CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Nursing is a key component of hospital care, typically being the only service that operates 24

hours a day, seven days a week. Nursing staff, that is registered nurses (RNs) and staff who

support them providing hands on care, make up the largest element of the health care workforce,

accounting for more than half the workforce in many countries and is the biggest single cost in

running a hospital. For example, in Sweden 71% of the health care workforce are said to be

nursing staff (Ridelberg et al., 2019).

Nurses are the cornerstone of hospital care delivery and the hospital’s most costly and valuable

resource; their efficiency and effectiveness are central to any effort to maximize patient safety or

minimize costs. Studies suggest that elements of the current hospital work environment,

including inefficient work processes and physical designs, gaps in technology infra- structure,

and unsupportive organizational cultures, contribute to inefficiencies and stress for hospital

nurses, limiting the time they can spend in direct patient care (Hendrich et al,.2018).

Nurses are a critical part of healthcare and make up the largest section of health profession.

According to the World Health Statistics Report, there are approximately 29 million nurses and

midwives globally, with 3.9 million of those individuals in the United States. Estimates of

upwards of one million additional nurses will be needed by 2020.

According to the American Nurses Association (ANA), more registered nurses jobs will be

available through 2022 than any other profession in the United States. According to an article in

the Nursing Times, The US Bureau of Labor Statistics projects that more than 275,000 additional
nurses are needed from 2020 to 2030. Employment opportunities for nurses are projected to

grow at a faster rate (9%) than all other occupations from 2016 through 2026.

Furthermore, reduced nurse-patient ratios have been linked to in- creased mortality, highlighting

the fact that nurse staffing and efficiency are linchpins of patient safety (Aiken et al,. 2018).

Hospital wards need enough nurses on duty to meet patient needs and deliver the care required,

safely and to a high standard. Too few staff may lead to care being compromised work pressures

intensified leading to burnout (Aiken et al. 2018), more staff going off sick and costly

recruitment and retention challenges (Duffield et al. 2020).

Nurse staffing has been the subject of extensive research. Efforts by a dozen states to mandate

nurse staffing levels speak to the mounting evidence that characteristics of the nursing work

force affect patient care. In their large 2012 study, Aiken et al. demonstrated a 7% increase in

mortality (and a 7% increase in the odds of failure to rescue) for every additional patient per staff

nurse (Aiken et al., 2018).

That there is a relationship between system factors such as staffing levels, the quality of care

provided, and patient outcomes would come as no surprise to many in health care. Decades of

research have sought to elucidate these relationships, looking for the potential effect of RN

staffing on patient outcomes. The research has focused primarily on negative outcomes or

‘harms’ which could in theory have been avoided: adverse events (medication errors, patient

falls), complications (hospital acquired infections, pressure ulcers) and potentially avoidable

deaths. ‘Avoidable deaths’ is a term used to refer to differences in hospital mortality rates that

appear to be related to differences in the hospitals and the care provided, as opposed to

differences related to patient factors such as diagnosis, co-morbidities, gender, age. The overall
conclusion of research to date is that patients who receive their care in environments with good

RN staffing levels are less likely to die from hospital related factors (Kane et al. 2019). Other

studies have found that poorer nurse staffing levels are associated with an increased risk that

some necessary nursing care is left undone, incomplete or missed. Whilst the overarching

message of the research on RN staffing and patient outcomes is clear, and chimes with the

analysis of systems failings put forward in various reports, there remains a lack of clarity in the

underlying theory and a lack of detail and specificity about necessary nurse staffing levels that

hampers translation into practice. (NICE 2019).

The work of investigators around the world supports these findings. Studies from North

America, Europe, Russia, and New Zealand have demonstrated a link between nurse staffing, the

quality of the nurse working environment, and quality of patient care (Clarke & Aiken, 2018).

Hospitals with the highest patient-to-nurse ratios had 26% higher mortality, and nurses in these

hospitals were approximately twice as likely to be dissatisfied with their jobs, show high burnout

levels, and report low or deteriorating quality of care. As intuitive as this finding appears to be

(i.e., more nursing equals better care), the mechanisms affecting the relationship between nurse

staffing and preventable patient mortality are multiple and not thoroughly understood. Nursing

skill mix, relation- ship and communication with clinicians, organizational status, stress, and job

satisfaction are among the factors suggested to influence patient outcomes (Aiken et al., 2018).

At least some of these issues can be affected by the work environment.

The health system size, economy and characteristics of the population impact the entire

healthcare system, including the types of healthcare professionals and distribution of the medical

workforce to meet the needs of its population (Drennan, 2019). For example, the ratios of nurses

to population based on data from 2017 range considerably from 17, 12 and 11: 1000 persons in
countries of Norway, Germany and Australia, to 2 and 1 to 1000 persons in countries like China,

India and South Africa (Drennan, 2019). According to the WHO, the largest needs-based

shortages of both nurses and midwives are in South East Asia and Africa (Drennan, 2019).

Nursing workforce predictions vary substantially across different countries, even with similar

levels of income and development. Of the five countries, four, including Australia, Canada,

Ireland and the United Kingdom have all predicted shortages. The USA, being the fifth, have

actually predicted a surplus of nurses by the year 2025 (Drennan, 2019). Other authors challenge

the projected surplus of nurses in the United States, claiming the country will face a shortage of

approximately 200,000 professionals by the year 2020 (Carnevale, 2015). Other francophone

countries include Belgium, France and Switzerland for which Belgium is currently not projecting

a future shortage of nurses (Rafferty, 2019). On the other hand, Switzerland is estimating a need

for an additional 60,000 nurses by the year 2030, with most needs in primary and long-term care

(Rafferty, 2019).

Nigeria is ranked 7th among 57 countries classified as facing a critical shortage of health workers.

The country has a shortage of 144,000 health workers. Nigeria is ranked second in Africa behind

Ethiopia with 152,000. Presently the country boasts of 240,000 nurses and midwives and by

2030 the country will be needing 149,852 doctors and 471,353 nurses and midwives (Adewole,

2017). It is based on this that the researcher intended to conduct this study.

1.2 Statement of Problem

Working with unsafe nurse-patient ratios and chronic understaffing on clinical units negatively

impact patient outcomes and contribute towards multiple poor outcomes among staff as well

(Sasso, 2019)
Evidence of the impact of nurse staffing on patient outcomes suggest that one approach to

maximizing outcomes and minimizing errors is to hire more nurses. The well-documented

nursing work-force shortage, unfortunately, complicates any attempt to increase nurse patient

ratios. Despite some recent gains, the current nursing work-force shortage is expected to grow

substantially over coming decades.

The limited supply of nurses in the work force emphasizes the importance of attracting and

retaining nurses. Several nurse-related factors that may influence patient outcomes, such as

organizational status, relation- ship and communication with clinicians, and stress may also

influence nurses’ job satisfaction and burnout, in turn, affecting retention and, ultimately, nurse

staffing and patient outcomes (Aiken et al., 2018).

The researcher being a student in Abraka and as a student has observed the effect short staffing

of nurses has on patient care and outcome. In view of the above, this study seeks to investigate

the impact of short staffing of nurses on the quality of patient care in General Hospital, Abraka,

Delta State.

1.3 Purpose of the Study

The purpose of this study is to investigate the impact of short staffing of nurses on the quality of

patient care in General Hospital, Abraka, Delta State.

1.4 Objectives of the Study

The specific objectives include the following:

Hospital, Abraka, Delta State.

2. To evaluate the level of patient satisfaction with nursing care in General Hospital,

Abraka, Delta State.

3. To ascertain the importance of adequate staffing of nurses in General Hospital, Abraka,

Delta State.

1.5 Research Questions

1. What effect does staffing levels have on quality of patient care in General Hospital,

Abraka, Delta State?

2. What is the level of patient satisfaction with nursing care they receive in General

Hospital, Abraka, Delta State?

3. What is the importance of proper staffing in General Hospital, Abraka, Delta State?

1.6 Significance of the Study

The benefit of this study is to evaluate the level of satisfaction of patients with the care they

receive, how short staffing of nurses affects the outcome of patient care and the importance of

good staffing on patients’ outcome. This study will help to create awareness on the importance of

proper staffing, improve care and satisfaction of patients, thereby improving the health and

participation of members of the society. Moreover, this study will be invaluable in designing

strategies for addressing gaps in patient care. It will also provide useful information for policy
makers at national level. Lastly, the results of this study will act as a baseline for other

researchers who may like to work further in this area.

1.7 Scope of Study

This study is delimited to investigate the impact short staffing of nurses have on the quality of

patient care in General Hospital, Abraka, Delta State. All registered nurses in General Hospital,

will be used for this study.

1.8 Operational Definition of Terms

Impact: refers to the effect of nursing staffing levels on the quality of patient care in General

Hospital, Abraka.

Nurses: refers to health care giver with a registered nursing qualification that is practicing in

General Hospital, Abraka.

Patient: refers to a person who is receiving care or treatment from registered nurses in General

Hospital, Abraka.

Quality: refers to the level of excellence in which registered nurses render care to patients in

General Hospital, Abraka.

Short staffing: refers to the reduced number of practicing registered nurses in General Hospital,

Abraka.
 CHAPTER TWO

LITERATURE REVIEW

Introduction

This chapter reviewed literature as related to this study under the following sub-headings,

conceptual review, theoretical framework, empirical review and summary of literature review.

2.1 CONCEPTUAL REVIEW

2.1.1 Shortage of Nurses

Globally speaking, health challenges are changing and becoming increasingly complex due to an

ageing population with a chronic disease burden, such as cardiovascular, hypertension, diabetes

and mental health conditions (Douglas, 2019) (Nwabuwe, 2019). Alongside these changes which

place difficult demands upon healthcare systems around the world, effective workforce strategies

that promote recruitment, retention and sustainability of qualified nurses are urgently needed to

properly meet these increasing demands.

Registered nurses (RNs) work in collaboration with other members of an inter-professional team,

providing health services to people of all ages, experiencing various forms of health challenges

(CIHI, 2018). A health workforce must be of sufficient capacity to meet the population health

needs, with world health leaders such as the World Health Organization (WHO) are predicting

an increase in the global demand for both health and social care (Drennan, 2019). As half of the

global healthcare workforce is comprised of nurses, nurses play a critical role in disease
prevention and health by providing care in primary, community and hospital settings, including

emergency and critical care areas (Drennan, 2019, WHO, 2019).

However, in 2014, both the WHO and the World Bank calculated a current global nursing

shortage of nine million nurses and midwives (Drennan, 2019, WHO 2019). The definition of a

shortage varies between healthcare systems but can be defined as a gap between the number of

nurses required (demand) and the future number who are available to work (supply). The WHO

and World Bank in particular, define a shortage in relation to the Sustainable Development Goals

(SDGs), whereby a shortage means a lower than the required minimum number of doctors or

nurses per head of population required to achieve the population health targets (Drennan, 2019).

For example, half of the WHO member states report having less than 3 nursing and midwifery

workers per 1000 population, with 25% reporting to have less than 1 personnel per 1000

population (WHO, 2019). The National Syndicate of Nursing Professionals (SNPI) has predicted

a shortage of 18 million healthcare professionals by the year 2030, whereby half of the need are

nurses.

Although a largely complex problem with many factors at play, in a nutshell, nursing shortages

are primarily caused by the increasing and more complex demands for population health services

coupled with a shrinking workforce, with more nurses retiring from the profession and others

leaving the workforce altogether due to unhealthy work environments, characterized as being

overly burdensome and stressful (Nwabuwe, 2018).

Nursing shortages are experienced worldwide with the situation worsening in the future without

policy interventions (Nwabuwe, 2018). Healthcare organizations in the Organisation for

Economic Co-operation and Development (OECD) countries, which includes Canada, Australia
and the United Kingdom for instance, are all experiencing unstable nursing labour markets,

characterized by extreme shortages and high turnover of staff. For OECD countries, there is a

predicted shortage of 2.5 million nurses by the year 2030 (Scheffler, 2019).

In this the research 11 patient outcomes were examined including: patient falls, medical errors,

urinary tract infections, and other adverse events plus ‘failure to rescue’ – defined as death

following sepsis, pneumonia, GI bleeding or shock, following the method previously adopted by

Silber and colleagues. Higher levels of nurse staffing were associated with lower levels of

adverse events. The differences persisted for three outcomes, when examined through a

multivariate analysis of matched units: central nervous system derangement, and urinary tract

infection and failure to rescue. Shekelle identified the work of Needleman and colleagues

published in 2011 as a key study (Needleman et al. 2020; Shekelle 2020b). Whilst it is also an

observational study, its strength lies in its retrospective design and use of survival analysis (using

Cox proportional-hazards regression models) which allowed temporal precedence to be

established: the outcomes observed follow the inputs observed. Nurse staffing was measured

through routinely collected administrative data, and was thus recorded for every shift, covering

176,696 eight-hour shifts from 43 units in one hospital. Low staffing was defined as shifts in

which the number of nursing hours per patient day was eight or more hours less than the planned

level. A significantly increased risk of mortality was observed after periods of exposure to low

staffing. An additional merit of the study is that it makes explicit an objective measure of ‘low

staffing’ rather than relying on a relative measure of RN staffing related to an arbitrarily defined

reference point. Risk of patient death is increased after exposure to an empiric nurse staffing

deficit: shifts where the number of nursing hours per patient day (NHPPD) is at least eight hours

fewer than estimated as required – i.e. a shortfall of nurses. The study has been widely cited by
academics, clinicians, and national bodies. For example, in a review undertaken by the Royal

College of Surgeons of England examining the care context of ‘forgotten patients’ (that is

technically ‘low risk’ surgical patients who unexpectedly deteriorate), they refer to the

Needleman et al study measure of ‘8 hours less nursing care than expected’ as a benchmark in

reviewing the post-surgical care of patients (RCSE 2021).

2.1.2 CAUSES OF SHORT STAFFING OF NURSES

In Delta state, some causes of nursing shortage include: rapidly growing population, government

policy in the employment of nurses. Adding to the shortage problem is that nursing is still

majority female, and often during childbearing years, nurses will cut back or leave the profession

altogether. Some may eventually return, but others may move to a new job.

Nigeria according to 2006 census, has a population of 139.9 million people. This rapidly

growing population puts a strain on the available health care infrastructures and the need to open

health facilities. This tends to create a gap between the supply and demand for nurses needed to

work in these new health facilities.

2.1.3 IMPACT ON HEALTH CARE

According to Brush et al 2019, general consequences of nursing staff shortages are as follows:

Increase in nurse-patient load, increase in the risk of error, increases risk of spreading infection,

increases mortality rate, increases the chance of quacks being employed, increases chances of

nurses being over stressed.

Care Left Undone

Much of the research on nurse staffing and mortality described above has focussed on
establishing that there is a significant association between RN staffing and case-mix adjusted

mortality, which remains even when controlling for other factors. Explanatory theories put

forward have suggested that lower staffing levels may lead to less surveillance, with potentially

fatal deterioration going undetected, or that when there are lower levels of RN staffing, the

capacity of the nursing team to provide care is reduced. Both of these theories potentially

connect to a single underlying construct: necessary nursing care being left undone at times of

insufficient nursing staffing – whether that care be vital signs observations, surveillance or other

fundamental care (Kitson et al. 2021; Feo & Kitson 2020). Hypothetically, care left undone may

be both a consequence of lower nursing staffing and precursor to adverse patient outcomes,

including mortality.

Measuring ‘Care left undone’

‘Care left undone’ is also described in the literature as ‘missed care’, ‘incomplete care’,

‘unfinished care’ and ‘implicitly rationed care’. Jones and colleagues, who comprehensively

reviewed the research on care left undone, make the point that “few care processes reach patients

without first passing through the hands of nurses” (Jones et al., 2019). If the ‘flow’ of nursing

care is blocked, there is an increased risk that patients may not receive all the care planned, with

some necessary care being unfinished or left undone. Incomplete or missed care represents a

form of health care ‘under-use’ which, argues Reason, is the most common cause of quality

problems in health care, more so than ‘over-use’ or ‘misuse’ combined. Yet despite a growing

body of literature within nursing over the past decade, missed nursing care as a form of ‘under-

use’ has received little attention within the patient safety world. Jones and colleagues suggest

that the lack of awareness may, in part, be due to the inconsistencies in terminology (Jones et al.,

2019).
Some instruments have been used to measure care left undone that is closely related, stemming

in part form that early work by Aiken and colleagues, is the Basal Extent of Rationing of Nursing

Care Instrument BERNCA (Schubert et al. 2018). The ‘MISSCARE survey’, was developed by

Beatrice Kalisch and colleagues (Kalisch & Williams 2019) drawing on qualitative research on

the activities and reasons for care being missed (Kalisch 2019).

Whilst all include an inventory of nursing care activities and capture responses through self-

report surveys, they each approach the measurement of care undone slightly differently: variation

in recall period, response scale (frequency not completed versus a dichotomous yes or no), the

number and range of activities, and the inclusion of ‘reason’ for care undone. A limitation of all

three instruments (and derivatives of them) is the reliance on self-report; there has been no

evaluation to establish congruence between reported missed care and directly observed missed

care. MISSCARE is the only instrument that has been adapted to enable its use by patients, to

capture their perceptions of care that is unfinished (Kalisch, & Dabney 2019); the others are used

by nursing staff only.

Causes of care left undone: lack of time

Time scarcity is frequently identified as the primary cause for care being left undone or missed.

Time scarcity itself is a reflection of workload, which in the case of ward nurses, is determined

largely by whether staffing levels are sufficient relative to both the number and dependency of

patients that are cared for. Nurse reported care intensity was found to be predictive of unfinished

care, but none of the studies reviewed by Jones examined had assessed nursing intensity formally

using a recognized system (Jones, & Murry 2020). In studies using the MISSCARE Survey,

‘inadequate labour resources’ (particularly unexpected workload increases due to changes in the

number or mix of patients) was the most significant identified as contributing to missed care.
Consequences of care left undone

The majority of research related to care left undone has examined the causes or antecedents of

missed care; few have focused on the possible consequences of missed care. Of the 54 studies

that Jones and colleagues reviewed on missed care only two examined patient outcomes (Jones

& Murry 2020). One of these looked at patient falls (Kalisch & Lee 2019), whilst the other

examined rationed care and hospital mortality, using data from eight Swiss acute hospitals

(Schubert et al. 2018). Schubert and colleagues concluded that their small sample size and study

design limited the generalizability of their findings and did not enable them to test the influence

of care left undone on the observed relationship between staffing and mortality. The challenge of

small hospital sample sizes is noted by others in relation to using hospital mortality as an

outcome measure.

The impact of missed care, through the eyes of patients and relatives who have reported adverse

events to Swedish ‘Medical Responsibility Board’ was highlighted by Andersson and colleagues

(Andersson et al. 2021). Through qualitative analysis of 242 adverse events in nursing, they

found that adverse events were caused not just by errors made by health care staff, but through

care that had been omitted. Increased attention to the implications of missed care is needed, they

concluded, in addition to an investigation of the relationship between missed care and lack of

staff with relevant competence.

Bruyneel and colleagues found that hospitals with lower levels of clinical care left undone (a

subscale based on aggregating seven activities of clinical care left undone) had higher levels of
patient satisfaction, and that clinical care left undone mediated the relationship between nurse

staffing and patient satisfaction (Bruyneel et al. 2021). This is one of the first to have tested the

mediating effect of care left undone between nurse staffing and a patient measure.

Impacts on Patients

The nursing profession is present twenty-four hours a day, seven days a week, 365 days a year

for which they are in the best position to detect changes in patient statuses, intervene early, and

catch errors that can all lead to adverse outcomes (Twigg, 2019). To better understand nursing

impacts on care, the term nurse-sensitive outcomes (NSO) have been developed. NSO’s are

variables in a patient state, behavior or perception that are responsive to nursing interventions

(Twigg, 2019). These variables are dependent upon both the quantity (staffing, nurse-patient

ratios) and quality of care (education level, age, nursing experience) (Twigg, 2019). The

relationship between nurse staffing levels and health outcomes for both the professionals and

who they care for, have been well-studied (Aiken, 2016, Needleman, 2019).

“Nursing shortages and low staffing ratios are associated with unmet patient needs and negative

nurse‐sensitive outcomes, such as mortality, failure to rescue, cardiac arrest, patient falls,

pressure injuries, nosocomial infections, and readmission rates,” ﴾Cho et. al, 2016﴿. What has

been well demonstrated is that higher staff levels are strongly associated with decreased adverse

patient outcomes (Needleman et al., 2019). Adverse patient outcomes include re-admission, falls,

failure to rescue, length of stay, medication errors, patient satisfaction and mortality.

Adverse Patient Outcomes

on the prevalence of; surgical wound infection, urinary tract infection, pressure injury,

pneumonia, deep vein thrombosis, upper gastrointestinal bleed, sepsis and physiological

metabolic derangements. In Stalper’s systematic review (2020), the authors find significant

effects of a health work environment, characterized by nurse-physician collaboration along with

a strong skills mix, that is more experienced and higher-educated staff were significantly

associated with decreased rates of pressure injuries and patient falls (Stalper, 2020). Many other

studies also demonstrate similar findings; higher nurse staffing levels decreased hospital-

acquired infections (Manojilovich, 2021), patient falls (Patrician, 2021), decreased occurrences

of failure to rescue (Shever, 2021), due to increased nursing assessments, decreased length of

stay. In Canada, the average length of hospital stay is ranges from $ 4,100 to $ 11, 400,

depending on the specialty, for the year 2017 (CIHI, 2017).

Patient Mortality

In Needleman’s (2019) study, 133, 742 unit shifts the authors analyze shifts with low RN

staffing (below typical or targeting staffing) and low nursing support staff were associated with

increased patient mortality (Needleman, 2019). Across Europe, RN staffing levels are not

stipulated in law, as they have been in California and parts of Australia (Aiken et al., 2018). The

number of nurses each ward needs to employ to meet patient needs, and the staffing levels on

each shift, is determined locally, by individual unit managers and hospitals. Decision makers

need good quality evidence as to the effects, and cost-effectiveness, of nurse staffing in order to

make such decisions.

outcomes are likely to be significant (Griffiths 2020). Others have reviewed the economic value

of professional nursing in terms of reduced patient complications and the shorter lengths of stay

associated with improved nurse staffing levels (Dall et al. 2019).

Conversely, the harm of failing to use evidence to plan nurse staffing can be devastating. In a

publicly funded National Health Service (NHS), with national professional and organizational

regulation, how had patient safety and care quality been so severely compromised, and why had

these systemic care failings not been detected earlier? RN staffing levels were identified as a key

issue in hospitals with higher than expected mortality rates (Keogh 2017).

The Importance of Appropriate Staffing

“Short staffing is, in a way, like driving drunk,” (McNamara, 2018). In my mind, interpreting

this quote is straightforward in that it places the lives of everyone in danger. Overworking nurses

can result in a decrease in the quality of care provided as well as threatening the safety of the

patient and the nurses providing care. In 2010, both the Senate and the House of Representatives

implemented the Registered Nurse Safe Staffing Act of 2010 which requires, “an appropriate

number of registered nurses provide direct patient care in each unit and on each shift of the

hospital to ensure staffing levels that: ﴾1﴿ address the unique characteristics of the patients and

hospital units; and ﴾2﴿ result in the delivery of safe, quality patient care consistent with specified

requirements,” ﴾Capps, 2018﴿. Through the implementation of this act, it has, “amplified the role

appropriate nurse staffing has in healthcare value and defining the quality healthcare delivery as

well as to open the discussion on how to best link individual nursing care and patient outcomes,”

﴾Pearce et. al, 2018,﴿.

care, which correlates with an increase in the percentage of nurses experiencing burnout, fueling

the shortage of nurses. While it is important to remember the principles that are applicable to the

role of a nurse, in instances where there is a poor work environment related to an increased

workload from ineffective staffing, the lines become blurred between providing patient‐centered

care and becoming task oriented to ensure completion of what needed to be accomplished during

the shift. “Safe staffing acts and the principle of nonmaleficence will only complement each

other and allow the nurse to practice in the way that is best for the patient,” ﴾Martin, 2018﴿

Despite the implementation of acts to promote improved ratios, confounding variables, such as

absenteeism related to a lack of compassion and exhaustion, still threaten safety of the patients

that are being cared for.

McHugh et al, 2016, conducted a study to reveal the directly correlated relationship between an

increased workload and poor patient outcomes. “As each additional patient added to the

workload of a nurse in a medical surgical unit results in 5% lower odds of survival and 16%

lower odds of survival for patients in hospitals with poor work environments” ﴾McHugh et. al,

2016﴿. The Quality and Safety Education of Nurses (QSEN) has compiled a list of competencies

that every nurse should be consciously aware of. “The QSEN initiative encompasses the

competencies of patient‐centered care, teamwork and collaboration, evidence‐based practice,

quality improvement, safety, and informatics,” ﴾Potter et. al, 2013﴿. Along with ensuring that the

focus of care is always patient centered, safety should be the leading consideration when

providing care for patients. One of the primary intentions of nursing is to promote patient care

and wellbeing, with an increased workload, there are instances where more harm than health

promotion occurs in the hospital. Aseptic technique may not always be maintained which can
lead to an increase in the number of hospital‐acquired infections. An overwhelming workload

from inappropriate staffing may influence patient safety by causing the nursing staff to “cut

corners” which could potentially result in failing to verify patient identifiers or allergies and

failure to scan medications to “save time”. As previously stated, it is important to maintain the

priority of patient safety in all procedures and in all aspects of care; however, it is equally

important for the nurses providing the care to maintain their own safety.

2.2 THEORETICAL REVIEW

Shekelle (2020) outlined four conceptual frameworks put forward to understand the relationships

between nurse staffing and in-patient mortality (Shekelle 2020), proposed by Aiken and

colleagues, Tourangeau, Thornlow and colleagues, and Despins and colleagues. The model put

forward by Aiken and colleagues in 2002 proposes that nurse staffing levels and skill-mix impact

on mortality indirectly through two routes (Aiken et al. 2018). Firstly through the association

between nurse staffing levels and broader organisational support for nursing, which is seen as

leading to better nurse outcomes. Broader organisational support (including staffing levels) is

thus put forward as a predictor of better patient outcomes. Secondly, nurse staffing is linked to

outcomes through improved nursing surveillance, via the ‘care process’.

Thornlow and colleagues proposed a model that applies specifically to post-operative outcomes

(Thornlow et Al., 2021). They summarise a range of factors that are likely to contribute to the

risk of post-operative respiratory failure (including surgical procedure, type of anaesthesia etc.).

The model includes staffing as one such factor, and interventions such as nursing surveillance as

another related factor. This idea, that nurse staffing may impact on patient mortality through

levels of surveillance that can be provided, is a common thread across the literature. It is found
informally in discussions of research findings to offer explanations for the observed relationship.

The hypothesis is this: the presence (or absence) of sufficient numbers of RNs determines the

level of surveillance that is possible, and this surveillance is required to detect and respond to

changes in a patient’s condition, and to avoid deterioration that could prove to be fatal.

Surveillance as a mechanism is encapsulated in the notion (and subsequent measurement of)

‘failure to rescue’ (Griffiths & Bottle ,.2020).

Despins and colleagues produced a model which focuses specifically on nurses’ ability to detect

and respond to changes in patients’ conditions that put patients at risk (Despins et al., 2019). In

this model, nurses’ sensitivity and ability to respond to signs of deterioration are seen as being

determined by the broader organisational context that shapes attitudes to failure, reluctance to

simplify, and operational sensitivity. The model does not include how RN staffing levels may

impact on nurses’ surveillance and response function.

Since Shekelle’s summary of conceptual models relating nurse staffing to patient outcomes was

published (Shekelle 2020), Bruyneel and colleagues have put forward an alternative model. They

have collated the ‘isolated findings’ from previous research examining different aspects of the

relationship between nursing inputs and patient outcomes and put forward an explanatory

framework that builds on Donabedian’s (Donabedian 1988) determinants of quality: structure,

process and outcomes (Bruyneel et al. 2021). Clinical care left undone is put forward as a

mediator between RN staffing and patient satisfaction with care, with level of nurse education

exerting a moderating influence between RN staffing and clinical care left undone. Whilst this

study looked at a different outcome – patient satisfaction rather than mortality – it one of the

only studies to have examined care left undone as a mediating factor in the relationship between
nurse staffing and outcomes.

Despite the large number of studies establishing associations between nurse staffing and patient

outcomes, each putting forward possible interpretations for the relationships observed, these

interpretations have rarely been stringently formulated. Models of mediation or moderation to

support theories regarding the relationship between nurse staffing and patient mortality have not

been fully tested.

The conceptual framework for this research is adapted from the nurse staffing and patient

outcome model developed by Kane et. al., (2019) to explain the relationship between nurse

staffing and outcome of care. Kane et. al., framework focuses on two types of outcomes: nurse

outcomes and patient outcomes. The researchers argued that nurse outcome variables can interact

with nurse staffing variables to affect patient outcomes, and that nurse characteristics and patient

factors can influence nurse staffing. Patient factors and hospital organizational factors were

included in the Kane et al framework because these factors may influence the effect of nurse

staffing on patient outcome.

In this present studied Kane et al’s (2019) framework is adapted to focus on aspects of care

addressed in the literature exploring the relationship between short staffing of nursing and patient

outcome in in-patient and out-patient units in General Hospital Abraka, Delta State.

2.3 EMPIRICAL REVIEW

Several studies have been carried out on short staffing of nurses and patient outcomes. In a study

by Emmanuel Andy et al, entitled,” Nursing Shortage paradigm: “The Delta State Situation”, In
Delta state, some factors such as cost of road transport, insecurity of life and properties, poor

housing, deplorable state of hospitals and health centers, lack of power supply, inadequate

nursing personnel and uneven distribution of the few nurses available, were identified to be

peculiar with Delta terrain. This consequently resulted in increased nurse-patient load, risk for

error, infection spread, high mortality rates and nurses being over stressed.

Aiken et al, 2018, also did a study titled “Hospital Nurse Staffing and Patient Outcomes”. The

result of this program of research have been influential in changing clinical practice, managerial

policies and governmental policies in many countries. Based upon the establishment of a link

between lower patient to nurse ratios and better patient outcomes, a number of jurisdictions and

countries have adopted safe nursing staffing standards.

Another study by Canadian Federation of Nurses Union, CNFU (2021), entitled “Nursing

workload and Patient care”. This study reviews the now incontrovertible body of evidence

linking inadequate nurse staffing with increases in mortality and other negative outcomes for

patients.
2.4 SUMMARY OF LITERATURE REVIEW

This chapter reviewed the concept of short staffing of nurses and patient outcomes. The

empirical review shows that several studies have been conducted on the impact of short staffing

of nurses on the quality of patient care. The researcher decided to use conceptual framework

developed by Kane et al (2019) entitled, Nurse Staffing and Patient Outcome Model to support

the study.