Staffing for Safety: A Synthesis of the Evidence on Nurse Staffing and Patient Safety

Main Messages

  • Safe and appropriate nurse staffing is critical to patient health, safety, and well-being, as nurses deliver more individual healthcare than any other healthcare provider.
  • Current nurse staffing conditions demand immediate attention, as they have become increasingly inadequate and can result in unacceptable compromises to patients as well as nurses. Creating and maintaining a work environment that supports and retains nurses is key to improving the quality of healthcare, including patient safety.
  • One of the most important predictors of patient well-being is the amount of direct nursing care patients receive per day.
  • Nurses are only one of many care providers. Efforts to improve patient safety should be led in tandem with other quality improvement initiatives involving other healthcare providers.
  • Improving patient outcomes through nurse staffing is really about improving the organization, delivery, and management of healthcare services.
  • Nurse staffing is a complex process. An effective and formalized staffing plan requires an understanding of the complexity involved in patient care and in matching human resources (skills, number of staff, education, and experience) to patient needs. Only those qualified to do this task should create these plans.
  • Five recommendations are presented in this report. They are:
    1. Effective, formal staffing plans should be implemented in all organizations employing nurses.
    2. Patients should be cared for by highly educated regulated nurses.
    3. Patients should be cared for by experienced nurses.
    4. Workplaces should encourage and sustain improved patient, nurse, and system outcomes.
    5. Standard nurse staffing definitions need to be created and used to ease comparison of research findings and to build stronger evidence for policy and practice.
  • These five recommendations can be incorporated into formal staffing plans. Such plans should be specific to the unit, ward, or program; address staffing needs required for quality healthcare delivery; and be formed in consultation with staff nurses, using a shared governance model. The plans should spell out options, repercussions, and alternatives when staffing goals are not met.

Executive Summary

Nurse staffing makes a critical difference to patients. Research reveals a close link between inappropriate nurse staffing levels and higher rates of unwanted outcomes for patients. This report highlights evidence-informed recommendations for improvements in patient outcomes through advancements in nurse staffing. It blends findings from a decision-maker roundtable with the research report Evaluation of Patient Safety and Nurse Staffing, led by Amy Sanchez McCutcheon.

Patients are sicker today than in the past and need more specialized and acute care. Nurse staffing has not kept pace with this greater patient need, and in effect, due to the restructuring era of the 1990s, nurse staffing has deteriorated. Heavy workloads and stressful working conditions are affecting nurses’ ability to provide quality healthcare. Rather than thinking of nurse staffing as a management concern or an expense, it is time to recognize it as a key intervention that affects all other healthcare interventions. Therapies such as drugs, medical procedures, and health education cannot be effective if nurses are not there to provide them at the right time, in the right way, or at all. If the well-being of Canadians is a priority, then appropriate nurse staffing must be seen not as an onerous expense but as a cost-effective quality and safety intervention worthy of investment.

Notably, improved nurse staffing has multiple beneficiaries: it benefits the patients through better health outcomes, and it supports nurses by increasing job satisfaction, reducing absenteeism, and encouraging retention. It also benefits hospitals and the healthcare system by reducing patients’ lengths of stay and therefore costs. One study concluded the savings from reduced lengths of stay would offset almost half of any increased labour costs.2 In this publicly funded system, advancements, efficiencies, and cost savings from improvements in the quality of care will benefit all Canadians.

Appropriate nurse staffing involves more than just the number of nurses on duty. Education, experience, skill mix, and leadership qualities have an enormous impact on the quality of nurse staffing. For example, studies show that the risk of people dying in hospitals decreases with the presence of highly educated nurses.3 Similarly, a Canadian study concluded that increased nursing experience is associated with fewer patient deaths.4

This report encourages evidence-informed decision-making around nurse staffing that will result in better patient outcomes. The available evidence on nurse staffing and patient outcomes focuses almost entirely on hospital and acute care settings. As of yet, there is little research on this topic in the community setting or in long-term care. Also, the research focuses mainly on registered nurses, with little focus on registered psychiatric nurses, licensed practical nurses, and advanced practice nurses such as nurse practitioners and clinical nurse specialists. To ensure inclusion of the spectrum of regulated nurses and sectors of public and community healthcare, this synthesis approach relied on evidenceinformed recommendations from decision makers with expertise on nurse staffing and patient safety. In addition to providing their expertise, decision makers helped identify specific areas for action, which are captured in this report’s recommendations.

This timely report is written for discussion and action. It is a celebration of the extensive work and collaboration from a number of groups and individuals involved in this synthesis endeavour.