PICOT question
Inadequate nurses in hospitals affect the quality of service rendered to patients. Contemporary health care lays emphasis on the importance of value-based care to ensure that patients receive quality care (Martin, 2015). The lack of enough nurses may result in patient dissatisfaction, longer stays in queues, increased number of readmissions and other adverse events. All these therefore, result in poor quality service provision and other major adverse impacts on the bottom line. For effective value-based care, adequate nurses are needed to deliver quality services. Inadequate nurse to patient ratio tampers with the safety of the patient and the quality of care. This literature review seeks to find out how inadequate nurses affect the quality-of-service care to patients as compared to adequate nurses.
Background
Evidence shows that staff shortages result in increased working hours for the nurses and more stress on their end. Patient outcomes closely relate with the staffing of nurses in health care facilities. Nurses burn out from the long working hours and therefore decreased value of the service they provide the patients. The patients depend on nurses greatly and an increased workload intensify the work of the few available nurses. These events make the patient outcome worse since the significant role played by nurses is not reached adequately due to shortages in staffing.
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Significance
This review seeks to find out ways in which inadequate nurses in health care facilities affect patient outcome when compared to facilities that have adequate staffing. Nursing workload and patient dependency directly correlate. Similarly, this literature review will propose a model to ensure a manageable nurse to patient ratio. It is important to understand the major role played by nurses and therefore adequate staffing. Additionally, this review may help stakeholders in the health care industry in making plans and implementation concerning quality health provision.
Methods
How literature was conducted and period
In this review, the literature was searched from the year 2015 to 2021. The key words used in the online search include inadequate staffing, patient satisfaction, service provision, nurse to patient ratio and patient outcome. The focus was on general outcome of the patients and the well-being of the nurses after such hefty workloads.
Databases
Research was collected from online databases including PubMed, CINAHL, Cochrane Library, ERIC, Web of Science and Embase databases.
Results
Six studies were reviewed “The effects of nurse staffing on quality of care”. It generally discussed the impact of nurse staffing in hospitals and other health care facilities on the quality of service the patient was accorded. Similarly, the study focused on addressing inconsistencies, which exist in previous health reviews and their limitations. The paper also recommended methods on how to address the current and underlying issues in the health care sector (Martin, 2015). The article finally ends with a discussion on how future research may be affected; public policy and proper management of healthcare.
The effects of nurse staffing on quality of care provides a framework relating nurse ratio to patients, the care quality and safety (Martin, 2015). The relationship forms correlated pathways linking staffing of the nurses to patient outcomes and their safety. The study determined that the number of nurse staffing in health care facilities is determined by the administration; and influenced by external forces such as the local labor markets. Therefore, the quality-of-service provision is equivalent to the interventions and assessments to maximize the outcomes of a patient. Human factors play a role in the care a nurse provides such as fatigue and intrinsic factors that is, experience and knowledge. Working environment or system the nurses are situated also have a major impact. These involve the needs of a patient in which the nurse in charge, level of staffing and the leadership culture created in the organization.
From the evidence, staffing and outcomes are closely related. It is therefore important that policy makers, managers and clinicians to constantly put under consideration the staffing level in health facilities (Martin, 2015). Inadequate nurse staffing in hospitals is linked to increased risk of poor patient outcomes. The workload of nurses affects both their psychological well-being and patient outcome. In acute settings especially, it is highly possible for the staffing to change hourly depending on the condition of the patient. The ratio of the nurse to patient differs according to the settings.
It is evident from the article that the number of registered nurses (RNs) in the United States is low in comparison to that of licensed practical nurses (LPNs). Most health care facilities therefore opt for LPNs or vocational outcomes, which leads to further worst outcomes for the patient (Martin, 2015). However, there is no evidence suggesting that employing LPNs is unsafe. It is basic knowledge that inadequately trained personnel may be prone to more errors therefore unsafe for the patient.
Nurse staffing, nurse prioritization, missed care, quality of nursing care, and nurse outcomes; examines and associates poor nurse staffing with the high rates of missed care that leads to reduced quality of care and nurse outcomes (Cho et al., 2020). The study examines the patient to nurse ratio to measure staffing using 2114 nurses as samples from 49 hospitals. The study applies multi regression analysis to determine any connection among the given variables. From the results of the study, inadequate or poor staffing is linked to a high rate of missed opportunities, which results to high intent to leave and a poor quality of nursing care. The article comes to a conclusion that adequate nurse staffing is vital in reducing missed care of patients and also improving the quality of care.
In “The Relationships between nurse staffing and Patients’ experiences, the mediating effects of missed nursing care”, the article determines the connection between the experiences of the patient and nurse staffing in health care (Cho et al., 2017). Compared to the previous article, the effects of neglect of nurses is connected between patients’ experiences and nurse staffing. It is a South-Korean based study and 208 patients are used with 362 nurses from 23 units of six health care facilities. The MISSACRE Survey-patient is used to measure patient-reported missed care and the patient to nurse ratio is measured. The findings associate poor nursing staff with high chances of bad communication with care providers and increased missed care.
“The Impact of Heavy Perceived Nurse Workloads on the Patient and Nurse Outcomes”, workload factors is studied. Similarly, MacPhee et al. (2017) focuses on both the patient and nurse outcome. It was a quantitative study and different quantitative measures studied and workload factors were critically examined. Workload factors include the reports from nurses from unit level RN levels of staffing, compromised standards of service provision, the level of patient dependency, and emotional exhaustion of the nurse and task level interruptions. The patient factors reviewed included medication errors reported frequently by nurses and patient falls. Heavy workloads and frequent interruptions greatly affected the relationship between nurses and patients; therefore, direct effect on patient outcome. The review concluded that administrations should work closely with nurses to come up with friendly working environments and address the workload demands in the different levels.
Data collected from 472 acute care nurses and a cross-sectional survey conducted. The major indicators of workload reviewed were incomplete nursing tasks, patient dependency, patient acuity, the staffing levels of registered nurses, professional nursing standards that were compromised, any interruptions to workflow and the general perception of the nurses concerning the workload. Patient acuity closely correlated with the main three adverse patient outcomes whereas the staffing of registered nurses had a weaker link. Patient dependency was not in any way associated with either the patient or the nurse outcome (MacPhee et al, 2017). However, patient dependency in the study only focused on the day-to-day living activities only.
A major finding from the study was that both nurse outcomes that is job satisfaction and the emotional exhaustion they felt resulted from compromising the professional nursing standards because of the pressure from the workload. Additionally, compromising professional standards was a major indicator of the interruptions while on duty and perceived workload. Therefore, heavy workloads on the nurses lead to interruption of their duties, which result in mental and emotional exhaustion. Strategies to help the nurses cope in such situations were highlighted in the article. These are forming health circles in their work places for the nurses to help deal with pressure from work (MacPhee et al., 2017). Here they will discuss and voice out their problems while giving roles according to areas where the employees are best suited. Incomplete tasks (tasks left undone) compromised a nurse’s ethical standards. Undone tasks have a direct negative impact both to the nurse and patient outcomes since nursing is a unique and essential profession, adverse effects may stem from such ignorance.
‘Association of nurse engagement and nurse staffing on patients’ compares how patient’s safety relates to staffing in clinics. The article argues that nurses’ engagement is an adjustable component of work and a feasible patient safety component. An analysis survey was carried out using 599 hospitals across four states in the United States. The research used regression as a method of analysis to find out the link between staffing, nurse assessment and engagement. From the findings, more than 60% of nurses graded their respective hospitals as poor in implementation of patient safety (Carthon et al., 2019). The article therefore concludes that adequate staffing and improving nurse engagement helps in improving patient safety.
The impact of nurse staffing levels and nurses’ education on patient mortality in medical and surgical words focused on improved and adequate nurse staffing in critical situations reduced levels of mortality (Haegdorens et al., 2019). The study was conducted in Belgium, 14 surgical and 14 medical wards in 7 hospitals reviewed. Pregnant patients and those below 17 years of age were excluded from the study. From the research findings, it is evident that a negative relationship between the hours nurses allocate to each patient, the less composite mortality rate. The study concludes that adequate nurse staffing leads to reduced mortality.
Major Patterns
Three main themes
The articles have a common intervention method, improving the number of nurses hence adequate staffing will generally improve patient outcome. The workload that comes with a shortage in staffing leaves the nurses fatigued; both emotionally and mentally, and are more prone to making errors (Haegdorens et al., 2019). Martin, points out those health care facilities with inadequate staffing tend to record high rates of poor-quality care. These therefore affects both the patient and the nurse. It is evident that the errors, which are made, stem from fatigue due to the heavy workload. However, with adequate nursing, nurses can respond more efficiently to the needs of their patient since they will be required to attend to fewer patients due to a lighter workload. MacPhee et al argues that although the workload will decrease, it is still important to put other factors into consideration that may be contributing to poor patient outcome, which will ensure a positive outcome for both the patient and the nurse.
Carthon et al. (2019) suggests that nurses are an adjustable factor in health care and therefore need to be organized depending on the needs of patients. An increase in the number of patients needs an adjustment in the nurse-to-patient ratio to ensure efficient service delivery. According to Wynendaele et al. (2019), nursing is a profession that is caring and should not be reduced to time and task, which is a mechanistic approach in service delivery. Use of mechanistic approaches eventually takes a toll on the nurses’ moral and emotional well-being (MacPhee et al., 2017). Compromising the standards of nursing is unethical and administrators have a duty therefore, to ensure the well-being of the nurses. Martin on the other hand argues that individual factors such as experience also contribute greatly to patient outcome. A nurse who has been in the field long enough has more experience develop over the years and therefore they are more likely to avoid errors despite shortage in staffing (certification).
Finally, another common theme in the articles is the working environment for the nurses. The administrators are responsible for employing nurses and therefore should create an environment that is friendly for quality service delivery. Collaborating with nurse leaders can help involve nurses in decision-making and learning their needs (Cho et al., 2020). Carthon et al. (2017) concludes from her research that most hospitals are poor at implementing patient safety through engaging nurses during policy and decision- making. Addressing work factors in the work environment is therefore an essential and crucial factor in ensuring patient satisfaction. Evaluating nurses’ workloads can help plan for the health care facilities through availing adequate staffing to reduce patient adverse effects (MacPhee et al., 2017). Analyzing critically and quantitatively will aid in the appreciation of the workload and meet their demands to ensure integrity in the profession.
Conclusion
Inadequate nurses in hospitals affect the quality of service rendered to patients. The workload increases and thereby affects the quality of service rendered. Different workloads have diverse effects on both the patient and the nurse. Work environment factors play a major role in patient outcome and administrators have an obligation to listen to the concerns of the nurses since they spend most of the time with the patients. Ensuring a manageable nurse to patient ratio will allow a lighter workload for the nurses’ hence effective service provision.
Unanswered questions
The low response rate about asking the nurses their perception on the workload phenomenon. Non-response error also resulting from many respondents fail to respond to the questions. Therefore, the findings did not come to a solid conclusion about how they perceived the concept of heavy workload.
Further research
Research needs to be conducted on shortage of nurse staffing and the effect it has on the nurses. The previous research findings did not avail enough information concerning the topic and only tend to focus on the patient outcome.
References
Carthon, J. M. B., Davis, L., Dierkes, A., Hatfield, L., Hedgeland, T., Holland, S., ... & Aiken, L. H. (2019). Association of nurse engagement and nurse staffing on patient safety. Journal of nursing care quality , 34 (1), 40.
Cho, S. H., Lee, J. Y., You, S. J., Song, K. J., & Hong, K. J. (2020). Nurse staffing, nurses prioritization, missed care, quality of nursing care, and nurse outcomes. International journal of nursing practice , 26 (1), e12803.
Cho, S. H., Mark, B. A., Knafl, G., Chang, H. E., & Yoon, H. J. (2017). Relationships between nurse staffing and patients’ experiences, and the mediating effects of missed nursing care. Journal of Nursing Scholarship , 49 (3), 347-355.
Haegdorens, F., Van Bogaert, P., De Meester, K., & Monsieurs, K. G. (2019). The impact of nurse staffing levels and nurse’s education on patient mortality in medical and surgical wards: an observational multicentre study. BMC health services research , 19 (1), 1-9.
Martin, C. J. (2015). The effects of nurse staffing on quality of care. MedSurg Nursing , 24 (2), S4-S4.
MacPhee, M., Dahinten, V. S., & Havaei, F. (2017). The impact of heavy perceived nurse workloads on patient and nurse outcomes. Administrative Sciences , 7 (1), 7.
Wynendaele, H., Willems, R., & Trybou, J. (2019). Systematic review: Association between the patient–nurse ratio and nurse outcomes in acute care hospitals. Journal of Nursing Management , 27(5), 896-917.
