Nurse staffing and compassion are recognized as essential components of value-based, patient-centered care. Studies have linked nurse staffing shortages to increased levels of burnout, job dissatisfaction and compassion fatigue-all of which challenge nurse retention, further exacerbating staffing deficits. Research has also confirmed that nurse experience is inextricably linked to both patient experience and clinical quality. New cross-domain analytics demonstrate the impact that staffing and the nurse work environment have on all of these outcomes.
These data reinforce that staffing plays an important role in the delivery of safe, effective and efficient care, but they also highlight the reality that staffing alone does not ensure clinical quality or an optimal patient or nurse experience. Organizational culture and work environment are fundamental to achieving excellence across these domains, as is the need for Compassionate Connected Care™, both for patients and providers who care for them.
Staffing and the Patient Experience
Relationships between nurse staffing and clinical quality, safety and patient experience outcomes are well established in the literature. New integrated analyses combining National Database of Nursing Quality Indicators (NDNQI) safety and quality data with Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Press Ganey patient experience data provide insight into the drivers of these relationships.
For example, HCAHPS measures of patient experience are significantly correlated with nursing hours per patient day and RN hours per patient across every dimension of the patient experience (Figure 1).
Further analyses at the item and question level show a marked discrepancy between the ability of hospitals in the top decile and the bottom decile of staffing to meet patient needs, highlighting opportunities in which staffing may be used to improve performance. Where the distance between the two points is greater, so is the opportunity to improve.
Patient clinical, safety and experience outcomes are influenced by the number and skill mix of nurses and the degree to which nurses are doing the right things to meet patients’ needs. These outcomes are also influenced by the nature of the environment in which nurses are working.
SEE ALSO: Nurse Leadership & Staff Satisfaction
To determine the relative impact of nurse staffing and nurse work environment on quality, safety and experience outcomes, composite measures for both domains were developed and analyzed using multiple regression models. The Nurse Staffing Composite measure consists of RN Hours per Patient Day, RN Skill Mix, and Education and Certification of Nurses. The RN Work Environment Composite comprises four of the subscales of the Nursing Work Index Practice Environment Scale (NWI-PES), including: Foundations for Nursing Quality of Care, Nurse Manager Leadership and Ability, Nurse Participation in Hospital Affairs, and Nurse-Physician Interactions.
Results were adjusted for the effect of hospital bed size, teaching status, ownership and metropolitan status.
Performance in the analyses was categorized using the following reference points:
- Work environment: Quartiles of performance from least favorable ( 1st quartile: 1-24%) to most favorable (4th quartile: 76-100%).
The analysis of mean patient falls by Work Environment and Staffing Composite scores demonstrates the powerful influence of work environment on outcomes. Organizations with above-median staffing composite scores have fewer falls than those with below-median staffing composites in each work environment quartile. However, hospitals with below-median staffing composites in the highest quartile of work environment have fewer falls than the hospitals with above-median staffing composites in the first three quartiles. Further, the difference in fall rates between above- and below-median staffing is virtually indistinguishable among hospitals in the least favorable work environment.
These findings show that in the least-optimal work environments, improving the staffing cannot be counted upon to reduce falls (Figure 4). Similar analyses on pressure ulcer rates revealed consistent findings that reinforce that staffing alone is not enough to ensure quality and safety.
Nurse engagement is linked to staffing through its impact on retention and recruitment. Certainly, work environment is essential to engagement as well. Available nurse engagement data show that the average engagement of RNs on a five-point scale is 4.11 in the Press Ganey database. Lowest-scoring items for nurses are almost all related to their engagement to the organization, including these survey items:
This organization takes steps to reduce unnecessary procedures.
- My work unit is adequately staffed.
- Different levels of this organization communicate effectively with each other.
- The amount of job stress I feel is reasonable.
- My pay is fair compared to other health care employers in this area.
- Employees who work here are seldom distracted from their work.
Press Ganey data on nurse engagement suggest that nurses who have been with an organization less than six months are the most engaged. The data also indicate that nurses at the bedside are less engaged than nurses who do not provide direct patient care. This is a call to action not only for nurse leaders but also for direct care nurses, especially in light of the influence nurse engagement has on patient outcomes.
Additional analyses reveal significant relationships between nursing structural and cultural measures with nurses’ global perceptions of their environment, patient perceptions of care, and patient clinical outcomes. Specifically, staffing, as defined by total nursing hours per patient day, is significantly and positively associated with nurses’ overall job satisfaction and perception of the quality of care provided at the organization. Staffing is also positively associated with patient perceptions of care with higher staffing being associated with greater likelihood for patients to rate hospital care as a 9 or a 10 and greater likelihood for patients to indicate that nurses always demonstrated that they were listening to them.
However, staffing is negatively associated with patient outcomes in that higher staffing levels are related to fewer falls, central line associated blood stream infections and pressure ulcers. Notably, nurse perception of the culture within their organization mirrors these findings while demonstrating even stronger relationships. How nurses perceive the professional status afforded to nurses within their hospital mirrors the direction of findings in that higher perception of nurse professionalism is associated with better nursing perceptions in general, better patient evaluations of care and fewer negative patient outcomes. It is notable, however, that perception of nursing status has comparatively stronger relationships with each of the outcome measures than does objective measures of staffing. That is, how nurses perceive the professional status of nursing within their organization is even more strongly correlated to these quality metrics than staffing alone.”
Status of Nursing RN Perception Job Satisfaction .370** .763** Quality in General .354** .779** Patient Experience Rate Hospital 0-10 .261** .678** Nurses Listen .190** .634** Prompt Response .199** .609** Patient Outcomes Unassisted Falls -.202** -.558** CLABSI -.168** -.383** HAPU II -.189** -.500**
**P value < .001
Compassionate Connected Care for the Caregiver
The relationship among patient experience, nurse experience and clinical quality is clear. This tells us that meeting the needs of the people who care for patients is essential to ensuring their ability to meet the needs of the patients themselves.
To understand what caregivers need in this regard, Press Ganey conducted a qualitative study asking thousands of clinicians across the United States to provide an image of what compassionate and connected care for the caregiver would look like to them. Their responses fell into these six themes.
Acknowledge the complexity and gravity of the work provided by caregivers
- Support from Management in the form of material, human, and emotional resources
- Teamwork is a vital component for success
- Empathy and trust must be fostered and modeled
- A positive work/life balance reduces compassion fatigue
- Communication at all levels is foundational
A further poll of more than 500 health care professionals revealed that, of these six themes, the most important was related to teamwork. This further emphasizes that health care is a team sport and in order to improve engagement, experience and clinical quality, we must work together to foster a collegial, collaborative, and cohesive environment in every healthcare venue.
Understanding the influence that the nurse work environment has on patient and nurse outcomes, together with its relationship with nurse staffing and engagement, is essential to the development and implementation of strategies designed to improve nurses’ ability to deliver safe, effective value-based health care that meets patients’ needs and reduces their suffering. To this end, health systems should focus their resources on creating a nurse work environment that looks beyond nurse staffing ratios and focuses on cultivating more effective staffing. Fulfilling the commitment to Compassionate Connected Care for patients requires committing to an environment that supports Compassionate Connected Care for nurses in ways that demonstrate respect, autonomy, trust and empathy.
Christy Dempsey, MSN MBA CNOR CENP, is SVP, and chief nursing officer, Press Ganey Associates, Inc. Deirdre Mylod is SVP, Research and Analytics, Press Ganey Associates, Inc. Emily Cramer is research assistant professor,University of Kansas School of Nursing.