Evidence-based staffing: a different perspective.

The question of how best to staff a patient care unit is a complex one. Considerable research has been reported over the last decade that examines the relationship among nurse staffing, skill mix, costs, quality, various aspects related to the amount and type of nursing care delivered, and the effects on patients. Some of the research has emphasized one aspect of the staffing equation more than another, for example, the characteristics of the nurses or the hours of care received. Other research has tried to include all parameters into the analyses and identify what relationships exist with desired or adverse patient outcomes. In general, the research results across studies often seem equivocal in that there are conflicting results and evidence, depending on the particular methods or type of data used. In a meta-analysis of more than 100 research studies, the primary conclusion was that there is a clinically and statistically significant association between increased registered nurse staffing and adjusted odds ratios of some patient outcomes ( Kane, Shamliyan, Mueller, Duval, & Wilt, 2007 ). The research has been primarily observational, and it is not possible to talk about causal pathways. Research to date has focused primarily on examining existing data from acute care settings and then determining what relationships exist with different types of staffing patterns or skill mix. This has resulted in a movement to base staffing on a certain percentage of nursing care provided by registered nurses or a required staffing ratio of nurses to patients even though the research does not always provide clear evidence for a given approach or method. The complexities of the work environment and its effect on the performance of the nursing team has been well established ( Page, 2004 ). Often the contextual factors that influence how nurses are able to work are a major factor in nurses' abilities to carry out their clinical responsibilities. Unfortunately, the contextual factors are often left out of the staffing equation. This, in part, may explain the conflicting evidence around how to match the nursing team with patient care requirements. A recent invitational conference, sponsored by Sigma Theta Tau International and the American Nurses Credentialing Center, took a different approach from that typically seen when staffing is examined. Fifty thought leaders from nursing, health services, health policy, and research organizations began by asking what excellent staffing is and developing a definition for it rather than the more common approach seen in research, that of examining data from practice and allowing that to define excellence. This definitional approach moves from examining what is safe staffing to attempting to define it first and then have that definition guide practice and research. This is a subtle difference but an important one. Staffing excellence was defined by the attendees as "a dynamic, evidence-based process that results in the efficient, effective use of qualified staff and the stewardship of resources to achieve the best possible outcomes for patients, their families, the workforce, and the organization in which care is delivered" ( Douglas, 2008 , p. …