The purpose of this review is to summarize the most relevant recent literature on patient safety practices focused on addressing acute care nursing staff shortages.
Methods
We followed the Evidence-based Practice Center Program's rapid response processes. We searched PubMed, CINAHL, and Cochrane for systematic reviews and original studies meeting specified inclusion criteria from January 2013 to October 2024.
Results
Our search identified six reviews and 16 primary studies. Our review found many approaches to addressing nursing shortages in acute care, but most studies were observational. The interventions ranged from individual staff support (e.g. training, incentives) and scheduling changes, to staffing level adjustments (e.g. acuity-based staffing), organizational changes (e.g. care models), and government policies (e.g. mandated ratios), as well as COVID-19-specific measures. Mandated staffing ratios were associated with positive patient and nurse outcomes. Patient acuity tools showed mixed results; some studies found improvements, while others did not.
Conclusions
While some nursing staff interventions show promise, inconsistent implementation and a lack of robust research limit our understanding of best practices. Strong studies are needed to test effective, comprehensive strategies for addressing nursing shortages.
JonesSMoultonCSwiftS, et al.Association between delays to patient admission from the emergency department and all-cause 30-day mortality. Emerg Med J2022; 39: 168–173.
4.
GriffithsPRecio-SaucedoADall'OraC, et al.The association between nurse staffing and omissions in nursing care: a systematic review. J Adv Nurs2018; 74: 1474–1487.
5.
NantsupawatAPoghosyanLWichaikhumOA, et al.Nurse staffing, missed care, quality of care and adverse events: a cross-sectional study. J Nurs Manag2022; 30: 447–454.
6.
AikenLHSloaneDMCimiottiJP, et al.Implications of the California nurse staffing mandate for other states. Health Serv Res2010; 45: 904–921.
CarayonPWooldridgeAHoonakkerP, et al.SEIPS 3.0: human-centered design of the patient journey for patient safety. Appl Ergon2020; 84: 103033.
9.
MileskyJRosenMSharmaR, et al.Acute Care Nursing Staff Shortages that Compromise Patient-to-Nurse Ratios. Making Healthcare Safer IV Rapid Response. (Prepared by the Johns Hopkins University Evidence-based Practice Center under Contract No. 75Q80120D00003). AHRQ Publication No. 25-EHC008-5. Rockville, MD: Agency for Healthcare Research and Quality. April 2025.
10.
GriffithsPSavilleCBallJ, et al.Costs and cost-effectiveness of improved nurse staffing levels and skill mix in acute hospitals: a systematic review. Int J Nurs Stud2023; 147: 104601.
11.
SermeusWAikenLHBallJ, et al.A workplace organisational intervention to improve hospital nurses’ and physicians’ mental health: study protocol for the Magnet4Europe wait list cluster randomised controlled trial. BMJ Open2022; 12: e059159.
12.
MoritaKMatsuiHOnoS, et al.Association between better night-shift nurse staffing and surgical outcomes: a retrospective cohort study using a nationwide inpatient database in Japan. J Nurs Scholarsh2023; 55: 494–505.
13.
De VriesNLavreysenOBooneA, et al.Retaining healthcare workers: a systematic review of strategies for sustaining power in the workplace. Healthcare (Basel)2023; 11: 1887.
14.
KingATSherrodBOrtoV, et al.The effect of a nurse manager's authentic leadership intervention on nurses’ well-being: a single unit QI project. Nurs Forum2022; 57: 694–702.
15.
ThomasJBLeeMA. Factors influencing the transition of foreign-educated nurses to the US healthcare setting: a systematic review. Int Nurs Rev2024; 71: 440–456.
16.
AparícioCNicholsonJ. Do preceptorship and clinical supervision programmes support the retention of nurses?Br J Nurs2020; 29: 1192–1197.
17.
WoodwardKFWillgerodtM. A systematic review of registered nurse turnover and retention in the United States. Nurs Outlook2022; 70: 664–678.
18.
KarhulaKTurunenJHakolaT, et al.The effects of using participatory working time scheduling software on working hour characteristics and wellbeing: a quasi-experimental study of irregular shift work. Int J Nurs Stud2020; 112: 103696.
19.
MorseLDuncanHApenLV, et al.Centralized scheduling of nursing staff: a rapid review of the literature. Nurs Adm Q2024; 48: 347–358.
20.
EastmanDKernanK. A new patient acuity tool to support equitable patient assignments in a progressive care unit. Crit Care Nurs Q2022; 45: 54–61.
21.
StephensonMJaburTYoungG, et al.Staffing models: making increased acuity safe in the pediatric ICU. J Nurs Adm2024; 54: E23–e26.
22.
CarlisleBPereraAStutzmanSE, et al.Efficacy of using available data to examine nurse staffing ratios and quality of care metrics. J Neurosci Nurs2020; 52: 78–83.
23.
ObayashiMShimoyamaKOnoK. Impact of collaborative nursing care delivery on patient safety events in an emergency intensive care unit: a retrospective observational study. J Patient Saf2024; 20: 252–258.
24.
de CordovaPBJonesTRimanKA, et al.Staffing trends in magnet and non-magnet hospitals after state legislation. J Nurs Care Qual2020; 35: 323–328.
25.
ClaretPGBobbiaXOliveS, et al.The impact of emergency department segmentation and nursing staffing increase on inpatient mortality and management times. BMC Health Serv Res2016; 16: 279.
26.
ZinkMPischkeFWendscheJ, et al.Managing the work stress of inpatient nurses during the COVID-19 pandemic: a systematic review of organizational interventions. BMC Nurs2024; 23: 1–18.
27.
de CordovaPBRogowskiJRimanKA, et al.Effects of public reporting legislation of nurse staffing: a trend analysis. Policy Polit Nurs Pract2019; 20: 92–104.
28.
TaraziWW. Associations between medicaid expansion and nurse staffing ratios and hospital readmissions. Health Serv Res2020; 55: 375–382.
29.
LawACStevensJPHohmannS, et al.Patient outcomes after the Introduction of statewide ICU nurse staffing regulations. Crit Care Med2018; 46: 1563–1569.
30.
LeighJPMarkisCAIosifAM, et al.California's nurse-to-patient ratio law and occupational injury. Int Arch Occup Environ Health2015; 88: 477–484.
31.
SpetzJHarlessDWHerreraCN, et al.Using minimum nurse staffing regulations to measure the relationship between nursing and hospital quality of care. Med Care Res Rev2013; 70: 380–399.
32.
RajaC. How do hospitals respond to input regulation? Evidence from the California nurse staffing mandate. J Health Econ2023; 92: 102826.
33.
McHughMDAikenLHSloaneDM, et al.Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals. Lancet2021; 397: 1905–1913.
SwartzMK. What health care is learning from the aviation industry. J Pediatr Health Care2015; 29: 1–2.
36.
AkyurtİZKuvvetliYDeveciM, et al.A new mathematical model for determining optimal workforce planning of pilots in an airline company. Complex Intell Systems2022; 8: 429–441.
