Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

The importance of nurse staffing to the delivery of high-quality patient care was a principal 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.


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.78 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 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.1011 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.”1314 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,115 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 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,91522 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

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