Running head: UNDERSTAFFING AND PATIENT OUTCOMES 1

Understaffing and Patient Outcomes

Cassity Clay

Brigham Young University-Idaho

Nursing 420

Sister Bennion

December 1, 2017.
UNDERSTAFFING AND PATIENT OUTCOMES 2

Understaffing and Patient Outcomes

Background

Healthcare is experiencing a shortage of nurses. It has been projected that by 2025 this

shortage will reach a deficit of 260,000 nurses nationwide (Rosseter, 2012). Meaning, there will

not be enough nurses to meet the projected demand. In their study on the nursing shortage and

understaffing, Cox, Willis, and Coustasse (2014), found that the two main causes of this shortage

are increased registered nurse (RN) retirement and decreased number of nurse educators.

Currently 50% of working RNs are over the age of 50 and the average RN retirement age is 57.

In other words, more than half of RNs today are nearing the age of retirement. Normally, this

would not pose a problem to nurse staffing because new graduate RNs would fill these

vacancies. However, because of the current lack of nurse educators in the United States (U.S.),

the number of graduate RNs has dropped substantially. Due to the increased number of RN

retirees that are not being replaced by new nursing graduates, nurse staffing is suffering. This

leaves working nurses responsible to care for higher patient loads.

Nurses are caring for too many patients at a time. Neff, Cimiotti, Heusinger, and Aiken

(2011), conducted a research study on job satisfaction and the current nurse-to-patient ratio.

During this study they established that the average nurse-to-patient ratio is 1:5. Thus, each nurse

is responsible for the medications, safety, and overall well-being for five patients during their

hospital stay. These researchers also found that over half of the nurses in their study did not feel

they were able to properly care for all of their patients because of understaffing. This occurs

when nurses have inadequate time to meet all patient needs. A large majority of these nurses

reported spending the majority of their time with their high-acuity patients, resulting in

insufficient time for their low-acuity patients. When this occurs, low-acuity patient needs are
UNDERSTAFFING AND PATIENT OUTCOMES 3

neglected. In addition, the nurses in this study reported feeling burnout when their patient care

load was greater than four patients, and suggests that the nurse-to-patient ratio is too high.

Moreover, 20% of these nurses reported wanting to leave their jobs because of the stress related

to caring for too many patients. If these nurses were to leave, this trend would result in increased

staff shortages and an even higher nurse-to-patient ratio.

Significance

The increased nurse-to-patient ratio has shown to have detrimental effects on patient

outcomes. Needleman, Buerhaus, Pankratz, Lebison, Stevens & Harris (2011) conducted a study

to determine the association between nurse staffing and adverse patient outcomes, specifically

patient mortality rates. They concluded that the risk of patient mortality increases 2% each time a

patient is cared for during an understaffed nursing shift. This statistic gives substantial evidence

that high-nurse-to patient ratios pose significant threats to patient safety and overall outcomes. In

addition, these researchers also found there was a 4% in patient mortality during times of high

patient turnover and nurse understaffing. Turnover, which is defined as the number of

admissions, transfers, and discharges, places an increased demand on nursing staff (Needleman

et al., 2011). This is due to required discharge teaching, lengthy admission assessments and

questionnaires at the time of admission, and in depth hand-off reports when a patient is being

transferred off a unit. Again, this statistic aids in showing that when nurses are assigned to care

for several patients at a time patient care suffers greatly.

In addition to increased patient mortality, other adverse patient outcomes have been

associated with high-nurse-to patient ratios during times of understaffing. In their study Twigg,

Gelder, and Myers (2015), researched the occurrence of urinary tract infections (UTIs),

pneumonia, upper gastrointestinal bleeding (GI bleeding), pressure ulcers, surgical wound
UNDERSTAFFING AND PATIENT OUTCOMES 4

infections, failure to rescue, pulmonary failure, shock/cardiac arrest, sepsis, and deep vein

thrombosis (DVTs). All of which are all considered to be nursing-sensitive outcomes (NSOs).

Meaning, their occurrence is directly correlated with the quality and quantity of nursing care

received (Twigg et al., 2015). These researchers found that there was an increase in studied

NSOs during times of nurse understaffing. Further, they found that patients were at a greater risk

of developing these NSOs if they were exposed to more than one understaffed nursing shift. This

evidence aids in showing that continued nurse understaffing poses an even greater risk to patient

outcomes.

Besides causing unnecessary harm to patients, NSOs have detrimental effects on hospital

finances. Several insurance companies no longer pay for conditions that develop during the

patients hospital stay, which leaves hospitals responsible for these expenses. For example, it has

been estimated that hospital-acquired pressure ulcers cost U.S. hospitals nearly $129,248 per

ulcer. (Brem, Maggi, Nierman, Rolnitzsky, Bell, Rennert, Golinko, Yan, Lyder, & Vladeck,

2010). Pressure ulcers have been classified as a NSO and can be readily avoided through risk

assessments and turning schedules, which are simple nursing cares. However, due to short

staffing, simple cares such as these are not being addressed. Furthermore, hospital acquired

UTIs cost U.S. hospitals an average of $45 billion per year (Kennedy, Greene & Saint, 2013).

UTIs are also classified as a NSO and could be significantly decreased if there were more

available nurses per shift. With these given examples, it is evident that nurse understaffing is

harming patients as well as hospital finances. However, even with these evidences showing a

direct relationship between understaffing and adverse patient outcomes, no evidenced-based

standard of practice has been put into place to correct the increased nurse-to-patient ratio.
UNDERSTAFFING AND PATIENT OUTCOMES 5

Maslows Hierarchy of Needs Theory

Abraham Maslows hierarchy of needs is a psychology-based theory focused around

human motivation, behavior, and the pursuit of happiness. It argues that, while human beings

seek to have their basic needs met they also wish to have successively higher needs met in a form

of a specific hierarchy (Paris & Terhaar, 2010). Maslow separated this hierarchy into five

different levels or goals: First, physiological needs - which encompasses food, water, air, sleep,

sex, and homeostasis; second, safety needs - which include security of environment,

employment, health, and property; third, belongingness - which incorporates love, friendships,

and intimacy; fourth esteem - which involve confidence, self-esteem, and achievement; and fifth

self-actualization - which include creativity and problem solving (Maslow, 1943). These

different levels in the hierarchy are specifically organized based on their level of propriety and

are often depicted using a pyramid. According to Maslows theory, an individual can advance

through the different levels of the pyramid only when their lower, and more innate, level of

needs have been met (Maslow, 1943). Therefore, the individual will not be able to achieve their

safety needs until their physiological needs for food and water have been met and so on.

Maslow further explained that as the individual advances through the levels of the

pyramid, they may experience setbacks or deficiencies in one of the more basic levels, which in

turn pauses the individuals further progression until that need has been met (Paris & Terhaar,

2010). Thus, the deficient need will become the predominant focus of the individual until it has

been sufficiently satisfied. Although Maslows work was originally written for psychology

purposes, it has been readily adapted into the nursing world and has been used as a guide to

prioritizing patient needs in nursing practice.

UNDERSTAFFING AND PATIENT OUTCOMES 6

Link Between Maslows Hierarchy and Understaffing of Nurses

Since Maslows hierarchy theory has been readily adapted into nursing practice, it can be

used to explain how the rising nurse-patient ratio poses a significant threat to the clients overall

health when being utilized incorrectly. As discussed earlier, in order to progress through the

pyramidal hierarchy, the essential needs, such as homeostasis and safety, must be met first

(Maslow, 1943). This becomes challenging when nurses are spread between several patients at

one time. Although food, water, and oxygen needs are usually sufficiently met in the hospital

setting, patient safety becomes a priority problem as the nurse-to-patient ratio increases (Clendon

& Gibbons, 2015). This is largely due to the fact that nurses have less time to spend with each

patient, which puts these nurses at a greater risk for missing pertinent assessment data that could

signal a life-threatening problem and in turn increases negative patient outcomes, the worst

scenario being patient death.

Although there have been several studies showing the improvement in patient outcomes

and increased patient safety when the nurse-to-patient ratio decreases, hospital boards across the

country have yet to incorporate these evidenced-based findings into practice (Brennan, Daly, &

Jones, 2013). These unchanging policies concerning nurse staffing deficits suggest that hospital

boards are deliberately ignoring their patients basic needs stated in Maslows hierarchy and

focusing largely on their own personal needs, specifically their financial achievement. This

assumption can be made because hospitals believe they are able to bring in larger sums of money

when there are fewer staff members to compensate. Therefore, hospital boards struggle to realize

the need to increase the nurse-to-patient ratio since their own needs in Maslows hierarchy are

being sufficiently met. However, this does not change the fact that their patients most basic

needs remain unmet. According to Twigg, Geelhoed, Bremner, and Duffields (2013) study on
UNDERSTAFFING AND PATIENT OUTCOMES 7

the economic influence of the current nurse-patient ratio, hospital finances actually suffer greatly

from having a high nurse-to-patient ratio. This can be attributed to the fact that patients most

basic needs are not being met, which results in additional complications that the hospital is

required to pay for, such as pressure ulcers. For these reasons, it is appropriate to state that a

mandated decrease in nurse-patient ratio would reduce adverse patient outcomes through

meeting their basic needs.

Research Method

As the nurse-patient ratio falls there should be a subsequent decrease in NSOs in patients

during their hospital stay. As evidenced by the principles of Maslows theory, increased nurse-

patient ratios are causing a disruption in the pyramidal hierarchy, leading to unmet basic needs.

The most concerning of those needs being the safety of the patient, which becomes compromised

when nurses are unable to devote an adequate amount of time to each of their patients.

Research Design

This research study will be performed by using quantitative research, specifically a quasi-

experimental design. The purpose of quasi-experimental research is to find cause and effect

relationships between the researcher-implemented intervention and selected study outcome in

studies where complete experimental control is not possible (Grove, Gray, & Burns, 2015). Thus

quasi-experimental designs are commonly used to study new interventions or treatments in

clinical practice, since true experimental designs require specific controls that usually cannot be

acquired in the clinical setting. Quasi-experimental designs differ from experimental designs in

the regard that they usually do not have randomly selected samples or settings. They also have a

lack of control over the manipulation of the specific treatments or interventions (Grove, Gray, &

Burns, 2015). In this study, the quasi-experimental design will be used to determine the
UNDERSTAFFING AND PATIENT OUTCOMES 8

relationship between lower nurse-patient ratios and NSOs in hospitalized patients. It has been

specifically selected to accommodate for the lack of control available while studying hospitalized

patients.

Research Population

The research population will include nurses employed at a magnet status level one trauma

center in Dallas, Texas. Specifically, nurses who have been practicing for a minimum of two

years. By adding this inclusion criteria, the results have a reduced chance of being skewed by

errors new graduate nurses may make. Further, this population was chosen because of the

nursing shortage Texas is currently experiencing (U.S.) Department of Health and Human

Services, 2014). The estimated sample size of nurses will range from 1,500 to 2,000. All nursing

units in the hospital will be studied. By doing so, the transferability and validity of the results

will be strengthened. Such units include but are not limited to, day surgery, medical-surgical,

cardiac, orthopedics, mental health, neonatal intensive care, pediatrics, mother baby,

rehabilitation, oncology, labor and delivery, wound care, intensive care, and emergency services.

Further, both day and night nursing shifts will be studied, in all units in order to decrease

participation bias. During the study, if a staffing error occurs, leaving one nurse responsible for

more than three patients, this shift will be excluded from the research results.

Methods and Measurements

This study will be conducted through implementing a strict 1:3 nurse-to-patient ratio

throughout the entire hospital, with the exception of the intensive care unit (ICU). The ICU will

have a 1:2 nurse to patient ratio, since these patients have a higher acuity and require additional

care. These changes will be implemented for a year. During this time, the care provided by all

nurses in the hospital will be monitored for improvement. This will be done by recording all
UNDERSTAFFING AND PATIENT OUTCOMES 9

NSOs that occur - such as, UTIs, pressure ulcers, falls, venous thromboembolisms and DVTs,

medication errors, shock/cardiac arrest, onset of pneumonia, sepsis, wound infections, GI

bleeding, or failure to rescue. The results of this study will be measured by comparing the

number of NSOs that occurred in the year prior to the implementation of the new nurse-to-

patient ratio, versus the number of NSOs that occurred the previous year. By examining the

number of NSOs that occur before and after the implementation of the 1:3 nurse-to-patient ratio,

researchers will be able to determine if this change had an effect on patient outcomes,

specifically NSOs.

Ethical Considerations

In order to uphold the ethics of this study, it is important to communicate to each nurse

that they may choose whether they will participate in the study. This is known as the right to

self-determination, which is based on the ethical principle of respect for persons. This principle

states, all people have the right to be treated as autonomous agents and not be coerced into

participation (Grove et al., 2015). Coercion is a direct violation to the right to self-determination

and occurs when participants are either threatened to participate in the study or given an

excessive compensation for their participation. In order to avoid coercion in this study, each

nurse will be given in depth information concerning the studies methods as well as the choice to

participate. In addition, participating nurses will be informed of their right to freely withdraw at

any point in the study. In the event that an entire unit decides not to participate in the study,

researchers will have back up units at a neighboring level one trauma center in order to

accommodate for such losses.

In addition to maintaining respect for persons, it is also important for each participant to

give written consent that they fully understand the study and wish to participate. This ethical
UNDERSTAFFING AND PATIENT OUTCOMES 10

principle is known as the right to information and informed consent. In order for informed

consent to be obtained the researchers are required to disclose specific information about the

study to all prospective participants. These specifics include, a statement of the research purpose,

an explanation of procedures, a description of benefits and risks, and why the participants were

selected for this study (Grove et al., 2015). The participants will be given an oral presentation

and a written document with the information regarding the study. Further, before the prospective

participants are asked to sign their consent forms, their comprehension of the study will be

evaluated. Once these items have been addressed, each participant will be given a consent form

that they will sign if they wish to participate in the study. Again, if a large amount of nurses

choose not to participate in the study, nurses from a neighboring hospital will be asked to

participate in their place.

Moreover, it is important to communicate to the participants that only NSOs will be

recorded during this study and any information about the nurse and patient will be exempt from

the results. This ethical principle is known as the right to anonymity and confidentiality. This

principle is based on a persons right to privacy and ensures all that the data collected in a study

will not be traced back to the research participants (Grove et al., 2015). A breach of

confidentiality can occur when a researcher accidently includes information regarding a

participant that may expose their identity (Grove et al., 2015). In order to avoid a breach in

confidentiality, the research participants, and their patients, need to remain completely

anonymous. This will be achieved by excluding all personal information about the nurses and

their patients in the research results. For example, both nurse and patient names, gender, and age

will be excluded. In addition, the patients original diagnoses will not be included in the results,

only NSOs that occurred during the study will be included.

UNDERSTAFFING AND PATIENT OUTCOMES 11

Annotated Bibliography

Aiken, L. H., Sloane, D. M., Bruyneel, L., Heede, K. V., Griffiths, P., Busse, R., . . . Sermeus,

W. (2014). Nurse staffing and education and hospital mortality in nine European

countries: A retrospective observational study. The Lancet, 383(9931), 1824-1830.

doi:10.1016/s0140-6736(13)62631-8.

In this observational research design, 18 authors from different health care professions in

the U.S. and Europe, collaborated to determine if differences in nurse-patient ratios and

nurse educational qualifications increased patient mortality 30 days after surgical

procedures had been performed. First, these authors obtained discharge information of

422,730 patients over the age of 50 who stayed in the hospital for at least two days after

undergoing minor surgery. They obtained this data from 300 different randomly selected

hospitals in nine European countries, which added great strength to their study because

their findings considered a wide population. They also made sure they had full access to

the study participants medical records in order to take co-morbidities into consideration

during the study, once again strengthening their results. Next, surveys administered to

26,516 practicing nurses from the study hospitals were used to measure nurse staffing and

education levels. Because each country in the study does not have the same requirements

for bachelors degrees, this could be considered a limitation of this study. Once all of the

data was collected and analyzed, the results of the study showed increased nursing

workloads increased the likelihood of an inpatient death within 30 days and an increase in

nurses with bachelors degrees decreased the likelihood of inpatient hospital death. These

results are of great importance to hospital administrators worldwide and can be used to

show the need for a change in nurse-patient ratios.

UNDERSTAFFING AND PATIENT OUTCOMES 12

He, J., Staggs, V. S., Bergquist-Beringer, S., &, N. (2016). Nurse staffing and patient outcomes:

A longitudinal study on trend and seasonality. Retrieved from

https://bmcnurs.biomedcentral.com/articles/10.1186/s12912-016-0181-3.

This longitudinal correlative study was conducted by three authors of different

professions, all of whom are professors at different universities. They combined their

different expertise to find an association between RN staffing hours and two specific

adverse patient outcomes: Falls and pressure ulcers. They collected their data from the

National Database of Nursing Quality Indicators (NDNQI), where participating NDNQI

hospitals submitted numbers of unit-level nurse staffing and inpatient falls monthly and

pressure ulcers quarterly. The usage of the NDNQI database added strength to their

research findings since this organization focuses on safety through evidenced-based

research. Their data collected ranged from 2004-2012, which increased the validity of

their findings since the data spanned over an eight-year period. To simplify their study,

they collapsed both pressure ulcers and falls into quarterly measurements. The inclusion

criterial was limited to nursing units where all four quarters of data had been submitted to

the NDNQI, which resulted in the analysis of 2,088 total units. Through statistical

analysis of the data, they concluded that decreased nurse staffing played a significant role

in the development of pressure ulcers and increased the likelihood of patient falls.

Nonetheless, the findings of this study are somewhat limited because the researchers did

not have access to patient records and preexisting conditions that could predispose them

for pressure ulcers and falls. This source is of great importance to organizations who
UNDERSTAFFING AND PATIENT OUTCOMES 13

establish evidenced-based practice guidelines and can be used to show there is a

relationship between nurse staffing and patient outcomes, which needs to be addressed.

Junttila, J. K., Koivu, A., Fagerstrm, L., Haatainen, K., & Nyknen, P. (2016). Hospital

mortality and optimality of nursing workload: A study on the predictive validity of the

RAFAELA Nursing Intensity and Staffing system. International Journal of Nursing

Studies, 60, 46-53. doi:10.1016/j.ijnurstu.2016.03.008.

The authors of this study conducted a cross-sectional retrospective observational study to

determine if patient mortality can be predicted based on nursing workload. All five of the

authors are professors at the Buskerud and Vestfold University College in Finland and

three of them are medical professionals. They conducted this study by collecting monthly

mortality statistics and daily registration reports from 34 inpatient units in two acute care

hospitals. The selection of the two hospitals was based on similar acuity level. This made

the research findings more accurate since both hospitals were equally equipped to handle

severely ill patients. Nonetheless, because the sample size was limited to two hospitals

the results of the study are limited. Once they collected their data, these five authors used

statistics to analyze the strength of the relationship between nurse staffing levels and

patient mortality. They concluded that decreased nurse-to-patient ratios were moderately

associated with increased patient mortality. However, they did not have access to patient

records, thus they could not take into account comorbidities that could strongly influence

the mortality rates of these patients. Further, in their discussion they determined further

research needs to be conducted in order to test the strength of the association they found

through their study. There findings could be of great use to nurse researchers and hospital
UNDERSTAFFING AND PATIENT OUTCOMES 14

safety managers to help them determine if a change in nurse staffing should be mandated

in order to increase safety.

Lewis-Voepel, T., Pechlavanidis, E., Burke, C., & Talsma, A. (2012). Nursing surveillance

moderates the relationship between staffing levels and pediatric postoperative serious

adverse events: A nested-case control study. International Journal of Nursing Studies,

50(7), 905913. DOI: 10.1016/j.ijnurstu.2012.11.014.

In their retrospective case-control research study, these four authors, all of whom are

health care professionals at the University of Michigan Hospital, collaborated to test the

role nurse staffing levels have on adverse patient outcomes. They began their study by

randomly selecting kids from large childrens hospitals in the mid-west. Their use of

random sampling added strength to their study through decreased sampling bias. They

later narrowed their research sample to children who had experienced a serious adverse

event within seven days of non-cardiac surgery. The results of this study showed an

overall decrease in nursing staff at the time these adverse events took place, which lead to

their conclusion that increased nurse staffing plays an important role in decreasing the

number of adverse patient outcomes. These researchers also took into account

comorbidities and the complexity level of the surgery and how these might have

influenced adverse events, in addition to nurse staffing, which further increased the

validity of their findings. However, they failed to quantify what they considered to be

appropriate nurse staffing, limiting the practical implication of their findings. Since they

specifically studied the adverse outcomes of postoperative pediatric clients, this study is

of great importance to nurses, anesthesiologists, and surgeons who deal with this patient

population. Overall, this study can be used to influence the increase of nurses per shift in
UNDERSTAFFING AND PATIENT OUTCOMES 15

the future and subsequently decrease the quantity of avoidable adverse events from

patients.

Research Implications

Nursing Knowledge

The expected findings of this study will increase nursing knowledge of the influence

nurse-to-patient ratios have on quality patient care and safety. Specifically, nurses will be able to

determine if high nurse-to-patient ratios of six or more patients influence patient safety and

NSOs compared to low nurse-to-patient ratios of three or fewer patients. Nurse researchers will

be able to determine this through examining the statistical findings from this study, which will

either show an increase, decrease, or no significant change in NSOs after the nurse-to-patient

ratio is decreased. In addition, the findings from this study could potentially add knowledge to

aid in identifying a new standard nurse-to-patient ratio. The purpose of this new nurse to patient

ratio would be to increase patient safety while decreasing the incidence of NSOs. The new

knowledge gained from these research results may be used in combination with other similar

research studies in order to generate a sound evidenced based nurse-to-patient ratio. Depending

on the strength of the evidence, this new nurse-to-patient ratio may someday be put into nursing

practice.

Nursing Theory

At the conclusion of this study, if the research results show that reduced nurse-to-patient

ratios of three or fewer patients decrease the incidence of NSOs in patients, then the results fully

support Abraham Maslows hierarchy of needs theory. As discussed earlier, Maslows theory

proposes that in order for a humans higher needs and desires to be addressed, their most basic

needs such as food, water, shelter, and safety must be cared for first (Maslow, 1943). Therefore,
UNDERSTAFFING AND PATIENT OUTCOMES 16

when nurses have a lighter patient load, they are more readily available to address basic patient

needs, such as repositioning and toileting, as well as performing more thorough assessments.

When these cares and assessments are addressed, NSOs, such as pressure ulcers and UTIs, will

not occur as readily, because the patients basic needs are being met. In contrast, if the research

findings do not show that decreased nurse-to-patient ratios reduce the occurrence of NSOs in

patients, then the findings of the study will refute Maslows theory, showing that nurse-to-patient

ratios do not influence patient outcomes.

Nursing Practice

Depending on the research results, nurses may or may not be influenced to change the

current nurse-to-patient ratio. If the research results conclude there is a significant decrease in

NSOs when nurses have fewer patients to care for, then nurses may be more willing to advocate

for a change in the standard nurse-to-patient ratio in order to promote patient safety.

Furthermore, nurses may also advocate for division of high acuity patients among the nursing

staff; RNs should not be responsible for three high acuity patients at one time. In addition, RNs

may be further inclined to promote the use of certified nursing assistants (CNAs) and licensed

practical nurses (LPNs) on their hospital units to assist in promoting patient safety. By doing so,

RNs will have the ability to delegate cares out to both the CNAs and LPNs so that patients

needs will be addressed in a timely manner. On the other hand, if the results do not show

significant changes in NSOs when the nurse-to-patient ratio decreases, then nurses may be less

likely to advocate for changes to the current nurse-to-patient ratio. However, no matter the

outcome of the research study, nurses will be more aware of RN staffing needs. Because of this,

nurses may be more inclined to be involved in staff organization on their particular units.
UNDERSTAFFING AND PATIENT OUTCOMES 17

Improved Patient Care

This study will improve patient safety if the results indicate NSOs decrease when nurses

have three or fewer patients at a time. In order for this to occur, hospital boards need to be made

aware of the significant improvements that will come about when nurses have lighter patient

loads. For example, when nurses have three or fewer patients, they have more time to spend with

each of them. This will allow nurses to perform more thorough assessments and catch subtle

symptoms, which may signal life threatening events or other unwanted outcomes. In contrast,

when the nurse-to-patient ratio remains high, these subtle symptoms may go unnoticed;

assessments become rushed and adverse patient outcomes may occur.

In addition, when the nurse-to-patient ratio decreases, patient outcomes will improve. As

discussed earlier, in the study done by Twigg, Gelder, and Myers (2015), patients who are

exposed to understaffed nursing shifts are two times more likely to develop pressure ulcers,

surgical wound infections, DVTs, and sepsis. Therefore, through implementing a new patient-

ratio protocol of three or fewer patients, nurses will be able to prevent the previously mentioned

complications. For instance, nurses will be available to give in depth patient teaching on post-

operative ambulation and its importance, which will prevent the formation of DVTs. In addition,

nurses will be able to follow up on their patient teaching and postoperative interventions more

effectively with the new nurse-to-patient ratio protocol.

Finally, as the nurse-to-patient ratio decreases, the quality of patient care will improve.

When nurses have fewer patients to care for they will be able to spend more time in their

patients rooms. This will give them the opportunity to establish rapport with each one of their

patients, as well as gain an understanding of their culture and health care practices. Once the

nurse has an understanding patients cultural beliefs, he or she will be able to implement these
UNDERSTAFFING AND PATIENT OUTCOMES 18

practices into their care plans. With these cultural practices being implemented, the patients

quality of care will increase greatly. Furthermore, with the decrease in the nurse-to-patient ratio,

nurses will be able to administer patient medication promptly. When medication is administered

quickly, especially when a patient is in severe pain, patient both patient satisfaction and quality

care increase.

Recommendations

Although there have been several studies concerning high nurse-to-patient ratios and

adverse patient outcomes, only a handful of research has been conducted concerning the

occurrence of NSOs in patients when the nurse-to-patient ratio is high. One recommendation to

be made would be for further research similar to this study to be conducted. This

recommendation will be made to further evaluate the influence nurse-to-patient ratios have on

NSOs in patients. With an increased amount of research being conducted on this particular

subject, a larger pool of research will be available to draw conclusions. The potential results

from this study, that NSOs decrease as the nurse-to-patient ratio decreases, will be strengthened

if reciprocal studies have similar findings. Therefore, if research findings consistently show that

decreased nurse-to-patient ratios greatly reduce NSOs in patients, hospital boards will be more

motivated to implement these findings.

Depending on the results of this study, hospital administration should make a

recommendation concerning the nurse-to-patient ratio. If the results demonstrate that the

decreased nurse-to-patient ratios of three or fewer patients leads to a decrease in the occurrence

of NSOs in patients, then administrators should take this information into account and consider

making a change to RN staffing. The purpose of this recommendation would be to improve

patient care, promote safety, and reduce the occurrence of NSOs. In addition, this
UNDERSTAFFING AND PATIENT OUTCOMES 19

recommendation will also decrease other adverse patient outcomes that may occur because of

short staffing. However, if the results do not show this evidence, then administration personnel

should not make a recommendation to change the current nurse-to-patient ratio.

As mentioned earlier, two main factors influencing the nursing shortage are the lack of

nurse educators and early nurse retirement. Therefore, a recommendation to solve both of these

problems would be for aging nurses, who no longer have the desire to work in the clinical

setting, to become nurse educators. This would be extremely beneficial in decreasing the nurse-

to-patient ratio. By increasing the number of nurse educators, the hope would be for an increased

number of new graduate nurses available to fill vacancies. This could be made possible through

nurse educators reaching out to aging clinical nurses and providing them with information

regarding the job of a nurse educator. These nurse educators could also communicate to these

aging clinical nurses the advantages of becoming a nurse educator. These advantages include:

not having to deal with the stress of caring for patients, continuing their career in nursing, and

make an income. In addition, a sign on bonus could be offered as an incentive to become a nurse

educator.

A final recommendation to be made, no matter the results of this study, would be for

nurses to advocate for an increased amount of nursing students across the country. This would

benefit nursing practice by increasing the number of practicing RNs and decreasing the high

nurse-to-patient ratio. Nurses could make this possible by volunteering at community high

schools during career day; education can be given to students regarding job requirements and

responsibilities of nurses. Additionally, while at these career days, nurses could have information

packets available for interested students. These packets would contain information regarding

local nursing schools and their prerequisites. Nurses could also work in coordination with local
UNDERSTAFFING AND PATIENT OUTCOMES 20

nursing schools faculty and ask for their participation in career day. By doing so, interested

students can ask program specific questions that may not be answered in the information packets.
UNDERSTAFFING AND PATIENT OUTCOMES 21

References

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