ethical conflict with hospitals: A longitudinal study of outcomes. Nursing Ethics. Vol 19(6). DOI: 10.1177/0969733011421626.
  10. This study examines ethical conflict encountered by nurses and emotional distress manifested by value differences leading to adverse patient outcomes. Patient outcomes are greatly dependent upon positive ethical climates and job satisfaction. A convenience sample of 126 nurses from various hospitals took part in the study. Data collected was obtain by administering two quantitative surveys given one year apart to develop and present a comprehensive measure of ethical conflict within hospitals. Three themes emerged from data analysis: patient care values, value of nurses, and staffing policy values. Findings suggest that ethical conflict is a work stressor leading to absence and turnover. Study also found that staffing policy value is predictive of turnover intention, and that patient care value is predictive of absenteeism.
  11. Harrington, C., Choiniere, J., Goldman, M., Jacobson, F., Lloyd, L., MsGregor, M., Stamatopoulos, V., Szebehely, M. (2012). Nursing Home Staffing Standards and Staffing Levels in Six Countries. Journal of Nursing Scholarship. Vol 44(1). 88-98. DOI: 10.1111/j.1547-5069.2011.01430.x.
  12. This study examines nursing home quality and staffing levels in the United States, Canada, England, Germany, Norway, and Sweden. Data analysis revealed wide variations in staffing standards compared to actual staffing levels in the six countries. Data was presented as hours per resident day or in ratio of residents to nursing staff. The study confirms that nursing staff standards are not acuity adjusted, except for Germany. As a result current standards for staffing do not address changing resident care needs. Research findings also show that for profit nursing homes had poor quality of care in comparison to non-for profit nursing homes.
  13. Harper, E. (2012). Staffing Based on Evidence: Can Health Information Technology Make it Possible? Nursing Economics. Vol 30(5). 262-269.
  14. This study acknowledges that nurse staffing has a significant impact on delivery of nursing care and patient outcomes, however hospitals and healthcare organizations must balance nurse staffing with financial viability of the institution. Using health information technology to explore staffing decisions is relatively new to nurse informatics. A pilot mixed method approach was used to answer the research question: “what are the factors that are significant to measuring nurse intensity?” Nursing intensity is defined as how much direct nursing care is needed for individual care needs on a given shift. Data collection methods include observation data of patients, observation data of staff nurses, study patients’ data abstracted from their electronic health record (EHR), and study units’ admissions, discharges, and transfers. Results of the pilot study suggest that health information technology has the potential to limit healthcare cost, improve staffing efficiency, and patient safety.
  15. Kalisch, B., and Lee, K.H. (2011). Nurse Staffing Levels and Teamwork: A Cross-Sectional Study of Patient Care Units in Acute Care Hospitals. Journal of Nursing Scholarship. Vol 43(1). 82-88. DOI: 10.1111/j.1547.5069.2010.01375.x.
  16. This study is a cross-sectional, descriptive study used to examine the importance of teamwork in achieving patient safety. Authors define teamwork based on five core elements; team orientation, team leadership, back up, mutual performance, and adaptability. Data collection was assembled using nursing staff on 52 patient care units. The Nursing Teamwork Survey was used to gather data. The NTS is a 33- item questionnaire with Likert scaling system, ranging from rarely to always. Data was collected for a total of four weeks and data was analyzed retrospectively, before and prior to intervention. Results show that nursing teamwork was impacted by bed size (beds in the hospital setting), case mix, and credentials of nurses staffed. Results also indicate that teamwork is more difficult to achieve in larger hospitals. When nurses are stressed and overwhelmed by staffing workloads, teamwork decreases often leading to increase in patient falls, turnover rates and vacancy rates.
  17. Larson, N., Sendelbach, S., Missal, B., Fliss, J., and Gaillard, P. (2012). Staffing Patterns of Scheduled Unit Staff Nurses vs. Float Pool Nurses: A Pilot Study. Medsurg Nursing. Vol 21(1). 27-32.
  18. This article examines staff nurse and float pool nurses and their contribution to patient care. The literature suggests that float pool nurses are more autonomous and reliable because they are cross-trained in several areas and have a wider range of nursing skills as a result.  However, nurses who are required to float tend to be uncomfortable when floating to unfamiliar units and thus have reservations about providing competent care. They are also often given the most difficult patient assignment contributing to burnout and dissatisfaction. This study was a mixed comparative study that observed various medical units in the Midwest. Data collection was done by assigned researchers whom randomly selected 3 shifts to go to these various units and obtain staffing sheets. Staffing sheets included nurse float or staff nurse information, patient flow, patient volume, and acuity of patient condition. Assignment difficulty ranged from 2 to 24 the higher the number the more difficult the assignment. Assistive personal were also factored into overall patient flow.
  19. Results suggests that on average float pool nurses handle more admissions, discharges, transfers, and surgical patients during any given shift, influencing overall patient outcomes. The authors believe that presenting this data to nurse managers may lead to changes in nursing support, and increase float pool recruitment, retention, and employee engagement.    
  20. Liang, Y., Chen, W., and Huang, L. (2012). Nurse staffing, direct nursing care hours and patient mortality in Taiwan: the longitudinal analysis of hospital nurse staffing and patient outcome study. BioMed Central. Health Services Research. Vol 12. 2-8.
  21. The article explores nursing staffing hours and patient mortality in Taiwan. Difficulties in nurse staffing are impacted by work conditions, job dissatisfaction, available positions, and burn out. Hospital administrators often hire more unlicensed assistive personnel to compensate for limited nursing staff. Taiwan current has legislation that mandates minimum nurse to patient ratios. Stratified random sampling was used to collect data.
  22. A Questionnaire survey was submitted to nurse managers of various nursing wards to answer questions of clinical standards. Results show that current mandates on nursing staffing are not being enforced. Nurses in some Taiwanese hospitals can be assigned up to five times the number of patients of nurses in European and U.S hospitals. In order to control hospital cost, shift-based minimum staffing ratios are a must. By mandating such nurse to patient ratios, nursing staff can improve nursing care and prevent mortality and nursing shortages. 
  23. McGillis Hall, L., Ferguson-Pare, M., Peter, E., White, D., Besner, J., Chishol, A., Ferris, E., Fryers, M., Macleod, M., Mildon, B., Pedersen, C., and Hemingway, A.  (2010). Going blank: factors contributing to interruptions to nurses’ work and related outcomes. Journal of Nursing Management. Vol 18. 1040-1047. DOI: 10.1111/j.1365-2834.2010.01166e.x.
  24. This article is an exploration of factors that interrupt the nurses’ work environment. Factors include noisy units, medication errors, available nursing staff, and managerial support. The research for this study was limited to a group of 36 medical and surgical units. This study uses a mixed method approach that involved direct observation of work interruptions. Types of work interruptions were separated by distractions, intrusions, and discrepancies. Of the sources of interruptions studied, nursing availability and staffing was categorized under discrepancies and revealed staffing patterns as posing the greatest potential to adverse outcomes.
  25. Nantsupawat, A., Srisuphan, W., Kunaviktikul, W., Wichaikhum, O., Aungsuroch, Y., and Aiken, L.H. (2011). Impact of Nurse Work environments and Staffing on Hospital Nurse and Quality of Care in Thailand. Journal of Nursing Scholarship. Vol 43(4). 426-433. DOI: 10.1111/j.1547-5069.2011.01419.x.
  26. This article is a predictive correlational study of issues related to nurse staffing in Southeast Asia. Major concerns include undesirable patient outcomes, nurse satisfaction, nurse burnout and turnover rates. Data collection for this study was obtained by using various Likert scale surveys to gather information about nurse’s interpretation of their work environments and staffing levels. Characteristics of information collected includes patient to nurse ratios, staffing and resource adequacy, leadership and management support, nurses’ participation in hospital affairs.
  27. The sample size for this study was relatively large including a total of 5,247 registered nurses in Taiwan. The mean age was 33 years old, with female participants tripling that of males. Highest level of education was Master’s degree in nursing, with Bachelor degree being the lowest degree obtainment. Results of data collection indicate that one out of four nurses were dissatisfied with their job and close to 40% experienced nurse burnout, resulting in nurses’ intent to leave. Findings show that hospitals with favorable work environments have lower nurse-assessed quality of care and lower rates of nurse burnout.
  28. Paquay, L., De Lepeleire, J., Milisen, K,. Ylieff, M., Fountaine, O., Buntinx, F. (2007). Tasks performance by registered nurses and care assistants in nursing homes: A quantitative comparison of survey data. International Journal of Nursing Studies. Vol 44. 1459-1467. DOI: 10.1016/j.ijnurstu.2007.02.003.
  29. This article is an analysis of task performance among nurses and assistive personnel in nursing homes in Belgium. The object of the study is to examine whether performance among different staffing categories is related to the dependency and diagnosis of dementia. The study involved registered nurses and certified nursing assistance as the two staffing categories. Subjects of the study were selected at random, residence of the nursing homes must be 65 years of age or older and were obtained from 26 Belgium care institutions. Conclusions of the study revealed that tasks delegated between RN’s and CNA’s was limited to specific tasks and staff tend to spend more time caring for patients suffering from dementia than on residence with higher dependency.  
  30. Reiter, K., Harless, D. W., Pink, G. H., and Mark, B. (2010).  Minimum Nurse Staffing Legislation and the Financial Performance of California Hospitals. Health Services Research and Educational Trust. DOI:10.1111/k.1475-6773.2011.01356.x.
  31. This article details a comprehensive analysis of staffing legislation. Currently, California is the only state within the United States that has mandated staffing laws. Determining staffing ratios is difficult because it is unknown whether the cost saving benefits outweighs the risks of patient outcomes. This article seeks to explore if minimum nurse staffing legislation will prove to positively or negatively affect hospital performance. The study examined the use of assistive personal to contribute to cost saving measures. It is suggested that higher labor cost can be offset by shifting hospital generated revenue away from non-profitable activities.
  32. Williams, H., Harris, R., and Turner-Stokes, L. (2009). Work Sampling: a quantitative analysis of nursing activity in a neuro-rehabilitation setting. Journal of Advanced Nursing. Vol 65(10). 2097-2107. DOI: 10.1111/j.365-2648.2009.05073.x
  33. This article is a quantitative analysis of nurse staffing and skill mix in proportion to requirements of indirect and direct patient related care in neuro-rehabilitation settings. The Northwick Park Dependency Score is a tool used to measure the need for nurses in rehabilitation settings based on care requirements. Data collection involved non-participant observational work sampling, on a 24 bedded neuro- rehabilitation unit in North London. Activity was observed over a two week period between the hours of 0600 and 1530. Results show that healthcare assistance performed majority of the direct nursing care, while RN’s provided a greater proportion of indirect care tasks. As a result, nurse staffing assignments must take into consideration delegation of tasks of indirect and direct care activities for patients in high acuity settings.  
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