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.

Operational failures – breakdowns in care processes, such as distractions or situational constraints – can impact healthcare delivery. This cross-sectional analysis using population-based survey data from 11,709 nurses examined the relationship between operational failures, patient satisfaction, nurse-reported quality and safety, and nurse job outcomes. Findings indicate that operational failures negatively impact patient satisfaction, quality and safety, and contribute to poor nurse job outcomes, such as burnout.  

While research shows that better nurse staffing ratios are associated with improved patient outcomes, policies setting minimum nurse-to-patient ratios in hospitals are rarely implemented. In 2016, select Queensland (Australia) hospitals implemented minimum nurse staffing ratios. Compared to hospitals that did not implement minimum nurse staffing ratios, length of stay, mortality, and readmission rates were significantly lower in intervention hospitals, providing evidence, once again, that minimum staffing ratios can improve patient outcomes. 

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

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

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.

Factors in the hospital work environment can affect nurses' ability to provide safe care. In this survey study, investigators examined trends in nurse ratings of their work environment and patient ratings of care quality at 535 hospitals between 2005 and 2016. Over this time frame, about 20% of hospitals showed significant improvements in work environment scores, while 7% of hospitals demonstrated declining scores. There was an association between an improving work environment and better patient satisfaction. The authors conclude that lack of improvement in work environments may worsen safety culture and impede efforts to enhance patient safety. A PSNet interview with Linda Aiken discussed how nurse staffing and the work environment can affect patient safety and outcomes.

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.

Missed nursing care may result from inadequate nurse staffing and explain the relationship between nurse-to-patient ratios and patient outcomes. Research has shown that higher nurse staffing levels are associated with lower inpatient mortality and that reduced staffing increases the risk for postoperative complications. In this study, investigators examined data from more than 400,000 surgical patients from 300 hospitals in 9 countries as well as survey responses from 26,516 nurses. They found a significant association between nurse staffing and missed nursing care with 30-day risk-adjusted postoperative mortality. The authors conclude that measuring missed nursing care may help identify patients at greater risk for adverse outcomes earlier in their course. A past WebM&M commentary highlighted important issues associated with nurse staffing ratios.

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.

… subsequent readmissions are warranted. A recent AHRQ WebM&M perspective discusses the nursing workforce and patient safety. … Carthon JM, Lasater KB, Sloane DM, Kutney-Lee A. The quality of hospital work …

This observational study sought to determine whether the ACGME 2011 duty hour reforms led to changes in 30-day mortality or readmissions for several medical diagnoses—acute myocardial infarction, stroke, acute gastrointestinal bleed, or congestive heart failure—and for general, orthopedic, or vascular surgery. The authors examined how hospital teaching status, which they defined using resident-to-bed ratio, affected outcomes for these conditions. This measure provides insight into the intensity of teaching at a given institution rather than defining each hospital as teaching versus nonteaching. During the study time period, although readmissions and mortality both declined overall, this decrease did not differ based on teaching status, suggesting that the improvement in readmissions and 30-day mortality is not attributable to duty hour reform. These results are consistent with prior work following the 2003 duty hour reforms which has failed to demonstrate benefit to patient outcomes from costly duty hour reforms. An editorial discussing this work and a companion study urge flexibility in duty hours for physicians in training.

… ratios may contribute to burnout . A past AHRQ WebM&M interview with Barbara Blakeney discussed the importance of … nursing staffing for patient safety, and a prior AHRQ WebM&M commentary examines the complexities around balancing nurse …

Accurately detecting safety events remains challenging, and health care organizations are still struggling to determine the incidence of adverse outcomes associated with nursing care. This study used chart reviews to identify the rates of six adverse events considered to be directly related to nursing care: pressure sores, falls, medication administration errors, pneumonia, urinary infections, and inappropriate use of restraints. One in seven hospitalized adults experienced at least one of these adverse events.

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.