While we know that increasing nurse workloads beyond optimal levels is associated with a greater risk of patient safety incidents and mortality, a new study from Finland illuminates another dimension of the much-debated staffing issue, since it focused on actual workload rather than the more familiar patient-to-nurse ratio.

In 90% of Finnish hospitals, nurse staffing is determined not by patient-to-nurse ratios but by a classification system developed in the 1990s called RAFAELA that assesses patients' nursing care needs. The system permits different staffing levels for each unit, based on a formula that considers such patient characteristics as age, sex, diagnoses, and functional ability.

In the study, researchers collected daily data for one year regarding patient safety incidents, patient mortality, and actual daily workload per nurse from 36 units at four Finnish hospitals. Nurse workloads on the units could have been at, above, or below recommended nurse staffing levels as determined by RAFAELA. Researchers then looked for associations between workload per nurse and adverse events or mortality.

They found that when a nurse's workload was above the optimal level, the likelihood of a patient safety incident-defined as a safety hazard that either could have caused harm, but was prevented, or did cause harm-increased 8% to 34% (depending on the type of incident), and the likelihood of patient mortality increased 43%. When nurse workloads were below the optimal level, the odds of a safety incident or death were each 25% lower. The study's authors interpreted this decrease to mean that nurses had more time "for caring and observing each patient, which may reduce the risk for adverse events and accordingly prevent the patient's health condition from deteriorating."

While the study had limitations-among others, it did not address the influence of nurse skill mix, competence, or work experience-it showed a correlation between higher than optimal nurse workloads and increased risk of adverse events and patient mortality.-Joan Zolot, PA

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