Introduction: Patient safety and the occurrence of adverse events in hospitals is a topic which has been widely addressed over the last decades. In that respect, there has been an increasing interest in the effect of working conditions on patient safety, and whether understaffing and adverse events are correlated. This paper therefore reports results from a study of under - staffing of nurses understood as a lack of nurses available to conduct the tasks required of them. This implies that nurses are forced to ignore or postpone important tasks, thereby compromising patient safety. Purpose: The purpose of the study is to increase the knowledge of understaffing of hospital nurses, and the consequences that understaffing may have on patient safety. Methods: A literature search of the databases Chinal, Medline, Cochrane library, Isi Web of Science and Academic Search premiere was conducted in the period January 2014 to February, 2016. Results: Results are categorized into two main themes and four subthemes. The first main theme describes the direct relationship between understaffing and patient safety. Poor staffing increases the risk of mortality, and adverse conditions such as pressure ulcers, deep vein thrombosis and hospital-related infections. The second main theme relates to the indirect implications of understaffing for patient safety. These implications pertain to the lack of time that nurses could give each patient, limitations in the quality of nursing, and challenges in safe medication administration. Conclusions: The study documents the relationship between understaffing of nurses and adverse events in hospitals, revealingthat understaffing of nurses is a risk factor for hospitalized patients.
The incidence of patients experiencing adverse events while hospitalized has proven a major problem [
The US Department of Health & Human Services defines patient safety as “the freedom of accidental or preventable injuries produced by medical care”. Patient safety measures are defined as interventions or work intended to reduce the occurrence of preventable events [
The requirement of professional responsibility is the most central demand in the legislation when it comes to safety practice in the healthcare service. The demand of professional responsibility is according to law, a shared responsibility, were the health workers are responsible for their own actions, and the healthcare system is responsible for the environment these actions are conducted in. Further on health workers, in this case nurses are obligated to perform safe healthcare through the nature of their public authorization, which is an arrangement built on common national and international demands in the nursing education and is a requirement to legally assess nursing tasks [
The International Council of Nursing states that nurses carry a responsibility to perform safe practice and to obtain the knowledge to do so. They are obligated to provide holistic patient care, which include giving the patients and families accurate information and education. Nurses are expected to participate in maintaining safe working conditions and safe practice [
The purpose of this study is to increase the knowledge of understaffing amongst nurses in hospitals, and the possible consequences of understaffing for patient safety. More specifically the study examines understaffing as a risk factor for hospitalized patients. The following research question has guided the study: How can understaffing amongst nurses in hospitals affect patient safety?
Understaffing is a term with numerous connotations and meanings. In the literature, understaffing is used, for instance, in reference to high patient-nurse ratios, heavy workload, large patient load, nursing hours per patient, and high bed occupancy. The common denominator of these definitions are that understaffing is a lack of personnel, in this case nurses, to conduct their required tasks. In this study, the term understaffing is defined as “a disparity between load of responsibilities/tasks and the possibility to conduct them in a professional manner”.
A nurse is in this study, defined as a person with a bachelor education in nursing, having regular contact with patients admitted to a hospital ward.
A literature review was conducted using a systematic approach as described by Bettany-Saltikov [
To be included in the review, articles had to be written in English, they had to have a clear qualitative or quantitative design, and they had to have been published between1997 and 2016. Eligible studies had to be concerned with nurses with patient contact, working in hospitals, some form of understaffing (excessive workload, high patient-to-nurse ratio, number of working hours per patient) and patient safety.
The search strategy was developed in accordance with Bettany-Saltikov [
All included studies were of quantitative study design, and underwent a quality assessment according to the Cochrane Quality Assessment Tool for Quantitative Studies [
We used a predesigned form for data extraction according to Dixon-Woods et al. [
The database searches identified 2847 records. Six articles were found through secondary searches and recommendations from researchers in the field of patient safety. Of the 2609 articles screened, 2495 were excluded. The remaining 114 articles were read and evaluated in full text (see
studies did not pass the quality assessment, and were excluded, resulting in a total of 33 quantitative studies being included in the current review. First author performed the searches and undertook the screening of titles and abstracts against inclusion criteria, with supervision from the research group. First researcher then undertook the read-through of selected full-text articles. Where there was question of inclusion eligibility, the research group was consulted independently to assess full-text item suitability.
The results of the included studies were analyzed through Thematic analysis which involve finding prominent or recurrent themes in included articles, and gather the themes under suitable headings [
Data represented in this study emerged from already published peer reviewed articles. Data collection did not involve human subjects, and a written informed consent has therefore not been obtained.
All the data supporting the conclusions can be found in
This literature review synthesizes evidence about the effects of the understaffing of nurses on patient safety in hospitals. Thirty-three studies of moderate-to-strong quality were included, from which two main themes and four subthemes emerged.
Twenty-three studies [
Six studies [
One study [
Of the thirty-three studies included, there are nine cohort studies, thirteen cross-sectional studies, two correlation studies, one case control study, three retrospective observational studies, two retrospective longitudinal studies and one with a four-stage sampling design. It was not possible to categorize the methods used in two of the studies. (
Author study design quality country | Aim | Informants/data material | Main findings | Themes |
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Aiken et al. (2014) [ | To determine whether differences in patient to nurse ratio and nurses educational qualifications were associated with hospital mortality after common surgical procedures. | Discharge data from 422.730 patients 50 years or older, who underwent surgery and survey of 26.516 Nurses | Each increase of one patient per nurse is associated with a 7% increase in the likelihood of a surgical patient dying within 30 days of admission, whereas each 10% increase in the percent of bachelor degree nurses in hospital is associated with a 7% decrease in this likelihood. | Direct consequences: mortality |
Aiken et al. (2002) [ | To determine the association between the patient-to-nurse ratio and patient mortality, failure to rescue among surgical patients, and factors related to nurse retention | Data from 10.184 staff nurses surveyed, 232.342 general, orthopedic and vascular surgery patients and administrative data from 168 general hospitals | Each additional patient per nurse was associated with a 7% increase in the likelihood of dying within 30 days of admission and a 7% increase in the odds of failure to rescue (Patient and hospital characteristics were adjusted). | Direct consequences: mortality |
Al-Kandari & Thomas (2009) [ | To identify the perceived adverse patient outcomes related to nurse’ workload | 780 registered nurses working in medical and surgical wards of five governmental hospitals in Kuwait. | Five major perceived adverse patient outcomes: 1) complaints from patient and their families, 2) patient received a late dose or missed a dose of medication, 3) discovering pressure ulcer, 4) wound infection and 5) infection on the site of IV cannula. | Indirect consequences: Poor basic quality of care |
Amarvadi et al. (2000) [ | To determine if having a 1:2 rather than a 1:3 or more night-time nurse-to-patient ratio (NNPR) in the intensive care unit affected hospital mortality | Adult patients who had esophageal resection in Maryland 1994 to 1998 (366 patients) | There were no significant difference in the risk of in-hospital mortality between patients with a NNRP > 1:2 (Night time nurse-to-patient ratio > one nurse caring for one or two patients) and those with a NNRP < 1:2 (Nurse caring for three or more patients) Patients with a NNPR < 1:2 had an increased risk of reintubation, pneumonia and sepsis | Direct consequences: Patient harm |
Carthonet al. (2012) [ | To determine the association between nurse staffing and postsurgical outcomes for older black adults, including 30-day mortality and failure to rescue. | 548.397 patients ages 65 and older, undergoing general, orthopedic or vascular surgery | One additional patient in the average nurse’s workload was associated with higher odds of 30 day mortality for all patients. Odds of failure to rescue were higher for patient in settings with poorer nursing staffing | Direct consequences: Mortality |
Cho et al. (2015) [ | To examine the relationship of nurse staffing levels and work environment with patient adverse events | 4864 nurses Data from 58 hospitals Discharge data from 113,426 Patients | A large number of patients per nurse were significantly associated with a greater incidence of administration of wrong medication or dose, pressure ulcers and patient falls with injury. | Indirect consequences: medication errors and patient harm. |
Cho et al. (2003) [ | Examine the effects of nurse staffing on adverse events, morbidity, mortality and medical costs | Existing databases from 232 acute care hospitals and 124,204 patients in 20 surgical diagnosis-related groups. 857 patients with hemorrhagic and ischemic stroke who were admitted to ICUs of 185 Korean hospitals | An increase of one hour worked by registered nurses per patient per day was associated with an 8.9% decrease in the odds of pneumonia. Hospitals with higher ICU staffing were more likely to fully provide basic care. Better staffing were associated with lower in-hospital and 30-day mortality. 30-day mortality had a more distinct decrease with lower staffing rates | Direct consequence: Patient harm |
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Cho & Yun (2009) [ | To examine differences in provision of basic nursing care and in-hospital and 30-day mortality by nurse staffing of ICUs and general wards among acute stroke patients | ICUs of 185 Korean hospitals | Better staffing was associated with lower in-hospital and 30-day mortality. 30-day mortality had a more distinct decrease with lower staffing rates. | Direct consequences: Mortality |
Cimotti et al. (2006) [ | To examine the association between registered nurse staffing and healthcare associated bloodstream infections in infants in neonatal intensive care units. | 2675 infants admitted to the NICUs for more than 48 hours and all registered nurse who worked in the same NICUs during the study | A greater number of hours of care provided by RNs in NICU 2 were associated with decreased risk of bloodstream infections. Number of hours of care provided by RNs in NICU 1 was not associated with bloodstream infections. | Direct consequences: Patient harm |
de Cordova et al. (2014) [ | Examine the association between night nurse staffing and work force characteristics and length of stay (LOS) | Monthly observations of administrative data from 138 acute care hospitals (N = 8243) | Higher night staffing and higher skill mix were associated with reduced LOS | Direct consequences: Patient harm |
Daud-Gallotti et al. (2012) [ | Evaluate the role of nursing workload in the occurrence of HAI in medical intensive care units. | 195 ICU-Patients | 22% developed HAI (healthcare-associated infection). Average NAS (Nursing activity score) and average proportion of non-compliance with NPC (Non-compliance to the nurse’s patient-care plans) were significantly higher in HAI patients. Only excessive nursing workload and severity of the patient’s clinical condition remained as risk factors to HAI. | Direct consequences: Patient harm |
Duffield et al. (2011) [ | Examine the relationship of nurse staffing and workload, in the context of the work environment, to patient outcomes. | Data from the public hospital system. Five years of data for 80 public hospitals | Increased RN staff were associated with significantly decreased rates of pressure ulcer, pneumonia, and sepsis, GI bleeding, physiological/metabolic derangement, pulmonary failure, sepsis and shock. There were several nursing-tasks left undone or postponed as a consequence of heavy workload. | Direct and indirect consequences: Poor basic care quality and patient harm |
Hugonnet et al. (2007) [ | To determine whether low nurse-to-patient ratio increases risk for VAP and whether this effect is similar for early-onset and late-onset VAP. | 2470 ICU patients. Variable such as number of patients and nurses on duty, patient characteristics, nurse training levels | 262 VAP episodes were diagnosed in 22.3% of the patients who underwent mechanical ventilation The median daily nurse-to-patient ratio was 1.9 over the study period. High nurse-to-patient ratio was associated with a decreased risk for late-onset VAP, but there was no association with early-onset VAP | Direct consequences: patient harm |
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Holden et al. (2011) [ | To measure each of the three types of workload experienced by nurses and to assess whether and which measures of workload were related to three important outcomes. | 99 nurses from two hospitals | The task level measure of mental workload related to interruptions, divided intention, and being rushed was associated with burnout and medication error. Workload was not significantly associated with any other outcomes | Indirect consequences: Medication errors |
Kiekkas et al. (2008) [ | Investigate differences in mortality of intensive care unit (ICU) patient according to the ratio between total patient care demands and nurse staffing | 396 patients admitted in the general ICU of an academic, tertiary care, Greek Hospital from October 2005 to September 2006 | Mortality on all patients increased from 22% in the low-exposure group (<21.9) Therapeutic Intervention Scoring System (TISS-28) point per nurse-workload measurement) to 25.0% in the medium exposure group (21.9 - 25.8 TISS-28 point per nurse) and reached up to 28.8% in the high-exposure group (>25.8 TISS-28 score per nurse) Despite these increases, differences in adjusted ICU mortality among groups did not reach statistical significance | Direct consequences patient mortality |
Kovner et al. (2002) [ | To examine the impact of nurse staffing on selected adverse events hypothesized to be sensitive to nursing care | Nurse staffing data from 1990-1996 from the American hospital association annual survey of hospitals. Includes 530 - 570 hospitals for each of the years from 1990-1996, with 187 hospitals having data for all seven years. | Registered nurse (RN) hours per patient per day were inversely related to all adverse events, but was significant (P < 0.05) only for pneumonia | Direct consequences: Patient harm |
Liang et al. (2012) [ | To explore the effects of nurse staffing ratios on patient mortality in acute care hospitals. | 108 hospital nursing units in 32 of Taiwan’s’ 441 accredited Western medicine district/regional hospitals and medical centers. Data from a survey on hospital nurse staffing levels and patient outcomes. | The risk of incidence of death seemed to be higher in high patient-nurse ratio groups than in low patient-nurse ratio groups. The risk of incidence of death in high healthcare workforce-bed ratio groups was much lower than in low healthcare workforce-bed ratio groups. | Direct consequences: Patient harm |
Needleman et al. (2002) [ | Not reported | Administrative data from 1997 for 799 hospitals in 11 states, covering 5,075,969 discharges of medical patients and 1,104,659 surgical patients | A higher proportion of hours of care per day provided by registered nurses and a greater number of hours of care provided per day were associated with a shorter length of stay and lower rates of urinary tract infections and upper gastrointestinal bleeding. A higher hour of care provided by RNs was associated with a lower rate of pneumonia, shock or cardiac arrest, and “failure to rescue”. | Direct consequences: Patient harm |
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Person et al. (2004) [ | Assess the association of nurse staffing with in-hospital mortality for patients with acute myocardial infarction. | 118,940 patients admitted with AMI in 6668 hospitals in the US | Patients treated in environments with higher RN staffing were less likely to die in-hospital. Patients treated in environments with higher LPN (licensed practical nurse) staffing were more likely to die in-hospital. (The data was adjusted with patient demographic, clinical characteristics, treatment, hospital volume, technology index teaching and urban status) | Direct consequences: Mortality |
Potter et al. (2003) [ | To determine baseline values of patient outcome measures and the relationship of nurse staffing to patient outcomes. | 32 acute inpatient care units 3418 patients | The percentage of RN hours was negatively correlated with patient pain and self-care ability, and positive correlated with patient health status and five out of seven measures of post-discharge patient satisfaction. | Indirect consequences: Poor quality of basic care |
Rogowski et al. (2013) [ | To study the adequacy of Neo Natal Intensive Care Unit (NICU) nurse staffing in the United States using national guidelines and analyze its association with infant outcomes | newborn very low-birth-weight infants discharged from the NICUs in 2008 (n = 5771) and 2009 (n = 5630) All registered nurses with infant assignments. | The percentage of Very Low Birth Weight (VLBW) infants with hospital associated infections were 16.4% in 2008 and 13.9% in 2009. Relative to the guidelines, on average, hospitals understaffed 47% of all NICU infants in 2008 and 31% in 2009. A 1 standard deviation increase in the amount of a nurse per infant to meet the guidelines was associated with higher odds of infection in 2008 and 2009 | Direct consequences: Patient harm |
Sasicbay-Akkadecbanunt et al. (2003) [ | To examine the association between in-hospital mortality and four nurse staffing variables. | Data of 2531 patients admitted to seven medical units and 10 surgical units of a 2300 bed university hospital. | The nurse-to-patient ratio was statistically correlated with in-hospital mortality. Nurse-to-patient ratio had an individual effect on in-hospital mortality. The ratio of total staff to patients was the best predictor of in hospital mortality among four staffing variables. There was not a significant relationship between in hospital mortality and the proportion of RNs to total nursing staff, the mean years of RN experience and the percentage of bachelor degree prepared nurses. | Direct consequences: Mortality |
Schreuders et al. (2014) [ | To compare characteristics of hospitalizations with and without complications and examine the impact of nurse staffing on inpatient complications | Administrative data from Western Australian Department of Health (2001-2008) | Nurse staffing levels were not associated with decreased patient complication risks. | No significant relationship |
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Seynaeve et al. (2011) [ | To examine the association between in-hospital mortality and four nurse staffing variables. | Data of 2531 patients admitted to seven medical units and 10 surgical units of a 2300 bed university hospital. | Statistically correlated with in-hospital mortality. Nurse-to-patient ratio had an individual effect on in-hospital mortality. The ratio of total staff to patients was the best predictor of in hospital mortality among four staffing variables. There was not a significant relationship between in hospital mortality and the proportion of RNs to total nursing staff, the mean years of RN experience and the percentage of bachelor degree prepared nurses. | Direct consequences: Mortality |
Shuldham et al. (2008) [ | To explore the relationship between nurse staffing characteristics and patient outcomes. | All patients, included day cases, who were admitted at two hospitals as an in-patient over 12 months | Weak association between nurse staffing and the majority of the outcomes in the lower dependency category wards. The Incidence Rate Ratio (IRR) for falls, GI bleeds, sepsis and Deep Vein Thrombosis (DVT) were reduced where nursing hour per patient day increased, but the numbers were not statistical significant. When adding bank hours (extra staff from the hospital), in addition to the permanent staff, only the result of pressure sores and DVT reached statistical significance. | No statistical significance. Indirect consequences: Patient harm |
Stone et al. (2007) [ | To examine effects of a comprehensive set of working condition on elderly patient safety outcome in intensive care units. | To examine effects of a comprehensive set of working condition on elderly patient safety outcome in intensive care units. | Units with higher staffing levels had lower incidence of CLBSI (central line blood stream infections), ventilator-associated pneumonia, 30-day mortality and pressure ulcer. | Direct consequences: Patient harm. |
Tarnow-Mordi et al. (2000) [ | Not reported | 1050 admissions in the ICU | Adjusted mortality were more than two times higher in patients exposed to low ICU workload. After exclusion of measures of nursing requirement, adjusted mortality increased with the ratio of occupied to appropriately staffed beds during each patient’s stay. | Direct consequence: Mortality |
Twigg et al. (2011) [ | To determine the impact of implementing the NHPPD (Nursing hours per patient day) staffing method on 14 nursing-sensitive outcomes | 236,453 patients from three adult hospital wards. Changes in nursing-sensitive outcomes were examined comparing the pre NHPPD-implementation-stage 0 and the post implementation-stage 2. | Significant decreases in the rates of nine out of fourteen nursing-sensitive outcomes when examining hospital-level data following implementation of NHPPD: Mortality, central nervous system complications, pressure ulcers, deep vein thrombosis, sepsis, ulcer/gastritis/upper gastrointestinal bleed, shock/cardiac arrest, pneumonia and average length of stay. | Direct consequences: Patient harm and patient mortality |
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Unruh (2003) [ | To examine the changes in licensed nursing staff and assess the relationship of nursing staff with patient adverse events in hospitals | A convenience sample of all Pennsylvania, acute-care, hospitals, 1991 to 1997 | Greater incidence of nearly all adverse events occurred in hospitals with fewer licensed nurses. There were a higher incidence of pressure ulcer and pneumonia in hospitals with a lower proportion of licensed nurses | Direct consequences: Patient harm |
Van den Heedeet al. (2009) [ | Examine the association between nurse staffing levels and 10 different patient outcomes potentially sensitive to nursing care | Data from 115 Belgian acute hospitals for the year 2003. | No significant relationship between acuity adjusted NHPPD (Nursing hours per patient day), proportions of registered nurses with at least a Bachelors’ degree and 10 patient outcomes. | No significant relationship |
Weissman et al. (2007) [ | To determine the relationship between peak hospital workload and rates of adverse events. | A random sample of 24,676 patients discharged from the medical/surgical services at 4 US hospitals | Admissions and patients per nurse were significantly related to the likelihood of an adverse event. For example 0.1% increase in the patient-to-nurse ratio led to a 28% increase in the adverse event rate in one urban teaching hospital with high occupancy. These results were only significant for this hospital. There were no significant results in the other three hospitals in the study. | Direct consequences patient harm |
Yang (2003) [ | To examine the effect of nurse staffing variables-daily average hours of care, ratio of RNs to average patients’ census, workload, and skill mix on patient outcomes as measured by five adverse occurrences | Data from hospital statistics. Sample composed of 347 FTE (fulltime equivalent) RNs distributed in 21 units with 793 beds ranging from 34 to 48 with a mean of 37.76 beds, as well as 29,424 inpatients. | Significantly positive correlation between daily average hours of care and urinary tract infections (r = 0.523, p < 0.05) and patient falls (r = 0.456, p < 0.05). Ratio of RNs to patient census negatively correlated to patient falls, urinary tract infections and complaints. Positive and significant relationship between workload and respiratory tract infections, patients’ complaints and their acuity level. | Direct consequences: Patient harm |
Zhu et al. (2012) [ | To examine the relationship between nurse staffing and patient outcomes in hospitals in mainland China. | 7802 nurses and 5430 patients | Higher levels of nurses per patient had a statistically significant positive effect on the conduct of important nurse related tasks, and therefore on patient outcomes. | Indirect consequences: poor quality of basic care. |
The thematic analysis [
Theme 1: Direct consequences
Twenty-three studies reported that understaffing had direct and severe consequences for patients.
1A) Patient harm
Sixteen of the twenty-three studies examined several adverse events as a direct consequence of understaffing among nurses working in hospitals [
Along with hospital-related infections, the incidence of pressure wounds was also a problem that, according to the literature, increased in proportion to understaffing [
Lastly, one study found that higher night staffing reduced the prevalence of extended hospital stays [
2B) Patient mortality
Nine studies found understaffing to affect mortality in hospitalized patients. Both surgical and medical patients were investigated [
In one observational study from 2014 and one cross-sectional analysis from 2002 Aiken and colleagues found that after adjusting for patient and hospital characteristics, each additional patient per nurse was associated with a 7% increase in the likelihood of dying within 30 days after admission. Carthon et al. [
In two studies, no correlation between mortality and understaffing were found [
Theme 2: Indirect consequences
Six studies found understaffing to affect patient safety, not by causing the patient direct harm but by increasing the risk for direct harm later on.
2A) Poor quality of basic care.
Four studies concluded that understaffing led to poor quality of care [
2B) Errors in administration of medication.
Two studies focused on understaffing and medication errors [
The results of the literature review indicate that understaffing of nurses have a negative effect on patient safety. The negative effect is reflected through various consequences for the patient’s wellbeing, health, and outcome of hospitalization. Even though the results of this study are divided into themes and subthemes, all four themes are interrelated. The literature review shows that the indirect consequences of understaffing (lack of managing important nursing task such as measuring vital signs, patient mobilization and responding to patient alarms) may cause severe and direct consequences (thrombosis, patient falls and mortality) later in the course of treatment.
A relationship between the themes can for example be seen in relation to pressure wounds; hygiene measures, skincare, and mobilization are measures intended to prevent pressure wounds [
Failure to provide basic care as a consequence of understaffing affects patients in ways that might not always be apparent. Tasks that do not seem as important as other tasks are constantly postponed or left undone, placing the patient at risk of severe harm.
As previously stated, the results of the studies reviewed here indicate that understaffing affects patient safety in numerous negative ways. However, several other aspects must be taken in consideration before formulating conclusions.
Many of the studies of mortality were conducted in intensive care units (ICU) [
Several of the studies describe surgical patients in conjunction with both patient mortality and patient harm [
Furthermore, the data used in most of the included studies were based singularly on administrative data (hospital statistics, discharge data, staffing data) and/or surveys. This type of data brings a few challenges. There will always be a chance of underreporting of adverse events, which may lead to unreliable results [
Another important aspect is that most of the studies are conducted in high income countries all over the world. There is one study from Brazil [
Lastly, the health personnel in this study include Registered Nurses (RNs), even though some of the studies also included data regarding other health personnel, the results of this study do not consider the effect of other health personnel on patient safety. It is known that for example nursing assistants and licensed practical nurses (LPN) are huge contributors to the basic care given in hospital wards. Further, there are also research results showing that wards with low RN-rates in the skill mix compared with other groups such as LPNs has less fortune outcomes when it comes to adverse events [
Kane and colleagues systematic literature review from 2007 [
As showed, there may be characteristics about the patient, the hospital, and the ward, that affect the results of the studies included in our literature review. Understaffing may be one of the contributing factors that affect patient safety, but other factors may most likely also be contributing
Methodological LimitationsThere are possible limitations in our literature review and several confounders need to be addressed when reviewing the results. Manual searches could have been conducted in other additional journals, by using citation tracking, and by assessing unpublished literature to increase chances of finding further relevant items. To test for additional findings, we tested new search terms and search words, without identifying new items meeting our inclusion criteria. The study was conducted according to strict methodological guidelines for literature reviews [
Secondly we excluded studies of other health facilities than hospitals, and other health personnel than nurses, and also publications on discharge outcomes, in accordance with the exclusion criteria. This may have led to the loss of valuable information about understaffing and patient safety.
Thirdly, the thematic analysis method used in this review is more commonly used in studies with singularly qualitative designs, or with mixed methods [
Finally, some general risks of bias will always be present in literature reviews. Studies with valuable results, but not written in English, are excluded because of the exclusion criteria [
The literature review documents that understaffing of nurses can affect patient safety negatively in both direct―(pressure wounds, infections, mortality) and indirect ways (poor documentation, failure to mobilize patients, lack of proper surveillance). The type of ward, hospital, patient group, and country in the included studies vary, but all studies show that too few nurses at the hospital wards give too little time to perform important nursing tasks, which may have consequences of varying degrees of severity for the patient. The current results show that numerous characteristics and factors (e.g. type of hospital, ward, and patient characteristics) are important when investigating the relationship between understaffing and patient safety. All of these characteristics and factors must be considered when reading the results of this and other studies. More research on the topic is needed, as the articles included in this study mention the lack of research, especially in the Nordic countries. Lastly, no clear and direct causal relationship between understaffing and patient safety is found, but the findings leads us to the conclusion that understaffing of nurses constitutes a risk factor for hospitalized patients and could be one threat to patient safety.
All the data supporting the conclusions can be found in
The results of this systematic review emerged from analysis of data extracted from already published peer reviewed articles. The study does not involve any data collection involving human subjects and does not require any consent or ethical approval.
None.
All members of the research group participated in the conception and design of the study as well as in analysis and interpretation of data. The first researcher undertook acquisition of data and the drafting of the manuscript. All authors were involved in critically revising the manuscript for important intellectual content and all read and approved the final manuscript.
Glette, M.K., Aase, K. and Wiig, S. (2017) The Relationship between Understaffing of Nurses and Patient Safety in Hospitals―A Literature Review with Thematic Analysis. Open Journal of Nursing, 7, 1387-1429. https://doi.org/10.4236/ojn.2017.712100
Search words:
1) Understaffing
2) Lack of nurses
3) Staffing levels
4) Under manning
5) Manning levels
6) Downsizing
7) Short-staffed
8) Short-handed
9) Inadequate in number of workers
10) Inadequate staffing
11) Insufficient number of personnel
12) Workload
13) Nurses
14) Health worker
15) RN (registered nurse)
16) Employee
17) Trained nurse
18) Patient safety
19) Patient
20) Outcome
21) Patient security
22) Patient mortality
23)Adverseevents
24) Hospital
25) Health care facilities
26) Hospital ward
27) Medical institution
Searches done in Chinal 04.02.14-
*Search word 4 (undermanning) didn’t give any results in any combinations. **Search word 5 (Manning levels) didn’t give any results in any combinations. ***Search word 6 (Downsizing) didn’t give any results in any combinations. ****Search word 8 (short-handed) didn’t give any results in any combinations.
Searches done in Medline―15.02.14
Searches done in ISI Web of science 31.03.14-
*Reduced the result to 7 hits, by checking of nursing and excluding case report, meeting and editorial. **Reduced the result to 280 hits, by checking of English, nursing and excluding Editorial, meeting and case report. ***Reduced the result to 34 hits by checking of nursing and English. ****Reduced the result to 36 hits by checking of nursing and English and excluding case report. *****Reduced the result to 5 by checking of nursing, English an exclude newsletter, editorial, reference material and case report.
Searches done in Cohrane library 29.04.14-
Searches done in Academic search premiere 31.04.14-
Searches done in Chinal December 2015-February 2016 (Year 2014-2015)
Fulltext Quality Assesement tool for quantitative studies: http://www.ephpp.ca/PDF/Quality%20Assessment%20Tool_2010_2.pdf
Fulltext Quality Assessment tool for quantitative studies dictionary: http://www.ephpp.ca/PDF/QADictionary_dec2009.pdf