title: Nurse staffing levels and the incidence of mortality and morbidity in the adult intensive care unit: a literature review.
abstract: BACKGROUND
  Studies have shown that nurse staffing levels, among many other factors in the hospital setting, contribute to adverse patient outcomes. Concerns about patient safety and quality of care have resulted in numerous studies being conducted to examine the relationship between nurse staffing levels and the incidence of adverse patient events in both general wards and intensive care units.
  
  
  OBJECTIVE
  The aim of this paper is to review literature published in the previous 10 years which examines the relationship between nurse staffing levels and the incidence of mortality and morbidity in adult intensive care unit patients.
  
  
  METHODS
  A literature search from 2002 to 2011 using the MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, and Australian digital thesis databases was undertaken. The keywords used were: intensive care; critical care; staffing; nurse staffing; understaffing; nurse-patient ratios; adverse outcomes; mortality; ventilator-associated pneumonia; ventilator-acquired pneumonia; infection; length of stay; pressure ulcer/injury; unplanned extubation; medication error; readmission; myocardial infarction; and renal failure. A total of 19 articles were included in the review. Outcomes of interest are patient mortality and morbidity, particularly infection and pressure ulcers.
  
  
  RESULTS
  Most of the studies were observational in nature with variables obtained retrospectively from large hospital databases. Nurse staffing measures and patient outcomes varied widely across the studies. While an overall statistical association between increased nurse staffing levels and decreased adverse patient outcomes was not found in this review, most studies concluded that a trend exists between increased nurse staffing levels and decreased adverse events.
  
  
  CONCLUSIONS
  While an overall statistical association between increased nurse staffing levels and decreased adverse patient outcomes was not found in this review, most studies demonstrated a trend between increased nurse staffing levels and decreased adverse patient outcomes in the intensive care unit which is consistent with previous literature. While further more robust research methodologies need to be tested in order to more confidently demonstrate this association and decrease the influence of the many other confounders to patient outcomes; this would be difficult to achieve in this field of research.
authors.affiliation: Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Butterfield St, Herston QLD 4006, Australia. m2.mcgahan@connect.qut.edu.au
authors.forename: Matthew
authors.initials: M
authors.lastname: McGahan
authors.forename: Geraldine
authors.initials: G
authors.lastname: Kucharski
authors.forename: Fiona
authors.initials: F
authors.lastname: Coyer
mesh_terms: D000328:Adult; D003428:Cross Infection / Q000453:epidemiology* / Q000517:prevention & control; D017052:Hospital Mortality; D006801:Humans; D015994:Incidence; D007362:Intensive Care Units; D009741:Nursing Staff, Hospital / Q000600:supply & distribution*; D061214:Patient Safety; D010561:Personnel Staffing and Scheduling; D003668:Pressure Ulcer / Q000453:epidemiology* / Q000517:prevention & control; D011787:Quality of Health Care; D000078329:Workforce