Reducing Nurse Workloads More Affected by Work Environment than Added Staff

Absent a good work environment, reducing nurse workloads by adding additional nurses, a costly proposition, may have little consequence.

That was the conclusion reached by a seminal study several years ago by esteemed nursing researcher Linda Aiken and others. The study, which first appeared in Medical Care in 2011, still has impact today as hospitals struggle with nurse-patient assignments and the proper workload.

The researchers were quick to point out that there’s a good scientific evidence of an association between lower nurse workloads and better patient outcomes, including lower hospital mortality. But they wanted to understand a different question – which investments in hospital nursing care delivery work best, for whom, and under what circumstances.

To answer these questions, the researchers mailed surveys to 272, 783 nurses in adult acute care hospitals in four states – California, Pennsylvania, Florid and New Jersey, and got a response rate of 39%.

They wanted to look at three key variables that could affect patient outcomes – nurse staffing, nurse education, and the nurse work environment. As for nurse staffing, that was calculated from nurse survey data by dividing the average number of patients reported by nurses on their units on their last shift by the average number of patients reported on the unit. Then, they used a scale of criteria that was shown to be strong predictors of patient and nurse outcomes – nurse participation in hospital affairs, nursing foundations for quality care, nurse manager ability, leadership and support of nurses, staffing/resource adequacy, and nurse-physician relations.

The results showed that slightly more than 1 in 4 hospitals had patient-to-nurse ratios of 4 or less, while 1 in 5 had ratios of 7 or more. In addition, 30% of the hospitals had poor work environments, more than half had “mixed” environments and only 20% had good work environments.

Perhaps the most notable result, however, was that in the poorest staffed hospitals – better environments decreased the odds on mortality and failure-to-rescue by approximately 2-3%. Meanwhile, in the best staffed hospitals better environments decreased the odds on mortality and failure-to-rescue by roughly 12-14%.

In other words, the effect of improving staffing will be more pronounced in hospitals where work environments are good than in hospitals with mixed or poor environments. The impact of nurse staffing was contingent upon the quality of the nurse environment, and vice versa.

Similarly, the research showed that nurse education may, like nurse staffing, have a more pronounced effect in hospitals with good work environments.

The researchers also noted that improving work environments was not expensive, but it did require changing interprofessional culture and “devolving more authority for care management decisions to those closest to the patients.”

The Effects of Nurse Staffing and Nurse Education on Patient Deaths in Hospitals With Different Nurse Work Environments
Linda H. Aiken, PhD, RN, Jeannie P. Cimiotti, DNSc, RN, Douglas M. Sloane, PhD, Herbert L. Smith, PhD, Linda Flynn, PhD, RN, and Donna F. Neff, PhD, APRN
Med Care. Author manuscript; available in PMC 2012 Dec 1.
Published in final edited form as:
Med Care. 2011 Dec; 49(12): 1047–1053.
doi: 10.1097/MLR.0b013e3182330b6e