Does the Usage of Agency Nurses Has a Negative Impact on Quality Patient Care?

Introduction

The significance of nurse staffing to the delivery of quality health care to patients was “the most important finding in the Institute of Medicine (IOM) committee report” (Wunderlich, Sloan, and Davis, 1996, p. 92). The report showed that “nursing was a critical factor in determining the quality of care in hospitals and the nature of patient outcomes” (Wunderlich et al., 1996, p. 92). Therefore, nurse staffing has been a critical health policy matter that policymakers must give serious consideration to.

However, there is a general agreement among stakeholders that nurse staffing has effects on the quality of health care outcomes and the safety of patients. Hospitals with low nurse staffing levels tend to “have higher rates of poor patient outcomes” (Stanton, 2004, p. 2). As a result, some hospitals have used agency nurses to complement the inadequate supply of nurses. There is no clear agreement on the impacts of using agency nurses to provide health care services to patients.

This is a literature review on the usage of agency nurses and its effects on the quality of patient care, specifically in failure to rescue, morbidity, and mortality.

Problem Statement

Many hospitals depend on agency nurses as ways of addressing the persistent shortage of nurses. However, this practice has raised issues about “the consistency and quality, as well as the cost of care provided by temporary staff” (Joint Commission on Accreditation of Health Care Organizations, 2002, p. 1).

Problem Symptoms

Recent studies have also indicated that work environment and management culture contributed to negative quality of care rather than agency nurses (Aiken et al., 2012). On the other hand, other studies have associated the poor quality of care and patient safety outcomes to agency nurses. There are also issues about the morale of nurses employed by the hospitals and poor relations with the agency nurses (Parsons, 2009). As a result, this literature review seeks to clarify whether usages of agency nurses have negative impacts on the quality of patient care within the hospital environment, specifically in failure to rescue, morbidity, and mortality.

Failure to rescue (FTR) refers to cases where caregivers “fail to notice or respond when a patient is dying of preventable complications in a hospital” (Aleccia, 2008, p. 1). Silber and colleagues referred to FTR as “a death after a treatable complication” (Silber et al., 2007, p. 918). The United States Agency for Healthcare Research and Quality has recognized data from rates of FTR as crucial indicators of the quality of care and patient safety outcomes. It shows how nurses are sensitive to the quality of care during medical care. Aleccia noted that data from HealthGrades reported that more than “188,000 patients lost their lives to FTR between 2004 and 2006” (Aleccia, 2008, p. 1).

Mortality reflects deaths that occurred due to nurse staffing characteristics. Morbidity showed the increment in complication among inpatients that delayed recovery and discharge when agency nurses administered care. The earlier research concluded that higher rates of agency nurses were mainly “associated with higher rates of mortality, morbidity, and failure to rescue” (Aiken et al., 2012, p. 931).

Research Questions

  • Do agency nurses neglect their roles and engage in actions that affect the quality of health care negatively?
  • Does the relationship between agency nurses and nurses directly employed by the hospitals affect the quality of health care outcomes?
  • Do agency nurses observe the quality of care during their work?
  • How do agency nurses affect the quality of health care outcomes?

Literature Review

For the past few decades, researchers in the area of health care services have reported the link between the nursing staff and the quality of health care outcomes in hospitals (Shortell and Hughes, 1998). As a result, there have been growing interests in staffing nursing. Interests in agency nurses have been due to staff shortages that started in the 1990s and have persisted to the present time. In addition, projections have shown that the nursing shortage shall persist in the US and the world at large. As a result, it shall affect the quality of health care provided and the safety of patients and limit the provision of health care services. This implies that staffing and outcomes in the health care quality are critical and relevant for stakeholders in the health care sector.

Mark Stanton notes that hospitals with low staff levels also experience higher rates of poor patient safety outcomes. However, increasing the level of staffing has not been easy because of the “needs of today’s higher acuity patients for improved care and a nationwide gap between the number of available positions and the number of registered nurses (RNs) qualified and willing to fill them” (Stanton, 2004, p. 179).

Still, interest in nursing shortages has also increased from the evidence that past studies have shown. Such studies have demonstrated how low numbers of nurses in hospitals have negative outcomes on the quality of care patients receive. Specifically, research by Needleman and Buerhaus (2000) and Aiken, Clarke, Sloane, Sochalski, and Silber (2002) have highlighted issues of the nursing shortage and their impacts on the delivery of health care services. Other studies have clarified that inadequate staffing is the major cause of poor health care outcomes, complications, and even deaths (Unruh, 2003; Mark, Harless, McCue and Xu, 2004).

Quality Care

Stakeholders in the health care sector believe that quality health care is the benchmark of patient safety. For instance, the IOM notes that patient safety is “indistinguishable from the delivery of quality health care” (Aspden et al., 2004, p. 12). Quality has remained a discrete concept, which only reflects best possibilities from the values, norms, and practices of an entity. Thus, stakeholders in the hospital setting have agreed on what practices and possibilities reflect quality care for patients.

There are several attempts to define quality care in the hospital environment. For instance, the IOM views quality health care as set standards. At first, the IOM referred to quality as the extent to which “health services for a given population reflected the possibilities of desired health outcomes and the modern professional practices and knowledge” (Aspden et al., 2004, p. 13). This approach established the benchmark for quality indicators, which reflected the preferred standards in health care provisions. Health care quality standards are not just conceptual frameworks or possibilities for quality outcomes.

On this note, Lohr viewed indicators of quality in terms of “death, disease, disability, discomfort, and dissatisfaction” (Lohr, 1988, p. 37) instead of positive aspects of quality. On the other hand, positive indicators of quality in health care provisions include “achievement of appropriate self-care, demonstration of health-promoting behaviors, health-related quality of life, perception of being well cared for, and symptom management to the criterion” (Mitchell and Lang, 2004, p.4). Still, it regarded “mortality, morbidity, and adverse occurrences” (Mitchell and Lang, 2004, p. 6) as negative outcomes in quality of care.

Recent developments by the IOM on aspects of quality care reflect aspects of quality rather than the indicators. These include safety, effectiveness, patient-centered approach, timely delivery, efficiency, and equitability in health care provisions. This suggests that patient safety is the most indicator of the quality of care in a hospital setting.

Patient Safety

Stakeholders in hospitals have regarded patient safety as the prevention of any possible danger or harm to the patient. The focus on patient safety has been the prevention of errors and reduction of recurrence of errors. This approach has accounted for health care professionals, institutions, and patients. Moreover, patient safety approaches must also ensure that patients are free from accidents and avoidable injuries during medical care.

Patient safety approaches should aim at reducing the risks of adverse events that occur during health care provisions. However, the area of patient safety is broad and may require a broad definition that accounts for all practices during medical care. Studies have explored several patient safety approaches with the view of identifying possible strategies for avoiding patient safety errors and enhancing the quality of health care outcomes. These approaches included the “use of simulators, barcoding, computerized physician order entry, and crew resource management” (Mitchell, 2008, p. 1).

Most definitions of patient safety focus on negative outcomes, which may be either permanent or temporary impacts on the physical or psychological health of the patient. Factors that may contribute to a lack of patient safety may include error, communication failures, poor patient management, and inadequate clinical performance. These failures, errors, and poor management may occur at any stage during the provision of health care services. Patient safety issues may also involve decision-making processes, policies, procedures, and distribution of resources with the hospital. Some may result from direct involvement with the patient. In some cases, errors and harm may be due to knowledge transfer, culture, practices within the hospital, and external issues.

There are mitigation and prevention strategies for errors and harm that may take place during medical care. However, preventive strategies vary, i.e., they may be uniform, selective, or specific to a given clinical situation.

Hospital Nurse Staffing and Outcomes

Hospital nurse staffing is a source of serious concern for health care providers because of its impacts on the quality of care provided. Stanton notes that nursing-sensitive outcomes are aspects of indicating the quality of care. Nursing-sensitive outcomes refer “to the variable patient or family caregiver state, condition, or perception responsive to nursing intervention” (Stanton, 2004, p. 6). He identified the following as sensitive patient outcomes:

  • Pneumonia
  • Urinary tract infections (UTIs)
  • Shock
  • Long hospital stays
  • Rescue failures
  • 30-day mortality
  • Upper gastrointestinal bleeding

Several studies tend to concentrate on adverse outcomes because nurses are likely to document such outcomes rather than positive ones.

Many studies have related adverse outcomes with low levels of nurse staffing. These studies focused on the correlation between nurse staffing levels and evidence of patient safety (Stanton, 2004). They related adverse cases to low levels of nurse staffing within the hospital setting. Moreover, other studies established that low ratios of patients and nurses were responsible for high rates of negative outcomes in the quality of care. The findings were consistent at both the hospital and the nursing units during medical care. However, the study did not relate cases of in-hospital deaths to a low number of nursing staff in the hospital.

According to studies that Stanton reviewed, a low nurse staffing rate was responsible for higher levels of adverse outcomes. In his review, Stanton claimed that all five studies indicated at least some relationship between a low number of nurses and adverse patient outcomes during care.

The frequencies and extent of adverse effects may vary from one hospital to another. Moreover, adverse outcomes also depend on the type of medical procedure e.g., surgical or medical.

These studies reviewed many medical records of patients from several hospitals in 1993. Some of the key findings were:

  • Hospitals with high numbers of RNs showed low rates of adverse outcomes in the five areas. Conversely, hospitals with low numbers of RNs had high rates of adverse outcomes.
  • High rates of RNs resulted in a three to 12 percent decrease in adverse outcomes
  • High rates of staffing at all levels of the hospitals resulted in a decline of two to 25 percent (May, Bazzoli, and Gerland, 2006, p. 316).

Therefore, it is appropriate to conclude that hospitals with a high number of nurses experienced low cases of adverse outcomes. As a result, patient quality of care was high. Moreover, patients were not likely to develop complications during medical care.

Nurse staffing shortages and responses from the hospital

Hospitals have formulated several methods of coping with the nurse staffing shortage. These approaches are both short-term and long-term, which include nurse training, competitive salaries, and the use of agency nurses or temporary nurses (May, Bazzoli, and Gerland, 2006).

Agency nurses

Agency nurses are temporary nursing employees that fill positions and shortages in hospitals. They include nurse aides (CNAs), licensed practical nurses (LPNs), and registered nurses (RNs). These nurses normally come from staffing agencies. According to Strzalka and Havens, in the hospital situation, the term ‘temps’ or ‘contract staff’ refers to agency nurses (Strzalka and Havens, 1996). Moreover, such terms are associated with the low quality of care provision.

According to May, Bazzoli, and Gerland (2006), more than three-quarters of hospitals depend on nurses from agencies. These hospitals rely on the services of “per diem and traveling nurses, who normally take short-term contracts for short-term staffing requirements and shifts of the hospitals” (May et al., 2006, p. 316).

Needs for nurses may result from vacations or annual leaves. However, several hospitals have expressed the need to reduce the dependence on agency nurses due to high costs and quality issues. May, Bazzoli, and Gerland (2006) noted that the number of hospitals had reduced reliance on agency nurses while others intended to reduce the number of agency nurses. However, States, such as Orange County, California, and Phoenix, with severe shortages of nurses have increased their dependence on nurses from the agencies.

Hospitals that use internal staffing or float pools have reported low costs and found an alternative method of meeting nurse shortages. It is important to note that nurses from the internal staff pool usually have premium pay than regular nurses. However, nurses from external agencies are more “expensive than all other nurses in the hospital” (May et al., 2006, p. 316). In addition, hospitals that rely on internal float pools usually have greater confidence in health care quality outcomes.

Internal pools consist of nurses who need extra shifts or retired nurses who need flexible work schedules. Other health care organizations have responded to staff shortage by introducing per diem nurses in which nurses from external agencies must undergo specific training or must meet certain levels of qualifications in order to guarantee high-levels of quality of care.

May, Bazzoli, and Gerland have noted that this approach has been effective for many hospitals, which have reduced the number of agency nurses. In fact, some hospitals have introduced bidding in which nurses can bid at premium rates than those of regular nurses, but not higher than rates from external agencies.

Nicholas Castle and John Engberg note that there has been no concrete empirical data on effects of using agency nurses on the quality of health. However, they observed that a report presented to the Congress warned that the use of agency nurses could compromise the quality of care (Castle and Engberg, 2007). This report acted as a catalyst to anecdotal claims that only poor performing hospitals were using agency nurses.

According to the IOM report, Keeping Patients Safe: Transforming the Work Environment of Nurses, the use of agency nurses or nurses from other external sources was a threat to the safety of patients. The IOM report noted that the use of staff with the low-level of knowledge about nursing and organizational care policies resulted in interruption of delivery of quality care and enhanced patients’ exposure to risks. The IOM concluded that hospitals should “avoid the use of nurses from external sources and agencies” (Aspden et al., 2004, 68).

According to Ann Page, in 2004, about 2.3 percent of the RNs offered their clinical services by using agencies (Page, 2008). In other words, this group of care providers was not a part of the employed nurses in the hospitals they served. This figure represented an increment from the previous rate that was 1.8 percent. Meanwhile, the rates of nurse employment through agencies were on the rise too. Agency nurses are the minority in the health care setting. However, the increment in the use of employment agencies is a global trend that affects many industries.

In the US, the term contingent workers refer to causal laborers, contract employees, semi-permanent workers, and other workers who may not have a standard form of relationship with the institution in which they work. In other regions, such workers are the precarious workforce.

Usages of nurses from nursing agencies have improved the number of nurses available to attend to patients. However, some claims about poor health care outcomes associated with the external or agency nurses also arise. Pages notes that such claims occur because:

temporary staff are less familiar with a nursing unit and a health care organization’s overall structure, policies, practices, and personnel, which include information systems, facility layout, critical pathways, interdependency among work components, ways of coordinating and managing its work, and other work elements” (Page, 2008, p. 1).

These challenges can increase if the hospitals in which agency nurses provide their services fail to provide any training and orientation programs to their temporary nurses. According to data from other industries, the use of temporary workers has contributed to high-rates of accidents and other serious issues. Some institutions have expressed that reliance on the agency staff is a form of a growing weakness in a firm’s safety culture. On this regard, health care studies have established similar trends (Page, 2008).

A number of terms exist to denote agency nurses. These terms include “temporary, float, casual nursing, contingent employment, or precarious employment” (Page, 2008, p. 1). These terms have presented challenges for researchers who have interests on the effects of agency nurses on safety and quality of care outcomes. In addition to challenges with the terms, not much research exists about the impacts of agency nurses on the quality of care. The available studies have not exclusively handled problems that relate to agency nurses and the quality of care. Such findings tend to focus on general issues about patient safety in a hospital setting.

Page used a search strategy and identified seven observational cases. From the seven outcomes, six studies had severe patient outcomes because of the use of agency nurses (Page, 2008). The seventh study did not specifically focus on patient outcomes. Instead, the study concentrated on “nurses’ documentation of their own performance of activities related to patient safety and better quality of care” (Page, 2008, p. 2).

Table 1: Evidence Table (adapted from Page, 2008)

Source Safety Issue Related to Clinical Practice Outcomes / Key findings
Alonso-Echanove, 2003 Use agency nurses or nurses from other hospital areas who have worked for less than one year in the hospital Risk of CVC-associated BSI was 2.6 times higher for patients cared for by float nurses. This was more than 60 percent of the time
Bourbonniere, 2006 Relying on a high number of RNs and LPNs to take positions of regular nurses Hospitals that relied on five percent or more contract RNs and LPNs had poor representation at the top rank in every State on annual basis. The results relied on discrepancies detected in health care provisions and certification inspections
Estabrooks, 2005 Use of agency or contract nurses in the hospital Hospitals with a higher proportion of casual and temporary nurses had higher rates of 30-day patient mortality
James, 1990 Use of agency or contract nurses in the hospital A significant increase in violent cases during research time was strongly associated with a reduction in the percentage of regular and permanent nursing staff employed by the institutions and high rates of using agency nurses. The hospitals maintained a constant level of nurse staffing. Study established a positive correlation between the number of violent incidents and use of agency nurses (P= 0.0018). On the other hand, the study found a negative correlation between regular nurses and violet events
Robert, 2000 A comparison between agency nurses and nurses permanently assigned to the surgical intensive care unit (SICU) The rate of BSIs was high during the use of nurses from the pool or agency. On the other hand, BSIs were low when nurses from the hospital participated in the process
The ration for agency nurses to patients was high. Conversely, the situation declined during the use of permanent nurses.
Roseman, 1995 Use of agency or temporary nurses The numbers of medical errors were significantly high and statistically important when agency nurses worked. On the other hand, cases of medical errors declined when permanent nurses were providing care.
(Strzalka and Havens, 1996) Use of agency nurses and nurses employed by the hospital a specified nursing unit under study “Nursing groups’ documentation varied from indicator to indicator, with internal float pool nurses generally documenting at the highest level and unit-hired nurses performing at the lowest, with agency nurses falling in between” (Strzalka and Havens, 1996).

The researcher acknowledged a possible reporting bias in all the six studies that showed adverse outcomes when agency nurses provided care to patients.

Agency nurses are sources of labor that many hospitals require. However, Bae, Mark, and Fried (2010) noted that such nurses may not provide the required care due to a lack of specific knowledge of the patient’s conditions for safe care. Specific knowledge is useful in understanding the specific needs of a given patient and is core in providing quality care for patients. For instance, such knowledge starts from an individual nurse and then to the entire nursing unit.

Past studies have indicated that high levels of staffing may reduce such risks. However, temporary nurses may not be the appropriate staff to reduce such risks because they are not familiar with practices and the specific needs of patients. Moreover, they may also not take part in teamwork. Therefore, hospitals with a high number of agency nurses may not be effective for managing the specific health care needs of regular nurses.

Equally, agency nurses may not be familiar with the specific medication procedures for a given nursing unit. This may pose a serious medical error to the patient. Some researchers have shown that cases of medical errors escalated as the number of agency nurses increased. On the other hand, issues of medical errors declined as permanent nurses participated in medical care. Other researchers also found out that rampant cases of medical errors were mainly associated with temporary nurses in which “patients received the wrong medication or dose” (Bae, Mark, and Fried, 2010, p. 333).

It is necessary to note that such relationships are significant after managing issues that arise from staff characteristics and staffing needs or adequacy. Several aspects of complex hospitals contribute to medical errors. As a result, most studies have recommended the use of technology, policies, and practices, which control issues about medical administration and interaction among health care providers. However, constant reliance on external nurses may lead to changes in the interaction among nurses. As a result, there may be inadequate and insufficient communication among unit nurses. Moreover, agency nurses may lack sufficient knowledge about patients’ conditions, which may result in low levels of interactions. In such cases, medical errors are normally rampant.

The relationship between agency nurses and the nurses directly employed by the hospital

Agency nurses are an important supplement to the persistent shortage of nurses in the US and other places around the globe. However, the relationship between agency nurses and nurses employed by the hospitals has not been good in some circumstances. According to Parsons, other nurses treat agency nurses “as second class citizens” (Parsons, 2009, p. 1), and this scenario should change to promote the maximum provision of health care.

Parsons notes that one agency nurse claims that too much hostility exists between hospital nurses and agency nurses. The agency nurse claims, “There is a lot of hostility towards temporary nursing staff, and that they’re given the most difficult patient and offered no support” (Parsons, 2009, p. 1). Moreover, the agency nurse claims, “We’re not treated like nurses – I’ve often been referred to as ‘agency nurse’ rather than by my name” (Parsons, 2009, p. 1). Some of the agency nurses claimed that some hospitals do not allow them to administer drugs. At the same time, such hospitals have declined to train them to administer drugs and do not offer alternatives to agency nurses.

It is a fact that due to a persistent shortage of nurses, many hospitals cannot operate effectively without support from agency nurses. Agency nurses have acquired the same levels of qualifications as other registered nurses. Therefore, agency nurses deserve similar treatment just like nurses employed by the hospitals.

The hostile attitude between the agency nurses and regular nurses has led to a poor focus on the provision of quality health care to patients (Parsons, 2009).

Parsons notes that some radical changes in the nursing qualification may escalate the problem of shortages in nursing staff. For instance, the requirement in the UK that nurses should have a degree qualification shall only aggravate the problem because highly qualified nurses are already in low supply.

Unfair blames

A study showed that the reliance on agency nurses to counter the shortage of nurses did not result in poor patient outcomes. Aiken, Shang, Xue, and Sloane noted that agency nurses received unfair blames because of poor health care outcomes (Aiken, Shang, Xue, and Sloane, 2012). The research showed that the harmful consequences of supplemental nurses from agencies on patient outcomes did not relate to characteristics of the agency nurses, but with hospital work conditions. These researchers found out that deficient in the hospital work conditions could be responsible for poor patient outcomes in hospitals where the usages of agency nurses were high.

The earlier research concluded that higher rates of agency nurses were mainly “associated with higher rates of mortality and failure to rescue” (Aiken et al., 2012, p. 931). However, when these researchers changed the data to reflect the work environment of the hospital, they established that issues about agency supplement nurses were insignificant and negligible. In this study, the researchers reviewed factors under hospital environment, which included “nurses’ participation in the hospital affairs, management abilities, support, leadership, relations among nurses and patients, the ratio of nurses to patients, and provisions of educational support to agency nurses” (Aiken et al., 2012, p. 931).

Therefore, controlling all factors about nursing resulted in “negligible impacts on mortality and failure to rescue” (Aiken et al., 2012, p. 931). These researchers also observed that hospitals with poor work conditions had challenges with recruitment and retention of regular staff nurses. As a result, such hospitals tended to use agency nurses to take the role of regular nurses and fill vacancies. This implied that agency nurses took unfair blame on poor patient outcomes while they were also “victims of the poor work conditions at the hospitals” (Aiken et al., 2012, p. 931). Therefore, the hospital management team must evaluate the hospital work condition to establish how such factors have contributed to adverse staff recruitment and attrition, and poor patient outcomes.

Qualifications and experiences of agency nurses

Past studies have not concentrated on trends and characteristics of supplemental nurse workforce. This has led to availability of insufficient data that can help policymakers to formulate effective work policies. Xue, Smith, Freund, and Aiken examined characteristics of agency nurses against those of regular nurses during 1984 and 2008 (Xue, Smith, Freund, and Aiken, 2012, p. 2510). They observed that both agency nurses and permanent nurse possessed “the same levels of education, which were usually a baccalaureate or higher degree” (Xue et al., 2012, p. 2510). On experiences, agency nurses had less experience than their permanent nurse counterparts did. On average, agency nurses had 12 years of experience against 18 years of regular nurses in 2008.

Nurses are important in enhancing quality of care

Hospital nurse staffing is a critical aspect of enhancing quality of care. Health care researchers have focused on significant factors such as staffing, stress, hospital cultures, shift work, and other processes and factors that can cause error during medical processes.

The IOM report advocated for a suitable system that can ensure that all health care institutions have a ‘flexible’ staffing to meet unexpected demands and acuity. However, it is important to note that the IOM recommends the avoidance of “using nurses from agencies as a way of meeting staff shortage in hospitals” (Aspden et al., 2004, p. 13). Therefore, according to the IOM, flexible staffing does not include nurses from the agencies or employment pools. Instead, the IOM requires hospitals to “use nurses from the internal nursing float pool” (Aspden et al., 2004, p. 13), which are mainly regular nurses employed by the hospitals.

The use of internal nurses is important because such nurses have received the same levels of induction about the hospital procedures and cultures. Assigning of agency nurses may result in deploying nurses to unfamiliar areas. Nurses from the hospital pools may not be familiar with the specific process. However, they are familiar with the hospital procedures and policies. Moreover, nurses from the hospital pool may be familiar with processes that a hospital uses for individual patient care. They also understand patient safety practices within the hospital, procedures for reporting errors, and decision-making processes, and technical aspects of the hospital.

Health care organizations must formulate ways of ensuring safe quality care. This requires collaboration between the hospitals and nursing professionals in order to evaluate and monitor alternative staffing models that can guarantee quality of care.

The main responsibility of the hospitals to patients is to ensure quality of care throughout the medical process. Therefore, it is necessary for health care organizations to deal with challenges of staff recruitment and retention. Health care facilities have the responsibilities of providing supportive work environment and methods of reducing workload and workforce stress. It is also fundamental to recognize that nurses also have responsibilities to hospitals, patients, and other stakeholders. For instance, nurses must observe safety, integrity, competence, and develop professionally.

Research Implications

The persistent scarcity of nurses has resulted in insufficient nurse staffing. Consequently, hospitals have turned to external agencies and internal pool floats to control staffing challenges as short-term approaches, which have become prevalent in most hospitals.

Thorough studies on agency nurses should rely on meta-analysis to establish the extent of impacts of using agency nurses on patient outcomes and safety. Moreover, further studies are necessary to improve empirical evidence on the effect of patient care outcomes and quality of care when agency nurses take the roles of regular nurses. It is also important to understand why hospitals resort to agency nurses. Such studies are fundamental for formulating health care policy decisions and for other organizations that interact with the health care workforce.

From previous studies in the use of agency nurses and patient outcomes and quality of care, various articles express diverse views. For instance, some studies show that the use of agency nurses led to negative patient outcomes and medical errors (Buerhaus and Needleman, 2000). Still, other studies show that moderate use of agency nurses was appropriate for meeting nurse shortages (Bae, Mark, and Fried, 2010).

On the other hand, some recent studies show that agency nurses take unfair blames because of poor work conditions in health care organizations where they work (Aiken, Shang, Xue and Sloane, 2012). However, most studies have depicted negative outcomes in cases where agency nurses provided health care to patients. For instance, several studies showed that medical errors and the use of wrong medicine were associated with agency nurses (Bae, Mark, and Fried, 2010). On the same note, some studies also cited failure to rescue and increase in rates of infections and associated them with agency nurses (Stanton, 2004).

On qualifications and experiences, Aiken and fellow researchers (2012) note that both permanent nurses and agency nurses have the same levels of qualifications (a baccalaureate or higher degree). However, permanent nurses have many years of experience than agency nurses. Agency nurses have more diversity than their permanent counterparts. This study showed that there was minimal difference between these nurses. In this regard, we can assert that poor patient outcomes did not relate to agency nurses, but such poor outcomes resulted from poor work conditions in the work environment. Therefore, hiring agency nurses was a significant step towards alleviating shortages of nurses in health care organizations.

Another study by Castle and colleagues did not find any linear correlations between services of agency nurses and quality of care outcomes (Castle and Engberg, 2007). However, when hospitals had high numbers of agency nurses, cases of poor quality of care were on the rise. On the contrary, the poor quality of care declined with low numbers of agency nurses.

Given these mixed results, it is necessary to conduct further studies to determine and understand the relationship between the use of agency nurses, regular nurses, and patient safety outcomes and quality of care. This is necessary for improving the quality of care that health care organizations provide. Still, health care researchers must also conduct studies at the nursing unit levels to determine an individual nurse and outcomes where nurses work as a team. This suggestion is appropriate because Parsons notes that poor relationships between regular nurses and agency nurses have affected health care outcomes because agency nurses do not receive adequate assistance from their regular counterparts or hospitals (Parsons, 2009).

Therefore, future studies should be comprehensive by accounting for agency nurses, regular nurses, and patient safety outcomes at the unit level. In addition, such studies must also control nurse characteristics and focus on relevant issues that relate to the hospital, which may include “nurse work environment and specific patients and nurses’ characteristics” (Bae, Mark, and Fried, 2010, p. 333). This approach is inclusive because Aiken and colleagues (2012) have pointed out that hospitals with poor recruitment and retention practices were likely to use the services of nurses from the agencies. Poor work conditions were “responsible for poor performances of agency nurses” (Aiken et al., 2012 p. 931).

Conclusion

The use of agency nurses has increased due to shortages in nurse staffing. However, some studies have linked negative health care outcomes with agency nurses. On the other hand, other studies have identified work environments as the contributing factors to poor quality of care. Such mixed results require further studies.

Hospital managers must ensure that whether agency nurses or regular nurses provide care to patients, the hospital must meet patient safety standards and quality of care. This can only change when the hospital culture facilitates teamwork between agency nurses and regular nurses. Hospitals have benefited from the flexibility that they get from agency nurses. However, hospitals must address the communication, training, and education needs of agency nurses. Such approaches allow agency nurses to understand procedures, processes, cultures, and practices within the hospital.

Though many authors have concentrated on negative aspects of agency nurses, recent studies have provided new insights about agency nurses (Aiken et al., 2012). Further studies are necessary to clarify the issue of quality of care and agency nurses. Therefore, the need to understand the relationship that exists between negative outcomes and agency nurses is necessary to enhance the provision of quality health care to patients.

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Unruh, L. (2003). Licensed Nurse Staffing and Adverse Events in Hospitals. Medical Care, 41(1), 142-152.

Wunderlich, S., Sloan F., and Davis, K. (1996). Nursing staff in hospitals and nursing homes: is it adequate. Washington, DC: National Academy Press.

Xue, Y., Smith, J., Freund, D., and Aiken, L. (2012). Supplemental Nurses Are Just As Educated, Slightly Less Experienced, And More Diverse Compared To Permanent Nurses. Health Affairs, 31(11), 2510-2517.

Appendix

The resources for the references

  • NCBI Resources
  • Mendeley Resources
  • Health Care Management Resources

Modification of Keyword Searches

Agency nurses + quality of care + outcomes

Agency nurses + patient safety + outcomes

Regular nurses + patient safety + quality of care

Agency nurses + failure to rescue

Agency nurses + mortality

The researcher combined the above keywords in the given combination in order to return a suitable search result for agency nurses and their impacts on the quality of care among patients. In some cases, the researcher changed aspects of the keyword searches to reflect nurse staffing and patient safety or quality of care.

Most useful keywords

Agency nurses, quality of care, patient safety, failure to rescue

These were the most useful keywords because they resulted in the best performance by helping the researcher to find issues associated with usages of agency nurses for care provisions. Modifications of these words with other phrases proved useful for the research, e.g., usages of agency nurses and quality of care.

The CARS Justification

Source Credibility Accuracy Reasonable Support
Aiken, H., Clarke, P., and Sloane, P. (2002).
  • Article is peer-reviewed
  • Authors have written several materials in health care
The researchers clearly identified all research instruments and measures
The article relies on provisions of in-depth information on the issue
Results are reasonably presented with precise conclusions
The article explored other relevant studies in the field
The article uses several existing works for support
The article supports the research by providing existing literature
Aiken, H., Shang, J., Xue Y., and Sloane, M. (2012)
  • Article is from a reliable source
  • Article is scholarly and written by academics
  • Provides recent views on agency nurses
Researchers identify purposes, indicators, setting, design, outcomes, and conclusion
The literature review provides accurate accounts in the field
Study based on real conditions in health care facilities
The study as latest findings on the field
Conclusions are reasonably presented
Peer-reviewed article
This is one of the most recent studies in the field and thus provides current knowledge about agency nurses
Bae, S-H., Mark, B., and Fried, B. (2010)
  • Scholarly article
  • No bias or personal interests identified
Precise presentation of findings
The article has adequately address the issue under focus
Provides reasonable account of the situation based on empirical evidence Article is from a reliable resource database
The article is peer-reviewed
Buerhaus, I., and Needleman, J. (2000)
  • Researchers identify weaknesses with past studies
  • Offers alternatives for further studies
The article’s abilities to identify weaknesses in past studies
The study provides background challenges in the field
Logical presentation of ideas
The study shows development from past studies
Article draws support from previous works
Identify and identify weaknesses
Castle, N., and Engberg, J. (2007)
  • Authors identify their funders
  • No interests
  • Declare their opinions
A precise and detailed presentation of the study
The logical presentation of ideas shows the accuracy of the work
A good account based on research findings
The literature covered in the article reflects issues in the field of study
All sources used and other supports declared
The article is from a reliable source for researchers to use
Mark, B., Harless, D., McCue, M., and Xu, Y. (2004)
  • Authors are academics with wide experience in the field
  • Acknowledged supporters
Present detailed and easy-to-follow study methodology
The study builds from previous research in the field
Important information about the study elements are present
The study has used wide literature to support the work
Peer-reviewed article
Hosted in a reputable database for researchers
May, J., Bazzoli, G., and Gerland, A. (2006)
  • Authors affiliated with reputable organization in health affairs and studies
Accurately presents study findings and provides suggestions for health care policymakers
The study has useful data on the issue
The source covers expected research area
The research shows major outcomes in usages of various nurses
Article reviewed by peers before publication
Article is from a reputable resource center
Mitchell, H., and Lang, M. (2004)
  • Scholarly article
  • Peer-reviewed journal
Show areas of improvement in the field
The study explores the usefulness of models used in the field
All research issues are clearly articulated
The article provides relevant information for this study
Article is from a reputable resource center
Article cited by other researchers
Mitchell, P. (2008)
  • The author has published several articles in the field
  • The article is peer-reviewed
Properly defined concepts based on best practices
The article is based on field studies
Reasonably clarify challenges with basic issues in the field
The study identifies various measures in the field
Cites the Institute of Medicine (IOM) for relevancy
Hosted in a reliable resource center
Xue, Y., Smith, J., Freund, D., and Aiken, L. (2012)
  • Authors have written several peer-reviewed journal
  • Have wide experience in the field
  • Authors are academics in nursing studies
Accurately discusses current issues in the field
The study convincingly showed that the problem arise from other factors and not from agency nurse
Introduces new perspectives on the issue
The study shows that the problem lies elsewhere and among care providers
Supported by several cited works and peers
Past studies from some of the authors have been used to support IOM recommendations in nursing quality of care

Annotated Bibliography

Does the usage of agency nurses have negative impact on quality patient care?

Aiken, H., Clarke, P., and Sloane, P. (2002). Hospital staffing, organization, and quality of care: cross-national findings. International Journal of Quality in Health Care, 14(1), 5-13.

Aiken and colleagues studied the impacts of nurse staffing and support from the organization for nursing. They reviewed job dissatisfaction, burnout, and reported quality of patient care from selected major hospitals. These authors noted that the above concerns were common in all the sampled hospitals. They also noted that organizational or managerial support had profound impacts on nurses.

In addition, these factors had direct and independent relations with the quality of care. Results further indicated that hospitals, which provided low nurse staffing and support, had three times the rate of low quality care than other hospitals with high staffing and support. The authors concluded that the provision of enough nurse staffing and managerial or organizational support were critical in enhancing the quality of care, reduce job dissatisfaction among nurses, burnout, and enhancing retention of nurses in the health care facility.

Aiken, H., Shang, J., Xue Y., and Sloane, M. (2012). Hospital Use of Agency-Employed Supplemental Nurses and Patient Mortality and Failure to Rescue. Health Services Research, 48(3), 931-948. Web.

These researchers conducted a study to determine the relationship between the use of agency nurses to supplement nurse staffing needs and patient mortality and failure to rescue (FTR). The study sample included 40,356 registered nurses from 665 hospitals. They conducted the study in four states during the year 2006. These hospitals were members of the American Hospital Association. They used inpatient mortality information from various state agencies that consisted of nearly 1.3 million patients.

The researchers used a logistic regression model to analyze the relationship between the agency nurses and “30-day in-hospital mortality and FTR, controlling for patient and hospital characteristics, nurse staffing, the proportion of nurses with bachelor’s degrees, and quality of the work environment” (p. 931). The results showed that high rates of agency nurses were mainly linked with the high rates of mortality and failure to rescue.

They also noted that hospitals that had high numbers of agency nurses had a poor work environment. However, the researchers noted that when they considered the work environment, then high rates of mortality and failure to rescue were not significant. They concluded that increased usage of agency nurses did not lead to adverse consequences on patient mortality and failure to rescue. Therefore, agency nurses were suitable for solving the nursing staff shortage.

Bae, S-H., Mark, B., and Fried, B. (2010). Use of temporary nurses and nurse and patient safety outcomes in acute care hospital units. Health Care Management Review, 35(4), 333-344.

The background of this article focused on the nursing shortage, and temporary nurses as solutions to the challenge. The researchers investigated the association between the usage of agency nurses within specific area and safety outcomes. They focused on the outcomes in “nurse (needlesticks and back injuries) and patient (patient falls and medication errors) safety outcomes at the nursing unit level” (p. 333).

They noted that nurse units with many agency nurses were likely to record high number of back injuries and great rates of patient falls as compared to other regular nurses. Nursing units without agency nurses reported few cases of medical errors. The researchers challenged hospitals to monitor usages of agency nurses (not more than 15 percent) in order to ensure safety outcomes of patients and nurses. They concluded that the use of agency nurses had both positive and negative outcomes to patients and nurses based on the rate of usages.

Buerhaus, I., and Needleman, J. (2000). Policy implications of research on nurse staffing and quality of patient care. Policy Politics Nurs Practic, 1(1), 5-15.

These authors provided a broad outline of nurse staffing, and past attempts to establish the association between the nurse staffing and patient health care outcomes. They also explored policy implications for both private and public stakeholders. However, public policy in the field did not have any significant impact. They noted that a lack of effective policy resulted from insufficient research and evidence, which associated changes in the nurse staffing to harmful patient outcomes.

In addition, Buerhaus and Needleman noted that new studies provide fresh evidence, but they cautioned readers to use such evidence with caution in nursing situations. They argued that it was difficult to achieve the exact and adequate staffing levels for hospitals. Consequently, they suggested that further studies were necessary to provide empirical evidence necessary for policy formulation in nurse staffing and restructuring.

Castle, N., and Engberg, J. (2007). The Influence of Staffing Characteristics on Quality of Care in Nursing Homes. Health Service Research, 42(5), 1822–1847.

The article examined staffing levels, agency nurses, attrition, and worker stability and their effects on quality of care. They used a sample of 1,071 nursing homes. The researcher conducted the research in 2003 and focused on staffing characteristics that consisted of “Nurse Aides, Licensed Practical Nurses, and Registered Nurses” (p. 1822). The resulted showed that there were impacts on the quality of care to some extent by various categories of nurses. The overall effects on nursing characteristics indicated that obtaining high-levels of quality care depended on the different nurse characteristics than a single staffing characteristic.

In other words, different nurse characteristics improved the level of quality of care. They concluded that it was imperative to address staff characteristics such as “turnover, staffing levels, worker stability, and agency staff should simultaneously to improve the quality of nursing homes” (p. 1882).

Mark, B., Harless, D., McCue, M., and Xu, Y. (2004). A Longitudinal Examination of Hospital Registered Nurse Staffing and Quality of Care. Health Services Research, 39(2), 279–300.

Mark and colleagues reviewed findings of past studies that focused on the relationship between nurse staffing and the quality of care. They focused on impacts of changes on registered nurses and quality of care. The study consisted of 422 hospitals from a longitudinal cohort. They analyzed data collected between 1990 and 1995 in order to establish the association between nurse staffing and quality of care outcomes.

Results indicated that increasing the number of registered nurses resulted in a marginal reduction in cases of mortality. However, it did not have a consistent impact on other complications. In addition, they also noted that defined characteristics of hospitals, market, and financial factors had some effects on the quality of care. They concluded that research findings yielded limited support for the claim that increasing the number of registered nurses resulted in improved quality of care completely.

May, J., Bazzoli, G., and Gerland, A. (2006). Hospitals’ Responses to Nurse Staffing Shortages. Health Affair, 25(4), W316-W323.

May and fellow researchers noted that hospitals used different approaches to handle challenges of nurse shortages. In most cases, the focus was on “nurse education, competitive compensation, and temporary staff” (p. 316). They conducted studies by using health care stakeholders from Round Five of the Community Tracking Study. The study indicated that the above practices, alongside other factors, were responsible for reduction in nurse shortages in hospitals. They also noted that some of these approaches resulted in high costs and issues about potential effect on the quality of patient care. Finally, the article showed that many hospitals doubted if they could meet future challenges regarding shortage in nurse staffing.

Mitchell, H., and Lang, M. (2004). Framing the problem of measuring and improving healthcare quality: has the Quality Health Outcomes Model been useful. Medical Care, 42(2), 4-11.

The objective of this article was to explore the application of the “Quality Health Outcomes framework and indicator categories in the healthcare literature” (p. 4). The researcher reviewed several materials and conducted Internet research since 1997. They noted that few research summaries and programs have applied the Quality Health Outcomes Model clearly. Outcomes from these studies were on the rise. Moreover, usages of such outcomes were also on the increase because they were sensitive and useful for quality of care. They provided methods for hospital interventions in order to improve quality of care.

These researchers concluded that hospitals were adopting the model and others for improving the quality of care. However, the available studies did not associate the models with potential negative outcomes in a nursing care situation. Consequently, the researchers recommended that there was a need to include a myriad of outcomes in the database.