Australian Health Review Australian Health Review Society
Journal of the Australian Healthcare & Hospitals Association

The impact of nurses on patient morbidity and mortality – the need for a policy change in response to the nursing shortage

Di Twigg A B , Christine Duffield C H , Peter L. Thompson D E F and Pat Rapley B G

A School of Nursing, Midwifery and Postgraduate Medicine, Edith Cowan University, Joondalup, WA 6027, Australia.

B Centre for Nursing Research, Innovation and Quality, Sir Charles Gairdner Hospital, Nedlands, WA 6009, Australia.

C Centre for Health Services Management, Faculty of Nursing, Midwifery and Health, and World Health Organization Collaborating Centre for Nursing, Midwifery and Health Development (WHO CC), University of Technology, Sydney, Ultimo, NSW 2007, Australia.

D School of Medicine and Pharmacology, The University of Western Australia, Crawley, WA 6009, Australia.

E West Australian Institute of Medical Research (WAIMR), Nedlands Campus, QEII Medical Centre, Nedlands, WA 6009, Australia.

F Sir Charles Gairdner Hospital, Nedlands, WA 6009, Australia.

G School of Nursing and Midwifery, Curtin University of Technology, Bentley, WA 6102, Australia.

H Corresponding author. Email:

Australian Health Review 34(3) 312-316
Submitted: 24 July 2008  Accepted: 18 November 2009   Published: 25 August 2010


Context. Workforce projections indicate that by 2012 there will be a shortfall of 61 000 registered nurses in Australia. There is a growing body of evidence that links registered nurse staffing to better patient outcomes.

Purpose. This article provides a comprehensive review of the research linking nurse staffing to patient outcomes at a time of growing shortages, highlighting that a policy response based on substituting registered nurses with lower skilled workers may have adverse effects on patient outcomes.

Method. An electronic search of articles published in English using the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Journals @ OVID and Medline was undertaken.

Findings. Robust evidence exists nationally and internationally that links nurse staffing to patient outcomes. Recent meta-analyses have found that there was a 3–12% reduction in adverse outcomes and a 16% reduction in the risk of mortality in surgical patients with higher registered nurse staffing. Evidence confirms that improvements in nurse staffing is a cost-effective investment for the health system but this is not fully appreciated by health policy advisors.

Conclusions. An appropriate policy response demands that the evidence that patient safety is linked to nurse staffing be recognised. Policy makers must ensure there are sufficient registered nurses to guarantee patient safety.

What is known about the topic? Projections indicate that by 2012 there will be an estimated shortfall of 61 000 registered nurses in Australia. However, research demonstrates the number of registered nurses caring for patients is critically important to prevent adverse patient outcomes. Evidence also confirms that improvements in nurse staffing is a cost-effective investment for the health system.

What this paper adds? The paper exposes the lack of an appropriate policy response to the evidence in regard to nurse staffing and patient outcomes. It argues that patient safety must be recognised as a shared responsibility between policy makers and the nursing profession.

What are the implications for practitioners? Policy makers, health departments, Chief Executives and Nurse Leaders need to ensure that adequate nurse staffing includes a high proportion of registered nurses to prevent adverse patient outcomes.


[1]  Access Economics. Employment Demand in Nursing Occupations. Canberra: Department of Health & Ageing; 2004.

[2]  Productivity Commission. Australia’s Health Workforce: Research Report. Canberra; 2005.

[3]  Kane RL , Shamliyan T , Mueller C , Duval S , Wilt T . Nursing Staffing and Quality of Patient Care. Evidence Report/Technology Assessment No. 151 (Prepared by the Minnesota Evidence based Practice Center under Contract No. 290-02-0009). Rockville, MD: Agency for Healthcare Research and Quality; 2007. Available at [verifed 11 April 2008].

[4]  Knaus WA Draper EA Wagner DP Zimmerman JE 1986 An evaluation of outcome from intensive care in major medical centers. Ann Intern Med 104 3 410 8 Pubmed Abstract

[5]  Aiken LH Clarke SP Sloane DM Sochalski J Silber JH 2002 Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA 288 16 1987 93 doi:10.1001/jama.288.16.1987 Pubmed Abstract

[6]  Aiken LH Clarke SP Cheung RB Sloane DM Silber JH 2003 Educational levels of hospital nurses and surgical patient mortality. JAMA 290 12 1617 23 doi:10.1001/jama.290.12.1617 Pubmed Abstract

[7]  Needleman J Buerhaus P Mattke S Stewart M Zelevinsky K 2002 Nurse-staffing levels and the quality of care in hospitals. N Engl J Med 346 22 1715 22 doi:10.1056/NEJMsa012247 Pubmed Abstract

[8]  Kovner C Jones C Zhan C Gergen PJ Basu J 2002 Nurse staffing and post surgical adverse events: an analysis of administrative data from a sample of US hospitals 1990–1996. Health Serv Res 37 3 611 29

[9]  Kovner C Gergen P 1998 Nurse staffing and adverse events following surgery in US hospitals. Image J Nurs Sch 30 4 315 21
doi:10.1111/j.1547-5069.1998.tb01326.x Pubmed Abstract

[10]  Blegen MA Goode CJ Reed L 1998 Nurse staffing and patient outcomes. Nurs Res 47 1 43 50 doi:10.1097/00006199-199801000-00008 Pubmed Abstract

[11]  Blegen MA Vaughn T 1998 A multisite study of nurse staffing and patient occurrences. Nurs Econ 16 4 196 203 Pubmed Abstract

[12]  Schultz MA van Servellen G Chang BL McNeese-Smith D Waxenberg E 1998 The relationship of hospital structural and financial characteristics to mortality and length of stay in acute myocardial infarction patients. Outcomes Manag Nurs Pract 2 3 130 6 Pubmed Abstract

[13]  Seago JA . Nurse staffing, models of care delivery, and interventions. Rockville, MD: Agency for Healthcare Research and Quality; 2001. Available at [verified 11 June 2008].

[14]  McGillis Hall L Doran D Baker GR Pink GH Sidani S O’Brien-Pallas L Donner GJ 2003 Nurse staffing models as predictors of patient outcomes. Med Care 41 9 1096 109 doi:10.1097/01.MLR.0000084180.07121.2B Pubmed Abstract

[15]  Heinz D 2004 Hospital nurse staffing and patient outcomes: a review of current literature. Dimens Crit Care Nurs 23 1 44 50 doi:10.1097/00003465-200401000-00011 Pubmed Abstract

[16]  Rafferty AM Clarke SP Coles J Ball J James P McKee M Aiken LH 2007 Outcomes of variation in hospital nurse staffing in English hospitals: cross-sectional analysis of survey data and discharge records. Int J Nurs Stud 44 2 175 82 doi:10.1016/j.ijnurstu.2006.08.003 Pubmed Abstract

[17]  Estabrooks CA Midodzi WK Cummings GG Ricker KL Giovannetti P 2005 The impact of hospital nursing characteristics on 30-day mortality. Nurs Res 54 2 74 84 doi:10.1097/00006199-200503000-00002 Pubmed Abstract

[18]  Tourangeau AE Doran DM McGillis Hall L O’Brien-Pallas L Pringle D Tu JV Cranley LA 2006 Impact of hospital nursing care on 30-day mortality for acute medical patients. J Adv Nurs 57 1 32 44 doi:10.1111/j.1365-2648.2006.04084.x

[19]  Duffield C , Roche M , O’Brien-Pallas L , Diers D , Aisbett C , King M , Aisbett K , Hall J . Glueing it together: nurses, their work environment and patient safety. Centre for Health Services Management, University of Technology, Sydney 2007. Available at [verified 11 June 2008].

[20]  Duffield C , Roche M , O’Brien-Pallas L , Diers D , Aisbett C , Aisbett K , Homer C . Nursing workload and staffing: impact on patients and staff. Centre for Health Services Management, University of Technology, Sydney; 2009.

[21]  Stanton MW . Hospital nurse staffing and quality of care. US Department of Health & Human Services; 2004. Available at [verified 11 June 2008].

[22]  Pearson A O’Brien-Pallas LL Thomson D Doucette E Tucker D Wiechula RJ Long LE Porritt KA Jordan ZL 2006 Systematic review of evidence on the impact of nursing workload and staffing on establishing healthy work environments. Journal of Evidence Based Healthcare 4 337 84 doi:10.1111/j.1479-6988.2006.00055.x

[23]  Needleman J Buerhaus P Stewart M Zelevinsky K Mattke S 2006 Nurse staffing in hospitals: is there a business case for quality? Health Aff 25 1 204 11 doi:10.1377/hlthaff.25.1.204

[24]  Michigan Nurses Association. The model case for reducing patient-to-nurse ratios in Michigan hospitals: two scenarios. Lansing, MI: Public Policy Associates, Incorporated; 2004.

[25]  Rothberg MB Abraham I Lindenauer PK Rose DN 2005 Improving nurse-to-patient staffing ratios as a cost-effective safety intervention. Med Care 43 8 785 91 doi:10.1097/01.mlr.0000170408.35854.fa Pubmed Abstract

[26]  Cho SH Ketefian S Barkauskas VH Smith DG 2003 The effects of nurse staffing on adverse events, morbidity, mortality, and medical costs. Nurs Res 52 2 71 9 doi:10.1097/00006199-200303000-00003 Pubmed Abstract

[27]  Buerhaus P Donelan K Ulrich BT Norman L DesRoches C Dittus R 2007 Impact of the nurse shortage on hospital patient care: comparative perspectives. Health Aff 26 3 853 62 doi:10.1377/hlthaff.26.3.853

[28]  Access Economics. Population ageing and the Economy. Canberra: Department of Aged Care; 2001. Available at [verified 6 June 2008].

[29]  Letvak S 2002 Myths and realities of ageism and nursing. AORN Journal 75 6 1101 7

[30]  Australian Institute of Health and Welfare. Nursing and Midwifery Labour Force 2005. Canberra: AIHW; 2008.

[31]  Duffield C O’Brien-Pallas L 2003 The causes and consequences of nursing shortages: a helicopter view of the research. Aust Health Rev 26 1 186 93
doi:10.1071/AH030186 Pubmed Abstract

[32]  Tourangeau AE Cranley LA Jeffs L 2006 Impact of nursing on hospital patient mortality: a focused review and related policy implications. Qual Saf Health Care 15 1 4 8 doi:10.1136/qshc.2005.014514 Pubmed Abstract

[33]  New Zealand Nurses Organisation. District Health Boards/NZNO multi-employer nursing/midwifery collective agreement 1 July 2004–31 December 2006. Wellington: New Zealand Nurses Organisation; 2004. Available at [verified 31 May 2009].

[34]  Australian Institute for Health and Welfare. Towards national indicators of safety and quality in health care. Discussion Paper. Canberra: AIHW; 2008.

[35]  Buchan J , Calman L . OEDC Health Working Papers No. 17: Skill mix and policy changes in the health workforce: nurses in advanced roles. Paris: Publication Services OEDC; 2005.

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