Saving lives and money: safe staffing in health care saves lives and money--this is the International Council of Nurses' (ICN) message next month to mark International Nurses' Day (IND) on May 12.

'There is no doubt. The numbers of health care workers make a difference," said ICN president Hiroko Minami at the launch of this year's IND theme. "Study after study has shown that improved nurse staffing--in numbers and skill-mix--is associated with lower inpatient mortality rates and shorter hospital stays, saving both lives and money. High patient-to-nurse ratios not only have a negative impact on patient outcomes, but also affect the nurses who are at higher risk of emotional exhaustion, stress, job dissatisfaction and burnout."

In its Safe Staffing Saves Lives information and action toot kit, ICN states that safe staffing is more than just numbers. Other variables affecting the provision of safe care include workload, work environment, patient complexity, skill Level of the nursing staff, mix of nursing staff, and the links of cost efficiency to patient and nurse outcomes.

Preventing adverse events

The kit points to growing evidence to support the need for adequate staffing. A Canadian study has shown that a high proportion of adverse events resulting from hospital care (eg falls, drug errors and inappropriate surgeries) were preventable. A higher registered nurse (RN) skill mix corresponded to fewer medication errors and pressure ulcers, and higher patient satisfaction. (1) Medication errors were reduced with a higher proportion of RNs in the staff mix. (2) Another study showed a relationship between full-time-equivalent (FTE) RNs per patient day and urinary tract infections, pneumonia, thrombosis and pulmonary compromise after major surgery. (3) Yet another that the risk of postoperative and pulmonary complications increased if a nurse cared for more than two intensive care esophagectomy patients at night. (4)

Most authors have found an inverse relationship between mortality and RNs per patient day, RNs as a percentage of all nursing staff and RNs per hospital. (5) Lower fall rates and higher patient satisfaction levels with pain management have been observed when there were increased RN hours worked per patient. (6) In a 2002 study, more RN hours of care per day were associated with a shorter length of stay in hospital; lower rates of urinary tract infections, upper gastrointestinal bleeding, pneumonia, shock and cardiac arrest; and reduced cases of failure to rescue. (7)

In 2005, the Canadian Federation of Nurses Union noted strong empirical evidence demonstrating the Link between inadequate nurse staffing and a range of adverse patient outcomes, including pressure ulcers, urinary tract infections, postoperative wound infections and medication errors. (8)

Improving nurses' health

Having adequate staff is important because it affects the health of nurses, the ICN kit says. In terms of trying to recruit or retain staff, studies have shown there is a relationship between staffing levels and job satisfaction. (9) A study in the United Kingdom (UK) last year found that high patient-to-nurse ratios were associated with increased risk of emotional exhaustion and dissatisfaction with current job. Nurses who continuously worked overtime or worked without adequate backup were prone to greater absenteeism and poorer health. (10)

Further exacerbating safe staffing is the migration of health care workers from the developing world to the developed. Nurses left behind are faced with very low staffing levels which hinder their ability to provide safe care. Safe staffing is cost effective, says ICN. A Californian study has shown the long-term investment in full-time staff yields cost savings in both recruitment and retention. (11) With good patient outcomes, families and communities benefit and patients are able to return to the workforce, thus contributing to the economy.

Recruiting nurses from other countries

International recruitment, the kit says, is not an adequate solution to resolving nursing shortages. However, foreign-educated health professionals now make up 25 percent of the medical and nurse workforces of Australia, Canada, the UK and the US.

The kit suggests a number of responses to resolving shortages, including:

* increasing new nurse supply from pre-registration/training;

* improving the retention of current staff;

* improving the utilisation of nurses' skills and mix with other staff;

* encouraging the return of nurses currently not practising;

* examining the scope for ethical international recruitment;

* lobbying governments to adequately subsidise the educational system to meet internal demand; and

* improving working environments to recruit and retain nurses in challenging work conditions. (12)

In the United States (US), particularly among private hospitals, organisations with an adequate number of nurses and physicians are using the size of their staff to increase their competitive edge against other hospitals. Called "magnet hospitals", they are able to use their attractive work environments to recruit and retain staff. (13)

Quantifying the work of nurses is an ongoing struggle. "While the tools have been helpful in identifying tasks of nurses, most have not been able to capture the cognitive/intellectual aspects of the role ... thus, while workload measurement tools have been used in safe staffing debate, they are by no means a complete solution to determine safe staffing," the kit states.

Safe staffing initiatives can be encouraged in a variety of ways. Legislated nurse-to-patient ratios have been implemented in California and in Victoria, Australia (see p12-14), and at least 14 other US states are considering similar legislation. (9) However, the pros and cons for this system are considerable. Instead of legislating safe staffing ratios, some authors suggest that organisations should identify their own definition of safe staffing, based on variables such as acuity of patients, number of ratios and staff mix. The ICN encourages nurses to continue the struggle to achieve safe staffing in their workplaces. Recommended activities include lobbying at work, in communities and nationally for safe staffing levels and healthy working environments; and negotiating safe staffing in collective bargaining agreements. Nurses need to demonstrate why safe staffing is important for their patients' safety and what type of care they can provide when staffed appropriately.

* References are printed on p22.