How is nursing quality of care affected by patient to nurse ratios? And how can involving staff with workload assignment benefit quality of care?

1. Increase quality care with staff
involvement with workload
assignment
Roberto Rivera-Olmo
NU420: Leadership and management in the changing health care environment
Barbara Findley
July 30th, 2015

2. Research findings
 Each additional patient a nurse care for increases the the
“likelihood of dying within 30 days of admission” and
increase failure to rescue odds by 7%, as well as increase
the odds of burnout by 23% and causing in increase of
job dissatisfaction by 15% (Aiken, Clarke, Sloane,
Sochalski, & Silber, 2002).
 Higher nurse to patient ratios have a significant
association with lower quality of care, increase in patient
exposer to avoidable adverse outcomes and healthcare
cost (Stanton, 2004).

3. Staff and quality findings
 Study findings show that nursing workload is affected by
“factors other than the patient’s clinical condition”
(Carayon & Gurses, 2008).
 Increasing registered nurses while decreasing unlicensed
staff by requiring nurses to take on more responsibilities
while having a slight decrease of patients to care for does
not improve patient satisfaction or quality of care
(Martin, 2015).
 Current nursing assignments are based upon a patient
acuity/classification scores or nursing care hours.

4. High workload

5. Cost of high workload
 In a literature review study on nursing turnover costs and rates,
Li and Jones found reported turnover rates “ranging from a
low of 9.49% to a high of 250%”, dependent on hospital
retention practices and staffing (2013). A report from The
Robert Wood Johnson Foundation found estimated
replacement cost per RN at about $22,000 to $64,000 (2007),
with cost being higher for new nurse turnover due to the higher
level of orientation involvement required.
 As staff are required to take care of more patients increase
chances of in hospital traumas like falls and quality of care
indicators like pressure ulcers. Falls can cost as high as $86,00
per incident and ulcers cost the US $11 billion (Gallagher).

6. Workload factors
 Nursing care hours do not differentiate for nurses and
unlicensed staff, nor for the different levels of acuity. Use of
NCH for workload factoring may allow incomplete patient care
to occur (Marquis & Huston, p. 385).
 Patient classification systems assist making nursing assignment
by classifying patients into a acuity level to determine the right
amount and mix of nursing and unlicensed staff (Marquis &
Huston, p. 385).
 Although PCS allows for a better assessment of staffing needs
than NCH, it only factors in the clinical aspect of the patient
and does not address other factors that may take addition time
from staff to provide to other patients, thus reducing quality of
care.

7. Workload factors
 Factors to consider when making assignments include
care areas like feeding, activities of daily living, and
general health. Other factors that need to be considered
in staffing assignment is required treatment, treatment
complexity, medication and there route of administration.
 Other factors that should be considered in workload
assignment due to time consumption are factors like
infection control (time of PPE donning and removal),
anticipatory interventions from disease process, cognitive
workload (intellectual information processing),
admission/discharge paperwork, and family support
(Connor, LaGrasta & Hickey, 2015).

8. Department based
staffing
 Due to the complexity of healthcare and the uniqueness
of each department and unit, department based staffing
and workload measurement tools implementation is more
beneficial than hospital wide-blanket staffing and
workload measurement tool implantation. Departmental
based staffing can be logistically implemented by having
unit/departmental nursing committees for workload
measurement tool creation and implementation.

9. Workload measurement
panels
 Departmental staff nurses may form a panel to discuss
unit based patient population complexity. Each panel can
be include experienced bedside nurses, charge nurses,
clinical nurse specialist, clinical coordinators and other
nursing staff (Connor, LaGrasta & Hickey, 2015).
.

10. Appropriate staffing
 By developing workload measurement tools for that are
specific to patient population complexities per unit,
staffing can be provided accordingly to anticipated
workload factors. This method would save each
department money while addressing adequate staffing
unlike a hospital wide staffing ratio with the required staff
which would understaff some units and over staff others.
 Unit based measurement tools can identify the required
need of nurse to patient and axillary staff to
patient/nurse. In units where patients are more self
reliable, the use of axillary units would be less, while more
complex patient population units would require small
nurse to patient and axillary staff to patient ratios.

11. Quality care from appropriate
staff workload
 As nurses and unlicensed staff are staffed to appropriate
workload, patient’s quality of care can improve due to
improved safety, decrease waiting times and increased
health care deliverance.

12. Cost savings
 Insuring quality of care improvements while keeping
expenditures low is important to any health care facility
success. By using available staff to create unit based
workload measurement tools, health care facilities remove
the need to hire outside consultants. Along with quality
improvement, the reduction of nursing turnover due to
understaffing can save the hospital hundreds of
thousands of dollars annually.
 Improving quality of care measures also saves health care
facilities money by anticipating issues (e.g. falls) common
to unit based patient population complexities and staffing
accordingly to prevent these issues from occurring.

13. Implementation

14. Attractiveness
 Health care facilities that can improve the quality of care
for patients, increase nursing retention, reduce nursing
turnover, and safe money, all by staffing to a safe
workload becomes an desired place for patients to seek
treatment and professionals (unlicensed staff, nurses and
providers) to seek employment.

15. References
 Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., Silber, J. H.
(2002). Hospital nurse staffing and patient mortality, nurse burnout, and job
dissatisfaction (p. 1987-1993). Journal of the American Medical
Association.
 Carayon, P. & Gurses, A. P. (2008). Nursing workload and patient safety: A
human factors engineering perspective (Ch. 30). Patient safety and quality:
An evidence-based handbook for nurses. Retrieved from
http://www.ncbi.nlm.nih.gov/books/NBK2657/#ch30.r25
 Connor, J. A., LaGrasta, C. & Hickey, P. A. (2015). Complexity
assessment and monitoring to ensure optimal outcomes tool for measuring pediatric
critical care nursing (p. 297-308). American journal of critical care.

16.  Gallagher, L. G. (2011). The high cost of poor care: The financial case for
prevention in American nursing homes. The national consumer voice
for quality long-term care. Washington, DC.
 Martin, C. J. (2015). The effects of nurse staffing on quality of care (p. 4-
6). Academy of Medical-Surgical Nurses.
 Marquis, B. L. & Huston, C. J. (2012). Staffing needs and scheduling
policies (p. 385). Leadership roles and management functions in
nursing: Theory and application (7th ed). Lippincott Williams &
Wilkins, Philadelphia, PA.
 Li, Y. & Jones, C. B. (2013). A literature review of nursing turnover cost
(p. 405-418). Journal of nursing management.

17.  Robert Wood Johnson Foundation (2007). Assessing the direct costs
of RN turnover. Evaluation of the Robert Wood Johnson
Foundation wisdom at work initiative. Retrieved from
www.rwjf.org/content/dam/files/legacy-files/article-
files/2/revlewinevalrnturnover.pdf
 Stanton, M. W. (2004). Hospital nurse staffing and quality of care (p.
7). Agency for healthcare research and quality: Research in action.