Nurse understaffing impacts quality of care, leads to increased infections

Two recent studies on nurse understaffing and nurse fatigue have revealed that these two prominent issues negatively impact the quality of care delivery, patient and employee satisfaction and operational costs in hospitals.

A national study that was published in a recent JAMA-Pediatrics issue and funded by the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative and the National Institute of Nursing Research found that very few neonatal intensive care units (NICUs) provide sufficient numbers of nurses to meet national guidelines and that the units caring for the most vulnerable babies are also the most understaffed, putting the health of critically-ill newborns at risk.

[See also: Nurses at Massachusetts hospital take pay cut for 'safer' staffing levels]

According to study author Eileen Lake, nursing professor and associate director of the Center for Health Outcomes and Policy Research at the School of Nursing at the University of Pennsylvania, staffing guidelines developed by the American Academy of Pediatrics (AAP) and affirmed by the Association of Women’s Health, Obstetric and Neonatal Nurses recommend a nurse-to-patient ratio of one nurse for every three to four infants for the lowest risk babies and a ratio of more than one nurse per baby for the most complex cases.

“We found that understaffing relative to the national guidelines is widespread and that one-third of NICU infants are not staffed according to the guidelines. We were surprised to find this out,” said Lake. “We also found that the extent of understaffing was higher among more complex and vulnerable infants, which was even more surprising.”

Lake added that nurse understaffing was also associated with higher rates of infections, which affects 13.9 percent of these infants. Premature infants are extremely susceptible to infections because they have underdeveloped immune systems, skin that is more easily penetrated and frequently need to have central venous lines inserted to administer nutrition or medication. For very low birth weight (VLBW) infants (less than 3.2 pounds at birth), hospital-acquired infections are associated with mortality and longer hospital stays.

Jeannette Rogowski, university professor in health economics in the School of Public Health at the University of Medicine and Dentistry of New Jersey and the other author of the study, said that the national guidelines categorize the acuity level of NICU babies with recommendations on how many nurses are needed for each level. Therefore, a first step for hospitals could be to measure their staff levels and how it relates to the national guidelines. From here, it can be determined if nurses should be assigned differently or if more nurses are needed, she said.

[See also: Nurse staffing, burnout linked to HAIs]

An issue that goes hand-in-hand with understaffing is nurse fatigue. Not enough hands to do the work means more burden and more fatigue on those on staff.

A recent study commissioned by Kronos ,“Nursing Staffing Strategy,” found that 69 percent of healthcare professionals surveyed said that fatigue had caused them to feel concern over their ability to perform during work hours. Additionally, nearly 65 percent of participants reported they had almost made an error at work because of fatigue and more than 27 percent acknowledged that they had actually made an error resulting from fatigue.

Susan Reese, the director of the healthcare practice group at Kronos, said the aging nurse population and nurses working shifts that are longer than eight hours are partially to blame for the high fatigue levels among nurses.

“In 2008, the average age of nurses was 45.5. It’s probably closer to age 50 now. One of the areas we consider is that the aging workforce gets fatigued easier. These highly-skilled workers have to make critical decisions related to patient care and if they are doing that in a fatigued state, they are putting themselves and their patients at a great risk for errors and injuries,” said Reese. “There is research that says every hour that a nurse works over 40 hours puts them at a greater risk for fatigue.”

Reese said there are a number of ways to utilize workforce management tools that can help hospitals better manage how they schedule and staff their nurses.

She also added that newer technology can match up specific patients with specific nurses for the best overall care.

“There are patient classification tools that measure the requirements needed for each patient, which then matches that patient with the best nurse for them,” she said. “This way, the work load is distributed more evenly and nurses do not get overloaded. It’s about matching the right patients with the right nurses.”

[See also: Staffing solutions save time, money]