Running Head: EFFECTS OF NURSE STAFFING AND PATIENT SAFETY

The Effects of Nurse Staffing On the Medical Surgical Unit Involving Patient Safety and Quality

of Care

Mariah Bianco, Olivia Engle, Kaitlyn Kalicatzaros, Rebecca Platt, Mackenzie Stanley

04/03/2017

NURS: 3947: Nursing Research

Dr. Valerie O’Dell

EFFECTS OF NURSE STAFFING AND PATIENT SAFETY 2

Abstract

This research looked at how staffing in hospitals can have an effect on patient safety.

Several sources were used that studied how a high nurse to patient ratios may adversely affect

the safety of a patient on a medical surgical floor in a hospital. These sources included both

literature reviews and qualitative studies. Medication errors, patient falls, and pressure ulcers

were the different factors of patient safety that were explored. It was found that the more patients

that a single nurse is responsible for, the more likely it is that a patient will be injured. Evidence

was found to support the fact that if a nurse is responsible for more patients, it is more likely that

a medication error will occur, a patient will fall or that skin breakdown will begin to occur. All

of these errors can lead to injury of a patient or possibly death.

EFFECTS OF NURSE STAFFING AND PATIENT SAFETY 3

The Effects of Nurse Staffing On the Medical Surgical Unit Involving Patient Safety and Quality

The rising levels of patients within hospital setting continues to increase and this can

often lead to an undesirable number of patients assigned to one single registered nurse (RN).

This increase in nurse to patient ratio not only affects the nurse, but the patient’s safety as well.

Many research studies have been conducted pertaining to the effect of these high ratios and what

affect it has on patient safety. The studies have suggested if a nurse is responsible for a higher

number of patients that there is a greater risk for medications errors, developing pressure ulcers,

and falls. This presents an issue to the nursing profession due to the fact that it puts patient’s

safety at a greater risk. Therefore, the following research question was addressed: In hospitalized

patients on a medical surgical unit, how does nurse staffing influence patient safety regarding

medication errors, development of skin breakdown, and patient falls?

Literature Review

Introduction

We acquired our information on this issue using Medscape, ProQuest, CINHAL, and Google

Scholar. We used a total of ten sources to review and research how nurse staffing on a medical

surgical unit influences patient safety. Medication errors, patient falls, and pressure ulcers will be

discussed specifically.

Medication Errors

Nurse staffing issues on medical-surgical units can result in a variety of unfortunate

events, and can ultimately impact the safety of both the patients and the nurses. In particular,

nursing shortages and high patient-to-nurse ratios can lead to medication errors, which can

contribute to patient mortality on understaffed units. Prior to administering medications, the

EFFECTS OF NURSE STAFFING AND PATIENT SAFETY 4

nurse is required to perform the “five rights” rule of medication administration to reduce

medication errors and harm; the “five rights” rule requires the nurse to verify the right patient,

the right drug, the right dose, the right route, and the right time (Federico, 2017). If the nurse

disregards the “five rights” medication rule, the patient may face an undesirable or life-

threatening situation.

According to Anderson, Fong, Frith, and Tseng, 2012, medication errors have attracted a

considerable amount of attention because of the complications such as high mortality rates and

the overwhelming cost of health-care. Shahrokhi, Ebrahimpour, and Ghodousi, 2013 found in the

United States, deaths related to medication errors have surpassed the number of deaths related to

car accidents, breast cancer and human immunodeficiency virus/acquired immune deficiency

syndrome combined. Also, approximately 44,000-98,000 medication error-related deaths occur

each year in the United States hospitals and it costs between six to 29 billion dollars to

compensate for the adverse effects of such errors. Studies show that some factors related to the

medication errors made by the nurses include medication miscalculations, lack of knowledge and

proficiency. The study also argued that nurses are neglecting the hospital's medication protocol

due to lack of time, extreme tiredness, heavy workload, a shortage in the nursing workforce,

inadequate work experience, an inappropriate work environment, and spending an excess amount

of time documenting and completing other tasks instead of monitoring the patient (Shahrokhi,

Ebrahimpour, and Ghodousi, 2013).

In the research study produced by Anderson et al., (2012), the most prevalent

contributing factor among nurse-related medical errors was careless performance with

medication administration; tiredness is the second most effective factor, and inadequate

knowledge in pharmacology is another significant factor involved in medication errors. In order

EFFECTS OF NURSE STAFFING AND PATIENT SAFETY 5

to prevent medication miscalculations and drug incompatibilities, some hospitals require nurses

to complete periodic continuing education programs to improve their pharmacological

knowledge and remain updated on new techniques, drug side-effects, drug incompatibilities, and

other information associated with safe medication administration.

Although some medication errors can be reversed, others can produce life-threatening

effects. The purpose of the study performed by Anderson et al., (2012) was to examine the

relationship between nurse staffing and medication errors on medical-surgical units. The

researchers found when nurses were unable to meet the needs of the patients, they omitted steps,

took shortcuts, or disregarded approved standards in order to complete their tasks. In this study,

24 medical-surgical units among eight hospitals were analyzed. Their results revealed that out of

31,080 patients, 335 medication errors occurred; these numbers represent the amount of patients

admitted to the medical-surgical units over a two-year time period. Their findings revealed that

nurse staffing is an important human resource to keep patients safe from medication errors. The

researchers suggest nurse administrators to evaluate the potential impact of reducing the nurses’

hours of care and number of assigned patients in regard to improving patient outcomes and

lowering medication errors.

Although medication errors are preventable, the number of tasks and medications needed

to be administered are affecting the quality of care provided by the nurse, especially when

assigned to a number of patients beyond a safe level. Henderson, (2016) found the most common

medication errors occurred on medical-surgical units, and the next most common errors occurred

on Intensive Care Units. The most common medications associated to medication errors were

cardiovascular agents, especially anticoagulants. The next most common medication errors

included antimicrobials, electrolytes, endocrine drugs, and analgesics. The most common drugs
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that harmed patients were furosemide, enoxaparin, insulin, and vancomycin. "Nurses play a

critical role in patient safety and carry an ultimate responsibility for preventing medication errors

(Henderson, 2016).”

In order to prevent medication-related sentinel events from occurring on medical-surgical

units, as well as other units, nurses should complete several steps before administering

medications. Some important aspects associated with performing safe medication administrations

are to verify the medication orders with the prescriber and the nurse from the previous shift,

question any conflicting medication orders, exhibit pharmaceutical knowledge, follow the “five

rights” rule of medication administration, acknowledge and abide by hospital protocol,

understand medication calculations, and be cautious of the adverse effects associated with the

medications prescribed. When attempting to achieve desirable patient outcomes, nurse staffing

strategies should be implemented in regard to providing measures for both the patient and the

nurse.

Pressure Ulcers

According to Eunhee Cho PhD, RN, Dal Lae Chin PhD, RN, Sinhye Kim MSN, RN,

OiSaeng Hong PhD, RN, FAAN, FAAOHN, 2015, the three most frequently reported adverse

events, regarding staffing and nurse patient ratio, brought up by nurses are medication errors,

injury from falls, and pressure ulcers. Pressure ulcers, also referred to as pressure injuries, or

bedsores, are caused by pressure or shearing of the skin over a bony prominence for an extended

period of time. This pressure causes injury to the outside skin and underlying tissue (Gillespie

BM, Chaboyer WP, McInnes E, Kent B, Whitty JA, Thalib L, 2014). Risk for developing

pressure ulcers increases with poor circulation, impaired mobility, poor nutrition, incontinence,

and rubbing or friction against the skin. Those at high risk are patients that are recovering from
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surgery, the elderly, those with an injury or condition requiring bedrest, diabetics, and paralyzed

or comatose patients (Qixia Jiang, Xiaohua Li, Xiaolong Qu, Yun Liu, Liyan Zhang,2 Chunyin

Su, Xiujun Guo, Yuejuan Chen, Yajun Zhu, Jing Jia, Suping Bo, Li Liu, Rui Zhang, Ling Xu,

Leyan Wu, Hai Wang, Jiandong Wang, 2014). When a patient comes to the hospital without any

documented pressure ulcers but develops one during their stay, it is referred to as a “hospital-

acquired” pressure ulcer. Not only does the development of pressure ulcers cause the patient

more complications, such as pain, infection, prolonged and expensive hospital stay, and

increased risk of death in certain patients, it also costs the hospital more money (Qixia Jiang et

al., 2014). In a study conducted by Joanne Spetz PhD, FAAN, Diane S. Brown PhD, RN, CPHQ,

FNAHQ, FAAN, Carolyn Aydin PhD, and Nancy Donaldson DNSc, RN, FAAN, 2013 they

studied the savings associated with implementing nursing interventions to prevent hospital-

acquired pressure ulcers. They found that on average they saved $127.51 per patient when

preventative actions were implemented. Therefore, they concluded that preventive measures can

be cost savings to the hospital and beneficial to the health of the patient. (Joanne Spetz PhD,

FAAN, et al., 2013) Prevention is key in the management of pressure ulcers. This is why nursing

care and the nurse to patient ratio plays such a large part in preventing hospital acquired pressure

ulcers and treating them.

One of the most effective nursing interventions in preventing and managing pressure

ulcers is repositioning or turning patients. Most hospitals will have different guidelines or orders

on turning patients that may depend on the ulcer or condition of the patient. Most patients will be

scheduled for turns every two hours. While more serious conditions such as paralysis patients,

should be turned every thirty minutes. Manually repositioning patients aids in preventing

pressure ulcers by redistributing pressure on the skin (Gillespie BM, et al., 2014). Lying or
EFFECTS OF NURSE STAFFING AND PATIENT SAFETY 8

sitting in a certain position for an extended period of time causes a lack of oxygen to that part of

the body. Under normal circumstance, people will feel discomfort or pain and reposition

themselves. However, patients who are unable to move themselves or have impaired sensation

and are unable to feel this pain, need nurses to aid them in repositioning (Gillespie BM, et al.,

2014).

Repositioning and turning schedules seem like an easy fix for preventing hospital

acquired pressure ulcers and treating current pressure ulcers. However, the nurse to patient ratio

on some hospital floors prevents nurses from having the time and ability to complete these turns

on every patient. A study examining the relationship between nurse staffing and adverse patient

outcomes was conducted by Eunhee Cho PhD, RN et al., (2015). They found that a large number

of patients per nurse was significantly associated with a greater number of pressure ulcers with

an odds ratio greater than one. A better work environment and smaller nurse to patient ratio

showed reports of pressure ulcers were thirty-nine percent lower. They concluded that the study

showed a larger number of patients per nurse increased the incidence of pressure ulcers and other

adverse events (Joanne Spetz PhD, FAAN, et al., 2013).

In other research the association between characteristics of the nurse work environment

and five nurse-sensitive patient outcomes in hospitals, including pressure ulcers was studied

(Brigitte J.M. de Brouwer, Marian J. Kaljouw, Marieke J. Schuurmans, Dewi Staplers,

2015). However, they found mixed results for nurse staffing and patient ratio related to pressure

ulcers. In their results they stated, that other characteristics of work environment other than nurse

staffing, showed significant effects such as collaborative relationships; positively perceived

communication between nurses and physicians was associated with lower rates of pressure ulcer
EFFECTS OF NURSE STAFFING AND PATIENT SAFETY 9

and nursing experience; lower levels of experience were related to more patient falls and higher

rates of pressure ulcers (Brigitte J.M. de Brouwer, et al., 2015).

In another study presented by Mary D. Still, MSN, Linda C. Cross, ADN, Martha

Dunlap, Rugenia Rencher, Elizabeth R. Larkins, MSN, David L. Carpenter, MPAS, Timothy G.

Buchman, PhD, MD, FACS, and Craig M. Coopersmith, MD, FACS, 2012, they researched the

idea of a “turn team.” The purpose of the study would be to determine if a team designated to

turning patients, rather than nurses, would decrease the amount of pressure ulcers. The studies

include 507 patients. They found that when turning patients was encouraged but not required by

the nurses, forty-two out of 278 patients developed pressure ulcers. However, when a specialized

team was designated to turn the patients only twelve out of 229 patients developed pressure

ulcers. They concluded that a turning team specifically for repositioning patients decreased the

incidence of pressure ulcers (Mary D. Still, MSN, et al., 2012).

Falls

Falls are a continuous challenge in many patient facilities, which is why it is especially

important to assess a patient whether they are at a low or high risk for falls because of patient

safety. Patient falls are still considered to be a leading cause of injuries in hospitals and also

continue to be a big patient safety concern (Trepanier, Hilsenbeck, 2014). In the hospital, falls

are the most common occurrence especially in the older population (National Patient Safety

Agency (NPSA) 2013). According to the Royal College of Physicians (RCP, 2015), there was a

national audit of inpatient falls which found that the rate of falls in the older population ranged

from 0.82 to 19.20 falls per 1,000 occupied bed days, along with a mean rate of 6.63 falls per

1,000 occupied bed days. But not all falls are learned, especially when the patient was not

harmed so it is likely that these fall rates are miscalculated (Shorr, 2013).
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Falls can happen to patients of any age while being in the hospital. But, older patients are

at increased risk while being in the hospital because of their instability, which is associated with

their illness, treatments and being in the hospital environment (NPSA, 2013). According to

NPSA (2013), 82.2% of falls occurred in patients aged 65 years and over, and 67.6% of falls

occurred in patients aged 75 years and over in hospital falls. It was found that approximately

31% of inpatient falls result in a physical injury such as contusion, laceration, fractures, injury of

the brain, and even patient death (NPSA, 2013). The mean rate of falls that resulted in moderate

and severe harm, and even death was 0.19 per 1,000 occupied bed days with a range of 0.01-2.00

recorded in a national audit of inpatient falls (RCP, 2015). A fall may affect a patient

psychologically, socially, and economically including physical effects, such as a fear of falling,

anxiety, depression, loss of self-confidence, a longer stay in the hospital, and increased

healthcare costs (RCP, 2015).

There are many risk factors that are associated with inpatient falls on the medical surgical

unit in the hospital. Parkinson’s disease can impair a patient’s movement and posture causing

them to be unstable. Stroke, degenerative joint diseases, and arthritis can cause the muscles to

weaken and impair the patient’s balance and coordination. Other conditions that put the patient

at an increased risk for falls include altered mental status, confusion, delirium, cognitive

impairment, urinary incontinence, depression and postural hypotension (Todd and Skelton 2014).

Visual impairment and medications, especially if the patient is taking more than four

medications, are important risk factors as well (Todd and Skelton 2014). Environmental factors

also put the patient at an increased risk for falls including slippery floors, bed rails and assistive

devices, and low or inadequate lighting. Patient activities such as walking, transferring, or

attending to urinary or bowel elimination needs also increases their risk for falls (Zhao and Kim
EFFECTS OF NURSE STAFFING AND PATIENT SAFETY 11

2015). It is important to know if the patient has had previous falls in the past because it is a

significant predictor of future falls. This is why it is important to assess the patient using a falls

risk assessment tool and falls risk screening tool upon patient admission to score them

accordingly and determine whether they are a low or high risk for falls, and that way the nurse

can prioritize their patients based on their medical needs (National Institute of Health and Care

Excellence (NICE), 2013).

Medical-surgical units have the highest rates of falls nationally and can cause significant

injuries resulting in an increased length of stay, unexpected surgeries, and deaths (Bouldin, 2013)

(Williams, Szedkendi, Thomas, 2014). According to Tzeng & Ying (2013), researchers have

shown that using effective teamwork through successful integration of standard evidence-based

practice tools reduces preventable inpatient falls significantly. Successful fall prevention

strategies included staff education, post-fall assessments, alarm devices, side effects of

medications, hourly rounding, call bell usage and offering toilet use more frequently (Tzeng &

Yin, 2013). It has been found that with teamwork among nurses and staff, and situational

awareness are the most crucial in mitigating risk for falls and improving patient safety on the

medical-surgical unit (Gadlock, Christiansen, Feider, 2016). It is also important for nurses to

prioritize their patients accordingly based on their level of care and needs. For example, the

nurse should put a high fall risk patient with dementia at the top of their list to help prevent any

upcoming falls and/or injuries associated with patient falls. In conclusion, falls are a high risk on

medical-surgical unit floors in the hospital and it is important to do frequent checks on the

patients and to monitor them closely to prevent a fall from occurring.

Conclusion
EFFECTS OF NURSE STAFFING AND PATIENT SAFETY 12

When addressing how staffing in hospitals can have an effect on patient safety, research

shows that a high nurse to patient ratio can lead to undesirable outcomes for the patient. These

high nurse to patient ratios lead to an increasing prevalence in medication errors which can

ultimately impact the safety of the nurse and the patient. Studies have shown that there was also

an increase in the development of pressure ulcers based on these high nurse to patient ratios. It

was shown that patients were put at a high risk for falls due to these high nurse patient ratios.

Patient falls are considered to be the leading cause of injury within the hospital setting and put

the patient’s safety at risk.

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