Organizational return on investment in nursing: A systematic review

High-quality nursing care is crucial for healthcare quality and safety, yet there's limited understanding of the business case for investing in nursing from an organizational perspective. This study seeks to address this evidence gap by identifying and synthesizing data on the organizational return on investment in nursing human capital, considering initial investment costs and the resulting impact on production costs and revenue.

We conducted a systematic review using four databases (PubMed, CINAHL, EconLit, Web of Science) to find nursing human capital studies from January 1990 to June 2024. Studies were eligible for inclusion if they examined nurses providing care within healthcare delivery organizations or systems and reported financial outcomes, were written in English, and used inferential statistics. The systematic review was registered in Prospero (CRD 42023462385).

From 37,132 search results, the final analysis included 59 studies from North America, Europe, Asia, and Australia/New Zealand. Thirty-two studies focused on nurse staffing, 14 on skill mix, and 8 on nurse education and experience. Most studies reported improved patient and nurse outcomes, reduced turnover, and lower production costs. However, few studies fully accounted for initial investment costs and their subsequent impact on production and revenue, complicating inferences about organizational return on investment. Only 12 studies conducted complete return on investment evaluations, covering 19 nursing variables: 11 evaluated nurse staffing (2 positive, 4 negative, 5 neutral), 3 examined skill mix (1 positive, 1 negative, 1 neutral), and 1 focused on increased education (neutral). Two studies examined the work environment (1 positive, 1 negative) and two evaluated programmatic interventions (1 positive, 1 neutral).

Based on the findings, we conclude that the existing evidence of organizational financial return on investment in nursing is limited in scope and contradictory. Although nurses improve patient outcomes and are valued by consumers, the lack of a strong organizational business case restricts organizational investments in their nurse employees' growth and development. Future research should evaluate organizational return on investment in nursing to better inform decisions on nurse employment and utilization.