1. Harper, Mary G. PhD, RN, NPDA-BC
  2. Maloney, Patsy EdD, MSN, RN, NPD-BC, CEN, NEA-BC
  3. Aucoin, Julia DNS, RN, NPD-BC
  4. MacDonald, Ryan PhD


A 2015 study exploring the relationship between nursing professional development (NPD) staffing and organizational outcomes was replicated in 2021. The background, including literature review, methods, and descriptive statistics, were presented in Part 1 of this report. Part 2 explores the relationships between NPD staffing and organizational outcomes. Evidence suggests that higher levels of NPD staffing are associated with many positive nursing and patient outcomes and provide financial benefit to the organization.


Article Content

Although many acute care hospitals seek data about appropriate nursing professional development (NPD) staffing, staffing metrics alone are insufficient. Relationships among NPD staffing metrics and organizational outcomes are needed to demonstrate the value that NPD practitioners provide for the organization and justify staffing levels. This study, which replicates a 2015 study commissioned by the Association for Nursing Professional Development (ANPD; Harper et al., 2016), provides national data to quantify the value of NPD practice to organizations.



As stated in Part 1, ANPD commissioned the initial NPD value analysis study to examine the relationships among NPD practitioner staffing and acute care hospital outcomes (Harper et al., 2016). The initial study found that higher patient satisfaction with discharge instructions and nurses' communication were significantly associated with higher numbers of NPD practitioners. Despite the increasing focus on NPD outcomes in the literature, no studies have been found that examine relationships between NPD staffing and organizational outcomes since the original work reported by Harper et al. (2016). The purpose of this article is to report the relationships between NPD staffing and organizational outcomes.



Although the purpose of this study was threefold (see Part 1), Part 2 is devoted to the exploration of relationships among NPD staffing levels and organizational outcomes, including Hospital Compare, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), and National Database of Nursing Quality Indicators (NDNQI) data.



Design and Instrument

As described in Part 1, a descriptive, cross-sectional design was used. The study was determined exempt by the University of Washington Human Subjects Division. A research team-developed survey, consisting of 89 items (93 items for NDNQI participating organizations), was used to collect organizations' descriptors; employee metrics; patient satisfaction and outcomes; NPD department size, structure, span of responsibility, and workload allocation; and NPD practitioner characteristics.


Sample and Data Collection

The population for this study included acute care hospitals (N = approximately 6,090) within the United States. A convenience sample of participants was solicited through e-mails sent to the ANPD e-mail list (19,000), Society of Pediatric Nurses membership (3,256), and the Children's Hospital Association's 217 member organizations, as well as through social media announcements. In addition, each announcement or e-mail suggested sharing the invitation to further enhance participation (i.e., snowball sampling). Data were collected for an 11-week period from July to September 2021.


Data Analysis

As indicated in Part 1, descriptive statistics were used to summarize individual and hospital-level data. For the organizational outcome relationships, children's hospitals have been removed from analysis because of missing and incomplete data. In addition, children's hospitals consider several different quality metrics. To assess the relationships between NPD staffing and organizational outcomes, the median for each outcome was determined. Rates for NPD full-time equivalent (FTE)/employee, NPD FTE/RN, and NPD FTE/bed were compared above and below the median for each outcome variable using Mann-Whitney U tests for nonparametric data. Given the descriptive nature of the study design and data attrition, statistical significance was set at a one-tailed p value of <=.10 (Forbes, 2012; Wasserman & Lazar, 2016). All data were analyzed using SPSS 26.0 (IBM Corporation, 2019).



Sample Description

The electronic survey was accessed 746 times and resulted in 398 usable surveys, which comprised the final sample. Many of these surveys lacked one or more responses. Organizations from 46 states and the District of Columbia participated. As reported in Part 1, most participating organizations were part of a healthcare system, nonprofit, community hospitals located in urban or suburban settings. Hospital size varied, with up to 4,000 beds. Nearly half (44%) held Magnet designation with an additional 15% on the journey. Another 8% were Pathway designated, with 8% on the journey. Most (72%) reported one or more quality awards, such as the Malcolm Baldrige National Quality Award or Leapfrog Group Top Hospital.


NPD Departments

As described in Part 1, 47.5% of the NPD departments' reporting was responsible for all staff education, 66.9% provided professional development for nonnursing professions, and 24.6% was responsible for nursing staff only. Nursing continuing education was provided as providers through the American Nurses Credentialing Center by 74% and/or through state approval (59.2%), and 21.8% held Joint Accreditation for Continuing Interprofessional Education.


NPD staffing was measured as ratios: beds/NPD FTE, employees/NPD FTE, and RNs/NPD FTE. As reported in Part 1, median staffing ratios were 70 individual RNs per NPD FTE, 250 individual employees per NPD FTE and 25.8 beds per NPD FTE, although these ratios varied by organization size.


Relationships Between NPD Staffing and Organizational Outcomes

Nursing staff outcomes

Nursing staff-related outcomes collected included percentage of certified nursing staff, newly licensed nurse retention rate, and overall nurse turnover. As shown in Table 1, higher numbers of NPD practitioners per hospital bed were associated with statistically significant higher newly licensed nurse retention and lower overall nurse turnover rates.

Table 1 - Click to enlarge in new windowTABLE 1 Relationships Between NPD Staffing and Nursing Staff Outcomes

Patient satisfaction

Publicly reported HCAHPS data points affected by NPD initiatives were included in this study. Six metrics were analyzed, as shown in Table 2. Each of the six metrics had a statistically significant positive relationship with at least one NPD staffing ratio.

Table 2 - Click to enlarge in new windowTABLE 2 Relationships Between NPD Staffing and Patient Satisfaction (HCAHPS)

Unplanned hospital visits

Publicly reported unplanned hospital visits for chronic obstructive pulmonary disease, myocardial infarction, heart failure, pneumonia, coronary artery bypass graft (CABG), and hip/knee replacement were obtained from the Hospital Compare website (see Table 3). Higher numbers of NPD practitioners per hospital bed were associated with statistically significant lower unplanned visits for heart failure, pneumonia, and CABG.

Table 3 - Click to enlarge in new windowTABLE 3 Relationships Between NPD Staffing and Unplanned Hospital Visits (Hospital Compare Data)

Timely and effective care

Timely and effective care metrics, as reported on the Hospital Compare website, were obtained for sepsis, chest pain, and stroke symptoms. As shown in Table 4, no statistically significant associations were found between NPD practitioner staffing and timely and effective care for severe sepsis/septic shock. Too few participants provided data to allow an analysis of relationships between NPD staffing with chest pain/possible heart attack pain (n = 23) and brain scans for patients with stroke symptoms (n = 33).

Table 4 - Click to enlarge in new windowTABLE 4 Timely and Effective Care

Hospital-acquired infections

Central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and Clostridium difficile (C. diff) intestinal infection measures from the Hospital Compare website were reported. No statistically significant association was found between CLABSIs and NPD staffing ratios (see Table 5). CAUTIs were statistically significantly higher with higher numbers of NPD practitioners per RN, and C. diff intestinal infections were statistically significantly higher with higher numbers of NPD practitioners per bed.

Table 5 - Click to enlarge in new windowTABLE 5 Relationships Between NPD Staffing and Hospital Acquired Infections

National Database of Nursing Quality Indicators

NDNQI data were requested from organizations that participate in NDNQI for the following metrics: total patient falls per 1,000 patient days, injury falls per 1,000 patient days, percentage of surveyed patients with hospital-acquired pressure injuries, and percentage of patients with physical restraints (limb and/or vest). Data received did not align with the data requested and were unable to be analyzed.



Implications for NPD practice

The relationship between NPD staffing ratios and organizational outcomes builds on the previous work of Harper et al. (2016). In the initial study, only two outcomes-nurses' communication and patient receiving information about recovery at home-demonstrated a statistically significant relationship with higher NPD staffing per hospital bed. This study expands positive associations to all HCAHPS metrics analyzed (see Table 2) with potential financial benefit for organizations. HCAHPS scores, which reflect patient satisfaction, can drive hospital choice. They also contribute to the organization's Centers for Medicare & Medicaid Services (CMS) rebate (CMS, 2021a). In addition, higher numbers of NPD practitioners were also statistically significantly associated with lower unplanned visits for pneumonia, heart failure, and CABG surgery, which can potentially reduce reimbursement through the CMS Hospital Readmission Reduction Plan (CMS, 2021b). These outcomes demonstrate the financial value of NPD practice to healthcare organizations by contributing to hospital utilization and CMS rebates, as well as cost avoidance by reducing readmissions. NPD practitioners must demonstrate and articulate their value by improving organizational outcomes that enhance patient satisfaction and outcomes and impact the organization's financial health (Harper & Maloney, 2022).


No significant associations were found between NPD staffing ratios and CLABSI rates. The increased rates of CAUTIs and C. diff intestinal infections among organizations with higher NPD staffing ratios were unanticipated. CAUTIs and C. diff intestinal infections are both preventable by interventions routinely delegated to unlicensed assistive personnel, such as catheter care and personal hygiene. On the other hand, central lines are managed by licensed personnel only. This differentiation suggests that NPD initiatives focused on education and competency management of unlicensed assistive personnel are warranted.


Potential causes for these unexpectedly higher rates of CAUTIs and C. diff intestinal infections were solicited from attendees at the 2022 ANPD annual convention using an online comment platform. Ninety-five comments were garnered with 499 total votes, signifying agreement with an individual comment. Most comments were COVID-19 pandemic related. One participant wrote: "The pandemic was the single most significant factor for the raised levels of CAUTI infections." The most frequently cited cause of higher CAUTI and C. diff intestinal infection rates was staffing and included items such as increased use of agency or travel nurses, increased workload (more patients with higher acuity), and redeployment of staff, especially unlicensed assistive personnel who were unfamiliar with standards of care. Patient causes identified were increased length of stay and isolation precautions, which might have been a barrier to routine care. Equipment shortages were also noted, with product substitutions creating confusion. A participant wrote, "During the pandemic, when data was collected, there were such massive supply chain issues that staff were reusing, misusing, creating ways to provide care." Lack of sufficient experienced preceptors was another potential cause, with preceptor burnout and novice preceptor use cited. In the words of one participant, "Many of the preceptors are young nurses when they start precepting. Do they have support to get help? Many times they don't because the advanced preceptors have all left to travel." Finally, NPD pandemic-related issues, such as the volume of orientees and NPD practitioner redeployment to patient care areas, precluded an educational focus on infection control. One participant stated NPD practitioners "were so busy on boarding that they weren't out there rounding with purpose to support CAUTI and C. diff prevention." Convention participants suggested ongoing preceptor development and the use of student nurses in innovative ways to ensure routine care is provided.


Missing data in the surveys submitted for this study might reflect a lack of knowledge among NPD practitioners and department leaders of organizational metrics-where to obtain the data, how data are measured, and how NPD practice impacts key measures. NPD practitioners, especially department leaders, must know how to access organizational metrics-such as those explored in this study-to demonstrate the organizational impact of NPD practice.


Implications for research

NPD practice extends to various settings, such as ambulatory care and long-term care. Research to examine the impact of NPD practice in these settings, using meaningful metrics, should be conducted. In addition, the current study with acute care hospitals should be replicated at regular intervals to provide ongoing evidence of the organizational value of NPD practice.



Data collection during the COVID-19 pandemic probably impacted participants' ability to acquire the requested data or participate in the study. Variations in the data submitted from NDNQI data were not evaluated because of variations in data submitted. Upon replication of this study, a screenshot of an NDNQI report, with the requested data highlighted could enhance receipt of the desired data. Survey fatigue and attrition resulting from the length of the survey resulted in a large volume of missing data.



Findings from this study demonstrate positive associations between NPD staffing and patient satisfaction, quality of care, and nurse retention-all of which have financial implications for healthcare organizations. NPD practitioners must know their individual organization's data and be able to articulate the specific impact of NPD initiatives upon these metrics.




Centers for Medicare & Medicaid Services. (2021a). HCAHPS: Patients' perspectives of care survey.[Context Link]


Centers for Medicare & Medicaid Services. (2021b). Hospital readmissions reduction program (HRRP).[Context Link]


Forbes D. A. (2012). What is a p value and what does it mean?Evidence-Based Nursing, 14(1), 34. [Context Link]


Harper M. G., Aucoin J., Warren J. I. (2016). Nursing professional development organizational value demonstration project. Journal for Nurses in Professional Development, 32(5), 242-247. [Context Link]


Harper M. G., Maloney P. (Eds.) (2022). Nursing professional development: Scope and standards of practice (4th ed.). Association for Nursing Professional Development. [Context Link]


IBM Corporation. (2019). IBM SPSS Statistics.[Context Link]


Wasserman R. L., Lazar N. A. (2016). The ASA statement on p-values: Context, process, and purpose. The American Statistician, 79(2), 129-133. [Context Link]