Nurse staffing, nursing intensity, staff mix, and direct nursing care costs across Massachusetts hospitals

OBJECTIVE

This study describes the distribution of patient-to-registered nurse (RN) ratios, RN intensity of care, total staff intensity of care, RN to total staff skill mix percent, and RN costs per patient day in 65 acute community hospitals and 9 academic medical centers in Massachusetts.

METHODS

We conducted a retrospective secondary analysis of the Patients First database published by the Massachusetts Hospital Association for planned nurse staffing in 601 inpatient nursing units in the state for 2005 using a multivariate linear statistical model controlling for hospital type and unit type. Nursing unit types were identified as adult and pediatric medical/surgical, step down, critical care, neonatal level II, and neonatal level III/IV nurseries.

RESULTS

Medical centers had significantly higher case-mix index (1.72 vs 1.20, P < .001), longer lengths of stay (5.18 vs 4.19, P < .001), more beds (574 vs 147, P < .001), discharges (31,597 vs 7,248, P < .001), and patient days (161,440 vs 31,020, P < .001) compared with to community hospitals. Medical centers had significantly lower patient-to-RN ratios (3.22 vs 4.64, P < .001), higher nursing intensity and total nursing staff intensity (9.62 vs 7.43/11.75 vs 9.87, both P < .001), higher percent of RN to all staff mix (79% vs 71%, P < .001), and higher RN costs per patient day ($385 vs $297, P < .001) compared with to community hospitals. There were significant differences in adult med/surg units between community hospitals and medical centers for patient-to-RN staffing ratios (5.25 vs 4.08), nursing intensity (5.1 vs 6.2 hours daily), skill mix (67% vs 73% RN), and RN costs per patient day ($203 vs $248, all P < .001). There were no significant differences between the adult step-down units.

CONCLUSION

The significant differences between community hospitals and medical centers, unit type, as well as the high degree of variability in patient-to-RN ratios, nursing intensity, skill mix, and RN costs per patient day suggest that nursing resource expenditure at Massachusetts hospitals is complex and affected by case mix, unit size, and complexity of care.

Managerial attitude to the implementation of quality management systems in Lithuanian support treatment and nursing hospitals

BACKGROUND

The regulations of the Quality Management System (QMS) implementation in health care organizations were approved by the Lithuanian Ministry of Health in 1998. Following the above regulations, general managers of health care organizations had to initiate the QMS implementation in hospitals. As no research on the QMS implementation has been carried out in Lithuanian support treatment and nursing hospitals since, the objective of this study is to assess its current stage from a managerial perspective.

METHODS

A questionnaire survey of general managers of Lithuanian support treatment and nursing hospitals was carried out in the period of January through March 2005. Majority of the items included in the questionnaire were measured on a seven-point Likert scale. During the survey, a total of 72 questionnaires was distributed, out of which 58 filled-in ones were returned (response rate 80.6 per cent; standard sampling error 0.029 at 95 per cent level of confidence).

RESULTS

Quality Management Systems were found operating in 39.7 per cent of support treatment and nursing hospitals and currently under implementation in 46.6 per cent of hospitals (13.7% still do not have it). The mean of the respondents' perceived QMS significance is 5.8 (on a seven-point scale). The most critical issues related to the QMS implementation include procedure development (5.5), lack of financial resources (5.4) and information (5.1), and development of work guidelines (4.6), while improved responsibility and power sharing (5.2), better service quality (5.1) and higher patient satisfaction (5.1) were perceived by the respondents as the key QMS benefits. The level of satisfaction with the QMS among the management of the surveyed hospitals is mediocre (3.6). However it was found to be higher among respondents who were more competent in quality management, were familiar with ISO 9000 standards, and had higher numbers of employees trained in quality management.

CONCLUSION

QMSs are perceived to be successfully running in one third of the Lithuanian support treatment and nursing hospitals. Its current implementation stage is dependent on the hospital size - the bigger the hospital the more success it meets in the QMS implementation. As to critical Quality Management (QM) issues, hospitals tend to encounter such major problems as lack of financial resources, information and training, as well as difficulties in procedure development. On the other hand, the key factors that assist to the success of the QMS implementation comprise managerial awareness of the QMS significance and the existence of employee training systems and audit groups in hospitals.

A Magnet community hospital: Fewer barriers to nursing research utilization

OBJECTIVE

To identify the barriers to research utilization for nurses within a Magnet community hospital.

DESIGN

A descriptive, quantitative design was used.

METHODS

The instrument used was the BARRIERS scale, a 29-item Likert-type questionnaire, regarding perceived obstacles to research utilization. It included 3 open-ended questions. In all, 584 packets containing the BARRIERS tool and a demographic survey were successfully distributed. A total of 275 (47%) completed questionnaires were returned.

RESULTS

The questions were categorized into 4 domains: Nurse, Setting, Research, and Presentation. The Setting domain was found to be the greatest barrier for nurses. Four of the top 5 barriers related to the Setting. Facilitators to implementing research fell within 4 distinct themes: access and availability, education and communication, practical application, and supportive environment. A statistically significant difference was found in the Nurse domain based on the education level (F = 2.932) (P = .034).

CONCLUSIONS

The results of this study will be useful in determining strategies for improving the nurse practice setting to facilitate the use of research by nurses. Suggested changes should encourage the reading of research; discussion of research; risk taking to implement new ideas; mentoring; and education of nursing staff, hospital administration, and physicians. Implementation of the Magnet standards is likely to diminish the barriers to research use by nurses within that facility.

Moving Forward

Discovering ways to engage new employees and make the orientation period prior to unit orientation more meaningful is a challenge for staff development educators. This important period focuses on patient safety and employee introduction to the organization. This article describes the redesign of a nursing services orientation program that led to increased employee satisfaction and an increased level of comfort with preparedness to deliver safe patient care.

The Benefits of Standardized Nursing Languages in Complex Adaptive Systems Such as Hospitals

Paperwork is a major source of frustration for hospital nurses and takes valuable time away from patient care. Studies indicate that nurses spend an estimated 13% to 28% of total shift time documenting. The growth in documentation requirements for nurses can, in part, be attributed to an exponential rise in health system complexity. Authors explore the documentation of nursing care plans from a complex adaptive system perspective and then analyze the utility of adopting a standardized nursing language. An actual case history of a nursing unit's attempt to reduce complexity, improve completion time, and increase staff satisfaction in care planning by adopting a standardized nursing language is provided to emphasize a practical application.

Trends in bed occupancy for inpatients with diabetes before and after the introduction of a diabetes inpatient specialist nurse service

AIMS

To compare diabetes bed occupancy and inpatient length of stay, before and after the introduction of a dedicated diabetes inpatient specialist nurse (DISN) service in a large UK Hospital.

METHODS

We analysed bed occupancy data for medical or surgical inpatients for 6 years (1998-2004 inclusive), with a DISN service in the final 2 years. Excess bed days per diabetes patient were derived from age band, specialty, and seasonally matched data for all inpatients without diabetes. We also analysed the number of inpatients with known diabetes who did not have diabetes recorded as a discharge diagnosis.

RESULTS

There were 14,722 patients with diabetes (9.7% of all inpatients) who accounted for 101 564 occupied bed days (12.4% of total). Of these, 18 161 days (17.8%) were excess compared with matched patients without diabetes, and were concentrated in those < 75 years old. Mean excess bed days per diabetes inpatient under 60 years of age was estimated to be 1.9 days before the DISN appointment, and this was reduced to 1.2 bed days after the appointment (P = 0.03). This is equivalent to 700 bed days saved per year per 1000 inpatients with diabetes under 60 years old, with an identical saving for those aged 61-75 years (P = 0.008), a saving of 1330 diabetes bed days per year by one DISN. Excess diabetes bed occupancy was 167 excess bed days per year per 1000 patients with diabetes in the local population after the DISN appointment. One quarter of the known Type 2 diabetes population were admitted annually, but one quarter of patients had no diagnostic code for diabetes.

CONCLUSIONS

Diabetes excess bed occupancy was concentrated in patients < 75 years old, and this was reduced notably following the introduction of a DISN service.

The development of critical care outreach nursing services

Critical care patients are among the sickest in hospital and require extensive facilities and equipment, and skilled care. This article outlines the rationale behind the development of critical care outreach services and discusses evaluation of the service.

Designing a new patient centred nursing strategy

City Hospitals Sunderland developed a 'pen portrait' initiative as part of their nursing strategy to ensure patients are the centre of services. This article outlines the development of pen portraits and evaluates the impact they have had on patient care.

Sexual Assault Nurse Examiner (SANE) Program Goals and Patient Care Practices

PURPOSE

To examine Sexual Assault Nurse Examiners (SANE) programs' goals and guiding philosophies and how they influence patient care practices for sexual assault victims.

DESIGN

Data were collected from a national random sample of SANE to examine whether programs differed significantly in their goals and patient care practices.

METHODS

Iterative cluster analysis was used to identify types of programs distinct in their stated goals.

FINDINGS

Three types of emphasis in SANE programs were identified: (a) prosecution of cases as a primary goal; (b) attending to patients' emotional needs, supporting feminist values, empowering patients, and changing the community response to rape; and (c) least importance on prosecution of cases and average importance on the other goals. Programs that were more focused on prosecution goals provided less comprehensive patient services.

CONCLUSIONS

Programs focused on prosecution as a primary goal were less likely to provide comprehensive services, especially those involving patient education. Such information is important for patients because their health concerns (e.g., pregnancy, STIs) have long-term implications for their well-being. Historical and structural differences among SANE programs might explain these different patient care practices. Researchers should examine the underlying processes in SANE programs that shape both their goals and patient care approaches.

The Magnet Recognition Program and Evidence-Based Practice

From the original Magnet study (1981) to now, health care organizations have begun to embrace the Magnet Recognition Program in record numbers. A visit to the Magnet web site (http://nursingworld.org/ancc/magnet.html) listed 186 Magnet hospitals, with many more healthcare facilities currently under review. As the Magnet Recognition Program has grown, so has the development of evidence-based practice (EBP). In fact, EBP is one of the cornerstones of the Magnet Recognition Program, as well as the involvement of staff nurses in research and/or EBP activities. This article will give a brief introduction of the Magnet Recognition Program and suggest activities that will involve staff nurses in EBP.

Policy and procedure management: a job that's never done

Accreditation, technology, procedures, and medications call for a constant focus on creating new or revising current regulations that govern nursing practice.

After-hours acute care. Night nurse

South Tees began a pioneering approach to the Hospital at Night programme in January 2004. A wireless system for data collection was key to the success of shift-based team Benefits include less spending on oncall staff and compliance with the European working time directive.

Structural Empowerment, Magnet Hospital Characteristics, and Patient Safety Culture

Nurse managers are seeking ways to improve patient safety in their organizations. At the same time, they struggle to address nurse recruitment and retention concerns by focusing on the quality of nurses' work environment. This exploratory study tested a theoretical model, linking the quality of the nursing practice environments to a culture of patient safety. Specific strategies to increase nurses' access to empowerment structures and thereby increase the culture of patient safety are suggested.

Application of the clinical nurse leader role in an acute care delivery model

The authors describe a 6-month pilot project incorporating a modified version of the American Association of Colleges of Nursing's (AACN) clinical nurse leader (CNL) role as a prelude to implementation of the AACN-defined CNL role. The purpose of the project was to evaluate a new nursing care delivery model on a designated nursing unit, incorporating the modified CNL role. The pilot was evaluated using nurse-sensitive indicators. Results showed positive trends for all indicators.

[A professional nursing practice environment and its impact on nurses' task motivation]

PURPOSE

This study was aimed at (a) describing professional nursing practice environments embedded in nursing care units and (b) examining its relationships to nurses' task motivation.

METHOD

Using the Nursing Work Index Revised (NWI-R) and the Work Preference Inventory (WPI), a descriptive study was conducted with a sample of 320 registered nurses on 26 nursing care units in one University hospital in Korea.

RESULT

Mean scores were 12.9 on a 5-20 score range of an autonomous environment scale, 7.3 on a 3-12 score range of a collaborative environment, and 15.8 on a 7-28 score range of control over nursing practice. Nurses' age, educational level, job position, working period at the hospital and employment status were significantly related to the degree of a professional practice environment. The extent to which a professional practice environment accounted for task motivation was 19.5%.

CONCLUSION

There is a certain degree of professionalism in the workplace environment that nurses perceived within the nursing care units. When nurses care for patients, the degree of task motivation depends on the work environment supporting the professional nursing practice.

Collaborative Strategies to Enhance Research and Evidence-based Practice

Whether the goal is to generate new knowledge through basic research or to effectively use existing knowledge in evidence-based clinical practice, collaborative exchange between service and academia is essential. The authors describe 2 successful strategies that have been mutually beneficial to a clinical agency and a school of nursing in fostering research and evidence-based practice. These strategies can be used by other institutions as they strive to meet standards for excellence in academia and service.