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Understaffing of Nurses


The understaffing of nurses in medical institutions is becoming a source of constant concern, including the health maintenance of patients in hospital setting. This paper will examine the crisis of understaffing of nurses in TenetHospital and its impact on patients. The main purpose of this research is to analyze and qualitatively assess the repercussions of understaffing of nurses on the health of patients. In this research, data was collected with a set of interview questions that examined the issues related to patient safety.  After completion of the interview undertaking, there will be an evaluation to show the different responses given by the interviewees in this case the nurses. A primary analysis of registered nurses (n=284) from the hospital staff were included in the population to approach for this research. 

Data was retrieved from the inpatient nursing floors (n = 7) throughout the hospital.  An interview shall be undertaken to assess the key independent variables and intention relationship between the responses of the participants.  Further, so as to identify the chief targets of action, there shall be the performance of a discriminant analysis. This study findings may indicate that the understaffing of nurses have negative effects on the health and care of patients.

 Short Staffing of Nurses

Although the research on staffing of nurses has not clarified the point, many believe that lower patient to nurse ratios ultimately reduces the cost of hospitalization by decreasing the length of patients stay and other hospital complications (Steinbrook, 2002; Coffman, Seago & Spetz, 2002).  A safe patient to nurse ratio ranges from 4:1 in telemetry care to 5:1 in a medical surgical floor.   According to Stone, Clark and Climioti (2004), evidence in all parts of the United States clearly shows the lack of qualified nurses is a major public safety issue that requires a new approach and policy changes. 

Monitoring and improving the working conditions of nurses are likely to improve the quality of health care by decreasing the incidence of many infectious diseases, assisting in retaining qualified nurses, and encouraging men and women to enter the profession (Stone et. al., 2004). Therefore, improvements should be made in the workforce to enhance these conditions by providing more staffing of nurses. This study shows that short staffing of nurses affects the quality of care by causing more harm than good.

 Problem Statement

            The understaffing of nurses puts patients at risk for poor patient outcomes such as increased risks of falls and spread of infections.  Research has shown that hospitals with low nurse staffing levels tend to have higher rates of poor patient outcomes such as pneumonia, shock, cardiac arrest, and urinary tract infections (Stanton, 2004).   

 Purpose of Study

The purpose of this study is to demonstrate how the care of patients is affected by the shortages of nursing staff through live experiences of the nurses recorded in an interview. This paper will present the crisis of understaffing of nurses in TenetHospital and its impact on patients. According to Fackelmann (2001) many U.S. hospitals have shifted work once done by aides to registered nurses, forcing them to answer phones, transport patients around the hospital and run samples to the laboratory. Researchers say such non-nursing work can leave nurses with little time to check on patients, a trend that can have dire results (Storfjell, 2008).  This study seeks to present documented studies and evidence exposing the fact that understaffing of nurses does have a negative impact on patients’ health and care.

 Significance of the Study

This paper will present the crisis of understaffing of nurses in TenetHospitalStates and its impact on patients. This study will also attempt to examine nurse staffing to demonstrate that nurses need a patient to nurse ratio and a stable working environment that promotes safe outcomes.  This study will benefit nursing students in making the right choices about where to work and what questions to ask in a job interview.  Instructors will also benefit by this research in the clinical area because they can show the students about obtaining balance and prioritizing the responsibilities of nursing to prevent burnout. Furthermore, this research will attempt to provide the recommended safe patient to nurse ratio and describe how to balance work as a nurse for the prevention of poor patient outcomes.

 Research Questions                   

  1. Is the short staffing of nurses related to the higher incidence of hospital acquired infections?

  2. Does the shortage of nursing staff increase the risk of falls in patients?

  3. Do nurses have a workload that includes a safe patient to nurse ratio? 

     Literature Review

 To ensure that the research is extensive and all the issues were addressed, a number of education resource databases were used including EBSCO and CINAHL.  EBSCO is essentially a global research database service that avails to those who are members (through subscription) a wide range of content in many subjects.  The initials EBSCO stands for Elton B Stephens and Company named after the founder, Elton Bryson Stephens.  CINAHL, on the other hand, is primarily a resource that avails to those who are members through subscription of a wide range of nursing literature.  The initials CINAHL stand for the Cumulative Index to Nursing and Allied Health Literature.  The search terms used in this case where nurse understaffing, medical institutions understaffing, nurse understaffing impact, nurse understaffing today, nurse understaffing research, nurse understaffing effects and nurse understaffing patients. 

 Hoi, Ismail and Onge (2010) reported that a workload measurement system is critical for identifying nurse staffing needs for safe care and for justifying nursing resource allocation as a cost conscious healthcare environment. Nineteen wards were observed over a period of one week on day shifts with the use of regression modeling (Hoi et al., 2010).   The results indicated nursing time required for a low-acuity ward increased from 90.5 to 177.1 hours per day (Hoi et al., 2010).

 This indicated that in a rapidly changing work environment, workload measurement systems should be reviewed periodically. The WIMS (Wireless Integrated Microsystems) was developed as a potential methodology for measuring staffing needs (Hoi et al., 2010)  The nursing workforce is confronted with the challenge of meeting competing demands as hospital activity and client acuity are reported to have increased during the 20th century (Buchan, 1997).  With the use of a measuring system, one can calculate the appropriate patient ratio required for the improvement of safety for the clients (Hoi et al., 2010).

 The study done by Tervo, Kiviniemi and Partenen (2009), was to assess the relationship between patient-to nurse ratios and outcomes.  Although there is a growing body of evidence showing that higher levels of registered nurse staffing are linked to better outcomes, it was still unclear how nurse staffing produced these effects (Tervo et al., 2009).  A survey of data of nurses (n = 854) in 46 inpatient units at five university hospitals in Finland was used to create a Bayesian Network (BN) model of connections between the variables (Tervo et al., 2009).The BN model showed that the quality of nursing care is influenced by multifaceted work environment measures (Tervo et al., 2009).

 A study conducted by Andrews, Burr and Bushy (2011), showed the narrative analysis of comments provided by 106 staff nurses working in a medical-surgical setting.  The result of the study suggested that nurses feel that the work environment neither empowers them to act effectively on behalf of their patients nor enhances their self-concept, leading to compromised quality of care (Andrews et al., 2011). Recommendations are offered to enhance nurses' professional self-concept through staff development and policy changes (Andrews et al., 2011). There is an urgent need for substantive changes aimed at lowering the patient to nurse ratio as this will go a long way to enhance patient outcomes.

 Lucero, Lake and Aiken (2009) conducted a study to describe registered nurses’ reports of unmet care needs and to examine the variation of nursing care quality across hospitals through a mail survey.  A total of 2,008 nurses responded with results to show that across hospitals, there was a wide range in the proportion of nurses who reported leaving nursing care needs uncompleted (Lucero et al., 2009). After controlling for nurses’ demographic information, they found statistically significant variations in the quality of nursing care across hospitals (Lucero et al., 2009). The study showed the differences in nursing care quality across hospitals appear to be closely associated with variations in the quality of care environments (Lucero et al., 2009).

 Literature Review Table








Aiken L.H., Clarke S.P., Sloane D.M., Sochalski J.A., Busse R., Clarke H., Giovannetti P., Hunt J., Rafferty A.M. & Shamian J. (2001) Nurses’ reports on hospital care in five countries. Medical News, [20] (3), 43–53.

To assess the variation in patient safety across hospitals and explore whether nurse staffing may be associated with safety.  

5,388 nursing units in 636 hospitals.

A cross-sectional observational study using 2004 NDNQI data.  

National Database of Nursing Quality Indicators (NDNQI) using an analytic file of monthly observations  

Nursing staff hours and hospital Magnet status were significantly associated with the fall rate (Aiken, Clark, Sloan, Sochalski, Busse, Giovannetti, Hunt, Rafferty & Shamian, 2001). 

According to the evidence in the study, there are two mechanisms for enhancing patient safety: becoming or emulating a Magnet hospital, or adjusting staffing patterns at the unit level (Aiken, Clark, Sloan, Sochalski, Busse, Giovannetti, Hunt, Rafferty & Shamian, 2001). 

Andrews, D., Burr, J. & Busy A. (2011). Nurses' self-concept and perceived quality of care: a narrative analysis. Journal of Nursing Care Quality, 26(1): 69-77       

To explore the comments of staff nurses to gain meaning of their experiences.

308 registered nurses caring for adult patients on medical-surgical units.


Written comments in a pre-printed one page with 15 questions.

This study suggest that nurses who feel that the work environment neither empowers them to act effectively on behalf of their patients nor enhances their self-concept may lead to compromised patient care quality (Andrews, Burr, Busy, 2011). 

Nurses who report higher levels of job satisfaction also report higher levels of autonomy, participation in decision making, and collaboration(Andrews, Burr, Busy, 2011).

Berlan, A., Berensten, S., & Gundersen, D. (2009).  Hospital-acquired infections and patient safety. Nordic journal of Nursing research & clinical studies, 29(1), 33-37.

To examine the thoughts andexperiencesof the critical care nurses in regard to hospital-acquired infections and patient safety(Berlan,Berensten & Gundersen, 2009).   

23 advanced nurses with  training in anesthesia,intensiveand surgery care. 

Descriptive byqualitative analysis.

Focus group interviews.

The findings show that respect for hygiene protocols becomes reduced over time and this affects patientSafety (Berlan, Berenstein, Gundersen, 2009).

Busy and stressful work environment can is an issue when having to adhere to the hospitals protocols. 

Borkowski, N., Amann, R., Song, S., & Weiss, C. (2007). Nurses’ intent to leave the profession: issues related to gender, ethnicity, and education level. Health Care Management Review,  32(2), 160-167  

To explore issues relating to the nursing shortage.

284 nurses


Electronic survey designed as a two step approach. 

Heavy workload and management leadership styles are predictors or significant influences for nurses' intent to stay with or leave an organization (Borkowski, Amann, Song, & Weiss, 2007).

Short staffing  of  nurses are associated with unsafe conditions in hospitals across the UnitedStates.

Geiger, J., Trinkoff, A., & Rogers, V. (2011). The impact of work schedules, home and work demands onself-reported sleep in registered nurses.  Journal of Occupational and Environmental Medicine, 53(3), 303-307.

To explore the relationship of work schedules to self reported restless and inadequate sleep in a large population-based sample of registered nurses (Geiger, Trinkoff, Rogers, 2011).

Nurses (n = 2246)           

Non- experimental correlational          

Cross-sectional mailed survey            

Odds of inadequate and restless sleep showed a clear dose effect for adversity of work schedule, even when adjusted for age and home demands (Geiger, Trinkoff, Rogers, 2011).  

Current scheduling practices and high work demands negatively impact nurses' sleep and may be partially explained by exposure to work demands(Geiger, Trinkoff, Rogers, 2011).    

Hertting, A., Nilsson, K., Theorell, T., & Larsson, U. (2004). Downsizing and reorganization: demands, challenges and ambiguity for registered nurses. Journal of advanced nursing, 45(2),145-154  

To explore registered nurses' experiences of psychosocial 'stressors' and 'motivators', and how they handled their work situations, following a period of personnel reductions and ongoing reorganization(Hertting, Nilsson,Theorell, & Larsson,  2004).

14 nurses followed for one year.

Explanatory research using interview questions.

Audio taped interviews.

Five themes are in relation to nurses' perceived stressors, motivators, and coping options. (Hertting, Nilsson,Theorell, & Larsson, 2004).   

The study demonstrated that the well-being of nurses depends on being an equal/parallel health professional in a comprehensive team that shares knowledge and improves collaborative care of patients(Hertting, Nilsson,Theorell, & Larsson, 2004).  

Hoi, S., Ismail, N. & Ong, L. (2010). Determining nurse staffing needs: the workload intensity measurement system. Journal of Nursing Management, (18), 44–53,   

To develop a prototype nursing workload intensity measurement system.  

Nineteen wards were observed over a period of one week day shifts in a 1500-bed acute care hospital involving 500 nurses.

A descriptive observation survey adopting a work sampling technique.

A questionnaire survey  

The nursing time required per day for each activitywas compared with the derived activity time in the current study (Hoi, Ismail & Ong, 2010).

In order to properly identify nursing staffing needs, a workload measurement system is highly recommended to assure safe patient care.

Lucero, R., Lake, E. and Aiken, L. (2009). Variations in nursing care quality across hospitals.  Journal of Advanced Nursing, 65(11), 2299-2310 

To describe registered nurses’ reports of unmet nursing care needs and examine the variation of nursing care quality across hospitals.   

1999 nurses              

Secondary analysis of a 2008 survey of registered nurses.          

Mailed questionnaire survey

Across hospitals there was a wide range in the proportion of nurses that reported leaving each nursing care need undone (Lucero, Lake, Aiken, 2009).

Differences in nursing care quality across hospitals appear to be associated with variations in the quality of care environments(Lucero, Lake, Aiken, 2009).  

Mark, B. & Belyea, M. (2009).  Nurse staffing and medication errors: cross sectional or longitudinal relationships? Research in nursing and health, 32, 18-30.

To examine the relationship between change in nurse staffing and medication errors.

284 nursing units and a total 1,892 nurses.  

Non-experimental, causal modeling design.     

284 nursing units in 145 hospitals. 

When RN proportion exceeded, medication errors increased (Mark & Belyea, 2009).

It demonstrated a significant relationshipbetween a higher proportion of professional nurses on thenursing staff andlower rates of medication errors (Mark & Belyea, 2009). 

Palfi, I., Nemeth, K., Kerekes, Z., Kallai, J., & Betlehem, J. (2008).  The role of burnout among nurses.International journal of nursing practice, 14(1),19-25

To explore the occurrence of burnout among nurses in health and social institutions, to reveal the connections between burnout and socio demographic factors, and to learn its extent in different types of care.

805 registeredNurses

Correlational design.

Survey was a one-off, represent-tative sample with 805 question-naires processed

Burnout is twice as high among intensive care nurses (10.7%) than among long-term care nurses (3.6%), and the least is among active ward nurses (0.6%)  (Palfi, Nemeth, Kerekes, Kallai, & Betlehem2008).

Prevention by providing safe staffing, could save health-care workers from burnout and leaving the job independently(Palfi, Nemeth, Kerekes, Kallai, & Betlehem2008).

Ruggiero, J. (2005). Health work variable, and job satisfaction among nurses. JONA, 35(5), 254-263.

To explore the relationships and relative contributions of selected work (stress, work load, weekends off), shift worker health (sleep, depression), and demographic variables (age, number of individuals needing care after work) to job satisfaction. 

247 critical care nurses.

Dillman Tailored Design Method of survey research was used to recruit participants and collect data.


There were no significant differences in these variables among self-defined day, night, and rotating shift nurses. Hierarchical regression analyses indicated that more weekends off per month and less depression and emotional stress contributed significantly to job satisfaction in nurses (Ruggiero, 2005).

Improvements in scheduling and interventions designed to reduce depression and emotional stress may help to improve job satisfaction in nurses and aid in nurse recruitment and retention (Ruggiero, 2005).  

Stelina, P., Groves, M., & Paffor, L. (2005). Managing medication errors – a qualitative study.  Medsurg nursing, 14(3), 174-178.

To forge a more intenseunderstanding of how nursesexperience making or beinginvolved in medication errors

1,384 nurses

Descriptive designusing qualitative analysis.

A 16-itemLiker survey.

Analysis of the participantsresponse revealed three key themes: time is on our side, context counts, and reliance on systems  (Stelina, Groves,  & Paffor, 2005).

Medication errors occur most when a nurse has a heavy load of patient care to provide (Stelina, Groves, & Paffor, 2005).  

Storfjell, J., Omoike, O., &   Ohlson, S. (2008). The balancing act: patient care time verses cost.  JONA, 38(5), 244-249.

To determine the time the nurses spend with their patients.

11,400 patient-days per unit across the 14 units consisting of general medicine, ortho-pedics, telemetry, and general surgery.

Observational design.

An activity-based costing approach was used in 14 medical-surgical nursing units to study nursing activities and their related costs.

Nurses spent more time on support activities (56%) than in providing patient care (44%), with the least amount of time being spent on patient teaching and psycho-social support(Storfjell, Omoike, &   Ohlson, 2008).

Nurses spent more time on support activities (56%) than in providing patient care (44%), with the least amount of time being spent on patient teaching and psychosocial support  Nurses spent more time on support activities (56%) than in providing patient care (44%), with the least amount of time being spent on patient teaching and psycho-social support(Storfjell, Omoike, &   Ohlson, 2008).

Tervo, T., Kiviniemi, V. and Partanen, P. (2009). Nurse staffing levels and nursing outcomes: a Bayesian analysis of Finnish-registered nurse survey data. Journal of Nursing Management, 37 (8)  

To assess the relationship between patient-to- nurse ratios and the nursing outcomes.

Registered nurses (n = 854) in 46 inpatient units at five universityHospitals.


A survey of data

The nursing care is influencedby multiple work environment measures  (Tervo, T., Kiviniemi, V. and Partanen, P., 2009).

Literature provides evidence that higher levels of nurse staffing are linked to improved patient outcomes (Tervo, T., Kiviniemi, V. and Partanen, P., 2009).

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