Effect of Staffing Ratios on Nursing Retention. Erin Burdi. Ferris State University

Transcription

1 Running head: EFFECTS OF STAFFING RATIOS ON NURSING RETENTION Page 1 of 21 Effect of Staffing Ratios on Nursing Retention Erin Burdi Ferris State University

2 EFFECTS OF STAFFING RATIOS ON NURSING RETENTION Page 2 of 21 Abstract This paper provides an issue analysis of the effects of staffing ratios and nurse retention. An analysis of theoretical basis for this issue is provided utilizing Orlando s nursing process theory and Maslow s interdisciplinary theory of human needs. An assessment of the health care environment, as well as, identification of implication, inference, and consequence of this issue is discerned through a Patient Care Delivery Model framework. Recommendations for research, quality and safety improvements are made through analysis of the American Nurses Association s (ANA) standards of nursing practice and Quality and Safety Education for Nurses (QSEN) competencies.

3 EFFECTS OF STAFFING RATIOS ON NURSING RETENTION Page 3 of 21 Effect of Staffing Ratios on Nursing Retention Staffing ratio, also known as Patient to Nurse Ratio (PNR), has been one of the largest topics of discussion within the nursing profession in recent years. PNR can be defined as the number of patients that one nurse is assigned to care for at a given time. The nursing profession is facing an ever growing threat of a continued nursing shortage. Erenstein and Mcaffrey (2007) estimated that by the year 2020, the United States will experience a shortage of 400,000 registered nurses (p.303). A contributing factor to the nursing shortage is the lack of nursing retention due to job dissatisfaction. Staffing ratios can directly influence the environment and our ability to provide patient care and safety. According to Aiken, Clarke, Sloane, Sochalski, and Silber (2002), nurses nationwide consistently report that hospital nurse staffing levels are inadequate to provide safe and effective patient care (p.1987). Insufficient staffing causes increased patient care workloads for nurses and through time constraints, can inhibit the nurse from developing the necessary nurse-patient relationship needed to provide quality care. This barrier to patient care is a major frustration in nursing because nurses have the desire to provide excellent patient care. Many enter into the profession because they care. The American Nurses Association (ANA) (2010) states the art of nursing is based on caring and respect for human dignity and a compassionate approach to patient care carries a mandate to provide that care competently (p.23). Nursing as a profession has developed a specialized knowledge set that gives nurses the tools to provide systematic, quality, evidence-based patient care. Nursing focuses on the promotion and maintenance of health and the prevention or resolution of disease, illness, or disability. The nursing needs of human beings are identified from a holistic

4 EFFECTS OF STAFFING RATIOS ON NURSING RETENTION Page 4 of 21 perspective and are met in the context of a culturally sensitive, caring, personal relationship (ANA, 2010, p.23). Working environments that impede a nurses ability to establish this relationship through perceived factors that are beyond individual control, such as staffing, may cause nurses to become overstressed, burned out, and potentially leave the profession. Cullen (1995) states that when a nurse works in a system where s/he's never allowed to give their best, one of two things happen: either s/he lowers her standards, in which case s/he works apathetically but comfortably for the rest of their career, or s/he continues trying to give their best, constantly bucking a system that doesn't put excellence first, until s/he finally burns out (p.26). In essence, Cullen (1995) identifies a prime candidate for burn-out to be the nurse who strives for excellence in a toxic environment (p.26). While the concept of burn-out is not unique to the profession of nursing, it is more likely to occur in the field of nursing. According to Aiken, Clarke, Sloane, Sochalski, and Silber (2002), job dissatisfaction among hospital nurses is four times greater than the average for all US workers, and one in five hospital nurses report that they intend to leave their current jobs within a year (p.1987). Erenstein and McCaffery (2007), state that few professions other than nursing are routinely responsible for another person s life and well-being on a daily basis. In addition, while caring for persons and improving healthcare are reasons why nursing is an attractive profession to many; however, it is also one of the inherent stressors within the profession (p.303). Cullen (1995) states that nurses burn-out primarily due to the toxic work environment in which they are placed (p.23). She further defines a toxic work environment as an environment in which the pressure that's put on you by organizational forces that determines the

5 EFFECTS OF STAFFING RATIOS ON NURSING RETENTION Page 5 of 21 conditions under which you work (p.23). Staffing can be identified as an organizational force. Nurses, through their own dedication and desire, will continue to try to provide quality patient care, even in the context of a toxic environment, until eventually s/he will burn-out; One cannot give quality patient care in a structural environment that's consistently understaffed, underequipped, and taxing on caregivers (Cullen, 1995, p.24). Inadequate staffing has the potential to increase the inherent stressors and responsibilities of nursing, leading to increased job dissatisfaction, and poor nurse retention. This could perhaps be due to the severity of consequences of poor job performance in nursing. Retention and job satisfaction among nurses has theoretical and patient care efficacy implications on the profession and healthcare as a whole. Consequences from the nursing shortage can affect the delivery of healthcare and the profession of nursing; continuing evidence exist that states that unsupportive and unhealthy environments contribute to medical errors and unsafe working conditions (Erenstein &McCaffery, 2007,p.303). In a research study performed by Aiken, Clark, Sloane, Sochalski, and Silber (2002), there was found to be a strong association between PNR and level of nursing exhaustion, burn-out, and job satisfaction (p.1990). Due to the potential effect staffing ratio could have on professional job satisfaction and exacerbation of a nursing shortage, the correlation between staffing ratios and nurse retention should be determined and discussed. Theoretical Base The profession of nursing has historically been driven to substantiate our practice as a profession rather than a trade through the development of theoretical base for practice. A theory is an organized, coherent, and systematic articulation of a set of statements related to significant questions in a discipline and communicated as a meaningful whole. It is a

6 EFFECTS OF STAFFING RATIOS ON NURSING RETENTION Page 6 of 21 symbolic depiction of those aspects of reality that are discovered or invented for describing, explaining, predicting responses, events, situations, conditions, or relationships. Theories have concepts that are related to the discipline s phenomena. These concepts relate to each other to form theoretical statements. Nursing theory is defined as a conceptualization of some aspect of nursing reality communicated for the purpose of describing phenomena, explaining relationships between phenomena, predicting consequences, or prescribing nursing care. (Meleis, 2012, p.29) Staffing ratios qualify as an aspect of nursing reality within the profession due to the profound effect it has on nursing practice. The primary uses of theory are to provide insights about nursing practice situations and to guide research. Through interaction with practice, theory is shaped and guidelines for practice evolve (Meleis, 2012, p.35). Due to the need for further research and practice guidelines on the topic, it is important to consider theoretical basis in analysis of the issue of staffing ratios and its effect on nursing retention. Ida Jean Orlando-Pelletier: Nursing Process Theory Orlando s theory of nursing process was chosen for theoretical basis on the analysis of staffing ratios and nurse retention due to the strong emphasis placed on the responsibility of nurses in meeting patient needs. She defines the nurse s responsibility as...consisting of whatever help the patient may require for his needs to be met (Tomey & Alligood, 2006, p.433). Whatever help encompasses physical and mental assistance required by the patient in order to meet identified needs. Orlando defines patient need as a requirement of the patient in which, if supplied, relieves or diminishes his immediate distressor and improves his immediate sense of well-being (Tomey & Alligood, 2006, p.433).

7 EFFECTS OF STAFFING RATIOS ON NURSING RETENTION Page 7 of 21 Simply stated, the patient s needs are somewhat subjective in nature. To some extent, the patient determines what need requirements they have. Orlando s theory assumes that patients needs for help are unique; patients are able and willing to communicate verbally and nonverbally their needs for help; when patients cannot meet their own needs they become distressed (Tomey &Alligood, 2006, p.435). It is then correct to assume, according to Orlando, that it is up to the nurse to identify and meet said needs and relieve patient distress. That being said, the responsibility of a nurse to identify and meet patient needs requires that the nurse develop and foster a working relationship with his/her patient. Orlando s nursing theory stresses the reciprocal relationship between patient and nurse. What the nurse and patient say or do affects both (Tomey & Alligood, 2006, p.432). In addition, Orlando asserts that the nurse-patient situation is a dynamic whole, and that the phenomenon of the nurse-patient encounter represents a major source of nursing knowledge (Tomey & Alligood, 2006, p.435). The nurse gains necessary information through his/her interaction with the patient that can have an effect on how the patient s plan of care is developed and provided. There-fore, factors that inhibit the development of the nurse-patient relationship could have a profound effect on the quality of patient care. In terms of relating to staffing ratios and nurse retention, Orlando places great emphasis on the assessment ability of the nurse. She states that each patient is unique and individual in his/her needs and responses and that the professional nurse can recognize that the same behavior in different patients can signal quite different needs (Tomey & Alligood, 2006, p.435). A patient care environment that is insufficiently staffed increases the patient care work load upon each nurse. Time becomes a major constraint on the nurses ability to develop and foster his/her relationship with his/her patients, thus potentially jeopardizing the nurses ability to

8 EFFECTS OF STAFFING RATIOS ON NURSING RETENTION Page 8 of 21 identify verbal, and especially non-verbal, needs of the patient. The nurse is placed in an environment in which he/she forced to prioritize patient needs and potentially compromise the quality of care given to each patient. Obviously, a nurse would prioritize physical patients needs, such as, food, water, medications, and needed treatments first. However, it is the emotional affirmation and reassurance, that according to Orlando are equally distressing patient needs, that are sacrificed. Such a scenario places great stress upon the nurse and when such a situation becomes a common occurrence, the nurse is at a tremendous risk for burn-out and may consider leaving the profession. "As one nurse said, if I can't look at myself in the mirror because I'm so ashamed of the level of care I've been reduced to giving, then it's time to get out'"(cullen, 1995, p.24). Stressed nursing care can also affect patients in a manner in which patients may observe that the nurse is stressed and pressed for time, and may feel uncomfortable verbalizing his/her needs for fear of adding further stress. Remember, Orlando asserts that what the nurse and patient say or do affects both (Tomey & Alligood, 2006, p.432). In reverse, a situation in which staffing produces manageable workloads, a nurse is given the opportunity to accurately assess, identify, and meet patients need requirements both physically and mentally fostering a healthy relationship that promotes health and well-being. Orlando also states that it is the nurse s responsibility to see that the patient s needs for help are met, either by her own activity or indirectly by calling in the help of others (Tomey &Alligood, 2006, p.433). This notion of interdisciplinary collaboration is widely found throughout the ANA s Standards of Nursing Practice. The registered nurse collaborates with the healthcare consumer, family and others in the conduct of nursing practice. S/he partners with

9 EFFECTS OF STAFFING RATIOS ON NURSING RETENTION Page 9 of 21 others to effect change and produce outcomes through the sharing of knowledge of the healthcare consumer and/or situation (ANA, 2010, p.57). Stressed nursing has the potential to jeopardize interdisciplinary collaborative efforts. Nurses working in a stressed environment are in danger of missing critical cues to information that could affect treatment plans developed by healthcare teams. However, when given an opportune working environment, a nurse has the ability to provide accurate patient assessment and condition information and coordinate interdisciplinary team members to meet patient needs. Abraham H. Maslow s Theory of Human Motivation. In 1943, Abraham Maslow developed his theory of human motivation, also known as Maslow s hierarchy of needs. His theory asserts that, people are motivated by a hierarchy of human needs (Yoder-Wise, 2011, p.10). His hierarchy of needs comprises of five levels of human needs beginning with the most basic and advancing in complexity. The first level is basic or physiological needs. Physiological needs as described by Maslow include, those that are directly related with the existence and survival of human beings, such as: food, water, clothing, sex and hygiene (Regis & Porto, 2011, p.333). Once an individual has met these basic needs, s/he will then address to second level of the human need hierarchy: safety needs. Safety needs are those human needs related to individual protection against danger and threats, such as: health, work, insurance, social insurance and social order (Regis & Porto, 2011, p.333). Again, once the individual has met his/her safety needs s/he can address more complex need requirements. The third level of Maslow s hierarchy of human needs is the human need for love and social contact. These needs are those that are related to with life in society, covering the needs

10 EFFECTS OF STAFFING RATIOS ON NURSING RETENTION Page 10 of 21 for contact, friendship, respect, love, leisure and participation, referring to the need for people s affect, such as friends, companionship, spouse and children (Regis & Porto, 2011, p.333). The need for esteem is the fourth human necessity in Maslow s hierarchy. The need for esteem encompasses the human need for self-satisfaction, such as: independence, appreciation, dignity, acknowledgement, subjective equality, respect and opportunities, referring to a stable self-assessment, as well as, a high level of self-esteem, leading to feelings of self-confidence, value, strength, ability, sufficiency and utility for the world (Regis & Porto, 2011, p.333-4). The final and most complex human need identified by Maslow is the need for selfaccomplishment. This encompasses the individual s need to full fill their potential for accomplishment, or utilizing to the best of their ability, their aptitude to achieve person al goals. This includes a human being s desire to know and gain knowledge, the human being s natural need to search the meaning of things, so as to organize his/her understanding about the world he/she lives in (Regis & Porto, 2011, p.334). Erickson, Tomlin, and Swain utilized Maslow s theory of human needs as a basis for their assertion that all people want to be the best that they can be; unmet basic needs interfere with holistic growth, whereas satisfied needs promote growth. Further-more they integrated the model to state that unmet basic needs create need deficits, which can lead to initiation or aggravation of physical or mental distress or illness (Tomey & Alligood, 2006, p.564). Staffing ratios affect a nurse s ability to meet his/her role demands and requirements. In an environment in which staffing is sufficient for the nurse to perform his/her duties associated with patient care, he/she is able to full-fill his/her own personal human needs as identified by Maslow. S/he can function at a capacity that allows him/her to be the best that they can be, thus promoting personal and professional growth, self- satisfaction and actualization.

11 EFFECTS OF STAFFING RATIOS ON NURSING RETENTION Page 11 of 21 This positive working environment potentiates the nurses ability to meet patient needs, as well as, his/her own personal needs leading to increased job satisfaction and nurse retention. In addition, one must consider Orlando s assertion that nurses are responsible for meeting patient needs and should help relieve physical or mental discomfort and certainly should not add to the patient s distress (Tomey & Alligood, 2006, p.435). If the nurse-patient relationship is defined as a reciprocal, fluid, dynamic of interaction, a nurse that is struggling with unmet human needs has the potential to transfer his/her feelings of distress to the patient. Nurses and other team members, when thirsty, hungry, tired, sleepy, sad, dissatisfied, and without recognition, do not manage to pay full attention to another human being. They first need to attend to their own needs in order to perceive/provide for other people s needs (Regis & Porto, 2011, p.337). Conversely, if a nurse is able to meet humanistic needs identified by Maslow, he/she has the ability to foster a positive, nurturing, relationship with his/her patient in order to meet care needs. Assessment of Healthcare Environment The Patient Care Delivery Model (PCDM) is a systematic framework that can be utilized to identify the relationship between nurse, patient and organizational, or system, factors that influence patient care delivery. The PCDM is designed to provide an understanding of the relationship between outcomes and input factors, such as patient, nurse and system characteristics (Meyer, Wang, Li, Thomson & O Brien-Pallas, 2009). Inputs (described as resources) are transformed into some level of outputs, and this transformation is affected by other factors such as workload organization characteristics and the environment, also known as throughputs. Throughput factors influence the relationships between input characteristics and patient, nurse, and system outputs (O Brien-Pallas, Meyer, Hayes, &

12 EFFECTS OF STAFFING RATIOS ON NURSING RETENTION Page 12 of 21 Wang, 2010, p.1642). Outputs encompass nurse, patient, and system outcomes, such as quality of care, safety, job satisfaction, and patient health status and behaviors (O Brien-Pallas et.al, 2009). This has relevance when discussing nursing staff ratios and nurse retention due to the following assumptions: nurses feel that it is their professional obligation to provide quality patient care; a nurse s ability to provide this level of patient care is directly affected by staffing ratios; nurses become frustrated and/or experience burnout when unable to provide this expected level of care and may leave the profession. Inputs Patient characteristics. According to O Brien-Pallas et.al. (2010), patients enter the healthcare system with characteristics that impact their own outcomes, care activities, and use of resources, as well as, nurse outcomes (p.1643). Patient characteristics include: demographics, personal support systems, health status and behaviors, healthcare knowledge, or lack of, symptoms, nursing and medical complexity, and nursing intensity (O Brien-Pallas et.al, 2010). Nurse characteristics. Nurse characteristics that affect patient and system outcomes include: demographics, level of education, clinical expertise and experience, and professional and employment status (O Brien-Pallas et.al, 2010). System characteristics. Organizational characteristics include: hospital size, location, type, unit size, type, occupancy, patient mix, nursing care delivery model, and system behaviors, such as staffing assignments, continuity of care, and adequate resources (O Brien-Pallas et.al, 2010).

13 EFFECTS OF STAFFING RATIOS ON NURSING RETENTION Page 13 of 21 Throughputs Throughput processes result in distal outputs which include patient, nurse, and system outcomes (O Brien-Pallas et.al, 2010, p.1643).throughputs include patient care delivery subsystems, interventions, perceived working environments, staffing utilization, and environmental complexity (O Brien-Pallas et.al, 2010). For example, according to the PCDM, nurses perceived working environment affect outcomes such as care quality, job satisfaction, retention, and patient health status (O Brien-Pallas et.al, 2010). Outputs PCDM outputs encompass patient, nurse and system outcomes. Inputs and throughputs interact constantly to influence and produce outcomes which feed back into the system (O Brien- Pallas et.al, 2010). Outputs provide feedback and reactivate the system itself because positive outcomes in each of these domains ensure that members of the community continue to utilize the organizations services, staff are retained to provide the services, and the organization s accreditation and funding are sustained (O Brien-Pallas et.al, 2010, p.1643). Patient outcomes. Patient outcomes include: reduced number of symptoms, or medical consequences, improved knowledge or behavior in relation to health condition (O Brien-Pallas et.al, 2010, p.1643). Nurse outcomes. Nurse outcomes include: burnout, general health, job satisfaction, and intent to leave, professional practice, and safety (O Brien-Pallas et.al, 2010, p.1643). System outcomes. System outcomes are defined through: quality of care provided, nurse turnover, cost, length of patient stay, staffing efficacy, and staff absenteeism (O Brien-Pallas et.al, 2010).

14 EFFECTS OF STAFFING RATIOS ON NURSING RETENTION Page 14 of 21 Root Cause Analysis (RCA) Through observation and analysis of the cause and effect relationship indicated by the PCDM, one could assume organizational staffing ratios to be a root cause for nurse job satisfaction and retention. For example, in a situation of high patient acuity, increased unit census, poor nursing resources, depending on patient care delivery subsystems and staffing utilization, could result in lowered nurse job satisfaction, higher turnover, efficacy of staff, and decreased quality of care provided. Implications/Inferences/Consequences Through utilization of PCDM framework to assess the healthcare environment, one can identify multiple implications, inferences and consequences nurse staffing ratios has on job satisfaction and nurse retention. Given the assumptions described above, nurse staffing can have either a positive or negative effect on patient, nursing, and organizational outcomes. Staffing ratios can have an effect on patient care quality and safety. As described above, patients enter into the healthcare delivery system with their own set of complex care needs and acuity. In addition, a patient s ability to comprehend and learn healthcare related behaviors is highly individualized. For example, a patient with an 8 th grade level of education would require more extensive educational resources and teaching to understand their diagnosis and treatment needs, than an individual with a higher level of education. Patients with limited resources and access to healthcare may enter into the healthcare system with more complex needs due to their inability to comply with personal healthcare needs. Cho, Ketefian, Barkauskas & Smith (2003) found, that patients with a greater number of diagnoses upon admission, which reflected patients co-morbidity, were associated with having

15 EFFECTS OF STAFFING RATIOS ON NURSING RETENTION Page 15 of 21 adverse events (p.75). In either case, patients entering the healthcare system have a wide range of nursing care needs. Nurses, as patient advocates, are responsible for protecting patients from adverse outcomes, especially those patients at higher risk of adverse events" (Cho, et.al, 2003, p.76). This places a great amount of responsibility on the registered nurse. When placed in a healthcare environment in which nurse staffing is insufficient, the RN faces an increased workload responsibility and potential for failure to meet patient needs, there-by compromising patient care. In a working environment in which staffing is chronically insufficient, the nurse faces an increased level of stress related to heavier workload and demands of meeting patient needs. Over time, this decreases the nurses job satisfaction and may lead to professional burnout and his/ her decision to leave the profession. In a survey of 960 currently licensed nurses, 50% of nurses currently employed stated that they had considered leaving nursing as a profession in the last 2 years. The primary reason listed by these nurses for wanting to change careers was low satisfaction in their jobs (Andrews & Dziegielewski, 2005, p.290.). Further-more, work-related stress was found to be a major influence on nurses job satisfaction. Concern with nurse staffing contributes to job-related stress. About 25% of nurses believe that their jobs have become harder because patients are acutely ill than in previous decades, and 45% cite downsizing of staff as the reason behind an increased workload (Andrews & Dziegielewski, 2005, p.291.) Poor quality of patient care and outcomes has an effect on the healthcare organization in the respect of budget costs and reimbursement. Patients with poor outcomes or complications have an increased length of stay and utilize more costly resources, in which the hospital may/

16 EFFECTS OF STAFFING RATIOS ON NURSING RETENTION Page 16 of 21 may not receive reimbursement. In addition, poor nurse job satisfaction and retention would cost the facility more in nurse turnover and replacement costs. Recommendations for Quality and Safety Improvements Recommendations for quality and safety improvements regarding the issue of staffing and nurse retention should entail interventions that focus on effective use of nurse staffing mixtures in providing patient care, as well as, efforts to improve nurse job satisfaction and increase nurse retention. The ANA s 2010 Scope and Standards of Nursing Practice and Quality and Safety Education for Nursing (QSEN) competencies will be used as a guideline for recommendations regarding this issue. Quality of Practice The ANA (2010) standard of quality of practice states that the registered nurse contributes to quality nursing practice. This includes competencies in which the registered nurse participates in quality improvement activities such as: identifying aspects of practice important for quality monitoring; using indicators to monitor quality, safety, and effectiveness of nursing practice; collecting data to monitor quality and effectiveness of nursing practice; analyzing quality data to identify opportunities for improving nursing practice; formulating recommendations to improve nursing practice or outcomes; implementing activities to enhance the quality of nursing practice ; developing, implementing, and/or leading inter-professional teams to evaluate clinical care or health services; participating on and/or leading inter-professional teams to evaluate clinical care or health services; identifying problems that occur in day-to-day work routines in order to correct process inefficiencies; and analyzing factors related to quality, safety, and effectiveness. (p.52)

17 EFFECTS OF STAFFING RATIOS ON NURSING RETENTION Page 17 of 21 This ANA standard of nursing practice collaborates with the QSEN competency of quality improvement. Quality improvement requires the nurse to use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems (QSEN, 2011, para.1). This means that nurses have a level of accountability to utilize quality control measures to observe, collect data, and make recommendations for improvement in the process of utilizing staffing resources to improve effectiveness and quality of patient care. Patient care delivery models have a profound effect on nurses and the means in which they deliver care. There-fore, it is an expectation that professional nurses become involved in stream-lining and improvement processes to improve staff utilization and improve care delivery. Resource Utilization This ANA standard of professional practice dictates that the registered nurse uses appropriate resources to plan and provide nursing services that are safe, effective, and financially responsible (ANA, 2010, p.60). This ANA standard entails that the nurse utilizes stream-lined and cost effective means in delivery of patient care, and gives him/her the responsibility to utilize available staff in an efficient manner to meet patient care needs. This includes the nurses ability to delegate non-nursing tasks to available unlicensed personnel so that s/he can focus on strictly nursing functions to meet patient care goals. This standard also commands of nurses to eliminate unnecessary costs and waste, which may alleviate organizational financial burden related to such wastes and make available funds for needed human resources. This is corroborated with QSEN competencies of safety and teamwork and collaboration. Safety is defined by QSEN as the nurses responsibility to minimize risk of harm to patients

18 EFFECTS OF STAFFING RATIOS ON NURSING RETENTION Page 18 of 21 and providers through both system effectiveness and individual performance (2010, Para. 1). Teamwork and collaboration are defined as the nurses responsibility to function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care" (QSEN, 2010, Para.1). Professional Practice Evaluation The ANA standard of professional practice evaluation asserts that, the registered nurse has the responsibility to evaluate his/her own nursing practice in relation to professional practice standards and guidelines, relevant statutes, rules, and regulations (ANA, 2010, p. 59). This professional standard applies to self and peer evaluation of practice. One can assume that through self and peer review, the nurse can identify his/her risk for professional burnout, assist peers in doing the same, and identify and implement interventions necessary to alleviate these risks. This ANA standard of professional practice is also corroborated by the QSEN competencies described above through the evaluation and improvement of individual practice. Conclusion One can assert that staffing ratios have an effect on nurse job satisfaction and nurse retention. Staffing ratios have a profound effect on the means in which nurses can provide care. Nurses have a social contract with patients, families, and the healthcare system to provide quality, safe patient care. When faced with the potential for compromised patient care quality through issues related to staffing, nurses become overstressed, burned out, and have the potential to leave the profession. This perpetuates the risk of nursing shortage, insufficient staffing in healthcare organizations and may lead to further compromise of

19 EFFECTS OF STAFFING RATIOS ON NURSING RETENTION Page 19 of 21 patient care quality. This is evidenced through analysis of the PCDM and cause and effect nature of the inter-related systems of nursing, patients and organizations. Further research should be conducted, and lead by professional nurses, to discern methods to improve effective utilization of staffing resources and identify means to alleviate nurse job related stressors that can lead to burnout and poor nurse retention.

20 EFFECTS OF STAFFING RATIOS ON NURSING RETENTION Page 20 of 21 References Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. (2002, October). Hospital Nurse Staffing and Patient Mortality, Nurse Burnout and Job Dissatisfaction. Journal of American Medical Association, American Nurses Association. (2010). Scope and Standards of Nursing Practice (2nd ed., p. 57). Silver Spring, MD: Nursing Standards. Andrews, D. R., & Dziegielewski, S. F. (2005, January 14). The Nurse Manager: Job Satisfaction, the Nursing Shortage and Retention. Journal of Nursing Management, 13, Retrieved from PubMed. Cho, S., Ketefian, S., Barkauskas, V. H., & Smith, D. G. (2003, March). The Effects of Nurse Staffing on Adverse Events, Morbidity, Mortality and Medical Costs. Journal of Nursing Research, 52(2), Retrieved from PubMed. Cullen, A. (1995, November). Burnout; Why Do We Blame Nurses? American Journal of Nursing, 95(11), Erenstein, C. F., & McCaffery, R. (2007). How Healthcare Work Environments Influence Nurse Retention. Holistic Nurse Practice, 21(6), Fagundes Ladeia Vitoria, L., & Setenta Porto, I. (2011). Basic human needs of nursing: situations of (dis)satisfaction at Work. Rev Esc Enferm USP, 45(2), Retrieved from Meleis, A. (2012). Theoretical Nursing: Development and Progress (5th Ed.). Philadelphia, PA: Wolters Kluwer Lippincott Williams & Wilkins.

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