The Role of Registered Nurses in Patient Safety and Outcomes


Pertinent Research Findings

Ulrich, B., & Kear, T. (2015). Decreasing infections in nephrology patient populations: Back to basics. Nephrology Nursing Journal, 42(5), 431-434.  
Ulrich, B., & Kear, T. (2015). Patient safety culture in nephrology nurse practice settings: Results by primary work unit, organizational work setting, and primary role. Nephrology Nursing Journal, 42(3), 221-236.  
Thomas-Hawkins, C., Flynn, L., Lindgren, T.G., & Weaver, S. (2015). Nurse manager safety practices in outpatient hemodialysis units. Nephrology Nursing Journal, 42(2), 125-133, 147.  
Ulrich, B., & Kear, T. (2015). Patient safety and patient safety culture in nephrology nurse practice settings: Issues, solutions, and best practices. Nephrology Nursing Journal, 42(2), 113-122.  
Ulrich, B., & Kear, T. (2014). Patient safety and patient safety culture: Foundations of excellent health care delivery. Nephrology Nursing Journal, 41(5), 447-456, 505.  
Ulrich, B., & Kear, T. (2014). Patient safety and patient safety culture: Initial findings. Nephrology Nursing Journal, 41(5), 459-475.  

Tellez M., & Seago, J.A. (2013). California nurse staffing law and RN workforce changes. Nursing Economics, 31(1), 18-26.


Chapman, S.A., Spetz, J., Seago, J.A., Kaiser, J., Dower, C., Herrera, C. (2009). How have mandated nurse staffing ratios affected hospitals? Perspectives from California hospital leaders. Journal of Healthcare Management, 54, 321–335.

Thomas-Hawkins, C., Flynn, L., & Clarke, S.P. (2008). Relationships between registered nurse staffing, processes of nursing care, and nurse-reported patient outcomes in chronic hemodialysis units. Nephrology Nursing Journal, 35(2), 123-130. Study findings revealed that high patient–to-RN ratios and increased numbers of tasks left undone by RNs were associated with an increased likelihood of frequent occurrences of dialysis hypotension, skipped dialysis treatments, shortened dialysis treatments, and patient complaints in hemodialysis units. These findings indicate that federal, state, and dialysis organization policies must foster staffing structures and processes of care in dialysis units that effectively utilize the invaluable skills and services of professional, registered nurses.
Gardner, J.K., Thomas-Hawkins, C., Fogg, L., Latham, C. (2007). The relationships between nurses’ perceptions of the hemodialysis unit work environment and nurse turnover, patient satisfaction, and hospitalizations. Nephrology Nursing Journal, 34(3), 271-281. Significant correlations were found among nurses’ perceptions of the dialysis work environment, nurses’ intention to leave their jobs, nurse turnover rates, and patient hospitalizations. Study findings suggest that nurses’ perceptions of the dialysis work environment are important for nurse and patient outcomes in dialysis settings.
Eisenhauer, L., Hurley, A., & Dolan, N. (2007). Nurses’ reported thinking during medication administration. Journal of Nursing Scholarship, 39(1), 82-87. In this study focused on thought processes nurses use during medication administration to prevent errors, to prevent harm, or promote therapeutic responses, the authors conclusion is nurses’ thinking processes extend beyond rules and procedures and are based on patient data and interdisciplinary professional knowledge to provide safe and effective care.

Horn, S., Buerhaus, P., Bergstrom, N., & Smout, R. (2005). RN staffing time and outcomes of long-stay nursing home residences. American Journal of Nursing105,58-70.

More RN direct care time per resident per day was associated with fewer pressure ulcers, hospitalizations, and urinary tract infections (UTIs); less weight loss, catheterization, and deterioration in the ability to perform activities of daily living (ADLs); and greater use of oral standard medical nutritional supplements.

Mapes, D. (2005). Nurses’ impact on the choice and longevity of vascular access.Nephrology Nursing Journal, 32(6), 670-674.

Data from the Dialysis Outcomes and Practice Patterns Study (DOPPS) reveal the potential impact that a nurse advocate can have on encouraging placement of AV fistulae. These data suggest that the preference of medical professionals in general - and of nephrology nurses in particular -influence the choice of vascular access.

Thomas-Hawkins, C., Denno, M., Currier, H., & Wick G. (2003). Staff nurses’ perceptions of the work environment in freestanding hemodialysis facilities. Nephrology Nursing Journal, 30(2),169-178.

Sixty percent of nurses felt that there were not enough RNs in the dialysis unit to provide quality patient care; 55% felt that there were not enough staff to get the work done or enough time to discuss patient problems with other nurses; and 60% felt that there were adequate support services to allow them to spend time with their patients.

Aiken, L.H., Clarke, S.P., Cheung, R.B., et al. (2003). Education levels of hospital nurses and patient mortality. JAMA, 290(12), 1-8.

A 10% increase in the proportion of nurses holding a bachelor’s degree was associated with a 5% decrease in both the likelihood of surgical patients dying within 30 days of admission and the odds of failure to rescue.

Institute of Medicine. (2004). Keeping patients safe: transforming the work environment of nurses. Washington, DC: National Academies Press.

Nursing is inseparably linked to patient safety. How well patients are cared for by nurses affect health and sometimes can be a matter of life or death. Necessary patient safeguards in the work environment of nurses are: governing boards that focus on safety, leadership and evidence–based management structures and processes, effective nursing leadership and adequate staffing.

Aiken, L.H., Clarke, S.P., Sloane, D.M., et al. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA, 288, 1987-1993.

Suggests that RN staffing may be associated with mortality. In 168 hospitals with mean nurse to patient ratio of 4:1 to 8:1, each additional surgical patient per nurse was associated with a 7% higher likelihood of dying within 30 days of hospital admission and a 7% higher likelihood of failure to rescue.

Sochalski, J. (2004). Is more better? The relationship between nurse staffing and the quality of nursing care in hospitals. Medical Care, 42, 67-73.

This study was an analysis of data from a 1999 statewide survey of 8670 inpatient staff nurses working in acute care hospitals. Quality of nursing care ratings were significantly associated with the number of patients who nurses care for, rates of unfinished care for those patients, and the frequency of patient safety problems. Unfinished care had the strongest relationship of all, with over 40% of the variation in quality ratings associated with the number of tasks undone.

Lovell, V. (2006). Solving the nursing shortage through higher wages. Washington, DC: Institute for Women’s Policy Research.


Inadequate staffing undermines patient care: the quality of patient care suffers when cost-cutting staffing practices reduce nurse/patient ratios.

Most analyses of the nurse workforce overlook the critical link between pay and nurse supply: nurse/patient ratios are 18% higher in the most unionized cities as compared to cities with the lowest levels of nurse unionization.

American Nurses Association. (2002). Nursing-sensitive indicators for community-based non-acute care settings and ANA's safety and quality initiative. Washington, DC: Author.


ANA defines nurse-sensitive quality indicators as those that capture care or its outcomes most affected by nursing care. ANA has identified 10 nurse-sensitive quality indicators for acute care settings and 10 for community-based, non-acute care settings.

Nurse-sensitive quality indicators for community-based settings have been identified as pain management, consistency of communication as evidenced by consistent RN/APRN provider identified in the medical record, staff mix, client satisfaction, prevention of tobacco use, cardiovascular risk reduction, caregiver activity, activities of daily living, and psychosocial interaction.

American Nurses Association. (1999). Nursing-sensitive quality indicators for acute care settings and ANA's safety and quality initiative.Washington, DC: Author.


Nurse-sensitive quality indicators for acute care settings have been identified as mix of RNs, LPNs, and unlicensed personnel caring for patients, total nursing care hours provided per patient day, pressure ulcers, patient falls, patient satisfaction with pain management, patient satisfaction with educational material, patient satisfaction with overall care, patient satisfaction with nursing care, nosocomial infection rate and nurse staff satisfaction.

Landon, B.E., Normand, S., T., Lessler, A, O’Malley, A.J., Schmaltz, S., Loeb, J.M., McNeil, B.J. (2006). Quality of care for the treatment of acute medical conditions in US hospitals. Archives of Internal Medicine, 166, 2511-2517.

Overall, 75.9% of patients hospitalized with acute myocardial infarction, congestive heart failure, and pneumonia received recommended care. After adjustment, for-profit hospitals consistently underperformed not-for-profit hospitals for each condition. Hospitals with more technology available, higher registered nurse staffing, and federal/military designation had higher performance.