The Influence of Appropriate Staffing and Healthy Work Environments on Patient and Nurse Outcomes

The association between nurse staffing and outcomes for both patients and nurses is not new. In 2002, Aiken and colleagues1 published a landmark study reporting that higher nursing workloads increased odds of patients dying and of nurses experiencing burnout and emotional exhaustion. These relationships, which may partially be explained by missed nursing care, have been confirmed in numerous other studies.2–7 Care omissions may result as nurses experience time pressures that affect surveillance and attention to complex needs of patients.8,9 Thus, inadequate staffing affects patient safety and nurse well-being, further eroding the quality and safety of care.Appropriate staffing ensures an effective match between the needs of patients and their families and the knowledge, skills, and abilities of nurses.10 It has been identified as an essential ingredient of the American Association of Critical-Care Nurses (AACN) framework for a healthy work environment. Growing research has examined the effect of work environments on patient and nurse outcomes, especially as the Magnet Recognition Program has grown. As a culture of excellence evolves, positive practice environments offer benefits to patients, including better safety and quality of care and greater satisfaction with nursing care. Nurses benefit from greater autonomy and control over practice, better relationships with physicians, and higher nurse to patient ratios and workplace safety that increases engagement and job satisfaction and lowers burnout and turnover.9,11–17 The PICO (problem/patient/population, intervention/indicator, comparison, outcome) question that guided this synthesis was “How do nurse staffing and the quality of practice environments affect patient, nurse, and organizational outcomes?”The strategy involved searching the Cumulative Index to Nursing and Allied Health Literature and MEDLINE for original research in the past 10 years. Key words included nurse, staffing, patient outcomes, Magnet hospitals, nursing excellence, and practice or work environments.Across 14 studies (Table 1), better staffing (measured by total hours per patient day [HPPD], nurses’ HPPD and skill mix, nurse-patient ratios) was associated with fewer hospital-acquired pressure injuries (HAPIs), catheter-associated urinary tract infections, surgical site infections, sepsis, and heart failure. Strong practice environments, as measured by the Practice Environment Scale or Magnet recognition, were associated with fewer admissions to intensive care units; greater nurse confidence about resolution of patient care problems and patient’s self-care ability after discharge; and decreased intent to leave.Both better staffing and practice environments were associated with improvedThis synthesis of level C evidence31 revealed that better staffing and practice environments had both individual and shared outcome effects. Better practice environments, including Magnet hospitals, had lower nurse to patient ratios, nearly 1 hour on average higher nurse HPPD for every unit type, higher nurse skill mix, and a more educated workforce.16,25,28,30 In turn, better environments led to less burnout, job dissatisfaction, and intent to leave.21–23,25,30However, the beneficial effect of nurse staffing on outcomes is conditional on the quality of the work environment.26 Consequently, addressing staffing without improving the practice environment will be ineffective.19 Investing in changing the culture as a broad, long-range solution can drive improvements in outcomes for both patients and nurses. Many elements10,32,33 affect the quality of practice environments:The Magnet Recognition Program34 provides a blueprint for shaping this positive culture of excellence. Heightening clinical nurse autonomy, ownership, and accountability for issues affecting nursing practice through shared governance is an essential step regardless of Magnet journey intent. Shared governance can advance many practice environment strategies like patient-centered care, evidence-based practice, and teamwork/collaboration.Specific to staffing, shared decision-making strengthens the voice of clinical nurses as they collaborate with leaders to develop optimal staffing plans and policies. The “RN Effectiveness Database,”7 housing evidence from more than 600 studies demonstrating that appropriate staffing is essential for high-quality care, is a resource for evidence-based decision-making related to staffing. Unless legislated, staffing models should be flexible,8 going beyond fixed numbers or ratios. In a recent retrospective cohort analysis,35 mandated 2:1 ICU ratios in Massachusetts were not associated with lower mortality, fewer complications (central catheter bloodstream-associated infection, catheter-associated urinary tract infections, HAPIs, injury falls) or do-not-resuscitate rates compared with hospitals without ratios. As a complex function, staffing must reflect the varying needs of patients and changing clinical conditions. In order to fully incorporate assessment of patient risk, a multitude of factors should be considered when planning the number of staff and skill mix needed on a given shift:Staff feedback is critical to assess ongoing staffing effectiveness. Schmalenberg and Kramer37 found that nurses’ perceptions of staffing adequacy were most influenced by the number of budgeted positions, using flexible care delivery systems, and having enough staff to provide safe, high quality care while ensuring nurse satisfaction with the care provided. Further analysis revealed that who nurses worked with (ie, competency, teamwork, cohesiveness), and administrators’ recognition of patient acuity when allocating positions were the 2 universal factors affecting perceptions. Thus, by focusing on elements of the practice environment such as competence, teamwork, and modifying care delivery to account for patients’ acuity, leaders can improve nurses’ perceptions of staffing adequacy.Additionally, staffing effectiveness should be evaluated by examining unit-level outcomes. Trends in evidence-based outcomes tied to staffing and the quality of the practice environment (Table 2) can be used to advocate for resources or systems that support the delivery of care. AACN is leading large-scale initiatives to transform nurse staffing as an investment in patient safety. Nurses in the field are leading local solutions to improve staffing. Some examples use technology for assignment-making to appropriately match patients’ needs to nurses’ competencies; others redesign care delivery models on the basis of skill mix or geographical care zones.38Culture—a powerful force. When effectively harnessed, organizational cultures can advance innovations that support positive work environments so that nurses and the health care team can do what they do best—provide exceptional patient care that yields high-quality outcomes.