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 …

Prior research has shown that lower nurse-to-patient ratios are associated with increased patient mortality. This cross-sectional analysis using multiple data sources from four states assessed the relationship between nurse staffing and survival disparities after in-hospital cardiac arrest. Results indicate that disparities in survival between Black and white patients may be linked to medical-surgical nurse staffing levels, and that the benefit of being treated at a hospital with higher staffing ratios may be especially pronounced for Black patients.

… 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 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.

… 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.

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.

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.

Extended work shifts for nurses have been linked to increased risk of errors. This large-scale study aimed to provide new information on hospital nurses' shift length and to estimate the effects on nurse-reported hospital safety and quality. Most hospital staff nurses were found to work extended shifts of at least 12 hours. Nurses that worked shifts of 10 hours or longer were more likely to report a poor safety grade compared with nurses working 8- to 9-hour shifts. Some authors have proposed harm reduction strategies for nurses that must work 12-hour shifts. A high-profile fatal medication error that occurred while a nurse was working a double shift previously spotlighted the issue of long nursing hours.

… discussed in this AHRQ WebM&M commentary . … Cimiotti JP, Aiken LH, Sloane DM, Wu ES. Nurse staffing, burnout, and …

… as nurses worked longer shifts. … Stimpfel  AW, Sloane DM, Aiken LH.  Health Aff (Millwood) . 2012;31(11):2501-2509. …

Seminal studies in the United States have shown strong associations between nurses' working conditions and patient safety, with high patient-to-nurse ratios and greater patient turnover being linked to increased mortality. This multinational survey of nurses and patients found that improved nurse work environments and reduced patient-to-nurse ratios were linked to better perceptions of quality and patient satisfaction. Moderately strong correlations were found between patient satisfaction and nursing reports of care quality, although there were wide variations in both measures across different countries. This study lends additional support to the view that improving the work environment for nurses can strengthen patient safety.

The association between lower patient-to-nurse ratios and inpatient mortality has been demonstrated in classic studies, providing an impetus for laws in 15 states that mandate the maximum number of patients per nurse. This study explores the mechanism by which reducing patient-to-nurse ratios improves outcomes. Using a large database of patient discharges and nurse surveys from 665 hospitals in 4 states, the authors found that decreasing the number of patients per nurse improved mortality and failure to rescue predominantly in hospitals rated as having a good work environment. Hospitals with a poor work environment derived no benefit from reducing patient-to-nurse ratios. The critical role that nurses play in ensuring patient safety is discussed further in this Patient Safety Primer.