Authors

  1. Lasater, Karen B.

Article Content

Most evidence about the benefits of staffing fewer patients per nurse in acute care settings has been generated in high-income countries.1-3 Assaye et al.4 conducted a systematic review of quantitative research investigating the nurse staffing-outcomes relationship in low- and middle-income countries (LMICs). A review of 27 quantitative studies demonstrated that patients in hospitals in which nurses care for fewer patients at a time have lower odds of negative health outcomes, such as mortality, hospital-acquired infection, medication errors, and falls. Nurses in better-staffed hospitals are less likely to be burned out, intend to leave their jobs, or experience a needlestick injury. The systematic review affirms that irrespective of countries' economic standing in the world, the benefits of nurse staffing are universal.

 

Evaluating the staffing-outcomes relationship in LMICs is a significant knowledge contribution because most of the world's population lives in an LMIC,5 the majority of adverse events occur in LMICs,6 and yet most of the evidence about the nurse staffing-outcomes relationship pertains to high-income countries. While better nurse staffing is universally associated with more favorable patient and nurse outcomes, improving unsafe nurse staffing practices likely requires country-specific solutions.

 

To be sure, most high-income countries have yet to attain widespread safe nurse staffing standards, and LMICs face even steeper barriers to resolving unsafe staffing practices, including fewer nurses per capita, maldistribution of qualified nurses, and constrained economic resources. Although the solutions and policy prescriptions for establishing safe nurse staffing might be unique to every country, region, or state, some lessons can be drawn from the progress that has been made in high-income countries.

 

Timely and local evidence to inform policy-makers and the public

Rigorously generated, timely, and local evidence is valuable for informing policy-makers and the public about why safe hospital nurse staffing ratios are in the public's interest. For example, in the United States, state-mandated staffing policies are often debated but rarely implemented, usually because of a lack of timely and state-specific data documenting how current staffing conditions threaten public health.

 

Using an innovative, rapid-cycle research approach, our research team is obtaining data from thousands of nurses in virtually every hospital in states actively considering nurse staffing legislation.7 This method allows us to capture an unbiased snapshot of the variation in current staffing ratios.8 For example, our data show that if New York hospitals were to staff at the levels proposed in legislation, many thousands of lives and many millions of dollars could be saved through shortened lengths of stay and reduced readmissions.9 Low- and middle-income countries considering implementation of staffing policies should account for the cost offsets that accompany better staffing and can help finance more nursing positions.

 

A similar research approach undertaken in Queensland, Australia, revealed large variation in nurse staffing across the public hospitals, with negative outcomes for patients and nurses.10 Variation in hospital nurse staffing is common within countries, even among those with a national health system and within the public hospital component of a national health system.11 Policies aimed at reducing such variation in staffing across public hospitals in LMICs are a worthwhile goal and would go a long way to improving inequities in care.

 

Tailored nurse staffing solutions

Policy prescriptions to regulate staffing at state, regional, or national levels may not be universally feasible. Especially in LMICs where resources are more limited, implementing tailored nurse staffing solutions may be the next best alternative; for example, hospitals can organize the provision of nursing care to ensure distribution of limited nursing resources to the patients who are likely to benefit the most. Studies have demonstrated that certain subgroups of patients may be more vulnerable to nurse understaffing; for example, several studies document that patients with the highest clinical risk (ie, the sickest patients) experience the greatest advantage from better nursing resources, including staffing.12-14 Other studies have shown that compared to similar White patients, Black patients experience better postoperative outcomes,15,16 and better survival following in-hospital cardiac arrest when cared for in hospitals with better nurse staffing.17 Thus, while better nurse staffing in hospitals benefits all patients, certain subgroups of vulnerable patients may experience greater benefits. In the context of limited resources to improve nurse staffing, tailoring the provision of care to the patients who are likely to receive the greatest benefit is a viable option.

 

A path forward: the COVID-19 era

As we celebrate International Nurses Day amidst the ongoing COVID-19 pandemic, the world's recognition of the value of nurses is more certain than ever. The path forward to improving safe nurse staffing in every acute care setting around the world will involve using real-time local evidence to demonstrate the impact of unsafe nurse staffing conditions on the public's health; developing evidence about why it is in the interest of hospitals and governments to invest in nurse staffing; and tailoring the provision of nursing care, as needed, for patients likely to receive the greatest benefits.

 

References

 

1. Kane RL, Shamliyan TA, Mueller C, Duval S, Wilt TJ. The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis. Med Care 2007;45 (12):1195-1204. [Context Link]

 

2. Shekelle PG. Nurse-patient ratios as a patient safety strategy: a systematic review. Ann Intern Med 2013;158 (5 pt 2):404-409. [Context Link]

 

3. Aiken LH, Sloane DM, Bruyneel L, Van den Heede K, Griffiths P, Busse R, et al. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet 2014;383 (9931):1824-1830. [Context Link]

 

4. Assaye AM, Wiechula R, Schultz TJ, Feo R. Impact of nurse staffing on patient and nurse workforce outcomes in acute care settings in low- and middle-income countries: a systematic review. JBI Evid Synth 2021;19 (4):751-793. [Context Link]

 

5. The World Bank. The World Bank in middle income countries. 2020 [cited 2021 Feb 18]. Available from: https://www.worldbank.org/en/country/mic/overview. [Context Link]

 

6. Jha AK, Larizgoitia I, Audera-Lopez C, Prasopa-Plaizier N, Waters H, Bates DW. The global burden of unsafe medical care: analytic modelling of observational studies. BMJ Qual Saf 2013;22 (10):809-815. [Context Link]

 

7. Lasater KB, Aiken LH, Sloane DM, French R, Martin B, Reneau K, et al. Chronic hospital nurse understaffing meets COVID-19: an observational study. BMJ Qual Saf 2020; [Epub ahead of print]. [Context Link]

 

8. Lasater KB, Jarrin OF, Aiken LH, McHugh MD, Sloane DM, Smith HL. A methodology for studying organizational performance: a multistate survey of front-line providers. Med Care 2019;57 (9):742-749. [Context Link]

 

9. Lasater KB, Aiken LH, Sloane DM, French R, Anusiewicz CV, Martin B, et al. In hospital nurse staffing legislation in the public's interest? An observational study in New York state. Med Care 2021; [Epub ahead of print]. [Context Link]

 

10. McHugh MD, Aiken LH, Windsor C, Douglas C, Yates P. Case for hospital nurse-to-patient ratio legislation in Queensland, Australia, hospitals: an observational study. BMJ Open 2020;10 (9):e036264. [Context Link]

 

11. Simonetti M, Soto P, Galiano A, Consuelo Ceron M, Lake ET, Aiken LH. Nurse staffing, skill mix, and job outcomes in Chilean public hospitals. Rev Med Chile 2020;148:1444-1451. [Context Link]

 

12. Lasater KB, McHugh M, Rosenbaum PR, Aiken LH, Smith H, Reiter JG, et al. Valuing hospital investments in nursing: multistate matched-cohort study of surgical patients. BMJ Qual Saf 2021;30 (1):46-55. [Context Link]

 

13. Lasater KB, McHugh MD, Rosenbaum PR, Aiken LH, Smith HL, Reiter JG, et al. Evaluating the costs and outcomes of hospital nursing resources: a matched cohort study of patients with common medical conditions. J Gen Intern Med 2020;36 (1):84-91. [Context Link]

 

14. Silber JH, Rosenbaum PR, McHugh MD, Ludwig JM, Smith HL, Niknam BA, et al. Comparison of the value of nursing work environments in hospitals across different levels of patient risk. JAMA Surg 2016;151 (6):527-536. [Context Link]

 

15. Brooks Carthon JM, Kutney-Lee A, Jarrin O, Sloane D, Aiken LH. Nurse staffing and postsurgical outcomes in black adults. J Am Geriatr Soc 2012;60 (6):1078-1084. [Context Link]

 

16. Lasater KB, McHugh MD. Reducing hospital readmission disparities of older black and white adults after elective joint replacement: the role of nurse staffing. J Am Geriatr Soc 2016;64 (12):2593-2598. [Context Link]

 

17. Brooks Carthon M, Brom H, McHugh M, Sloane DM, Berg R, Merchant R, et al. Better nurse staffing is associated with survival for black patients and diminishes racial disparities in survival after in-hospital cardiac arrests. Med Care 2021;59 (2):169-176. [Context Link]