While the association between clinician burnout and patient safety are not new, the COVID-19 pandemic brought this safety concern back to the forefront. In this study conducted at 60 US Magnet hospitals, nurses and physicians reported high levels of burnout and rated their hospital unfavorably on patient safety. Increased nurse staffing was the top recommendation to reduce burnout with less emphasis on wellness and resilience programs.

… ratios can improve patient outcomes.  … McHugh  MD, Aiken LH, Sloane DM, et al. Effects of nurse-to-patient ratio …

… pronounced for Black patients. … Carthon MB, Brom H, McHugh M, et al. Better nurse staffing is associated with …

… of understaffing, even before COVID-19.     … Lasater KB, Aiken LH, Sloane DM, et al. Chronic hospital nurse …

The nursing work environment affects patient safety. This cross-sectional study surveyed nearly 2000 pediatric acute care nurses about their work environment and safety culture. Researchers measured the hospital work environment using a validated scale, and they assessed safety using the AHRQ Survey on Patient Safety Culture. A culture of blame and fear of speaking up remained prevalent among nurses participating in this survey. As with prior studies, investigators found an association between a high-functioning work environment and positive safety culture. The authors recommend enhancing pediatric acute care work environments for nurses in order to improve patient safety. A previous PSNet interview discussed how nurse staffing and the work environment can affect patient safety and outcomes.

Prior research suggests that improved nursing resources may be associated with decreased mortality and adverse events. However, less is known about how changes to nursing resources in the inpatient setting may affect quality and safety over time. In this study involving 737 hospitals and survey data from nurses obtained in 2006 and 2016, researchers found that after adjusting for numerous factors, better nursing resources in terms of work environment, staffing, and education was associated with improvement in quality and patient safety outcomes. A PSNet perspective discussed the impact of nursing resources on patient safety.

… efforts to enhance patient safety . A PSNet interview with Linda Aiken discussed how nurse staffing and the work environment …

This secondary analysis combined survey data from individual nurses with hospital safety culture data and found that both individual characteristics such as education level and hospital characteristics such as safety culture were associated with risks of medication administration errors and falls. The authors conclude that improving safety culture should be a high priority.

This cross-sectional study found that nurses reporting a lower level of engagement also described worse patient safety in their work environment. These concerns were exacerbated when higher patient–nurse staffing ratios were present. The authors suggest that increasing nurse engagement may improve patient safety.

Duty hour reform for trainees was undertaken to improve patient safety. However, experts have raised concerns that duty hour limits have reduced educational opportunities for trainees. This study randomized internal medicine residency programs to either standard duty hour rules from the Accreditation Council on Graduate Medical Education (ACGME) or less stringent policies that did not mandate the maximum shift length or time off between shifts. Investigators found that trainees in both groups spent similar amounts of time in direct patient care and educational activities, and scores on examinations did not differ. Interns in flexible duty hour programs reported worse well-being and educational satisfaction compared to those working within standard duty hours. As in a prior study of surgical training, program directors of flexible duty hour programs reported higher satisfaction with trainee education. These results may help allay concerns about detrimental effects of duty hour reform on graduate medical education. A PSNet perspective reviewed changes to the ACGME requirements to create flexibility for work hours within the maximum 80-hour workweek.

This literature review found that the relationship between safety culture and patient safety outcomes is inconsistent across studies. Researchers recommend use of a theoretical framework and validated safety culture instruments to shed light on the correlation between safety culture and patient harm.

… with nurse staffing ratios. … Ball JE, Bruyneel L, Aiken LH, et al. Post-operative mortality, missed care and …

Missed nursing care is common and has been linked to adverse events. This survey found that more than half of pediatric intensive care unit nurses reported missing care during their prior shift. Higher patient loads and poor working environments were associated with more episodes of missed care, corroborating prior research.

Researchers analyzed patient discharge data and hospital characteristics, as well as patient and nurse survey data, across adult acute care hospitals in six European countries. After adjusting for hospital and patient variables, they found that hospitals in which nursing care was provided to a greater degree by skilled nurses had lower odds of mortality. The authors argue against replacing professional nurses with nursing assistants and suggest that doing so may compromise patient safety by increasing preventable deaths.

The health care environment is known to influence teamwork and the culture of safety. This integrative review explored the literature to clarify the relationship between nurses' work environment and patient safety. The authors found weak definitional concurrence and measure inconsistency in the evidence base and advocate for improved research design to support future investigation in this area.

This survey of nurses found that those who rated their work environment as poor were more likely to report quality and safety problems, underscoring the well-described link between nurses' working conditions and patient safety. Improving nurse working conditions is a patient safety strategy.

Although 12-hour nursing shifts are common in the United States, this study found that only 15% of European nurses worked 12 hours or more. Similar to prior research, longer nursing shifts were associated with lower quality of care and compromised patient safety. This study also found that nurses working extended shifts reported more care left undone. Nurses who worked overtime, even if shift length was less than 10 hours, described similar concerns. The authors warn that policies to adopt standard 12-hour nursing shifts as a cost-effective way of maintaining nurse–patient ratios may contribute to burnout. A past AHRQ WebM&M interview with Barbara Blakeney discussed the importance of proper nursing staffing for patient safety, and a prior AHRQ WebM&M commentary examines the complexities around balancing nurse staffing and workload.

This retrospective cohort study across nine European countries revealed that higher patient–nurse staffing ratios increased the likelihood of inpatient mortality. A larger proportion of nurses with bachelor's degrees decreased this risk, consistent with previous research that found a relationship between nurse education levels and patient outcomes. This finding emphasizes the importance of maintaining an adequately staffed and trained nursing workforce to support safety in hospitals.

Sleep deprivation can worsen clinical performance. Early studies on the effects of fatigue in clinical trainees formed some of the basis behind duty hour restrictions for resident physicians. This study surveyed intensive care unit (ICU) nurses about levels of fatigue and clinical decision-making. Nurses who regretted a clinical decision were more apt to be fatigued and to work 12-hour shifts. Sleep deprivation among ICU nurses was found to be common, with almost three-quarters of surveyed nurses having lost 8 or more hours of sleep in a 5-day period. The study was limited by a very low (17%) response rate, potentially biasing the results. Prior research has linked extended nursing shift lengths with compromised patient safety.

Nurses are frequently forced to prioritize tasks during busy shifts, leading to some nursing care being left undone. In this multinational European study, nurses most frequently omitted time-intensive but critical practices such as talking with, educating, and providing comfort for patients.