Page 362 - Encyclopedia of Nursing Research

NuRSe STAFFING n 329

hospitals in many Western countries in the educational composition of the registered
1990s involved experimentation with staff- nurse workforce in hospitals (notably the pro-
ing configurations, including decreased portion of nurses holding bachelor’s degrees) N
staff-to-patient ratios and increased use of has emerged, beginning with Aiken, Clarke,
non-registered nurse personnel. Concerns Cheung, Sloane, and Silber (2003). Staffing
about deteriorating working conditions and research designs remain principally corre-
potential impacts of staffing changes on lational and cross-sectional in nature, with
patient safety drove interest in studying con- few exceptions (for instance, Mark, Harless,
nections between staffing levels and patient McCue, & Xu, 2004).
outcomes at this time. The analysis of Kovner Research on nurse staffing and its out-
and Gergen (1998), which linked higher RN comes in hospitals is complicated by the
staffing coverage in u.S. acute care hospitals scarcity of reliable and valid staffing data
to lower surgical complication risks, was a in sufficient quantities and at reasonable
landmark publication in this area in terms of cost to allow the examination of the rela-
both methods and findings. tionships, as well as by the availability of
Most scholars in the field conceptual- outcome variables of acceptable methodo-
ize staffing as a structural element within logical quality and of potential sensitivity to
Donabedian’s structure–process–outcomes nursing care (e.g., symptom management).
framework, assume that staffing levels reflect Methodological considerations in this area of
management decisions, and in their recom- research are discussed extensively in several
mended solutions, presume that resources reviews, including Clarke and Donaldson
exist to supplement low staffing levels as (2008) and Mark (2006). The formal study
needed. However, staffing decisions are of mechanisms or pathways linking staff-
clearly also made in relation to operational ing levels (either ratios or staff mix statistics)
demands, financial constraints, and local with clinical outcomes has been very lim-
labor market forces, as well as preferences ited, raising the possibility of confounding
and traditions in a particular setting. Also variables as an explanation for the observed
left implicit are the pathways or mechanisms associations and heightening doubts in some
through which staff coverage or qualification that maintaining high levels of staffing or
mixes could impact outcomes; these mecha- shifting staffing upwards will ensure better
nisms are generally believed to affect the outcomes.
amount and skill of nursing care provided to Policy implications arising from nurse
care recipients. staffing research have been controversial.
The body of empirical findings related Recommendations have included requiring
to staffing outcomes comes largely from monitoring and public reporting of staffing
American hospitals, with the heaviest con- levels, outcomes potentially sensitive to staff-
centration of the literature dealing with out- ing, or both. Others have claimed that this
comes of adult medical–surgical acute care literature demonstrates that staffing levels
inpatients, although a variety of populations have sufficient public health implications to
have been studied and a subset of the litera- warrant close regulation by governments, for
ture pertains to long-term care facilities. The instance, in the form of minimum mandated
main outcome variables tied to staffing have staffing ratios. Still, others have argued that
been mortality and complications, and the the evidence clearly indicates preferred direc-
most consistent findings relate to coverage tions for state and national policies around
of acute care hospitals with registered nurses the funding of nursing education.
rather than staff mix, although mixed find- Staffing researchers, like others in areas
ings for other outcomes have been identified. of nursing health services research, will
An intriguing body of findings related to the likely increasingly examine the multiple