NUR 4102 Module 3 Staffing and Budget Paper: Evidence Linking Nurse Staffing to Patient Mortality Example

Six Patients at Night: Making the Case for a Fifth Nurse

Student Name

Bachelor of Science in Nursing, Thomas Edison State University

NUR-4102: Leadership and Management in Nursing: Scholars Track

Mentor Name

Month Day, Year

Six Patients at Night: Making the Case for a Fifth Nurse

The Problem

On day shift our nurses each carry four or five patients. Nights are different: with five nurses for 32 beds, six or seven patients per nurse is routine, and a single sick call pushes some assignments to eight. Night nurses describe pain medication given late, reassessments that slide and admissions done in a rush. Over the last quarter we had three rapid response calls at night in which, looking back, the patient's vital signs or behavior had been changing for hours. Two of our most experienced night nurses have told me they are applying elsewhere. Our director has said she needs a written case before she can ask finance for anything.

Workload and Mortality

Aiken et al. (2002) linked survey data from over 10,000 nurses with discharge records for surgical patients in 168 hospitals across Pennsylvania. Once differences in patients and hospitals had been accounted for, every extra patient added to a nurse's average load went along with odds of death within 30 days about 7 percent higher, and with a comparable increase in deaths among patients who had developed complications, the measure called failure to rescue. Heavier loads also raised the odds that nurses reported burnout and dissatisfaction with their jobs. The authors calculated that going from four to six patients per nurse would add a meaningful number of deaths across a hospital's surgical population.

Understaffed Shifts

Needleman et al. (2011) took a closer look, shift by shift, in one large academic medical center, covering roughly 198,000 admissions and 177,000 eight-hour shifts. They compared the registered nurse hours actually worked on each shift with a target set by the unit's patient classification system. Each time a patient lived through a shift on a unit that fell eight or more hours short of its target, that patient's risk of death rose by about 2 percent. Shifts with heavy patient turnover, meaning many admissions, discharges and transfers, raised the risk by about 4 percent each. Because the analysis followed individual patients through individual shifts, it showed that a hospital's average staffing can look adequate while specific shifts are dangerous.

Evidence From Legislation

McHugh et al. (2021) studied what happened after Queensland, Australia, passed a law requiring at least a single nurse per four patients during the day and one for every seven overnight in public medical-surgical wards. They compared 27 hospitals covered by the law with 28 that were not. Staffing improved in the covered hospitals, and across the sample every one-patient drop in workload went with lower odds of death and readmission and with shorter stays. Over the two-year period, the authors estimated that the law prevented about 145 deaths and 255 readmissions and that money saved came to over double what the added nurses cost.

The Proposal

My proposal adds one registered nurse to every night shift, which would bring assignments down to five or six with five as the goal. Covering every night of the year with one additional nurse takes about 1.4 full-time equivalents once days off, vacation and sick time are counted. With help from the unit manager and the finance office, I built the cost from a base salary, benefits and the night differential. I set this against costs the research suggests better staffing could reduce: rapid response calls, unplanned moves to intensive care, falls and pressure injuries on nights, overtime paid to cover gaps and the expense of replacing nurses who resign, which our human resources office estimates at more than a year's salary per nurse.

Turnover Costs

Turnover was the part of the case that most surprised our director. Losing the two night nurses who have told me they are leaving would mean recruiting, orienting and precepting two replacements for about three months each, during which they cannot carry a full assignment. Agency nurses would fill the gap at a premium rate. Aiken and colleagues tied heavier workloads to burnout and dissatisfaction, so lighter assignments may protect not only patients but also the nurses the unit has already trained.

Alternatives Considered

I set out three other options so the director could choose. A float nurse shared among several units would cost less but would often be pulled elsewhere. A dedicated night admission nurse would target the high-turnover shifts Needleman and colleagues identified and could be a smaller first step. Capping night admissions would protect staff but push delays onto the emergency department. I recommended the added nurse, with the admission nurse as a fallback.

Presenting to the Director

I submitted the proposal as a two-page memo plus a single page of evidence and a simple cost table, and asked for 20 minutes at her next staff meeting. I opened with our three night rapid response calls, not with complaints about workload, and closed with how we would measure results. She asked hard questions about the cost estimates, and I answered with figures rather than impressions.

Measuring Success

If the position is approved, the unit will track night assignments, rapid response calls in which warning signs went unrecognized, transfers to intensive care, falls and pressure injuries, overtime hours and night-shift resignations, and will report them to the director every quarter.

Ethics and Advocacy

The American Nurses Association's code of ethics expects nurses to work for practice environments that allow safe, quality care. Bringing evidence, costs and options is a professional way to meet that duty, and it is far more likely to change a budget than frustration voiced in the break room.

Limits

None of the three studies was an experiment, and staffing interacts with nurse education, skill mix and the work environment. A ratio law in Australia may not translate exactly to a New Jersey hospital. My cost figures are estimates. The unit is invented.

Conclusion

Aiken and colleagues and Needleman and colleagues tied heavier workloads and short-staffed shifts to patient deaths, and McHugh and colleagues showed that a ratio law improved outcomes and more than paid for itself. A costed request for one more night nurse, with alternatives, turnover figures and clear measures, turned the night shift's frustration into a case our director could take forward.

References

Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA, 288(16), 1987-1993. https://doi.org/10.1001/jama.288.16.1987

McHugh, M. D., Aiken, L. H., Sloane, D. M., Windsor, C., Douglas, C., & Yates, P. (2021). Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: A prospective study in a panel of hospitals. The Lancet, 397(10288), 1905-1913. https://doi.org/10.1016/S0140-6736(21)00768-6

Needleman, J., Buerhaus, P., Pankratz, V. S., Leibson, C. L., Stevens, S. R., & Harris, M. (2011). Nurse staffing and inpatient hospital mortality. New England Journal of Medicine, 364(11), 1037-1045. https://doi.org/10.1056/NEJMsa1001025