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Nursing July 12, 2016

Inadequate Staffing Harms Quality and the Bottom Line

The lack of adequate nurse staffing can result in longer lengths of stay, patient dissatisfaction, higher readmissions and more adverse events — all things that can decrease quality and increase impacts on the bottom line.

“With the increased focus on value-based care, optimal nurse staffing will be essential to delivering high-quality, cost-effective care,” concluded a 2015 white paper from the American Nurses Association. The paper also cited the growing body of evidence on economic benefits associated with optimal nurse staffing. Through the years, study after study has supported the benefits of better nurse staffing.

“If there are not enough nurses at the bedside, bad things are likely to happen,” said Matthew McHugh, PhD, JD, MPH, RN, FAAN, an associate professor at the University of Pennsylvania (Penn) School of Nursing in Philadelphia, an author of the paper, in a statement.

Patient Outcomes

A 2002 study by Linda Aiken, PhD, RN, at Penn, first caught people’s attention. It found that for every additional patient a nurse cared for, patients were at a 7% greater risk of dying within 30 days of admission, and there also was a greater risk of failure to rescue. A 2011 University of California, Los Angeles, study also reported that nurse staffing below target levels was linked to increased patient mortality.

Patients suffering an in-hospital cardiac arrest were more likely to survive in hospitals with good nurse staffing levels, according to a 2015 Penn study. A 2016 Aiken study found that patients undergoing surgery at Magnet hospitals, which are more likely to have optimal nurse staffing, had better outcomes at the same or lower cost than at other hospitals. Fewer complications and nurses picking up on subtle changes in a patient’s condition can lead to shorter lengths of stay, improving throughput and reducing costs.

Additionally, better staffing can reduce patient falls, costing an average of $17,500 per hospitalization; pressure ulcers, costing an average per stay of $37,800; and infections, according to the 2015 ANA report.

Patient Satisfaction

Press Ganey’s study, “The Nursing Special Report: The Influence of Nurse Work Environment on Patient, Payment and Nurse Outcomes in Acute Care Settings,” found nursing environment and good staffing associated with higher Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. These scores on patient experience are used by the Centers for Medicare & Medicaid Services (CMS) in determining a hospital’s reimbursement rates. An earlier 2008 Harvard University study reported in The New England Journal of Medicine found a similar association between better nurse staffing and higher HCAHPS scores.


A March 2016 study from Penn found patients undergoing elective hip and knee surgery in hospitals with inadequate nurse staffing and poor nurse work environments are more likely to require rehospitalization, most commonly for infection. The authors explain that nurses are essential for preventing and monitoring for signs of infection and when understaffed, they may not have time for diligent care. Nurses also are responsible for educating the patient about how to manage the wound, what symptoms to watch for and when to contact the physician, so a readmission is not needed.

CMS hold hospitals financially accountable for patient outcomes, including readmission rates following hip and knee replacements; reducing readmissions for these very common surgeries are important for controlling costs at hospitals. A 2013 study by Penn in Health Affairs found that hospitals with higher nurse staffing were less likely to receive readmission penalties than hospitals with lower staffing.

Nurse burnout

The 2002 Aiken paper found each additional patient a nurse cared for was linked with a 23% jump in nurse burnout and a 15% bump in job dissatisfaction. A 2016 study from Mercy Hospital St. Louis confirmed an association between inadequate staffing and job stress and dissatisfaction. The cost of nurse turnover is well-known to healthcare organizations. The 2015 ANA report cites the average cost of replacing a nurse varies from $22,000 to $64,000.

Nurse staffing levels are a controversial subject in healthcare. But research clearly shows that inadequate staffing can lead to higher costs and quality of care problems. Solutions exist to nurse staffing challenges in these times of supply shortages, including the optimization of existing staff, creating an optimal balance of permanent and contingent staff, improved forecasting of patient demand and staffing need, and development of training programs to move new nursing grads into practice.

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