Chapter 25. Nurse Staffing and Patient Care Quality
and Safety
Sean P. Clarke, Nancy E. Donaldson
The importance of nurse staffing to the delivery of high-quality patient care was a principle
finding in the landmark report of the Institute of Medicine’s (IOM) Committee on the Adequacy
of Nurse Staffing in Hospitals and Nursing Homes: “Nursing is a critical factor in determining
the quality of care in hospitals and the nature of patient outcomes”1 (p. 92). Nurse staffing is a
crucial health policy issue on which there is a great deal of consensus on an abstract level (that
nurses are an important component of the health care delivery system and that nurse staffing has
impacts on safety), much less agreement on exactly what research data have and have not
established, and active disagreement about the appropriate policy directions to protect public
safety.
The purpose of this chapter is to summarize and discuss the state of the science examining
the impact of nurse staffing in hospitals and other health care organizations on patient care
quality, as well as safety-focused outcomes. To address some of the inconsistencies and
limitations in existing studies, design issues and limitations of current methods and measures will
be presented. The chapter concludes with a discussion of implications for future research, the
management of patient care and public policy.
Background
For several decades, health services researchers have reported associations between nurse
staffing and the outcomes of hospital care.2–4 However, in many of these studies, nursing care
and nurse staffing were primarily background variables and not the primary focus of study.5 In
the 1990s, the National Center for Nursing Research, the precursor to the National Institute of
Nursing Research, convened an invitational conference on patient outcomes research from the
perspective of the effectiveness of nursing practice.6 It was hoped that as methods for capturing
the quality of patient care quantitatively became more sophisticated, evidence linking the
structure of nurse staffing (i.e., hours of care, skill mix) to patient care quality and safety would
grow. However, 5 years later, the 1996 IOM report articulating the importance of nurses and
nurse staffing on outcomes concluded that, at that time, there was essentially no evidence that
staffing exerted an effect on acute care hospital patients’ outcomes and limited evidence of its
impact on long-term care outcomes.1
There has been remarkable growth in this body of literature since the 1996 IOM report. Over
the course of the last decade, hospital restructuring, spurred in part by a move to managed care
payment structures and development of market competition among health care delivery
organizations, led to aggressive cost cutting. Human resources, historically a major cost center
for hospitals, and nurse staffing in particular, were often the focus of work redesign and
workforce reduction efforts. Cuts in nursing staff led to heavier workloads, which heightened
concern about the adequacy of staffing levels in hospitals.7, 8 Concurrently, public and
professional concerns regarding the quality and safety of patient care were sparked by research
and policy reports (among them, the IOM’s To Err is Human9), and then fueled by the popular
1
,Patient Safety and Quality: An Evidence-Based Handbook for Nurses
media. A few years ago, reports began documenting a new, unprecedented shortage of nurses
linked to growing demand for services, as well as drops in both graduations from prelicensure
nursing education programs and workforce participation by licensed nurses, linked by at least
some researchers to deteriorating working conditions in hospitals.10, 11 These converging health
care finance, labor market, and professional and public policy forces stimulated a new focus of
study within health services research examining the impact of nurse staffing on the quality and
safety of patient care. An expected deepening of the shortage in coming years12 has increased the
urgency of understanding the staffing-outcomes relationship and offering nurses and health care
leaders evidence about the impacts of providing care under variable nurse staffing conditions.
This chapter includes a review of related literature from early 2007.
Identifying Nurse-Sensitive Outcomes
The availability of data on measures of quality that can be reasonably attributed to nurses,
nursing care, and the environments in which care is delivered has constrained research studying
the link between staffing and outcomes. While nurse leaders have been discussing the need to
measure outcomes sensitive to nursing practice back to at least the 1960s, widespread use of the
terms “nurse/nursing-sensitive outcomes” and “patient outcomes potentially sensitive to nursing”
is a relatively recent development. Nurse-sensitive measures have been defined as “processes
and outcomes that are affected, provided, and/or influenced by nursing personnel, but for which
nursing is not exclusively responsible.”13, 14 While some scholars feel the term “nurse-sensitive
measure” is fundamentally incorrect because patient outcomes are influenced by so many
factors, health care is practiced in a multidisciplinary context, and few aspects of patient care are
the sole purview of nurses, there is a broad recognition that some outcomes reflect differences in
the quality of nursing care patients receive and therefore presumably respond to the
characteristics of the environments in which care is provided (including staffing levels).
No matter what label these measures are given, measures that have conceptual and clinical
links to the practice of nursing and are sensitive to variations in the structure and processes of
nursing care are an essential ingredient in this area of research. Data sources from which to
construct these measures must be identified, and exact definitions indicating how measures are to
be calculated must be drafted. This is particularly critical if different individuals or groups are
involved in compiling quality measures. There have been calls for standardization of measures of
the quality of health care for some time,1, 15 along with outcome measures related to the quality
of nursing care. Inconsistent definitions have slowed progress in research and interfered with
comparability of results across studies. A paper, now under review, examines and compares
common measures of adult, acute care nurse staffing, including unit-level hospital-generated data
gleaned from the California Nursing Outcomes dataset, hospital-level payroll accounting data
obtained from the California Office of Statewide Health Planning and Development, hospital-
level personnel data submitted to the American Hospital Association, and investigator research
data obtained from the California Workforce Initiative Survey. Findings reveal important
differences between measures that may explain at least some inconsistencies in results across the
literature (Spetz, Donaldson, Aydin, personal communication February, 2007).
Efforts to address the standardization imperative began with the American Nurses
Association’s (ANA) first national nursing quality report card initiative. This initiative began
with a literature search to identify potential nurse-sensitive quality indicators. Next, expert
reviewers examined and validated a smaller, selected group of indicators and measures from
2
, Staffing
among these.16 The ANA then funded six initial nursing quality report card indicator feasibility
studies, which developed and refined these first sets of measures, documenting the quality of
nursing care in acute care settings. The California Nursing Outcomes Coalition (CalNOC) was
among the first State-based feasibility projects conducted by the ANA that ultimately served as
the basis for the National Database for Nursing Quality Indicators (NDNQI) established in 1997.
Maintaining an informal collaboration with the NDNQI, CalNOC continues to function as a
regional nursing quality database, and more recently, CalNOC methods have been adapted by
both the emerging Military Nursing Outcomes Database and VA Nursing Outcomes Database
projects. All four groups currently collect and analyze unit-level data related to the associations
between nurse staffing and the quality and safety of patient care. Together, they have formed an
unofficial collaborative of nursing quality database projects.17–21
The most recent initiative in standardizing staffing and outcomes measures for quality
improvement and research purposes was undertaken by the National Quality Forum (NQF). The
mission of the NQF is to improve American health care through consensus-based standards for
quality measurement and public reporting related to whether health care services are safe, timely,
beneficial, patient centered, equitable, and efficient. To advance standardization of nurse-
sensitive quality measures and respond to authoritative recommendations from multiple IOM and
Federal reports,9, 15, 22 the NQF convened an expert panel and established a rigorous consensus
process to generate the Nation’s first panel of nursing-sensitive measures for public reporting.
The aim of the expert panel was to explicate and endorse national voluntary consensus standards
as a framework for measuring nursing-sensitive care and to inform related research. Potential
nursing-sensitive performance measures were subjected to a rigorous and systematic vetting
under the terms of the NQF Consensus Development Process, which included a thorough
examination of evidence substantiating each measure’s sensitivity to nursing factors, alignment
with existing requirements being made of providers, and validation/recommendations of
advisory bodies to Federal agencies. As illustrated in Figure 1, the resulting first 15 NQF
nursing-sensitive measurement standards were informed by earlier work by the NDNQI and
CalNOC, as well as measures arising from formal research studies.
3
and Safety
Sean P. Clarke, Nancy E. Donaldson
The importance of nurse staffing to the delivery of high-quality patient care was a principle
finding in the landmark report of the Institute of Medicine’s (IOM) Committee on the Adequacy
of Nurse Staffing in Hospitals and Nursing Homes: “Nursing is a critical factor in determining
the quality of care in hospitals and the nature of patient outcomes”1 (p. 92). Nurse staffing is a
crucial health policy issue on which there is a great deal of consensus on an abstract level (that
nurses are an important component of the health care delivery system and that nurse staffing has
impacts on safety), much less agreement on exactly what research data have and have not
established, and active disagreement about the appropriate policy directions to protect public
safety.
The purpose of this chapter is to summarize and discuss the state of the science examining
the impact of nurse staffing in hospitals and other health care organizations on patient care
quality, as well as safety-focused outcomes. To address some of the inconsistencies and
limitations in existing studies, design issues and limitations of current methods and measures will
be presented. The chapter concludes with a discussion of implications for future research, the
management of patient care and public policy.
Background
For several decades, health services researchers have reported associations between nurse
staffing and the outcomes of hospital care.2–4 However, in many of these studies, nursing care
and nurse staffing were primarily background variables and not the primary focus of study.5 In
the 1990s, the National Center for Nursing Research, the precursor to the National Institute of
Nursing Research, convened an invitational conference on patient outcomes research from the
perspective of the effectiveness of nursing practice.6 It was hoped that as methods for capturing
the quality of patient care quantitatively became more sophisticated, evidence linking the
structure of nurse staffing (i.e., hours of care, skill mix) to patient care quality and safety would
grow. However, 5 years later, the 1996 IOM report articulating the importance of nurses and
nurse staffing on outcomes concluded that, at that time, there was essentially no evidence that
staffing exerted an effect on acute care hospital patients’ outcomes and limited evidence of its
impact on long-term care outcomes.1
There has been remarkable growth in this body of literature since the 1996 IOM report. Over
the course of the last decade, hospital restructuring, spurred in part by a move to managed care
payment structures and development of market competition among health care delivery
organizations, led to aggressive cost cutting. Human resources, historically a major cost center
for hospitals, and nurse staffing in particular, were often the focus of work redesign and
workforce reduction efforts. Cuts in nursing staff led to heavier workloads, which heightened
concern about the adequacy of staffing levels in hospitals.7, 8 Concurrently, public and
professional concerns regarding the quality and safety of patient care were sparked by research
and policy reports (among them, the IOM’s To Err is Human9), and then fueled by the popular
1
,Patient Safety and Quality: An Evidence-Based Handbook for Nurses
media. A few years ago, reports began documenting a new, unprecedented shortage of nurses
linked to growing demand for services, as well as drops in both graduations from prelicensure
nursing education programs and workforce participation by licensed nurses, linked by at least
some researchers to deteriorating working conditions in hospitals.10, 11 These converging health
care finance, labor market, and professional and public policy forces stimulated a new focus of
study within health services research examining the impact of nurse staffing on the quality and
safety of patient care. An expected deepening of the shortage in coming years12 has increased the
urgency of understanding the staffing-outcomes relationship and offering nurses and health care
leaders evidence about the impacts of providing care under variable nurse staffing conditions.
This chapter includes a review of related literature from early 2007.
Identifying Nurse-Sensitive Outcomes
The availability of data on measures of quality that can be reasonably attributed to nurses,
nursing care, and the environments in which care is delivered has constrained research studying
the link between staffing and outcomes. While nurse leaders have been discussing the need to
measure outcomes sensitive to nursing practice back to at least the 1960s, widespread use of the
terms “nurse/nursing-sensitive outcomes” and “patient outcomes potentially sensitive to nursing”
is a relatively recent development. Nurse-sensitive measures have been defined as “processes
and outcomes that are affected, provided, and/or influenced by nursing personnel, but for which
nursing is not exclusively responsible.”13, 14 While some scholars feel the term “nurse-sensitive
measure” is fundamentally incorrect because patient outcomes are influenced by so many
factors, health care is practiced in a multidisciplinary context, and few aspects of patient care are
the sole purview of nurses, there is a broad recognition that some outcomes reflect differences in
the quality of nursing care patients receive and therefore presumably respond to the
characteristics of the environments in which care is provided (including staffing levels).
No matter what label these measures are given, measures that have conceptual and clinical
links to the practice of nursing and are sensitive to variations in the structure and processes of
nursing care are an essential ingredient in this area of research. Data sources from which to
construct these measures must be identified, and exact definitions indicating how measures are to
be calculated must be drafted. This is particularly critical if different individuals or groups are
involved in compiling quality measures. There have been calls for standardization of measures of
the quality of health care for some time,1, 15 along with outcome measures related to the quality
of nursing care. Inconsistent definitions have slowed progress in research and interfered with
comparability of results across studies. A paper, now under review, examines and compares
common measures of adult, acute care nurse staffing, including unit-level hospital-generated data
gleaned from the California Nursing Outcomes dataset, hospital-level payroll accounting data
obtained from the California Office of Statewide Health Planning and Development, hospital-
level personnel data submitted to the American Hospital Association, and investigator research
data obtained from the California Workforce Initiative Survey. Findings reveal important
differences between measures that may explain at least some inconsistencies in results across the
literature (Spetz, Donaldson, Aydin, personal communication February, 2007).
Efforts to address the standardization imperative began with the American Nurses
Association’s (ANA) first national nursing quality report card initiative. This initiative began
with a literature search to identify potential nurse-sensitive quality indicators. Next, expert
reviewers examined and validated a smaller, selected group of indicators and measures from
2
, Staffing
among these.16 The ANA then funded six initial nursing quality report card indicator feasibility
studies, which developed and refined these first sets of measures, documenting the quality of
nursing care in acute care settings. The California Nursing Outcomes Coalition (CalNOC) was
among the first State-based feasibility projects conducted by the ANA that ultimately served as
the basis for the National Database for Nursing Quality Indicators (NDNQI) established in 1997.
Maintaining an informal collaboration with the NDNQI, CalNOC continues to function as a
regional nursing quality database, and more recently, CalNOC methods have been adapted by
both the emerging Military Nursing Outcomes Database and VA Nursing Outcomes Database
projects. All four groups currently collect and analyze unit-level data related to the associations
between nurse staffing and the quality and safety of patient care. Together, they have formed an
unofficial collaborative of nursing quality database projects.17–21
The most recent initiative in standardizing staffing and outcomes measures for quality
improvement and research purposes was undertaken by the National Quality Forum (NQF). The
mission of the NQF is to improve American health care through consensus-based standards for
quality measurement and public reporting related to whether health care services are safe, timely,
beneficial, patient centered, equitable, and efficient. To advance standardization of nurse-
sensitive quality measures and respond to authoritative recommendations from multiple IOM and
Federal reports,9, 15, 22 the NQF convened an expert panel and established a rigorous consensus
process to generate the Nation’s first panel of nursing-sensitive measures for public reporting.
The aim of the expert panel was to explicate and endorse national voluntary consensus standards
as a framework for measuring nursing-sensitive care and to inform related research. Potential
nursing-sensitive performance measures were subjected to a rigorous and systematic vetting
under the terms of the NQF Consensus Development Process, which included a thorough
examination of evidence substantiating each measure’s sensitivity to nursing factors, alignment
with existing requirements being made of providers, and validation/recommendations of
advisory bodies to Federal agencies. As illustrated in Figure 1, the resulting first 15 NQF
nursing-sensitive measurement standards were informed by earlier work by the NDNQI and
CalNOC, as well as measures arising from formal research studies.
3
