Does Investing in Nurse Staffing Provide Dividends?

Purpose:

Over a decade of research has established that better nurse skill mix and staffing levels are linked to positive patient outcomes in hospital settings. Hospital executives are more likely to support a richer skill mix or increased nurse staffing levels if these decisions can be shown to be cost effective.

This paper will discuss the evidence in regard to the cost effectiveness of increasing nursing hours or skill mix to improve patient outcomes. It will highlight the evidence to date to guide nurse leaders in staffing decisions and make recommendations on future research directions.

 Methods:

 To determine if the evidence in regard to increasing nursing hours or providing a richer skill mix was cost effective, a systematic review on economic evaluations of nurse staffing and patient outcomes was conducted. The Cochrane Collaboration systematic review method incorporating economic evidence was used. The CINAHL, MEDLINE, SPORTDiscus, and PsychINFO databases were searched in 2013 (with no date limits) for published and unpublished studies in English. Papers with full economic evaluations were included where the costs of increasing nursing hours or changing the skill mix were reported along with patient outcomes.

Results:

The systematic review identified five cost effectiveness and four cost benefit analyses. No cost minimisation or cost utility studies were identified in the review. As the studies used a variety of methods to conceptualise and measure costs and patient outcomes,   comparison of results were difficult.

Due to the small number of studies identified in the search, the mixed results and the variability in the methods used the reviewers were unable to determine conclusively whether or not increases in nurse staffing levels or a richer skill mix is a cost effective intervention for improving patient outcomes. In contrast to the large body of literature that links nurse staffing and skill mix to high quality patient care there are only a small number of studies that have investigated the cost of changing staffing levels and skill mix. The evidence does not enable the identification of a nurse staffing level or a particular skill mix that gives better patient outcomes in the most cost effective way. 

 Conclusion:

The evidence to date suggests that increasing nurse staffing and/or improving the skill mix has a beneficial effect on patient outcomes and from the societal perspective may be cost effective. However, increased staffing at a hospital level comes at a cost and payers are left to determine if this cost is acceptable.  On the other hand, there is some evidence that changing the skill mix may be more cost effective than increasing nursing hours although this requires further investigation. Further high quality studies are required using a well-defined reference base case to provide sufficient evidence to support nurse staffing decision making by nurse leaders.