Using p using patient staff ratio t atient staff ratio to improve patient car atient care outcomes

Walden University ScholarWorks Walden Dissertations and Doctoral Studies Walden Dissertations and Doctoral Studies Collection 2020 Using Patient-Staff Ratio to Improve Patient Care Outcomes Fadekemisola Oludayo Timothy Walden University Follow this and additional works at: https://scholarworks.waldenu.edu/dissertations Part of the Nursing Commons This Dissertation is brought to you for free and open access by the Walden Dissertations and Doctoral Studies Collection at ScholarWorks It has been accepted for inclusion in Walden Dissertations and Doctoral Studies by an authorized administrator of ScholarWorks For more information, please contact ScholarWorks@waldenu.edu Walden University College of Health Sciences This is to certify that the doctoral study by Fadekemisola Oludayo Timothy has been found to be complete and satisfactory in all respects, and that any and all revisions required by the review committee have been made Review Committee Dr Francisca Farrar, Committee Chairperson, Nursing Faculty Dr Patricia Senk, Committee Member, Nursing Faculty Dr Patti Urso, University Reviewer, Nursing Faculty Chief Academic Officer and Provost Sue Subocz, Ph.D Walden University 2020 Abstract Using Patient-Staff Ratio to Improve Patient Care Outcomes by Fadekemisola Timothy Project Submitted in Partial Fulfilment of the Requirements for the Degree of Doctor of Nursing Practice Walden University May 2020 Abstract The persistence of nurse scarcity has been documented by many researchers as the leading problem in the critical care setting A high nurse to patient ratio leads to poor healthcare outcomes associated with increased nurse burn out, medical errors, and low-quality care services Solving the issue of nurse scarcity is still a challenge due to lack of an effective multidimensional staffing model In this project, a multidimensional staffing model was developed based on the relationship between patient-to-staff ratio, together with and other factors in the care environment which impacts patient outcome The project was framed on Donabedian's structure, process, and outcomes model The research question involved establishing the multidimensional staffing model on the interaction between staffing levels and other contextual factors in a critical care setting The research methodology involved a systematic review of 13 articles to develop the evidence-based best practice multidimensional staffing The inclusion criteria were articles published between 2014 and 2019 and had been developed from quantitative methods, mixed methods, systematic reviews, or meta-analyses A thematic analysis was used as the main data analysis method to develop meanings, subjectively, from the collected data The results show that the best staffing model for nurses in a critical care unit is the nurse-to-patient ratio model The proposed nurse-to-patient ratio is 1:2 These findings have strong implications for the nursing practice and the patients since the nurse-to-patient ratio model will lead to an increased number of nurses, reduced workload, and improve patient outcomes Using Patient-Staff Ratio to Improve Patient Care Outcomes by Fadekemisola Timothy Project Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Nursing Practice Walden University May 2020 Dedication I would first like to express my gratitude and praises to Almighty God for his strength and wisdom through my postgraduate program and the rigorous process of my project I also want to say a heartfelt thank you to my supportive husband, Funso Timothy Thanks to my precious children who are jewels, Boluwaji, Foluwake, Motunrayo, and Oluwatimilehin Timothy for allowing me time away from them to focus on my studies Children you deserve a trip to Disney! It would be a big mistake to fail to recognize the unconditional love and support from my parents Mr and Mrs Olatise The countless times you flew in from Nigeria and cared for my children during my hectic schedules will not be forgotten, you are worth more than gold To my sisters, Helen Olobashola and Funmilayo Jewesimi, thanks for your prayers and support The three of us rock Finally, I say thank you to Walden University and its faculties for the opportunity to grow and making my dream come true I dedicate this final capstone project to my family for your support and missed family times during my DNP journey Acknowledgements I would like to express thanks to my committee members for their continued support and encouragement To Dr Francisca Farrar, my committee chairman, I greatly appreciate your unwavering support, continued encouragement, taking my calls at odd hours, and responding to my text messages without a prior appointment, and helping me grow Dr Patricia Senk and Dr Patti Urso I am grateful and appreciative of the learning opportunities and constructive feedback you provided I would not have managed to complete this project without the support of my practicum mentor on-site, Mr Dennis Olaniyi who provided all needed resources for the success of my program Thanks to my course colleagues for their engagement and feedback in my courses and strong moral support that enabled me to focus on completing my project and achieving my academic goals I extend my gratitude to you Finally, I say thanks for Walden University and its faculties for the opportunity to grow and making my dream come true Table of Contents List of Figures iv Section 1: Nature of the Project Introduction Problem Statement Purpose Nature of the Project Significance Summary 11 Section 2: Background and Context 13 Introduction 13 Concepts, Models, and Theories 13 Relevance to Nursing Practice 15 History of the Broader Problem 15 Current State of Nursing Practice in the Area and Recommendations to Improve Practice 17 Applied Strategies and Standard Practices to Address the Problem in the Past 18 Local Background and Context 20 The Relevance of the Problem 20 Institutional Context to Which the Problem Applies 21 Definition of Locally Used Terms 21 Role of the DNP Student 22 i Summary 23 Section 3: Collection and Analysis of Evidence 24 Introduction 24 Practice Focused Questions 25 Sources of Evidence 27 Analysis and Synthesis 30 Summary 31 Section 4: Presentation of the Results and Findings Section 32 Introduction 32 Collection of Secondary Data Set 32 Methodological Quality of the Recruited Studies 35 Study Characteristics 35 Analysis of Findings 36 Relationship between Workload and Staffing Ratio to Patient Outcome 36 Nurse Staffing Models 38 Proposed Nurse Staffing Model 40 Summary 40 Section 5: Application to Professional Practice and Implications for Social Change 42 Introduction 42 Implications for Professional Practice 42 Positive Social Change 43 Study Limitations 44 Recommendations 44 ii Conclusion 45 References 46 Appendix: Summary Table 53 iii 36 patient ratio is 1:2 However, in most hospitals, this ratio is not achieved due to a shortage of staff nurses Summary This section reports the process used to select appropriate studies as well as the outcomes In this section, the studies analyzed have been summarized, with the major variables and themes identified All the studies selected focus on the relationship between patient-to-nurse ratio and patient outcomes All studies agree that a high patient-to-nurse ratio leads to negative outcomes such as high fall rates, increased hospital-acquired pressure ulcers, and mortality rates Unfortunately, most of the studies reveal that a specific method for determining the level of nursing staff has not been established Only two studies propose models that can help to identify nursing staff requirements The considerations are based primarily on judgment, workload, and the number of patients The model from the two studies applicable to staffing is the nurse-patient ratio model More research is needed in this area to determine how this model can contribute to addressing nursing staff requirements 37 Section 5: Application to Professional Practice and Implications for Social Change Introduction With this project, I aimed to develop a staffing model for informing sufficient staffing and management of contextual factors affecting the relationship between staffing levels and patient outcomes I sought to address the existing gap in nursing practice, which is the lack of a multi-dimensional model for determining optimal and feasible staffing levels and moderating the effects of the staffing levels on patient outcomes The main research question was: In the critical care setting, what is the multidimensional staffing model on the interaction between staffing levels and other contextual factors? During the literature search process, 58 articles were identified; however, only 13 met the inclusion criteria The findings of the articles reviewed show that a high patient-to-nurse ratio leads to negative patient outcomes such as high fall rates, increased hospital-acquired pressure ulcers, and high mortality rates The findings also show that it is difficult to determine a specific framework that can help to address nursing requirements Only two of the articles had information on the multidimensional framework that can be applied to identifying the level of nurse staffing needed in healthcare facilities Implications for Professional Practice This systematic review has several implications for professional practice First, the findings of the reviewed studies show that a high patient-to-nurse ratio is the main factor for poor patient outcomes The nursing shortage is a key determinant of quality of healthcare services offered The results, therefore, imply that increasing the number of nurses is a major step towards improving the quality of healthcare services Second, the findings show that there is no specific 38 approach or a framework for staffing nurses Therefore, nurse leaders need to understand the workload at their facilities and use their judgment to determine the level of staff nurses required to address patient needs Finally, the findings can be adopted in future practice to help in establishing the effectiveness of workload model or nurse-to-patient ratio model in determining the optimal nursing workforce The study also has implications for the research methodology used in nursing Systematic review does not lead to a collection of primary information Therefore, nursing research should involve mostly randomized controlled trials and observations These methods will aid in collection of experimental data that can help to create a framework for assessing the requirements for staffing nurses For example, Kim et al (2017) suggest that workload model is the best for determining the optimal nursing workforce Future research should, therefore, provide an in-depth investigation into how the workload model can help establish the ideal number of nurses in emergency or critical care setting Positive Social Change This systematic review has the potential to impact a positive social change at the individual, social and policy levels At the individual level, increasing the number of staff nurses will help to address all patient needs, thereby promoting their health and wellbeing Improvement in individual health will also indicate the wellbeing of the entire society Last, the study can be used to encourage policy changes, especially on the level of nursing staff needed in each healthcare facility The policy can offer guidance on the approach to use to recruit nurses and maintain the correct nurse-to-patient ratio For instance, Kim et al (2017) provide a detailed description of the methodology that can help in establishing the optimum nursing staff An 39 increase in nursing staff, leads to improved access to healthcare, thereby improving quality of life Study Limitations This systematic review was associated with several limitations First, several studies did not have a clear description of a patient or hospital details Therefore, it was difficult to establish if the patients were in critical or acute care settings Second, only two studies had information on appropriate multidimensional frameworks for determining the level of staffing required in healthcare facilities Finally, most of the studies selected had many participants (nurses or patients) and healthcare units Therefore, chances of having researcher bias were high The bias could have a negative impact on the outcome of this systematic review Recommendations From the analysis, the best model for addressing nurse staff requirements is the nursepatient ratio model or the workload model Future research should focus more on collecting primary data that shows how this model can be improved and used to address nursing shortage Through research, it will be possible to identify the effectiveness of the workload model in determining appropriate nursing staff requirements for hospitals The research should also identify the best skill mix that can improve patient outcomes despite the high patient-to-nurse ratio (Thériault et al., 2019) For instance, the workload model proposed by Kim et al (2017) can identify an appropriate skill mix for RNs, APNs and NPs needed to improve the quality of healthcare services Conclusion From the systematic review of different studies, the best staffing model for nurses in a critical care unit is the nurse-to-patient ratio model According to this mode, the number of 40 nurses in a critical care unit should depend on the number of patients The recommended nurseto-patient ratio as per the model is 1:2 In this systematic review, 13 articles that met the inclusion criteria were analyzed From these articles, it is was evident that a high patient-to-nurse ratio is associated with poor health outcomes such as increased falls, high mortality rates and a rise in hospital-acquired pressure ulcers Therefore, this study shows the need to address the issue of the nursing shortage, although there is no effective policy or framework From the 13 articles reviewed, only two have information that can help to develop a model The study has a positive implication to the professional practice since it shows how the nurse-to-patient ratio model can help to address the issue of nurse shortage and challenges encountered when determining appropriate nursing staff requirements Future research should focus on how the nurse-to-patient ratio model can be improved and applied to many healthcare settings 41 References American Nurses Association (2015) Nursing: Scope and standards of practice (3rd Ed.) Silver Spring: American Nurses Association American Nurses Association (n.d.) Practice and policy Retrieved from https://www.nursingworld.org/practice-policy/ Ball, J E., Murrells, T., Rafferty, A M., Morrow, E., & Griffiths, P (2014) ‘Care left undone’ during nursing shifts: Associations with workload and perceived quality of care BMJ Qual Saf, 23(2), 116-125 Berkowitz, B (2016) The patient experience and patient satisfaction: Measurement of complex dynamic Online Journal of Issues in Nursing, 21(1), doi:10.3912/ojin.vol21No01Man01 Bridges, J., Griffiths, P., Oliver, E., & Pickering, R M (2019) Hospital nurse staffing and staff– patient interactions: An observational study BMJ quality & safety, 28(9), 706-713 Brunell, M & Ross, A (2015) The nursing workforce In D Mason, D Gardner, F Outlaw, & E O’Grady (Eds.) Policy and politics in nursing and healthcare (7th Ed., pp 502-510) St Louis: Elsevier Health Sciences Butler, K (2016) The DNP graduate as an educator In L Chism (Ed.), The doctor of nursing practice: A guidebook for role development and professional issues (3rd Ed., pp 175201) Burlington: Jones & Bartlett Publishers Catalono, J (2015) Nursing now! Today’s issues, tomorrow’s trends (7th Ed) Philadelphia: F.A Davis Cochrane (N.d.) About us Retrieved from https://www.cochrane.org/about-us Denscombe, M (2014) The good research guide: For small-scale social research projects (5th Ed.) Berkshire: McGraw-Hill Education 42 Dietrich, M & Anderson, G (2012) The financial professional’s guide to healthcare reform Hoboken: John Wiley & Sons Donabedian, A (2003) An introduction to quality assurance in health care New York: Oxford University Press Driscoll, A., Grant, M., Carroll, D., Dalton, S., Deaton, C., Jones, I., …, Astin, F (2018) The effect of nurse-to-patient ratios on nurse-sensitive patient outcomes in acute specialist units: A systematic review and meta-analysis European Journal of Cardiovascular Nursing, 17(1), 6-22 Garner, B., Lwin, A., Sickler, G., Hunter, B., & Shepard, D (2018) Pay-for-performance as a cost-effective implementation strategy: Results from a cluster randomized trial Implementation Science, 13(1), 1-11, doi:10.1186/s13012-018-0774-1 Greenhalgh, J & Brown, T (2017) Quality assessment: Where I begin? In A Boland, G Rumona, & R Guide (Eds), Doing a systematic review: A student’s guide (2nd Ed pp 107-131) London: SAGE Griffiths, P., Saville, C., Ball, J., Jones, J., Pattison, N., Monks, T., & Safer Nursing Care Study Group (2020) Nursing workload, nurse staffing methodologies and tools: A systematic scoping review and discussion International Journal of Nursing Studies, 103, 103487 He, J., Staggs, V S., Bergquist-Beringer, S., & Dunton, N (2016) Nurse staffing and patient outcomes: a longitudinal study on trend and seasonality BMC nursing, 15(1), 60 Hsieh, H., Gu, S., Shin, S., Kao, H., Lin, Y., & Chiu, H (2015) Cost-effectiveness of a diabetes pay-for-performance program in diabetes patients with multiple chronic conditions Plos One, 10(7), 1-15, doi:10.1371/journal.pone.0133163 43 Hughes, R G., Bobay, K L., Jolly, N A., & Suby, C (2015) Comparison of nurse staffing based on changes in unit-level workload associated with patient churn Journal of Nursing Management, 23(3), 390-400 Joanna Briggs Institute (2018) About us Retrieved from http://joannabriggs.org/about.html Johnson, B & Reppert, B (2015) Quality improvement and accreditation issues in college health In H Turner & J Hurley (Eds.), The history and practice of college health (pp 79-103) Kentucky: University Press of Kentucky Joint Commission Performance measurement Retrieved from https://www.jointcommission.org/certification/hcs_performance_measurement.aspx Jordi, F., Pierre-Yves, B., Jerome, S., Katiuska, M., Francois, L., Pascal, A., & Laura, T (2014) Management of nurse shortage and its impact on pathogen dissemination in the intensive care unit Epidemics, 9, 62-69 Kim, J., Kim, S J., & Lee, E (2017) Optimal Nursing Workforce and Financial Cost to Provide Comprehensive Nursing Service in the National Health Insurance System Journal of the Korea Academia-Industrial cooperation Society, 18(6), 119-128 Kitonsa, J., Manyanja, Y., Aling, E., Kiwanuka, J., Namutundu, J., Anywaine, Z., …, Kaleebu, P (2019) Factors affecting mortality among HIV positive patients two years after completing recommended therapy for Cryptococcal meningitis in Uganda Plos One, 14(1), doi: 10.1371/journal.pone.0210287 Konetzka, R., Sharma, H., & Park, J (2018) Malpracitce environment vs direct litigation: What drives nursing home exit? Inquiry, 55, 1-12 Kuckartz, U (2015) Qualitative text analysis: A guide to methods, practice and using software Thousand Oaks: SAGE 44 Kutney-Lee, A., Sloane, D M., & Aiken, L H (2013) An increase in the number of nurses with baccalaureate degrees is linked to lower rates of postsurgery mortality Health Affairs, 32(3), 579-586 Lee, A., Cheung, Y., Joynt, G., Leung, C., Wong, W., & Gomersalt, C (2017) Are high nurse workload/staffing ratios associated with decreased survival in critically ill patients? A cohort study Annals of Intensive Care, 7(1), 46 Linda, H., Consuelo, C., Marta, S., Eileen, T., Alejandra, G., Alda, G., …, Herbert, L (2018) Hospital nurse staffing and patient outcomes Revista Medica Clinica las Condes, 29(3), 322-327 Liu, L F., Lee, S., Chia, P F., Chi, S C., & Yin, Y C (2012) Exploring the association between nurse workload and nurse-sensitive patient safety outcome indicators Journal of nursing research, 20(4), 300-309 MacPhee, M., Dahinten, H., & Havaei, A (2017) The impact of heavy perceived nurse workloads on patient and nurse outcomes Administrative Sciences, 7(1), Malatji, M., Ally, V., & Makhene, F (2017) Nurses experiences regarding staffing patterns in the surgical wards of a private hospital in Gauteng South Africa Health SA Gesondheid, 22, 325-332 Mariano, C (2015) Current trends and issues in holistic nursing In B Dossey, L Keegan, C Barrere, & M Helming (Eds.), Holistic nursing (7th Ed.) (pp 77-100) Burlington: Jones & Bartlett Publishers Masters, K (2014) Nursing theories: A framework for professional practice (2nd Ed.) Burlington: Jones & Bartlett Publishers 45 Meadows, G (2002) The nursing shortage: Can information technology help? Nursing Economics, 20(1), 46-48 Medicare (2016) Increasing reimbursement to improve staffing levels Retrieved from https://www.medicareadvocacy.org/increasing-reimbursement-to-improve-staffinglevels/ Newman, P (2013) The contributing factors to the nursing faculty shortage: Nursing faculty shortage Bloomington: Xlibris Corporation Perry, A (2016) Nursing and the health care environment In P Potter, A Perry, P Stockert, & A Hall (Eds.) Fundamentals of nursing (9th Ed.) pp 1-13 St Louis: Elsevier Health Sciences Pham, S (2011) Healthcare services In S Pham (Ed.), Recent trends in U.S services trade: 211 Annual report (pp 6-1-6-26) Washington: DIANE Publishing Shekelle, P G (2013) Nurse–patient ratios as a patient safety strategy: a systematic review Annals of Internal Medicine, 158(5_Part_2), 404-409 Shinde, S., Balushi, Y., Hossny, M., Jose, S., & Busaidy, S (2018) Factors affecting the outcome of extracorporeal shockwave lithotripsy in urinary stone treatment Oman Medical Journal, 33(1), 209-217 Smith, A (2002) Responses to the nursing shortage: Policy, press, pipeline, and perks Nursing Economics, 20(6), 287-290 Stevenson, D., Spittal, M., & Studdert, D (2013) Does litigation increase or decrease health care quality? A national study of negligence claims against nursing homes Med Care, 51(5), 430-436 46 Taylor, B., Yankey, N., Robinson, C., Annis, A., Haddock, K S., Alt-White, A., & Sales, A (2015) Evaluating the Veterans Health Administration's Staffing Methodology model: a reliable approach Nursing Economics, 33(1), 36 Thériault, M., Dubois, C A., Borgès da Silva, R., & Prud’homme, A (2019) Nurse staffing models in acute care: A descriptive study Nursing open, 6(3), 1218-1229 Walden University (N.d.) Evidence-based practice research: Evidence-based practice Retrieved from https://academicguides.waldenu.edu/healthevidence Ward, N S., Afessa, B., Kleinpell, R., Tisherman, S., Ries, M., Howell, M., & Members of Society of Critical Care Medicine Taskforce on ICU Staffing (2013) Intensivist/patient ratios in closed ICUs: a statement from the Society of Critical Care Medicine Taskforce on ICU Staffing Critical care medicine, 41(2), 638-645 Washington, C & Leaver, D (2015) Principles and practice of radiation therapy (4th Ed.) St Louis: Elsevier Health Sciences Wendsche, J., Hacker, W., & Wegge, J (2017) Understaffing and registered nurses’ turnover: The moderating role of regular rest breaks German Journal of Human Resource Management, 31(3), 238-259 West, E., Griffith, W., & Iphofen, R (2007) A historical perspective on the nursing shortage MedSurg Nursing, 16(2), 124-130 Winstein, C., Stein, J., Arena, R., Bates, B., Cherney, L., Cramer, S., …, Zorowitz, R (2016) A guideline for healthcare professionals from the American Heart Association/American Stroke Association Stroke, 47(6), doi: doi.org/10.1161/STR.0000000000000098 Wright, P & Bretthauer, K (2010) Strategies for addressing the nursing shortage: Coordinated decision making and workforce flexibility Decision Sciences, 41(2), 373-401 47 Zheng, L., Ren, H., Shi, R., & Lu, L (2019) Spatiotemporal characteristics and primary influencing factors of typical dengue fever in China Infectious Diseases of Poverty, 8(1), doi: 10.1186/s40249-019-0533-9 48 Appendix: Summary Table Study title, Author and date of publication Problem description Aim of the Study, Setting, and Sample Study Design and Interventio n Results Limitations Conclusions Level of Eviden ce based on the type of study Nursing workload, nurse staffing methodologie s, and tools: A systematic scoping review and discussion Griffiths et al., 2020 There is weak evidence on the tools required to determine staffing requirement s in acute hospital settings A systematic review of literature Key approaches include professional judgment, patient prototype/classific ation, and patient to nurse ratios The main tool identified is staffing assessment The authors did not critique some studies to draw appropriate conclusions There is still limited information or evidence on the correct tools for determining nurse staffing requirements Level III The effect of nurse-topatient ratios on nursesensitive patient outcomes in acute specialist units: A systematic review and metaanalysis Driscoll et al., 2018 There is a lack of clarity on determining appropriate nurse staffing levels other than the number of patients Systematic review and metaanalysis 35 articles, out of the 3429 identified were included in this study The authors found that high nurse staffing levels resulted in a reduction in medication errors, mortality rates, pressure ulcers, and infections, which indicate positive patient outcomes Some studies reviewed had patients combined from nonspecialized units The calculation of NPR also had a high level of heterogeneity Nurse to patient ratio influences patient outcomes, particularly mortality rates Level II Good quality Nurse–patient ratios as a patient safety strategy: a systematic review Shekelle, 2013 A small number of patients die shortly after hospitalizati on It is possible to prevent these deaths with more nursing care Despite an increase in the number of ICU that offers critical care services, it has become difficult to provide quality care due to a shortage of staff The study aims to give approaches that can be used to measure nurse staff requirements for acute wards in general hospitals To determine the relationship between nurse staffing levels and patient outcomes in acute care The setting is acute care units The sample consists of patient receiving acute specialized care To determine impacts of interventions used to increase the nurse-patient ratio on patient outcomes and mortality rate Qualit y rating based on the eviden ce provid ed Good quality A systematic review of literature Nine longitudina l studies were reviewed Increasing the nurse staffing ratio reduces hospitalrelated mortality rates Researchers reviewed only longitudinal studies, which makes it difficult to rely primarily on the results obtained Increasing the nurse-patient ratio leads to positive patient outcomes and reduces mortality rates Level II Good quality To establish a maximum intensivist/pat ient ratio required in a critical care setting A systematic review of literature The quality of healthcare offered improves following an increase in the number of current intensivist and staff nurses High staff turnover decreased the quality of care indicators in the critical care setting The study focused primarily on a literature review and some of the studies used did not have a clearly described methodology A commonsense approach should be applied to determine the optimum number of patients each intensivist should care Important principles should also be applied Level III Good quality Intensivist/pat ient ratios in closed ICUs: a statement from the Society of Critical Care Medicine Taskforce on ICU Staffing Ward et al., 2013 49 Are high nurse workload/staf fing ratios associated with decreased survival in critically ill patients? A cohort study Lee et al., 2017 Exposure to inadequate staffing ration/workl oad in ICU settings contributes to high mortality rates The authors sought to establish a threshold for workload/staf fing ratio that can reduce the probability of patient survival in ICU and show the relationship between exposure to inadequate staffing and survival chances The design was a retrospectiv e analysis of collected data The interventio n used was the Therapeutic Interventio n Scoring System The analysis involved 894 separate admissions The findings show that the probability of surviving after discharge was 90% when the workload –to nurse ration is 52 The study was primarily observational, hence it was not easy to establish a causal relationship between workload/staf fing ratios and hospital survival A high workload/staf fing ratio reduce the odds of patient survival Level II Good quality The setting was ICUs in a district hospital and a university teaching referral hospital The sample consisted of patients admitted to ICU hospitals in Hong Kong Nurse staffing and patient outcomes: a longitudinal study on trend and seasonality He et al (2016) Nurse understaffin g is among the leading threats to patient safety in most of the US hospitals The current research on the relationship between nursing staff and patient outcomes is still incomplete To examine the longitudinal relationship between nursing staff and patient outcomes The research design was a longitudina l study of the National Database of Nursing Quality Indicators ® (NDNQI®) data collected between 2004 and 2012 Higher staffing leads to improved patient outcomes (reduction in fall rates and pressure ulcers) The authors analyze only existing data without considering other variables likely to influence the outcome Changes in nursing staff are inversely associated with changes in patient outcomes – pressure ulcers and patient falls Level IV High quality Care left undone during nursing shifts: associations with workload and perceived quality of care The main source of worse patient outcomes is lower nursing staff levels Low mortality rates The aim of this study is to examine the relationship between nursing staff levels and missed care episodes as well as A crosssectional survey design was used A low nurse to patient ratio contributed to missed care The survey method used focuses mainly on nurse’s perception of the amount of work undone depending on the number of shits Nursing shortage and a high workload contribute to a low quality of care Level IV High quality Questionna ires were then distributed 50 Ball et al (2014) Hospital nurse staffing and staffpatient interactions: an observational study Bridges, Griffiths, Oliver & Pickering, 2019 According to the existing evidence, reducing nursing staff and skill mix as well as substituting assistant personnel for registered nurses affects the quality of care Previous studies failed to show how nurse staffing relates to staff-patient interactions quality of care and patient safety environment The study was conducted in wards in selected healthcare facilities The sample consisted of 2917 registered nurses working in 401 wards The study explores the relationship between nurse staffing levels, skill mix and quality of care The intervention entails observation data using Quality of Interaction Schedule to collect data The study design is a secondary analysis of observation al data A low number of staff nurses reduced the interaction between nurses and patients RN and HCA nurse staffing levels determined the rate of interactions per patient It is difficult to make a causal inference on the study because it is primarily observational Low RN staffing affects negatively the interaction between patients and staff Level II Good quality