Quality improvement paper (Nursing)

ajn@wolterskluwer.com AJN ▼ August 2018 ▼ Vol. 118, No. 8 17

While we know that in-creasing nurse work-loads beyond optimal levels is associated with a greater risk of patient safety incidents and mortality, a new study from Fin- land illuminates another dimen- sion of the much-debated staffing issue, since it focused on actual workload rather than the more familiar patient-to-nurse ratio.

In 90% of Finnish hospitals, nurse staffing is determined not by patient-to-nurse ratios but by a classification system developed in the 1990s called RAFAELA that assesses patients’ nursing care needs. The system permits differ- ent staffing levels for each unit, based on a formula that considers such patient characteristics as age, sex, diagnoses, and functional ability.

In the study, researchers col- lected daily data for one year re- garding patient safety incidents, patient mortality, and actual daily workload per nurse from 36 units at four Finnish hospitals. Nurse workloads on the units could have been at, above, or below recom- mended nurse staffing levels as determined by RAFAELA. Re- searchers then looked for associa- tions between workload per nurse and adverse events or mortality.

They found that when a nurse’s workload was above the optimal level, the likelihood of a patient safety incident—defined as a safety hazard that either could have caused harm, but was prevented, or did cause harm—increased 8% to 34% (depending on the type of incident), and the likelihood of patient mortality increased 43%.

When nurse workloads were be- low the optimal level, the odds of a safety incident or death were each 25% lower. The study’s authors in- terpreted this decrease to mean that nurses had more time “for caring and observing each patient, which may reduce the risk for adverse events and accordingly prevent the patient’s health condition from deteriorating.”

While the study had limita- tions—among others, it did not address the influence of nurse skill mix, competence, or work experience—it showed a correla- tion between higher than optimal nurse workloads and increased risk of adverse events and patient mortality.—Joan Zolot, PA

Fagerström L, et al. BMJ Open 2018;8(4): e016367.

Higher Than Optimal Nurse Workloads Increase the Odds of Patient Mortality

When workloads dropped below the assumed optimal levels, patient outcomes improved.