Running head: SAFE HOSPITAL STAFFING

Safe Hospital Staffing

Christan Mulder
Western Washington University

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Safe Hospital Staffing
As my first year of employment as a Registered Nurse comes to an end, I have begun to
question whether this is something that I can continue doing for another thirty years. There is no
doubt in my mind that I love my job and I am motivated to continue my education to advance
further into the field of nursing. I start to get frustrated reflecting on how little time I have
available during my shift to be at the patients bedside in comparison with the time spent at the
computer charting. As I reflect on these thoughts, I questioned whether its just me as a new
nurse and in time I would feel confident in my ability to provide safe care without rushing out of
patient rooms, or is there something else missing? Many evenings I often feel that if I had just
one less patient assignment I could get everything done. Various groups and organizations such
as the American Nurses Association and the Institute of Medicine have expressed concerns
regarding hospital staffing. The Institute of medicine (IOM) has conducted research on hospital
staffing concerns over the past 20 years and has set forth guidelines for hospitals to begin to
model in hopes of improving staffing systems. Staggs and Dunton (2013)
We know a great deal about patient safety measures within the hospital and I am always
hearing about patient satisfaction but nearly nothing regarding nurse retention rates or registered
nursing job satisfaction. After spending many long nights past my scheduled shift I started to
realize I wasnt the only one who believed a change in staffing models was needed. I have
watched nurses who have been hospital RNs for decades retire due to the stress of the job and
dissatisfaction. I have come to the conclusion that many of these nurses were retiring due to
increase in job demand and when patient safety was questioned due to staffing levels. I began
researching to find out what the current staffing model was for other hospitals and how this has
changed within the past 20 years. A controversial issue is presented with mandated RN-patient

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ratio assignments. While some might argue that staffing with a set number of patients per RN is
beneficial, others may contend that this would not be an appropriate solution. As the patient
acuity levels rise in the hospital, staffing models will continue to be questioned. Some evenings
are smooth sailing and I clock out on time, other nights I may stay late and chart up to 2 hours
past my scheduled shift. It isnt uncommon for one patient to take up the majority of a shift while
the others I have hardly spent an hour with. High patient to RN ratios have a negative impact on
patient safety, as evidenced by poor patient outcomes, missed nursing care, and RN
dissatisfaction within the job.
The Research Process
I began researching the topic Safe hospital staffing as I questioned safety above all
other things in regards to staffing. The articles link patient mortality to hours of provided care
and examined if these mandated RN to patient ratios were indeed the best staffing model. Most
scholars in the field recognize the need for a staffing model change but are uncertain of an
adequate solution. Authors Staggs and Dunton explain an analysis study performed on nursing
units through the National Database of Nursing Quality Indicators to promote an understanding
of how RN staffing is directly related to unassisted falls in the hospital. The primary focus point
for this study was to equip hospital managers with evidence that demonstrated an association
between falls and RN staffing. The hope was that this could serve as an improvement strategy in
safety.
Staggs and Dunton (2013) revealed that the majority of units that were staffed with
higher RNs had a lesser amount of unassisted falls. They concluded that the nurses with higher
experience levels and had been employed on a particular unit contributed to a decrease in fall

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rates. As these authors explain the correlation between education level and fall rates, those
unfamiliar with this school of thought may be interested to know that it basically boils down to
the amount of RNs present on the unit. Although this article argues that an increase in RN
staffing has shown a decrease in multiple adverse patient outcome events its information is
limited in regards to proving that increased RN staffing would actually decrease the amount of
falls. Staggs & Dunton (2013) Falls are costly, both in dollars and in human suffering, primarily
because they cause injuries (Staggs and Dunton, 2013). As these authors attempt to explain the
association between patient falls and RN staffing, its important to remember that this will vary
depending on unit type and patient condition.
Staggs and Duntons (2013) article explains the importance of changing the way in which
units are staffed in order to decrease unassisted fall rates and concludes that an increase in nonRN staff may have little or no impact on the decrease in falls. Patients are scored when admitted
to the hospital for risk of falling. This takes patient acuity back into consideration by recognizing
this risk when the patient care assignment is being completed. In decreasing the amount of falls
within the hospital this would promote patient safety and provide for positive patient outcomes.
These conclusions, which Staggs and Dunton (2013) discuss in the research study performed,
add weight to the argument that current staffing models need adjustment in order to provide safe
care and decrease the amount of negative patient outcomes.
Mandated patient to RN Ratios
In addition to the study performed by Staggs and Dunton (203) multiple studies have
focused on the direct correlation of mandated patient to RN ratios on safety. Author Shekelle
evaluates whether the patient ratios should be utilized as a safety strategy in general. A small

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percentage of hospitalized patients die during or shortly after hospitalization. Evidence suggests
that some proportion of these deaths could probably be prevented with more nursing care
Shekelle (2013). The article claims that by simply increasing the ratio of RNs to patients we can
decrease illness and death rates based on hospital admissions. This is due to the simple fact that
its believed by improved attention to the patient the less of a risk they are at for negative
outcomes. Shekelle (2013) during this study they found that several outcomes that were thought
of as nurse sensitive had no consistent correlation with the nurse staffing levels. Examples
included pressure ulcers, falls and urinary tract infections, both of which are considered poor
patient outcomes. Shekelle (2013). After this study was performed, researchers discussed the
possibility that patient mortality may not actually be reduced by increasing RN staffing but is
directly affected by what the nurse actually does for the patient during hospitalization.
Determining what this is and how it can best be facilitated should be the goal of an effective
patient strategy (Shekelle, 2013).
This study demonstrates that although most nursing professionals believe that an increase
in the amount of RNs working and a decrease in the amount of assigned patients would promote
positive patient outcomes it still comes down to how the nurse performs his or her job. In
relationship to Staggs and Duntons (2013) study, additionally education levels must be taken
into consideration. This study appears to have reveled opposing results as Staggs and Dunton in
that there was no strong relationship between the staffing levels and nurse sensitive outcomes
whereas Staggs and Dunton (2013) found a direct correlation between RN staffing and fall rates.
With a primary focus on examining the patient to RN ratio as a safety strategy Shekelle
concludes that much research is still necessary in order to implement the safest care possible.

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Multiple researchers have demonstrated the positive effects of mandated RN-patient
ratios and prior to this evidence analysis search I also believed this was the best practice. By
examining evidence and considering my recent work on a medical care unit I understand now
that this indeed should not be the way hospitals are staffed. As discussed above, Shekelles
(2013) research proves that ultimately what the nurse does for the patient should be at the
forefront of staffing assignments which then brings acuity back to the top of staffing
considerations.
Missed Nursing Care
The link between staffing levels and patient outcomes has been well established, few
studies have focused on the process of nursing care that results in better outcomes when nurse
staffing is richer (Hee Lee, Kalisch, Tschannen, 2011). A study conducted to examine whether
nurse staffing levels could predict missed nursing care examined six significant care activities
found frequently missed. Nurses must possess a skill set that encompasses many things including
an ability to multitask and be flexible when completing job duties. Its well known that nurses
must possess an ability to predict negative outcomes in patient condition and anticipate any
adverse events. Frequent assessments and monitoring by the nurse is critical in the hospital
setting. In a similar aspect, missed nursing care significantly increases the risk for negative
patient outcomes and places the patient at a higher risk for adverse events. The six missed
nursing care activities examined during the study were patient teaching, ambulation, mouth care,
assessment of medication effectiveness, repositioning, and the timeliness of as needed
medication administration. The focus of the study was to examine and relate missed care
activities to nurse staffing. HPPD (hours per patient day), in this study was the strongest

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predictor of missed nursing care. It is possible that when staffing is less, a staff member may not
be able to complete all care required (Hee Lee, Kalisch, Tschannen, 2011).
Similarity is noted between this research study by Hee Lee, Kalish and Tschannen (2011)
compared to Shekelles (2013) study on RN-patient ratios for safety strategy in that both studies
address that patient outcomes are frequently positive with an increase in nurse staffing but more
importantly outline the fact that the care actually provided by the nurse is most important in
promoting positive patient outcomes. Understanding what care is being provided (or not) will
assist in the development of focused interventions. Unless we understand what is actually
occurring at the point of nursing care delivery, we will not be able to develop interventions to
improve processes which lead to higher quality of nursing care and in turn, better patient
outcomes (Hee Lee, Kalisch, Tschannen, 2011).
A New Staffing Model
When it comes to the topic of hospital staffing, most people educated on this topic would
readily agree that a change in the staffing model is necessary. Where this argument usually ends
however, is on the question of the best possible way to make this change. Whereas many are
convinced that by regulating the nurse to patient ratios we can solve the problem, others maintain
that there are too many associated risks with regulating and mandating ratios. In Robin Hertels
(2010) article both sides to this staffing dilemma are addressed. Nurses are dedicated to the
safety of their patients, working diligently toward positive outcomes. In order to succeed,
patient-staff ratios must be reasonable (Hertel, 2010). Its important to take into consideration
financial implications on hospitals when making a major staffing change. In 2003 California
became the first state to implement a mandated RN-to patient ratio. The results of change are

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variable and there is still not enough evidence to support that this should be an appropriate
measure to be taken nationwide.
Hertels article explains the proposed staffing plans that have been presented to both the
United States House and Senate, both address different staffing models but share a requirement
for Medicare participating hospitals. Hertel (2010) Establish nurse staffing committees to
implement and oversee hospital-wide staffing plan for nursing services. Plan requires appropriate
number of nurses provide direct patient care in each unit and on each shift to ensure staffing
levels that address the unique characteristics of the patient and hospital unites and result in
delivery of safe, quality patient care (Hertel, 2010). Nurse staffing committees have been
implemented in hospitals around the country and have positively impacted most staffing models.
By providing nurses with a chance to voice concerns and bring ideas to the table also encourages
retention of currently employed nurses in addition to job satisfaction.
Although there are multiple variables that come into play when attempting to develop a
major staffing change, financial implications, hospitals current staffing model and we then
cannot forget about the current nursing shortage. Hertel (2010) explains that if hospitals begin
regulating staffing ratios it may place an increased financial burden on the hospital. In order to
meet this increase in costs ancillary staff may be cut which in turn may increase the overall
burden on the RN. In regards to the nursing shortage this ties back into nurse retention and job
satisfaction. Hospitals need to continue to focus on improvement and implementation of
residency programs to train new RNs and generally increase the amount of staff available for
work. Nurses who feel overworked especially shorthanded are more likely to resign from
practice then those who feel supported and that a change of action is in place. Its also important

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to consider the fact that if all states had a mandated RN-patient set ratio we may not have enough
working nurses to meet this requirement.
Alternatively to set RN-patient ratios is an idea Hertel (2010) explains is the model based
on patient acuity. This staffing model is used in multiple hospitals around the United States but
yet still yields inconclusive results of a measureable benefit. Hertel explains the model as based
on a classification system to predict patient needs and requirements for staffing. Although
reliability and validity is questioned with this model I believe it reflects a more true description
of the way in which hospitals should be staffing. The use of a standardized staffing model does
not produce accurate results (Hertel, 2010). These conclusions, which Hertel (2010) discusses in
the article add weight to the argument that a new staffing model should incorporate current
practicing RNs input into the new model. My own view is that with an acuity based staffing
model, we could assume that although additional work on the hospitals part upfront may be
require, in the long run patient safety and outcomes could be much better. Hertel (2010)
concludes his article with expressing that the debate will simply continue on until an appropriate
solution has been found.
Nurse Job satisfaction and Retention
Nurse staffing and the relationship to job satisfaction and retention mentioned briefly
above in regards to the nursing shortage is an important consideration to be made on the topic of
hospital staffing. An article written by a group of professors serves to explain the study
performed to examine the relationship between nurse staffing, job satisfaction and retention rates
within the acute care environment. The study reveals that work environment and dissatisfaction
with work were the major contributors to turnover rates in the hospital. Hairr, Johannsson,

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Redfern-Vance, Salisbury (2014) As nursing turnover is costly researchers argue that with
continued improvement in hospital practices promoting a healthy/happy work environment the
retention of nurses should increase.
The authors of this article argue that improvement of hospital staffing could be a feasible
solution for patients and nurses in regards to outcomes, safety and job retention. A key strategy
for retaining bedside nurses was identified as improving nurse patient ratios. Improving nurse
staffing will likely improve nurses job satisfaction and in doing so will help in keeping needed
nurses at the bedside and decrease the likelihood of a new nursing shortage (Hairr, Johannsson,
Redfern-Vance, Salisbury,2014) The conclusion of the article explains that by improving job
satisfaction hospitals will notice retention of experienced nurses.
Hairr, Johannsson, Redfern-Vance, Salisbury (2014) claim that by simply decreasing the
number of assigned patients to the RN during a shift will improve job satisfaction of the nurse
rests upon the questionable assumption that many nurses may always have something to
complain about. I am not arguing that lowering the number of patients assigned to the nurse is a
bad idea, I am simply stating that it will not completely fix or solve the problem at hand. By
focusing on a set number assignment, the authors overlook the deeper problem of not addressing
patient acuity. As Hertel (2010) explained in his article, its vital that nurses participate in this
change and aid in development of a practice change and staffing model.
Consideration of unit characteristics must be acknowledged when a major staffing change
is ready to be made. Childbirth centers, emergency departments and post operational care units
all operate and serve a very different patient population group versus a medical unit. There is
only one unit within my hospital that staffs strictly on patient acuity. Other units such as the

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medical care unit where I work will accommodate for patient acuity concerns if and when they
arise and its all based on who is working during that particular shift. The progressive care unit
treats a variety of patient populations including drug and alcohol withdraw, cardiovascular rehab
and cerebral vascular accident monitoring. The problem with this unit being the only unit
implementing an acuity based scoring system is that many of the patients on the unit are also
placed on the medical care unit which does not score patients based on acuity. I began to wonder
if the patients on the progressive unit were receiving better quality of care resus the medical unit
based on more time with the RN.
What Happens Next?
In conclusion its been demonstrated through all of these articles that much work is to be
made on development of the best staffing model to be implemented. As mentioned earlier, when
I started this research project I had believed that by having a set ratio of patients per nurse would
enable myself to provide the safest possible care. After researching the subject and experiencing
a set ratio of patients on multiple occasions I have come to the conclusion that many other
nursing units should be staffing based on acuity. Patient safety, outcomes, nurse retention and job
satisfaction are all negatively impacted by the use of set RN-patient ratios. Conducting this
research and comparing it to my current practice in an impatient acute care setting has enabled
me to improve my critical reading skills and has given me the opportunity to change my opinion
on staffing models. All of the authors of these articles share the same common belief that a
change in the current staffing model needs to be addressed. In order for nurses who are currently
working to feel satisfied with their work and to believe that patient safety and patient outcomes
are at the forefront of the hospitals mission, a change in staffing models is absolutely necessary.

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Much research will still need to be conducted in order to implement a change and although I feel
a complete change is a long way out, evidence has proven that its definitely a work in progress.
What I Have Learned
During the process of writing this paper I have learned a few different things not only
about hospital staffing but in regards to the writing/research process and myself. Academic
writing isnt a new concept for me but analyzing and synthesizing sources is. I found that once I
had chosen a topic of interest my research all appeared to be one sided, it all pointed towards
mandating patient to ratios. Since beginning this research study I have changed my point of view
and definitely agree that a change in staffing model is necessary but I am learning more towards
an acuity based approach. Finding and evaluating these sources was the difficult part of this
paper. I wanted to agree with all the articles I read or I didnt feel they should be in my paper. As
the process of writing this source analysis essay continued, I started recognizing the importance
of really digging into the article and figuring out the authors key points. Overall I have improved
in my ability to identify a good and accurate source of information and have developed a basic
understanding for developing arguments and comparing them to another writers ideas.

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References
Hairr, D.C., Johannsson, M., Salisbury, H. & Redfern-Vance, N. (2014). Nurse Staffing and the
Relationship to Job Satisfaction and Retention. Nursing Economics, 32(4), 142-147.
Retrieved from http://www.medscape.com/viewarticle/828494
Hee Lee, K., Kalisch, B.J., Tschannen, D (2011). Do staffing levels predict missed nursing care?
International Journal for Quality in Health Care, 23(3), 302-308. Retrieved from
http://intqhc.oxfordjournals.org/content/intqhc/23/3/302.full.pdf
Hertel, Robin. (2010). Regulating patient staffing: A complex issue. Health Care Reform &
Issues In Nursing, 21(1), 3-7. Retrieved from
https://www.amsn.org/sites/default/files/documents/practice-resources/healthy-workenvironment/resources/MSM-Hertel-Jan12.pdf
Shekelle, P. G. (2013). NursePatient ratios as a patient safety strategy a systematic review.
Annals of Internal Medicine, 158(5_Part_2), 404409. http://doi.org/10.7326/0003-4819158-5-201303051-00007
Staggs, V. S., & Dunton, N. (2014). Associations between rates of unassisted inpatient falls and
levels of registered and non-registered nurse staffing. International Journal for Quality in
Health Care, 26(1), 8792. http://doi.org/10.1093/intqhc/mzt080