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Nursing and Health Sciences (2015), 17, 112–118
Research Article
Relationship between nurse staffing levels and nurse outcomes in community hospitals, Thailand Apiradee Nantsupawat, PhD, RN,1 Raymoul Nantsupawat, PhD, RN,1 Wipada Kulnaviktikul, DNS, RN1 and Matthew D. McHugh, PhD, JD, MPH, RN, FAAN2 1 Department of Nursing Administration, Chiang Mai University, ChiangMai, Thailand and 2Center for Health Outcomes & Policy Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
Abstract
A growing body of research has shown an association between nurse staffing levels and a range of nurse outcomes. There is little empirical research evaluating this relationship in Thailand. This study evaluated the influence of nurse staffing levels on outcomes among nurses. A cross-sectional survey design was conducted at 92 community hospitals using a stratified random sampling design across Thailand during May and July 2012. Questionnaires included items focusing on nurse staffing levels; job dissatisfaction and emotional exhaustion, both related to nurse retention; and needlestick and sharps injuries. The study sample comprised 1412 registered nurses who provided direct patient care. The findings showed that each additional patient per nurse was associated with an additional 5% of nurses reporting dissatisfaction in their job; 8% of nurses reporting high emotional exhaustion, and 4% of nurses reporting needlestick and sharps injuries. This study provides evidence of how nurse staffing levels result in nurse outcomes. Nurses are significant healthcare providers that directly affect quality of care and patient safety in hospitals. Improvement of nurse staffing levels holds promise for improving nurse outcomes in Thailand.
Key words
burnout, job dissatisfaction, needlestick injuries, nurse staffing levels, sharps injuries, Thailand.
INTRODUCTION Nurses are the foundation of good health care. They are the principal health care professionals in hospitals, providing patients and their families with holistic care 24 h a day. Insufficient nurses in hospitals have effects on the quality of patient care, as well as for the nurses themselves. Nurses’ job dissatisfaction and emotional exhaustion have been associated with low staffing levels (Aiken et al., 2002; 2008; 2010; Rafferty et al., 2007; You et al., 2012), and can lead to nurse turnover (Hayes et al., 2012; Lu et al., 2012) and intention to leave (Cai & Zhou, 2009). Needlestick and sharps injuries (NSSI) are also associated with low staffing levels (Clarke et al., 2002b; Smith et al., 2004; Kakizaki et al., 2011; Patrician et al., 2011). These occupational injuries are not only a cause of infections and hospital costs, but also nurse stress (Sohn et al., 2006), and are one of the factors leading to intention to leave. Research over several decades affirms that the consequences of heavy nurse workloads are associated with adverse nurse outcomes (Aiken et al., 2002; 2010; You et al., 2012). These findings have not been evaluated in Thai community hospitals, where there are the front-line public hospiCorrespondence address: Apiradee Nantsupawat, Faculty of Nursing, Chiang Mai University, 110/406 Inthawaroros Road, Sriphum, ChiangMai 50200,Thailand. Email: [email protected] Received 4 July 2013; revision received 27 January 2014; accepted 6 February 2014
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tals providing primary health care to the Thai population. Understanding factors influencing job dissatisfaction, emotional exhaustion, and NSSI might allow hospital administrators and policy makers to create strategies that can improve nurse retention and nurse safety in Thai community hospitals, and also in other countries, especially in rural or remote areas, where the shortage of nurses and nurse safety have been issues of the healthcare system.
Literature review Job satisfaction is the affective orientation that an employee has toward his or her current work (Price, 2001). Consequences of low levels of job satisfaction include nurses’ absenteeism, nursing turnover, and intention to quit. In China, Chen et al. (2008) noted in a longitudinal study that job satisfaction was highly associated with the intent to stay or leave, and that low satisfaction is an important factor of nurses’ turnover (Van der Heijden et al., 2010). Similarly, De Gieter et al.’s (2011) study in Belgium concluded that job satisfaction significantly predicted nurse turnover intention. In Israel, Toren et al. (2012) found that low satisfaction within the nursing profession was a predictor of turnover of registered nurses. A systematic review of job satisfaction among hospital nurses showed that hospital nurse job satisfaction is closely related to absenteeism, turnover, and intention to quit (Lu et al., 2012). doi: 10.1111/nhs.12140
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Burnout is defined as a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who work with other people in some capacity (Maslach et al., 1996). A metaanalysis of 61 studies from 1982 to 1994 concluded that nurse burnout was related to turnover intentions (Lee & Ashforth, 1996). Various studies have verified burnout as the indicator of voluntary turnover intentions (Coomber & Barriball, 2007). More recently, Heinen et al. (2013) studied nurses’ intention to leave their profession in a cross-sectional observational study in 10 European countries, and found that burnout is consistently associated with nurses’ intention to leave their profession. An updated literature review of nurse turnover also suggested that stress and burnout lead to greater turnover intent (Hayes et al., 2012). Burnout can not only lead to job turnover and absenteeism, but also to a deterioration in the quality of care (Nayeri et al., 2009; McHugh et al., 2011). Widespread job dissatisfaction, burnout, and frustration among nurses signal problems for patient care (Maslach et al., 1996; Van Bogaert et al., 2013). The published research shows that job dissatisfaction and burnout, especially emotional exhaustion, are predicted by nurse staffing levels. This association was initially demonstrated in Aiken et al.’s (2002) study, which indicated that an increase in workload of one patient per nurse increases emotional exhaustion and job dissatisfaction by a factor of 1.23 (95% confidence interval [CI]: 1.13–1.34) and 1.15 (95% CI: 1.07–1.25), respectively, or by 23% and 15%. Later studies also support this association. For instance, the finding from Rafferty et al.’s (2007) study revealed that the nurses in 30 English acute trusts with the highest patient-to-nurse ratios had 71% higher emotional exhaustion (odds ratio [OR] = 1.71, 95% CI: 1.33–2.19) and 78% higher job dissatisfaction (OR = 1.78, 95% CI: 1.35–2.37) than hospitals with the most favorable nurse staffing. Aiken et al. (2008) indicated that after controlling for the effects of care environments, the odds of nurses reporting high emotional exhaustion or dissatisfaction increased by approximately one-fifth (OR = 1.17, 95% CI: 1.09–1.25) and one-tenth (OR = 1.11, 95% CI: 1.04–1.18), respectively, with each increase of one patient per nurse in mean workloads in their hospitals. Aiken et al. (2010) determined that nurse staffing in California hospitals, where state-mandated minimum nurseto-patient ratios are in effect and differ from Pennsylvania and New Jersey, are associated with nurse outcomes. They also found that when nurses’ workloads were in line with California-mandated ratio in all three states, nurses’ emotional exhaustion and job dissatisfaction were lower, and nurses reported consistently better quality of care. Similarly, a recent study in Chinese hospitals showed that higher patient-to-nurse ratios were associated with poorer nurse outcomes, and each additional patient per nurse increased both emotional exhaustion (OR = 1.04, 95% CI: 1.01–1.08) and dissatisfaction (OR = 1.04, 95% CI: 1.01–1.07) by a factor of 1.04 (You et al., 2012). Nurse safety, especially NSSI, is another nurse outcome of inadequate staffing. NSSI are one of the major occupational injuries experienced by registered nurses in hospitals, and are a concern because they might transmit serious infections
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from blood-borne pathogens, such as hepatitis B and C and HIV infection (Cho et al., 2013), and other blood-borne pathogens, including cytomegalovirus, herpes simplex virus and parvovirus B19 (Wicker et al., 2008). The hospital costs for tests and treatments of infection diseases (Saia et al., 2010); nurses’ psychological well-being, such as fear of needles following a needlestick injury; feeling anxious, depressed (Lee et al., 2005; Wang et al., 2012), or stressed; acute severe distress and persistent moderate distress result in some nurses leaving their jobs (Henry et al., 1990). Among the cited causes in a critical review of the literature on sharp injuries are engineering, behavioral, and organizational factors (Hanrahan & Reutter, 1997). Inadequate nurse staffing, one of the organizational factors, has been implicated as a cause of NSSI. Prior studies reported the association between nurse staffing and NSSI. For instance, Clarke et al.’s (2002b) study found that nurses from units with low staffing were generally twice as likely as those from well-staffed units to report risk factors, needlestick injuries (OR = 2.06, 95% CI: 1.0–4.25). Smith et al. (2004) found that nurses in Chinese hospitals, who indicated that their departments were understaffed, were 7.6 times more likely to have incurred a NSSI than nurses who said their departments were adequately staffed (OR = 7.6, 95% CI: 2.5–33.3). Patrician et al. (2011) indicated that staffing is associated with needlestick injuries. Long working hours, an indicator of understaffing, was found to be an important factor increasing the rate of NSSI (Kakizaki et al., 2011).
Background in Thailand Thailand is a middle-income country located in the South– East Asia region, and is part of regional collaborations, such as the Association of South–East Asian Nations. The health system of Thailand is based on primary health care, which emphasizes prevention and promotion, and ensures adequate and high-quality primary care (World Health Organization, 2012). The Universal Coverage Scheme provides equitablyaccessible, responsive, qualified, and efficient services to Thai citizens. Despite equitable access to services, a nursing shortage in Thai public hospitals, the sector with primary responsibility for providing healthcare services (Srisuphan, 2012), raises concerns about variations in the quality of care. The average density of nursing personnel during the 2000–2010 was 15.2 per 10,000 population, which was higher than Cambodia, Laos, Myanmar, and Vietnam, but lower than Brunei, Indonesia, Malaysia, the Philippines, and Singapore (World Health Organization, 2011). The nursing shortage is linked to a high turnover of nurses and concerns about workplace safety (Clarke et al., 2002b; Aiken et al., 2010; Kakizaki et al., 2011; You et al., 2012). Community hospitals that make up the front-line public hospitals serving fundamental health care to the Thai population are particularly affected by the nursing shortage. Although the government has approved an increase in the training of new nurses, retention strategies are needed (Thailand Nursing and Midwifery Council, 2009). Understanding the underlying causes for the high nurse turnover is necessary to provide an evidence base for policy making in retention strategies. © 2014 Wiley Publishing Asia Pty Ltd.
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Previous studies in Thailand found that nurses’ job satisfaction were at moderate-to-high levels (Silaphan P., 2005, pers. comm.). However, there are difficulties in interpreting these results and predicting trends, because there are a variety of instruments used to measure job satisfaction.A few studies investigated the relationship between nurse staffing levels and job satisfaction, with inconsistent results. The relationship between nurse staffing, nurses’ job satisfaction, and selected patient outcomes in medical and surgical nursing units in university hospitals has been identified (Chitpakdee B., 2006, pers. comm.). The results revealed that the proportions of expert position professional nurses to all professional nurses were positively related to nurse’ job satisfaction. The relationship between nurse staffing and job satisfaction of nurses in inpatient units of public hospitals was also explored (Khumya A., 2002, pers. comm.). The results found that the nurse-to-patient ratio was not related to job satisfaction. In terms of burnout, prior studies have revealed that nurses reported high-to-low levels of burnout (Hasithawech N., 2003, pers. comm.; Theucksuban B., 2007, pers. comm.). Burnout was significantly related to stress (Theucksuban B., 2007, pers. comm.), and associated with high workload (Hasithawech N., 2003, pers. comm.). Registered nurses make up the greatest number of those who experience NSSI in hospitals among healthcare providers (Limtrakul et al., 2004). No accurate reports on the number of NSSI in Thailand exist, because of differences in the measures used. In addition, incident reports are underreported compared to self-reports. Although a substantial body of research indicates that nurse staffing levels have been linked to job dissatisfaction, emotional exhaustion, and NSSI, there has been no research investigating the association of nurse staffing levels with job dissatisfaction, emotional exhaustion, and NSSI in community hospitals in Thailand. Therefore, the purpose of this study was to assess the relationship between nurse staffing levels and job dissatisfaction, emotional exhaustion, and NSSI among nurses in community hospitals in Thailand.
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patients, on their last shift. For each hospital, 25–30 nurses in inpatient units, from which they were selected by stratified random, were approached.
Data collection After obtaining permission from the hospital directors and nursing departments, the researcher sent questionnaires to nurse coordinators in quality and research departments at each hospital. Questionnaires were delivered by nurse coordinators, with a cover page explaining the study purpose, methodology, and instructions. For each hospital, the nurses were approached and asked to seal their completed questionnaires in the provided envelopes and return them to the nurse coordinators. The nurse coordinators then returned the completed questionnaires by mail to the researcher. The nurses were surveyed between May and July 2012. A total of 2415 (98.6%) questionnaires were returned. Of these, only 1412 (57.6%) met the sample criteria.
Instruments and variables Nurse staffing levels Nurse staffing levels were measured based on the nursereported number of patients assigned to each nurse. Nurses were asked how many patients were assigned on their last shift. Nurse responses were calculated as the mean patient load across all registered nurses who reported having responsibility for at least one patient, but fewer than 21 patients, on the last shift they worked. Based on Aiken et al.’s (2002) study, this was chosen as a reasonable cut-off for case workload for the study hospitals. This measure has been found to be superior to those derived from administrative databases, because it includes only those nurses who have clinical caseloads (Aiken et al., 2002). The reports were for all shifts, with the study units aggregated to the hospital level, so the staffing measure captured the average number of patients per nurse for each hospital.
METHODS Study design This study was a cross-sectional design. The findings reported here are from a larger study that involved collecting data via nurse surveys in 2012 as part of a hospital nurse-surveillance capacity profile study (Nantsupawat et al., 2012, pers. comm.).The survey was conducted in community hospitals in Thailand with ≥ 90 beds during May and July 2012. At the time of study, there were 93 hospitals across Thailand, 92 of which agreed to participate in the study.
Setting and participants The sample for this study focused on nurses who provided direct patient care in the study hospitals in which they had worked for more than one year, and who had responded that they had cared for at least one patient, but fewer than 21 © 2014 Wiley Publishing Asia Pty Ltd.
Job dissatisfaction Job dissatisfaction was measured by single item that asked nurses to rate how satisfied they were with their job. The response categories ranged from 1 (very satisfied) to 4 (very dissatisfied). Nurses were considered to be dissatisfied if they reported being very dissatisfied or moderately dissatisfied.
Emotional exhaustion Emotional exhaustion was measured by the Maslach Burnout Inventory – Human Service Survey – Thai version (Maslach et al., 1996), the most commonly-used instrument for measuring burnout (Poghosyan et al., 2009). Respondents rate the frequency with which they experience various job related feelings on a seven point scale, ranging from never to every day. Maslach et al. (1996) suggested mean scores ≥ 27 on the emotional exhaustion subscale
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demonstrate high burnout. Mean scores of 26–19 on the emotional exhaustion subscale demonstrate average burnout, and scores ≤ 18 demonstrate low burnout. Cronbach’s α coefficient of this study sample for emotional exhaustion subscale was 0.91.
NSSI NSSI were measured using items that asked whether or not the nurse had ever been injured with a needle or sharp instrument that was used on a patient in the past year, and whether or not they had ever had a near miss with a used needle or sharp instrument in the past year. If they answered yes, they were asked how many times they had been injured by a used needle or sharp instrument or the number of near misses in the past year. This measure has established predictive validity (Clarke et al., 2007; Cho et al., 2013). Demographic characteristics, including age, sex, total number of years of experience as registered nurses, the highest education level in nursing, and hospital location, were assessed via the survey in order to describe and include these characteristics as control variables.
Data analysis Categorical variables were examined by frequency, percentage, and range. Means and standard deviations were used to assess continuous variables. Logistic regression was used to estimate the relationship between nurse staffing levels and nurse outcomes. Adjusted models controlling for nurse characteristics (i.e. nurse’s age, years as a registered nurse, sex, education) were shown in an attempt to control for confounding factors. The statistically-significant (P-value) level of the analyses was set at α ≤ 0.05. Analyses were performed using STATA 10.1 (StataCorp LP,College Station, TX, USA).
Ethical considerations Approval was obtained from the Faculty of Nursing, Chiang Mai University, Chang Mai, Thailand, and permission was
obtained from the hospital and nursing directors of the participating hospitals. All data were maintained on a restricted hard drive. All analyses were conducted and stored on a password-protected computer. The dataset was not identifiable by name. Nurses and their hospitals could not be linked in the datasets. Hospitals were identifiable only by the return of completed questionnaires, which indicated informed consent to participate by code; hospital names were not included in the analytic dataset.
RESULTS The average age of nurses was 33 years, and the mean years of experience as a registered nurse was approximately 8.5 years. Almost 96% of the nurses were women, and 96% held a baccalaureate degree. Approximately 40% of nurses worked in surgical and medical units. In terms of outcomes, approximately one-fourth of nurses were dissatisfied with their job and one-third of nurses were reported high emotional exhaustion. Regarding occupational injuries, approximately half of the nurses reported having a needle injury in the past year, and three-fifth of nurses reported having near misses in the past year. The average number of needle injuries and near misses in the past year were 1.22 and 1.69, respectively (Table 1). The average number of working hours of nurses was 55 h per week.The average number of patients per nurse ratio was 11, and the average number of registered nurses per nurse aide ratio was two (Table 2). The results of the relationship between nurse staffing levels on job dissatisfaction, emotional exhaustion, and NSSI from unadjusted and adjusted models are shown in Table 3. The unadjusted models estimate the relationship between nurse staffing levels at a given time, but the adjusted models estimate impact simultaneously, with controls for nurse characteristics. Before and after controlling for nurse characteristics, each additional patient per nurse was associated with a 5% increase in the odds of nurses reporting dissatisfaction in their job (OR = 1.05, 95% CI: 1.00–1.10), an 8%
Table 1. Characteristics of nurses reporting outcomes Nurse outcomes Job satisfaction Very satisfied Moderately satisfied A little unsatisfied Very dissatisfied Emotional exhaustion High Average Low Needle injury in the past year Yes No Near miss in the past year Yes No
Mean
Standard deviation
Frequency
Percentage (%)
249 814 321 27
17.65 57.69 22.75 1.91
450 304 658
31.85 21.53 46.60
1.22
0.63
682 730
48.30 51.70
1.69
1.28
857 555
60.69 39.31
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increase in the odds of nurses reporting high emotional exhaustion (OR = 1.08, 95% CI: 1.03–1.13), and a 4% increase in the odds of nurses reporting NSSI while caring for a patient (OR = 1.04, 95% CI: 1.00–1.08) (Table 3).
DISCUSSION Nurses cared for approximately 11 patients each, which was higher than the recommended ratio of the Thailand Nursing and Midwifery Council (2005), in which patient-to-nurse ratios should be 4:1–6:1 in inpatient units for secondary care hospitals. This study finding was also higher than the patientto-nurse ratios of general hospitals in Thailand (Nantsupawat et al., 2011). Compared with similar studies, the patient-tonurse ratios in the hospitals of this study were higher than those reported in other settings, such as acute care hospitals in Canada, England, Scotland, Norway, Sweden, Switzerland (Aiken et al., 2001; 2012), and the USA, and chronic hemodialysis centers (Fynn et al., 2009) and English hospitals (Sheward et al., 2005). In this study, we found that nurses worked approximately 55 h per week on average. This implies that these nurses worked approximately seven shifts per week, as well as dealing with larger-than-recommended patient workloads. This is consistent with Sawaengdee’s (2008) study, which reported that the average monthly workload for staff nurses in public hospitals in Thailand was more than the general standard (22 days or shifts) by nearly 10 days (shifts). Approximately one in four nurses in the study reported being dissatisfied with their job, and approximately one in three had higher emotional exhaustion than the norm, which is similar to the results from international studies in general acute hospitals in Europe (Van Bogaert et al., 2009a,b; Aiken et al., 2012), an inpatient unit in a US-based army medical
Table 2. Characteristics of nurse staffing levels in the study’s hospitals reported by nurses Characteristics Working hours per week Patient-to-nurse ratio (patient) Registered nurses : nurse aides
Mean
Range
55 11:1 4:2
41–84 6:1–15:1 (3–8):(1–4)
department hospital (Pantrician et al., 2010), and inpatient units in China (You et al., 2012). This implies that job dissatisfaction and emotional exhaustion are also issues in other countries. After controlling for nurse characteristics, there was evidence that higher patient-to-nurse staffing ratios were significantly associated with higher job dissatisfaction levels among nurses. This finding was consistent with prior studies (Aiken et al., 2002; 2008; 2012; Rafferty et al., 2007). Furthermore, after controlling for nurse characteristics, there was evidence that nurse staffing levels were significantly positively associated with high emotional exhaustion. This study result is consistent with prior studies, which suggested that emotional exhaustion was related to workload (Aiken et al., 2002; 2008; 2012; Rafferty et al., 2007). Nurses are the main healthcare providers and constitute an around-the-clock surveillance system in hospitals. They can detect and provide early intervention when patients’ conditions deteriorate. Moreover, the effectiveness of this surveillance system is affected by the number of nurses available to assess patients continuously. Nurses who are responsible for a high workload or care for many patients within a limited timeframe cannot provide adequate nursing care for patients. Consequently, they have coexisting feelings of frustration and tension, lack of energy, and feel that their emotional resources are used up, thus resulting in dissatisfaction. This study reported on nurse-reported NSSI and associated predictors of NSSI in study hospitals. Approximately half of the nurse respondents experienced NSSI in the past year. The average incidence was 1.22 times/nurse/year. Approximately 60% of the study nurses experienced a near miss with a used needle or shape instrument in the past year, with an average of 1.67 times/nurse/year. Because NSSI are rarely investigated in Thailand, the number of NSSI for comparison was not available. However, a study consistent with this result on the risks associated with NSSI in Thai nurses reported an incidence rate of 1.7 times/nurse/ year (Danchaiwichit & Judangn, 1997). Based on the results of this study, and after controlling for nurse characteristics, NSSI were found to be associated with nurse staffing, which is similar to findings from prior studies (Clarke et al., 2002a,b). It could be that nurses’ excessive workloads result in stress and emotional and physical exhaustion, as well as hurried and incautious work. This could reduce the likelihood of following the nursing
Table 3. Unadjusted and adjusted odds ratios (OR) for the relationship between nurse staffing levels on nurse outcomes and needlestick and sharps injuries Outcomes Job dissatisfaction High emotional exhaustion Needle injury Near miss
Unadjusted OR (95% CI)
P-values
Adjusted OR (95% CI)
P-values
1.05* (1.01–1.11) 1.08** (1.03–1.14) 1.04* (1.00–1.09) 1.03 (0.98-1.08)
0.017 0.001 0.053 0.153
1.05* (1.00–1.10) 1.08* (1.03-1.13) 1.04* (1.00–1.08) 1.03 (0.98-1.08)
0.021 0.002 0.054 0.151
*P < 0.05, **P ≤ 0.001. Adjustments were made for nurse characteristics (nurse’s age, years as a registered nurse, sex, education). CI, confidence intervals.
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Nurse staffing levels and nurse outcomes
process and standard precautions, while increasing the chance of human error and risky behaviors, such as recapping needles and poor compliance with precautions in general. The possible reasons for emotional exhaustion among the hospital nurses within this study are that nurses who work in hospitals with ≥ 90 beds have to work with advanced technology, with a greater emphasis on costeffectiveness, decreased length of patient stay, and increasing pressure to conform to quality standards, while the number of nurses is limited. Moreover, the need for access to healthcare services is increasing, with a 2005 report finding that approximately 96.3% of people can access healthcare services and are highly satisfied with this access, whereas healthcare providers are moderately satisfied in providing service (57%) due to heavy workloads (Thailand Nursing and Midwifery Council, 2005). Based on the findings, the link between workload, emotional exhaustion, job dissatisfaction, and NSSI is evident.
Study limitations There are some limitations of this study. Nurse staffing in this study referred to the patient-to-nurse ratio, which is only one method of measuring nurse staffing levels. An exploration of other methods might inform further studies. NSSI rates were derived from self-reports, without validation from other data. Recall bias and underreporting are a possible concern. This study was a cross-sectional design, so causal inferences cannot be made. Longitudinal research is warranted. Moreover, generalization of the research findings might be limited to only the hospitals in this study. Future research should conduct similar studies in other settings.
Conclusions In this first assessment of nurse staffing levels and nurse outcomes in community hospitals in Thailand, we conclude that there needs to be improvements in strategies for enhancing nurse retention and safety. This study replicated the findings of previous international research and highlighted the link between low staffing levels and job dissatisfaction, emotional exhaustion, and NSSI in a Thai context. We suggest that policy makers and hospital managers improve patient-to-nurse ratios, and by doing so, reducing nurse burnout and improving nurse job satisfaction, which will in turn improve patient safety and nurse retention rates. Our findings also suggest that improving patient-tonurse ratios might decrease hospital costs for tests and treatments of infections resulting from NSSI. These findings recommend that a strategy for improving nurse outcomes might be to conduct future research that examines the link between staffing levels and nurse outcomes in hospitals in other countries.
ACKNOWLEDGMENT This study was funded by Chiang Mai University. The authors would like thank all of the participants involved in this study.
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CONTRIBUTIONS Study Design: AN, RN, WK. Data Collection: AN. Data Analysis: AN, RN, WK. Manuscript Writing: AN, RN, WK, MDM.
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Nursing and Health Sciences (2015), 17, 112–118
Research Article
Relationship between nurse staffing levels and nurse outcomes in community hospitals, Thailand Apiradee Nantsupawat, PhD, RN,1 Raymoul Nantsupawat, PhD, RN,1 Wipada Kulnaviktikul, DNS, RN1 and Matthew D. McHugh, PhD, JD, MPH, RN, FAAN2 1 Department of Nursing Administration, Chiang Mai University, ChiangMai, Thailand and 2Center for Health Outcomes & Policy Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
Abstract
A growing body of research has shown an association between nurse staffing levels and a range of nurse outcomes. There is little empirical research evaluating this relationship in Thailand. This study evaluated the influence of nurse staffing levels on outcomes among nurses. A cross-sectional survey design was conducted at 92 community hospitals using a stratified random sampling design across Thailand during May and July 2012. Questionnaires included items focusing on nurse staffing levels; job dissatisfaction and emotional exhaustion, both related to nurse retention; and needlestick and sharps injuries. The study sample comprised 1412 registered nurses who provided direct patient care. The findings showed that each additional patient per nurse was associated with an additional 5% of nurses reporting dissatisfaction in their job; 8% of nurses reporting high emotional exhaustion, and 4% of nurses reporting needlestick and sharps injuries. This study provides evidence of how nurse staffing levels result in nurse outcomes. Nurses are significant healthcare providers that directly affect quality of care and patient safety in hospitals. Improvement of nurse staffing levels holds promise for improving nurse outcomes in Thailand.
Key words
burnout, job dissatisfaction, needlestick injuries, nurse staffing levels, sharps injuries, Thailand.
INTRODUCTION Nurses are the foundation of good health care. They are the principal health care professionals in hospitals, providing patients and their families with holistic care 24 h a day. Insufficient nurses in hospitals have effects on the quality of patient care, as well as for the nurses themselves. Nurses’ job dissatisfaction and emotional exhaustion have been associated with low staffing levels (Aiken et al., 2002; 2008; 2010; Rafferty et al., 2007; You et al., 2012), and can lead to nurse turnover (Hayes et al., 2012; Lu et al., 2012) and intention to leave (Cai & Zhou, 2009). Needlestick and sharps injuries (NSSI) are also associated with low staffing levels (Clarke et al., 2002b; Smith et al., 2004; Kakizaki et al., 2011; Patrician et al., 2011). These occupational injuries are not only a cause of infections and hospital costs, but also nurse stress (Sohn et al., 2006), and are one of the factors leading to intention to leave. Research over several decades affirms that the consequences of heavy nurse workloads are associated with adverse nurse outcomes (Aiken et al., 2002; 2010; You et al., 2012). These findings have not been evaluated in Thai community hospitals, where there are the front-line public hospiCorrespondence address: Apiradee Nantsupawat, Faculty of Nursing, Chiang Mai University, 110/406 Inthawaroros Road, Sriphum, ChiangMai 50200,Thailand. Email: [email protected] Received 4 July 2013; revision received 27 January 2014; accepted 6 February 2014
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tals providing primary health care to the Thai population. Understanding factors influencing job dissatisfaction, emotional exhaustion, and NSSI might allow hospital administrators and policy makers to create strategies that can improve nurse retention and nurse safety in Thai community hospitals, and also in other countries, especially in rural or remote areas, where the shortage of nurses and nurse safety have been issues of the healthcare system.
Literature review Job satisfaction is the affective orientation that an employee has toward his or her current work (Price, 2001). Consequences of low levels of job satisfaction include nurses’ absenteeism, nursing turnover, and intention to quit. In China, Chen et al. (2008) noted in a longitudinal study that job satisfaction was highly associated with the intent to stay or leave, and that low satisfaction is an important factor of nurses’ turnover (Van der Heijden et al., 2010). Similarly, De Gieter et al.’s (2011) study in Belgium concluded that job satisfaction significantly predicted nurse turnover intention. In Israel, Toren et al. (2012) found that low satisfaction within the nursing profession was a predictor of turnover of registered nurses. A systematic review of job satisfaction among hospital nurses showed that hospital nurse job satisfaction is closely related to absenteeism, turnover, and intention to quit (Lu et al., 2012). doi: 10.1111/nhs.12140
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Burnout is defined as a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who work with other people in some capacity (Maslach et al., 1996). A metaanalysis of 61 studies from 1982 to 1994 concluded that nurse burnout was related to turnover intentions (Lee & Ashforth, 1996). Various studies have verified burnout as the indicator of voluntary turnover intentions (Coomber & Barriball, 2007). More recently, Heinen et al. (2013) studied nurses’ intention to leave their profession in a cross-sectional observational study in 10 European countries, and found that burnout is consistently associated with nurses’ intention to leave their profession. An updated literature review of nurse turnover also suggested that stress and burnout lead to greater turnover intent (Hayes et al., 2012). Burnout can not only lead to job turnover and absenteeism, but also to a deterioration in the quality of care (Nayeri et al., 2009; McHugh et al., 2011). Widespread job dissatisfaction, burnout, and frustration among nurses signal problems for patient care (Maslach et al., 1996; Van Bogaert et al., 2013). The published research shows that job dissatisfaction and burnout, especially emotional exhaustion, are predicted by nurse staffing levels. This association was initially demonstrated in Aiken et al.’s (2002) study, which indicated that an increase in workload of one patient per nurse increases emotional exhaustion and job dissatisfaction by a factor of 1.23 (95% confidence interval [CI]: 1.13–1.34) and 1.15 (95% CI: 1.07–1.25), respectively, or by 23% and 15%. Later studies also support this association. For instance, the finding from Rafferty et al.’s (2007) study revealed that the nurses in 30 English acute trusts with the highest patient-to-nurse ratios had 71% higher emotional exhaustion (odds ratio [OR] = 1.71, 95% CI: 1.33–2.19) and 78% higher job dissatisfaction (OR = 1.78, 95% CI: 1.35–2.37) than hospitals with the most favorable nurse staffing. Aiken et al. (2008) indicated that after controlling for the effects of care environments, the odds of nurses reporting high emotional exhaustion or dissatisfaction increased by approximately one-fifth (OR = 1.17, 95% CI: 1.09–1.25) and one-tenth (OR = 1.11, 95% CI: 1.04–1.18), respectively, with each increase of one patient per nurse in mean workloads in their hospitals. Aiken et al. (2010) determined that nurse staffing in California hospitals, where state-mandated minimum nurseto-patient ratios are in effect and differ from Pennsylvania and New Jersey, are associated with nurse outcomes. They also found that when nurses’ workloads were in line with California-mandated ratio in all three states, nurses’ emotional exhaustion and job dissatisfaction were lower, and nurses reported consistently better quality of care. Similarly, a recent study in Chinese hospitals showed that higher patient-to-nurse ratios were associated with poorer nurse outcomes, and each additional patient per nurse increased both emotional exhaustion (OR = 1.04, 95% CI: 1.01–1.08) and dissatisfaction (OR = 1.04, 95% CI: 1.01–1.07) by a factor of 1.04 (You et al., 2012). Nurse safety, especially NSSI, is another nurse outcome of inadequate staffing. NSSI are one of the major occupational injuries experienced by registered nurses in hospitals, and are a concern because they might transmit serious infections
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from blood-borne pathogens, such as hepatitis B and C and HIV infection (Cho et al., 2013), and other blood-borne pathogens, including cytomegalovirus, herpes simplex virus and parvovirus B19 (Wicker et al., 2008). The hospital costs for tests and treatments of infection diseases (Saia et al., 2010); nurses’ psychological well-being, such as fear of needles following a needlestick injury; feeling anxious, depressed (Lee et al., 2005; Wang et al., 2012), or stressed; acute severe distress and persistent moderate distress result in some nurses leaving their jobs (Henry et al., 1990). Among the cited causes in a critical review of the literature on sharp injuries are engineering, behavioral, and organizational factors (Hanrahan & Reutter, 1997). Inadequate nurse staffing, one of the organizational factors, has been implicated as a cause of NSSI. Prior studies reported the association between nurse staffing and NSSI. For instance, Clarke et al.’s (2002b) study found that nurses from units with low staffing were generally twice as likely as those from well-staffed units to report risk factors, needlestick injuries (OR = 2.06, 95% CI: 1.0–4.25). Smith et al. (2004) found that nurses in Chinese hospitals, who indicated that their departments were understaffed, were 7.6 times more likely to have incurred a NSSI than nurses who said their departments were adequately staffed (OR = 7.6, 95% CI: 2.5–33.3). Patrician et al. (2011) indicated that staffing is associated with needlestick injuries. Long working hours, an indicator of understaffing, was found to be an important factor increasing the rate of NSSI (Kakizaki et al., 2011).
Background in Thailand Thailand is a middle-income country located in the South– East Asia region, and is part of regional collaborations, such as the Association of South–East Asian Nations. The health system of Thailand is based on primary health care, which emphasizes prevention and promotion, and ensures adequate and high-quality primary care (World Health Organization, 2012). The Universal Coverage Scheme provides equitablyaccessible, responsive, qualified, and efficient services to Thai citizens. Despite equitable access to services, a nursing shortage in Thai public hospitals, the sector with primary responsibility for providing healthcare services (Srisuphan, 2012), raises concerns about variations in the quality of care. The average density of nursing personnel during the 2000–2010 was 15.2 per 10,000 population, which was higher than Cambodia, Laos, Myanmar, and Vietnam, but lower than Brunei, Indonesia, Malaysia, the Philippines, and Singapore (World Health Organization, 2011). The nursing shortage is linked to a high turnover of nurses and concerns about workplace safety (Clarke et al., 2002b; Aiken et al., 2010; Kakizaki et al., 2011; You et al., 2012). Community hospitals that make up the front-line public hospitals serving fundamental health care to the Thai population are particularly affected by the nursing shortage. Although the government has approved an increase in the training of new nurses, retention strategies are needed (Thailand Nursing and Midwifery Council, 2009). Understanding the underlying causes for the high nurse turnover is necessary to provide an evidence base for policy making in retention strategies. © 2014 Wiley Publishing Asia Pty Ltd.
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Previous studies in Thailand found that nurses’ job satisfaction were at moderate-to-high levels (Silaphan P., 2005, pers. comm.). However, there are difficulties in interpreting these results and predicting trends, because there are a variety of instruments used to measure job satisfaction.A few studies investigated the relationship between nurse staffing levels and job satisfaction, with inconsistent results. The relationship between nurse staffing, nurses’ job satisfaction, and selected patient outcomes in medical and surgical nursing units in university hospitals has been identified (Chitpakdee B., 2006, pers. comm.). The results revealed that the proportions of expert position professional nurses to all professional nurses were positively related to nurse’ job satisfaction. The relationship between nurse staffing and job satisfaction of nurses in inpatient units of public hospitals was also explored (Khumya A., 2002, pers. comm.). The results found that the nurse-to-patient ratio was not related to job satisfaction. In terms of burnout, prior studies have revealed that nurses reported high-to-low levels of burnout (Hasithawech N., 2003, pers. comm.; Theucksuban B., 2007, pers. comm.). Burnout was significantly related to stress (Theucksuban B., 2007, pers. comm.), and associated with high workload (Hasithawech N., 2003, pers. comm.). Registered nurses make up the greatest number of those who experience NSSI in hospitals among healthcare providers (Limtrakul et al., 2004). No accurate reports on the number of NSSI in Thailand exist, because of differences in the measures used. In addition, incident reports are underreported compared to self-reports. Although a substantial body of research indicates that nurse staffing levels have been linked to job dissatisfaction, emotional exhaustion, and NSSI, there has been no research investigating the association of nurse staffing levels with job dissatisfaction, emotional exhaustion, and NSSI in community hospitals in Thailand. Therefore, the purpose of this study was to assess the relationship between nurse staffing levels and job dissatisfaction, emotional exhaustion, and NSSI among nurses in community hospitals in Thailand.
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patients, on their last shift. For each hospital, 25–30 nurses in inpatient units, from which they were selected by stratified random, were approached.
Data collection After obtaining permission from the hospital directors and nursing departments, the researcher sent questionnaires to nurse coordinators in quality and research departments at each hospital. Questionnaires were delivered by nurse coordinators, with a cover page explaining the study purpose, methodology, and instructions. For each hospital, the nurses were approached and asked to seal their completed questionnaires in the provided envelopes and return them to the nurse coordinators. The nurse coordinators then returned the completed questionnaires by mail to the researcher. The nurses were surveyed between May and July 2012. A total of 2415 (98.6%) questionnaires were returned. Of these, only 1412 (57.6%) met the sample criteria.
Instruments and variables Nurse staffing levels Nurse staffing levels were measured based on the nursereported number of patients assigned to each nurse. Nurses were asked how many patients were assigned on their last shift. Nurse responses were calculated as the mean patient load across all registered nurses who reported having responsibility for at least one patient, but fewer than 21 patients, on the last shift they worked. Based on Aiken et al.’s (2002) study, this was chosen as a reasonable cut-off for case workload for the study hospitals. This measure has been found to be superior to those derived from administrative databases, because it includes only those nurses who have clinical caseloads (Aiken et al., 2002). The reports were for all shifts, with the study units aggregated to the hospital level, so the staffing measure captured the average number of patients per nurse for each hospital.
METHODS Study design This study was a cross-sectional design. The findings reported here are from a larger study that involved collecting data via nurse surveys in 2012 as part of a hospital nurse-surveillance capacity profile study (Nantsupawat et al., 2012, pers. comm.).The survey was conducted in community hospitals in Thailand with ≥ 90 beds during May and July 2012. At the time of study, there were 93 hospitals across Thailand, 92 of which agreed to participate in the study.
Setting and participants The sample for this study focused on nurses who provided direct patient care in the study hospitals in which they had worked for more than one year, and who had responded that they had cared for at least one patient, but fewer than 21 © 2014 Wiley Publishing Asia Pty Ltd.
Job dissatisfaction Job dissatisfaction was measured by single item that asked nurses to rate how satisfied they were with their job. The response categories ranged from 1 (very satisfied) to 4 (very dissatisfied). Nurses were considered to be dissatisfied if they reported being very dissatisfied or moderately dissatisfied.
Emotional exhaustion Emotional exhaustion was measured by the Maslach Burnout Inventory – Human Service Survey – Thai version (Maslach et al., 1996), the most commonly-used instrument for measuring burnout (Poghosyan et al., 2009). Respondents rate the frequency with which they experience various job related feelings on a seven point scale, ranging from never to every day. Maslach et al. (1996) suggested mean scores ≥ 27 on the emotional exhaustion subscale
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demonstrate high burnout. Mean scores of 26–19 on the emotional exhaustion subscale demonstrate average burnout, and scores ≤ 18 demonstrate low burnout. Cronbach’s α coefficient of this study sample for emotional exhaustion subscale was 0.91.
NSSI NSSI were measured using items that asked whether or not the nurse had ever been injured with a needle or sharp instrument that was used on a patient in the past year, and whether or not they had ever had a near miss with a used needle or sharp instrument in the past year. If they answered yes, they were asked how many times they had been injured by a used needle or sharp instrument or the number of near misses in the past year. This measure has established predictive validity (Clarke et al., 2007; Cho et al., 2013). Demographic characteristics, including age, sex, total number of years of experience as registered nurses, the highest education level in nursing, and hospital location, were assessed via the survey in order to describe and include these characteristics as control variables.
Data analysis Categorical variables were examined by frequency, percentage, and range. Means and standard deviations were used to assess continuous variables. Logistic regression was used to estimate the relationship between nurse staffing levels and nurse outcomes. Adjusted models controlling for nurse characteristics (i.e. nurse’s age, years as a registered nurse, sex, education) were shown in an attempt to control for confounding factors. The statistically-significant (P-value) level of the analyses was set at α ≤ 0.05. Analyses were performed using STATA 10.1 (StataCorp LP,College Station, TX, USA).
Ethical considerations Approval was obtained from the Faculty of Nursing, Chiang Mai University, Chang Mai, Thailand, and permission was
obtained from the hospital and nursing directors of the participating hospitals. All data were maintained on a restricted hard drive. All analyses were conducted and stored on a password-protected computer. The dataset was not identifiable by name. Nurses and their hospitals could not be linked in the datasets. Hospitals were identifiable only by the return of completed questionnaires, which indicated informed consent to participate by code; hospital names were not included in the analytic dataset.
RESULTS The average age of nurses was 33 years, and the mean years of experience as a registered nurse was approximately 8.5 years. Almost 96% of the nurses were women, and 96% held a baccalaureate degree. Approximately 40% of nurses worked in surgical and medical units. In terms of outcomes, approximately one-fourth of nurses were dissatisfied with their job and one-third of nurses were reported high emotional exhaustion. Regarding occupational injuries, approximately half of the nurses reported having a needle injury in the past year, and three-fifth of nurses reported having near misses in the past year. The average number of needle injuries and near misses in the past year were 1.22 and 1.69, respectively (Table 1). The average number of working hours of nurses was 55 h per week.The average number of patients per nurse ratio was 11, and the average number of registered nurses per nurse aide ratio was two (Table 2). The results of the relationship between nurse staffing levels on job dissatisfaction, emotional exhaustion, and NSSI from unadjusted and adjusted models are shown in Table 3. The unadjusted models estimate the relationship between nurse staffing levels at a given time, but the adjusted models estimate impact simultaneously, with controls for nurse characteristics. Before and after controlling for nurse characteristics, each additional patient per nurse was associated with a 5% increase in the odds of nurses reporting dissatisfaction in their job (OR = 1.05, 95% CI: 1.00–1.10), an 8%
Table 1. Characteristics of nurses reporting outcomes Nurse outcomes Job satisfaction Very satisfied Moderately satisfied A little unsatisfied Very dissatisfied Emotional exhaustion High Average Low Needle injury in the past year Yes No Near miss in the past year Yes No
Mean
Standard deviation
Frequency
Percentage (%)
249 814 321 27
17.65 57.69 22.75 1.91
450 304 658
31.85 21.53 46.60
1.22
0.63
682 730
48.30 51.70
1.69
1.28
857 555
60.69 39.31
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increase in the odds of nurses reporting high emotional exhaustion (OR = 1.08, 95% CI: 1.03–1.13), and a 4% increase in the odds of nurses reporting NSSI while caring for a patient (OR = 1.04, 95% CI: 1.00–1.08) (Table 3).
DISCUSSION Nurses cared for approximately 11 patients each, which was higher than the recommended ratio of the Thailand Nursing and Midwifery Council (2005), in which patient-to-nurse ratios should be 4:1–6:1 in inpatient units for secondary care hospitals. This study finding was also higher than the patientto-nurse ratios of general hospitals in Thailand (Nantsupawat et al., 2011). Compared with similar studies, the patient-tonurse ratios in the hospitals of this study were higher than those reported in other settings, such as acute care hospitals in Canada, England, Scotland, Norway, Sweden, Switzerland (Aiken et al., 2001; 2012), and the USA, and chronic hemodialysis centers (Fynn et al., 2009) and English hospitals (Sheward et al., 2005). In this study, we found that nurses worked approximately 55 h per week on average. This implies that these nurses worked approximately seven shifts per week, as well as dealing with larger-than-recommended patient workloads. This is consistent with Sawaengdee’s (2008) study, which reported that the average monthly workload for staff nurses in public hospitals in Thailand was more than the general standard (22 days or shifts) by nearly 10 days (shifts). Approximately one in four nurses in the study reported being dissatisfied with their job, and approximately one in three had higher emotional exhaustion than the norm, which is similar to the results from international studies in general acute hospitals in Europe (Van Bogaert et al., 2009a,b; Aiken et al., 2012), an inpatient unit in a US-based army medical
Table 2. Characteristics of nurse staffing levels in the study’s hospitals reported by nurses Characteristics Working hours per week Patient-to-nurse ratio (patient) Registered nurses : nurse aides
Mean
Range
55 11:1 4:2
41–84 6:1–15:1 (3–8):(1–4)
department hospital (Pantrician et al., 2010), and inpatient units in China (You et al., 2012). This implies that job dissatisfaction and emotional exhaustion are also issues in other countries. After controlling for nurse characteristics, there was evidence that higher patient-to-nurse staffing ratios were significantly associated with higher job dissatisfaction levels among nurses. This finding was consistent with prior studies (Aiken et al., 2002; 2008; 2012; Rafferty et al., 2007). Furthermore, after controlling for nurse characteristics, there was evidence that nurse staffing levels were significantly positively associated with high emotional exhaustion. This study result is consistent with prior studies, which suggested that emotional exhaustion was related to workload (Aiken et al., 2002; 2008; 2012; Rafferty et al., 2007). Nurses are the main healthcare providers and constitute an around-the-clock surveillance system in hospitals. They can detect and provide early intervention when patients’ conditions deteriorate. Moreover, the effectiveness of this surveillance system is affected by the number of nurses available to assess patients continuously. Nurses who are responsible for a high workload or care for many patients within a limited timeframe cannot provide adequate nursing care for patients. Consequently, they have coexisting feelings of frustration and tension, lack of energy, and feel that their emotional resources are used up, thus resulting in dissatisfaction. This study reported on nurse-reported NSSI and associated predictors of NSSI in study hospitals. Approximately half of the nurse respondents experienced NSSI in the past year. The average incidence was 1.22 times/nurse/year. Approximately 60% of the study nurses experienced a near miss with a used needle or shape instrument in the past year, with an average of 1.67 times/nurse/year. Because NSSI are rarely investigated in Thailand, the number of NSSI for comparison was not available. However, a study consistent with this result on the risks associated with NSSI in Thai nurses reported an incidence rate of 1.7 times/nurse/ year (Danchaiwichit & Judangn, 1997). Based on the results of this study, and after controlling for nurse characteristics, NSSI were found to be associated with nurse staffing, which is similar to findings from prior studies (Clarke et al., 2002a,b). It could be that nurses’ excessive workloads result in stress and emotional and physical exhaustion, as well as hurried and incautious work. This could reduce the likelihood of following the nursing
Table 3. Unadjusted and adjusted odds ratios (OR) for the relationship between nurse staffing levels on nurse outcomes and needlestick and sharps injuries Outcomes Job dissatisfaction High emotional exhaustion Needle injury Near miss
Unadjusted OR (95% CI)
P-values
Adjusted OR (95% CI)
P-values
1.05* (1.01–1.11) 1.08** (1.03–1.14) 1.04* (1.00–1.09) 1.03 (0.98-1.08)
0.017 0.001 0.053 0.153
1.05* (1.00–1.10) 1.08* (1.03-1.13) 1.04* (1.00–1.08) 1.03 (0.98-1.08)
0.021 0.002 0.054 0.151
*P < 0.05, **P ≤ 0.001. Adjustments were made for nurse characteristics (nurse’s age, years as a registered nurse, sex, education). CI, confidence intervals.
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process and standard precautions, while increasing the chance of human error and risky behaviors, such as recapping needles and poor compliance with precautions in general. The possible reasons for emotional exhaustion among the hospital nurses within this study are that nurses who work in hospitals with ≥ 90 beds have to work with advanced technology, with a greater emphasis on costeffectiveness, decreased length of patient stay, and increasing pressure to conform to quality standards, while the number of nurses is limited. Moreover, the need for access to healthcare services is increasing, with a 2005 report finding that approximately 96.3% of people can access healthcare services and are highly satisfied with this access, whereas healthcare providers are moderately satisfied in providing service (57%) due to heavy workloads (Thailand Nursing and Midwifery Council, 2005). Based on the findings, the link between workload, emotional exhaustion, job dissatisfaction, and NSSI is evident.
Study limitations There are some limitations of this study. Nurse staffing in this study referred to the patient-to-nurse ratio, which is only one method of measuring nurse staffing levels. An exploration of other methods might inform further studies. NSSI rates were derived from self-reports, without validation from other data. Recall bias and underreporting are a possible concern. This study was a cross-sectional design, so causal inferences cannot be made. Longitudinal research is warranted. Moreover, generalization of the research findings might be limited to only the hospitals in this study. Future research should conduct similar studies in other settings.
Conclusions In this first assessment of nurse staffing levels and nurse outcomes in community hospitals in Thailand, we conclude that there needs to be improvements in strategies for enhancing nurse retention and safety. This study replicated the findings of previous international research and highlighted the link between low staffing levels and job dissatisfaction, emotional exhaustion, and NSSI in a Thai context. We suggest that policy makers and hospital managers improve patient-to-nurse ratios, and by doing so, reducing nurse burnout and improving nurse job satisfaction, which will in turn improve patient safety and nurse retention rates. Our findings also suggest that improving patient-tonurse ratios might decrease hospital costs for tests and treatments of infections resulting from NSSI. These findings recommend that a strategy for improving nurse outcomes might be to conduct future research that examines the link between staffing levels and nurse outcomes in hospitals in other countries.
ACKNOWLEDGMENT This study was funded by Chiang Mai University. The authors would like thank all of the participants involved in this study.
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CONTRIBUTIONS Study Design: AN, RN, WK. Data Collection: AN. Data Analysis: AN, RN, WK. Manuscript Writing: AN, RN, WK, MDM.
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