What’s So Hard to Understand: Patient Safety, Quality Care Linked to Nurse Staffing

By Maureen Shawn Kennedy, AJN editor-in-chief

shawnkennedyThe data linking nurse staffing as well as shift length with patient outcomes and satisfaction with care continue to roll in. The latest report on nurse staffing, published in the January 13 issue of Medical Care by McHugh and MA, links higher nurse–patient ratios and good work environments to reduced 30-day readmission rates. Read the abstract here.

Most nurses seem to support better nurse–patient ratios, but there’s continuing ambivalence about reducing shift length, as seen in the comments we received on a recent blog post asking whether it’s time to retire the 12-hour nursing shift.

In August, researchers reported a link between nurse staffing and hospital-acquired infections.  Publishing in the American Journal of Infection Control, the authors noted a “significant association” between nurse–patient staffing ratios and both urinary tract infections and surgical site infections. Further, they noted that reducing nurse burnout was associated with fewer infections. (Read our news report on the study here.)

Health Affairs published a report in November called “The Longer the Shifts for Hospital Nurses, The Higher the Levels of Burnout and Patient Dissatisfaction.” The findings were there, loud and clear—researchers Stimpfel, Sloane, and Aiken found that “extended shifts undermine nurses’ well-being, may result in expensive turnover and can negatively affect patient care.”

And in December, we published a CE article (“Staffing Matters—Every Shift”) that looked at data suggesting that not just nurse–patient ratios, but the skill mix and relative experience levels among nurses in a unit, affected patient outcomes. (Here’s the blog post we ran describing the article’s main points.)

But all this shouldn’t be news. In 2004, Health Affairs carried a report by Ann Rogers and colleagues noting the link between long working hours and the risk of error. And in 2002, researchers led by Jack Needleman and Peter Buerhaus reported study findings in the New England Journal of Medicine: in brief, data from 799 hospitals in 11 states showed that more care by RNs (as opposed to LPNs or nurse aides) led to better patient outcomes.

The Institute of Medicine released its own report in 2003, Keeping Patients Safe: Transforming the Work Environments of Nurses, which it recommended the prohibition of working more than 12 hours in 24 hours and more than 60 hours per week. It also recommended that hospitals and nursing homes evaluate mechanisms for determining staffing requirements to ensure patient needs are being met safely.

So what’s changed in the last 10 years as a result of these findings and high-level recommendations? Have hospitals worked to improve staffing? Have hospitals moved away from “12-hour-plus” shifts or refused to let nurses work “double shifts” (back-to-back eight-hour shifts)? We reported on this issue last May, but we’d like to know—is your facility paying attention to the evidence and making changes to ensure patient safety and a healthy work environment for you?

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Senior editor/social media strategy, American Journal of Nursing, and editor of AJN Off the Charts.


  1. Teresa, the PhD nurse from Oregon February 20, 2013 at 11:53 pm

    I call it a “warm body” model, but I’m not sure it has an official name. I think administration thinks it knows what nurses need to do, so there is no need for nurse experts. A nurse with no oncology experience took over as the “professional practice leader” on the oncology unit, and administration is pleased because she allows the staff to be the clinical experts while completing falls reduction and similar programs that are required for maximum CMS reimbursement. On my unit (Trauma ICU) the “professional practice leader” has a master’s degree, but no ICU experience. She is widely viewed as ineffective, and I understand why. She doesn’t have the needed clinical skills.

    I think one of the unintentional effects of the patient safety movement has been that hospitals focus only upon nationwide initiatives, ignoring institution-specific needs. Our model is an outgrowth of that.

  2. Shawn Kennedy February 20, 2013 at 5:07 pm

    Very disheartening. So what kind of “model” is it?

  3. Teresa, the PhD CNS from Oregon February 20, 2013 at 1:47 pm

    Dr. Kennedy, CMS payment initiatives began in 2008. Since then, we have seen safe mobilization equipment and better access to lifting help at my institution, but not more nurses or nurse aides. We also no longer employ clinical nurse specialists to guide practice. Instead we have staff educators and “professional practice leaders” – the former are staff nurses and the latter: anyone who seems to meet the (loose) job criteria. I was told by a top nursing administrator “our model is not an expert model.” This de-expertising of nursing is a huge problem in my opinion.

  4. Shawn Kennedy February 20, 2013 at 11:26 am

    The new CMS payment reforms will withhold payments for preventable complications (eg, hospital-acquired infections, pressure ulcers). Does anyone think hospitals recognize that the way to avoid these penalties is to invest in nurses?

  5. Lee Anne February 16, 2013 at 10:36 pm

    I think part of our current problems stem from the fact that when nurse-patient ratios were mandated we didn’t also mandate UC-patient ratios or CNS/PCT-patient ratios. Another concern is even if we had appropriate ratios for all HCWs we don’t have enough people WILLING and ABLE to provide the care. That’s the bigger issue.

  6. Jenny February 16, 2013 at 3:20 am

    For me the question I always wonder when it comes to staffing ratios is if we mandate nurse-to-patient rations are we also taking away axillary staff to cut costs? That is my prediction for mandated ratios. Without axillary staff such as cnas & secretaries our jobs double. The other hospital in my area tried it and there were letters to the editor in my local paper about how patients who couldn’t feed themselves weren’t being fed, no one was being bathed, patients had to sit in their filth if they couldn’t walk to the bathroom. Mandated nurse-to-patient ratios are a great idea but if it includes the loss of axillary staff to cut costs I predict patient care still will not improve.

  7. blueeyedsunshine February 1, 2013 at 9:14 am

    One of my jobs is a nurse for a prison. I am routinely mandated for 17 hour shifts in an environment that is, by nature, unsafe. I am often expected to go home for 7 hours and return for another shift, in which it is not uncommon to again be mandated.

    Mentioning that I feel unsafe as a nurse to continue duty gets me threatened with abandonment reporting.

    Although my part time job at a hospital only expects 12.5 hour shifts, we work often with LPNs who cant push meds, making our already borderline patient ratios harder because each RN has to cover pushes on another 6 to 8 patients.

  8. nelgail January 31, 2013 at 12:53 pm


  9. Katheren Koehn January 31, 2013 at 11:45 am

    I think we need to look at some of the states where safe staffing legislation has been adopted and see where it has made a difference. Are mandated staffing committees working? Are nurses being given the information and tools they need to be effective on these committees? The Washington State Nurses Association’s website has developed a comprehensive tool box for safe staffing – http://www.wsna.org/Topics/Safe-Nurse-Staffing/ – that looks very helpful.

  10. Teresa, the PhD nurse from Oregon January 31, 2013 at 11:42 am

    Dr. Kennedy, the answer is no. On yesterday’s shift at a Magnet hospital, I cared for two critical patients. The charge RN boasted about how our unit moves patients around from room to room in order to “double up” more, so we can use fewer nurses. When one of my patients crashed, the other was ignored, despite my colleagues’ efforts to help. (There is only so much a “helper” who does not know the patient can do, after all.) There is no time to think in the midst of all the tasks. Years ago, our nursing assistants were taken away, so now nurses empty trash after the housekeeper leaves for the day, empty the linen hampers, empty the Foley bags, and clean up messes when something spills. Nurses wash cardiac chairs after using them, do quality checks on glucometers, report broken and missing equipment, hunt for supplies, and do dozens of other things that do not require a license. In my practice, there are 5 different places where a medication that I intend to administer might be found; administration does not see this as a problem. It seems pushing off new tasks on nurses is a favorite cost-cutting strategy for management, while they admonish us to satisfy patients and tick off all the right boxes on the electronic health record to show that we’re giving good care. I’ve been an ICU nurse for 30 years, and I despair for how nursing care is still devalued and how we are consistently the lowest member in the rigid hospital hierarchy, despite our truly heroic efforts to show the importance of nursing practice.

  11. Shawn Kennedy January 31, 2013 at 9:49 am

    Thanks to all for great comments and food for thought! I wonder, though, if anyone has ideas on how nurses can push safe staffing in their hospitals, when faced with responses like that Desmo Reno reports in her post above?

  12. Pat D'Antonio January 31, 2013 at 9:05 am

    A colleague and I were just passing a poster announcing a presentation Amy Stimpfel would be making about her research (“Tales of a Tired Nurse”) and we began talking about how the demands of 12 hour shifts are so context dependent: that 12 hours on an adult medical or surgical unit (with its heavy demands vis-à-vis body work) is quite different than 12 hours in a NICU (where you can turn a baby with one hand). But I might only add that this research is in its infancy… and might raise the question about what other kinds of variables need to be considered / teased out as we move forward: types and staffing of different kinds of units? day or night shifts? Intersections of personal and family life? Institutional supports?

  13. Michael Bleich January 30, 2013 at 4:39 pm

    Nursing is a relationship-centered discipline. Fatigue is a human factor that impacts the energy and focus that nurses can provide to their patients and families, but also to peers and other health colleagues. The data is clear that if we can about the product and outcome that we create when interacting and carrying out therapeutic interventions, then we must create models that honor both the nurse (willfully wanting to free her/himself to a personal lifestyle that invokes freedoms) and what is right for the patient, for whom we have a social policy statement that serves as a contract between society and the discipline. Future dialogue must be waged with a “both/and” spirit, rather than an “either/or” mentality that is so pervasive in our society.

  14. Barbara Glickstein January 30, 2013 at 2:14 pm

    We are the catalysts for this conversation moving forward. The evidence is in and translating that evidence (cited in this post) into practice is critical. Shawn Kennedy is blogging about it, are you? Have you called your local health reporter to pitch them this story so the public is informed? When we engage traditional media and make media through digital media (or make noise on any platform) about policies that improve healthy outcomes it matters. Start making more noise. The time is now.

  15. Cny rn January 29, 2013 at 5:39 pm

    You need more nurses, period. Won’t happen though as it lowers the bottom line.

  16. Shirie Leng, MD January 29, 2013 at 2:30 pm

    Of course patient outcomes are linked to nurses. You don’t go to the hospital because you need a doctor; you go because you need a nurse. The nurse is the most important part. The problem is that those who control the money control the power, and nurses tend to have a lot of responsibility but not a lot of power. Hopefully the new emphasis on quality in the ACA will take into account the data you present.

  17. nelgail January 29, 2013 at 2:07 pm

    I know of a Nurse that works 16 hours every day,works 8 hours at two diffrent places. The places are near each other,so it easy to get to each one without being too late,and at least twice a week,this Nurse works 24 straight ,of course they sleep most of the 11-7 shift,
    Your comment about the care given by CNA,LPN,and RN,well I have seen CNA’S that I would rather take care of me,than “some” of the Dr.,RN’S,or LPN”S
    It really depends of the person,are they there for a pay check,or to give their best in caring for the Pt.?

  18. Desma Reno January 29, 2013 at 1:31 pm

    I say it over and over and over again…I had a former student who has been a nurse for a little over a year. She came to my class last week to dialogue with my students about the experience of NCLEX and also her experience as a new nurse. This student graduated with honors, was very engaged with NSNA/SNA and excellent in clinical. She works in a magnet hospital. Their pitch to her to get her was we strive to staff with high nurse to patient ratio…..mentioned 4 to 1….no mention by the way about acuity measurement…the reality was for her immediately post orientation was 8-1 or more…on a neuro stroke unit where cognitive issues were the norm and delirium was rampant…she as a member of a new nurse council…repeatedly discussed their distress about the staffing issues…..the response….”our accountants have crunched the numbers and this is the staffing ratio we have been given that should work”. It was that moment that this new graduate burned out completely…she is leaving as soon as she can find new position in another place…though she is going to look closely at the organization before accepting a position….Has this changed…..not for most organizations…in fact with the new health care reform issues hospitals are facing with penalties, etc…more of the cost sharing will be at the expense of the nursing staff in staffing and salaries…that is my prediction. How can we change this is the issue for the nursing profession. I strongly urge the new generation of nurses to get involved and have a stronger voice at the table to prevent the accountants from making the decisions for our profession and for our patient’s safety.

    Desma Reno, MSN, APRN, GCNS-BC
    Jackson, Missouri

  19. MedoraRN (@MedoraRN) January 29, 2013 at 1:12 pm

    Thank you for continuing to highlight this connection! Nurse staffing and patient safety are intertwined in my eyes – how could we be providing top-notch care if we’re exhausted? And worse, not even realize it? I am lucky enough to work in a health system that does place great emphasis on patient safety, and also on patient and employee satisfaction. We are not scheduled for more than 12 hours at a time, not encouraged to “stay longer” after a full shift, and rarely have overtime needs on the unit where I work. However, the entire hospital system uses the 12-hour-shift format, even while our online education modules are reminding us each year that “more than 8 hours worked in a shift” can lead to safety concerns.

  20. collinsonyango (@collinsony76) January 29, 2013 at 12:19 pm

    I work in a hospital that demands 12hour shifts from nurses and sometimes back to back overtime shifts.
    How can these findings be incorporated int nursing practice?

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