Nurse Staffing and Patient Care Quality and Safety


Patient care quality and safety are the primary concerns of the health care system that are influenced by many factors. These factors include professionalism and competence of healthcare providers, availability of care, patients’ condition and treatment compliance, equipment and funding of a healthcare facility, etc. One of these factors that directly influence the delivery of high-quality patient care is nurse staffing. Committee on the Adequacy of Nurse Staffing in Hospitals and Nursing Homes (as cited in Clarke & Donaldson, 2008, p. 1) claims that “Nursing is a critical factor in determining the quality of care in hospitals and the nature of patient outcomes.” The purpose of this paper is to investigate the impact of nurse staffing on patient care and reveal opportunities for quality improvement.

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Interrelation of Nurse Staffing and Patient Care: Human Factors

One of the problems of nurse staffing that appeared in the recent decades is an unprecedented shortage of nurses caused by some reasons. On the one hand, demand for services increased. At the same time, graduations from prelicensure nursing education programs as well as workforce participation by licensed nurses shortened (Clarke & Donaldson, 2008). The second aspect is frequently linked to working conditions in hospitals that tended to be worse compared to those of earlier years.

One of the burning problems related to the nursing shortage and staffing problems became deterioration of patient care quality and safety. For example, studies provide evidence that in the majority of nurses one or more care activities remain undone during the shift due to lower than necessary staffing levels (Ball, Murrells, Rafferty, Morrow, & Griffiths, 2013). Therefore, the quality of care decreases. Research by Aiken et al. (2014) proves that an increase in nurses’ workload that is usually caused by understaffing leads to a higher probability of a patient’s lethal outcome within 30 days of admission. Another aspect to mention in the context of staffing policies is the work schedule, which comprises shift length and working overtime. Griffiths et al. (2014) prove that nurses working 12-hour shifts or longer demonstrate poor or failing patient safety, poor or fair quality of care, and report more activities not completed during the shift. Similar results are observed among nurses who work overtime. Thus, it can be concluded that inefficient staffing policies negatively influence the quality of care and patient safety.

Methods, Tools, and Measures to Improve Patient Care Quality and Safety

In conditions of nurse understaffing, there is a need for measures to be taken to improve patient outcomes and improve patient care quality and safety. Such a method as a survey can be used to identify the existing problems of the nursing staff and thus prevent them. For example, surveying the nursing staff can reveal such problems as burnout, fatigue, working long shifts, or working overtime. Moreover, nurses themselves suggest ways of resolving these issues and focus on the improvements they need.

As for the measures and tools with the potential to influence care quality and safety, information technologies can be mentioned. Thus, Electronic Health Records or Computerized Order Entry tools if implemented appropriately can reduce time wasted on routine procedures and thus be useful in conditions of nurse understaffing. Moreover, the use of technology in healthcare reduces the incidence of medication errors that are a frequent outcome of the lack of staffing and generally decreases the role of human factors in patient care quality and safety.

Culture of Safety Principles

Safety principles should be integrated as parts of the culture of a healthcare facility and be a focus of every unit. A culture of safety is expected to have a positive impact on patient outcomes. Helbling and Huwe (2015) single out key components of a culture of safety that can also be treated as its principles. Thus, the first principle is team empowerment. It implies providing every individual with an opportunity to be an equal part of a team and make a contribution to the result. The second principle is communication, which is crucial for team members. Effective communication is likely to reduce misunderstanding and human factor-related mistakes. Transparency is another principle that can be implemented to achieve safety. Efforts of every team member should be transparent and understandable to other individuals involved in the process of care (Helbling & Huwe, 2015). Finally, accountability should be accepted as a culture of safety principle. It means that nursing staff and other healthcare professionals claim their human errors and are ready to disclose them to prevent similar errors in the future.

Standards Related to Quality and Nurse Staffing

Standards that determine nurse staffing and thus influence the quality of care are developed by American Nurses Association (2015). Nurse staffing usually depends on some key factors, such as “patient complexity, acuity, or stability; number of admissions, discharges, and transfers; professional nursing and other staff skill level and expertise; physical space and layout of the nursing unit; and availability of technical support and other resources” (American Nurses Association, 2015, para. 2). Also, the issue of staffing is conducted by Federal regulations, 42 Code of Federal Regulations (42CFR 482.23(b) in particular. It demands hospitals to be provided with an adequate number of nurses and other professionals to provide the necessary patient care (American Nurses Association, 2015).

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Quality Initiatives in Nurse Staffing

Quality initiatives in nurse staffing are necessary to provide improvement in patient care quality and safety. The major initiative is a change in state regulations or their adoption in case they are absent. Thus, representatives of hospitals including nurses should be the members of working groups that develop state regulations for nurse staffing. Another initiative is educating nurse managers on effective staffing strategies. Also, there is an initiative involving nurses on the whole and nurse graduates in particular. Thus, nursing students should be prepared for the peculiarities of nursing work and have enough practice during their studies to be aware of work in different units. This approach is expected to increase retention rates and contribute to the successful integration of graduate nurses.


To summarizing, it should be mentioned that patient care quality and safety depend on nurse work on the whole and nurse staffing in particular. Consequently, wrong staffing policies and understaffing are threatening the quality of care and safety of patients. Therefore, there is a need for developing quality initiatives aimed at improving safety and quality of care. Also, an increase in patient care safety and quality can be achieved due to the implementation of tools and technologies that simplify the routine work of nurses and help to reduce the incidence of errors. For example, these technologies include Electronic Health Records and Computerized Order Entry. On the whole, the problem of nurse staffing in relation to patient care quality and safety is a complex problem that demands common efforts of nursing staff, hospital administration, and state authorities.


Aiken, L., Sloane, D., Bruyneel, L., Van den Heede, K., Griffiths, P., & Busse, R. et al. (2014). Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. The Lancet, 383(9931), 1824-1830. Web.

American Nurses Association. (2015). Nurse staffing. Web.

Ball, J., Murrells, T., Rafferty, A., Morrow, E., & Griffiths, P. (2013). ‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care. BMJ Quality & Safety, 23(2), 116-125. Web.

Clarke, S. P., & Donaldson, N. E. (2008). Nurse staffing and patient care quality and safety. In R. G. Hughes (Ed.). Patient safety and quality” An evidence-based book for nurses. Agency for Healthcare Research and Quality.

Griffiths, P., Dall’Ora, C., Simon, M., Ball, J., Lindqvist, R., Rafferty, A., … Aiken, L. H. (2014). Nurses’ Shift Length and Overtime Working in 12 European Countries. Medical Care, 52(11), 975-981. Web.

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Helbling, N., & Huwe, J. (2015). Finding the balance for a culture of safety. Nursing, 45(12), 65-68. Web.

Spetz, J., Harless, D., Herrera, C., & Mark, B. (2013). Using minimum nurse staffing regulations to measure the relationship between nursing and hospital quality of care. Medical Care Research And Review, 70(4), 380-399. Web.

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