Nurse staffing and nurse outcomes: A systematic review and meta-analysis

What is the role of transformational leadership, work environment and patient safety culture for person-centred care? A cross-sectional study in Norwegian nursing homes and home care services

Aim

To examine how transformational leadership, job demands, job resources and patient safety culture contribute in explaining person-centred care in nursing homes and home care services.

Design

Cross-sectional study.

Methods

Healthcare professionals in four Norwegian nursing homes (N = 165) and four home care services (N = 139) participated in 2018. Multiple regression analyses were used to examine to what degree transformational leadership, job demands, job resources and patient safety culture dimensions predicted person-centred care.

Results

Transformational leadership, job demands and job resources explained 41% of the variance in person-centred care, with work pace as the strongest predictor (β = 0.39 p < .001). The patient safety culture dimensions explained 57.5% of the variance in person-centred care, with staffing being the strongest predictor (β = 0.31 p < .001). There were small differences between nursing homes and home care. In total, transformational leadership, pace of work, staffing and factors related to communication were the strongest predictors for person-centred care.

The Frontline Nurse's Experience of Nursing Outlier Patients

The frontline nurses' experience of nursing with overstretched resources in acute care setting can affect their health and well-being. Little is known about the experience of registered nurses faced with the care of a patient outside their area of expertise. The aim of this paper is to explore the phenomenon of nursing the outlier patient, when patients are nursed in a ward that is not specifically developed to deal with the major clinical diagnosis involved (e.g., renal patient in gynecology ward). Using a hermeneutic phenomenological approach, eleven individual face-to-face in-depth interviews were conducted with registered nurses in New South Wales, Australia. The study identified that each nurse had a specialty construct developed from nursing in a specialized environment. Each nurse had normalized the experience of specialty nursing and had developed a way of thinking and practicing theorized as a "care ladder". By grouping and analyzing various "care ladders" together, the nursing capacities common to nurses formed the phenomenological orientation, namely "the composite care ladder". Compared to nursing specialty-appropriate patients, nursing the outlier patient caused disruption of the care ladder, with some nurses becoming less capable as they were nursing the outlier patient. Nursing the outlier patient disrupted the nurses' normalized constructs of nursing. This study suggests that nursing patients in specialty-appropriate wards will improve patient outcomes and reduce impacts on the nurses' morale.

The Perils of Privatization: Bringing the Business Model into Human Services

During the last three decades in both the United States and Europe, neoliberal policies, especially privatization, have restructured services in ways that dramatically affect the capacity of human services workers and agencies to serve all clients. Privatization means not only transforming public programs such as Social Security, but also managerialism-the incorporation of business principles, methods, and goals into public and nonprofit human services organizations. Few researchers have looked at the impact of market-based managerialism (focused on productivity, accountability, efficiency, and standardization) on social work's mission and the effectiveness of human services workers and organizations. Using an anonymous survey of 3,000 New York City human services workers, authors examined the impact of managerialist practices including performance measures, quantifiable short-term outcomes, and routinized practices on frontline workers and service provision. A troubling trend emerged. Workers in agencies with a high commitment to managerialism found it considerably more difficult to adhere to social work's mission and fundamental values. This conflict between the "logic of the market" and the "logic of social work" subsided dramatically in agencies with a low commitment to managerialism, indicating that even in today's competitive environment, agencies can protect the social work mission.

Interventions to reduce burnout of physicians and nurses: An overview of systematic reviews and meta-analyses

OBJECTIVE

Numerous systematic reviews and meta-analyses on the interventions to reduce burnout of physicians and nurses have been published nowadays. This study aimed to summarize the evidence and clarify a bundled strategy to reduce burnout of physicians and nurses.

METHODS

Researches have been conducted within Cochrane Library, PubMed, Ovid, Scopus, EBSCO, and CINAHL published from inception to 2019. In addition, a manual search for relevant articles was also conducted using Google Scholar and ancestral searches through the reference lists from articles included in the final review. Two reviewers independently selected and assessed, and any disagreements were resolved through a larger team discussion. A data extraction spreadsheet was developed and initially piloted in 3 randomly selected studies. Data from each study were extracted independently using a pre-standardized data abstraction form. The the Risk of Bias in Systematic reviews and assessment of multiple systematic reviews (AMSTAR) 2 tool were used to evaluate risk of bias and quality of included articles.

RESULTS

A total of 22 studies published from 2014 to 2019 were eligible for analysis. Previous studies have examined burnout among physicians (n = 9), nurses (n = 6) and healthcare providers (n = 7). The MBI was used by majority of studies to assess burnout. The included studies evaluated a wide range of interventions, individual-focused (emotion regulation, self-care workshop, yoga, massage, mindfulness, meditation, stress management skills and communication skills training), structural or organizational (workload or schedule-rotation, stress management training program, group face-to-face delivery, teamwork/transitions, Balint training, debriefing sessions and a focus group) and combine interventions (snoezelen, stress management and resiliency training, stress management workshop and improving interaction with colleagues through personal training). Based on the Risk of Bias in Systematic reviews and AMSTAR 2 criteria, the risk of bias and methodological quality included studies was from moderate to high.

CONCLUSIONS

Burnout is a complicated problem and should be dealt with by using bundled strategy. The existing overview clarified evidence to reduce burnout of physicians and nurses, which provided a basis for health policy makers or clinical managers to design simple and feasible strategies to reduce the burnout of physicians and nurses, and to ensure clinical safety.

Improvement Plan of Nurse Staffing Standards in Korea

PURPOSE

This study compares the expected nurse-to-patient ratio, penalties for violating these regulations, and the laws enacted in the medical and nursing fields in Korea and advanced countries like Germany, Australia, the United States, and Japan.

METHODS

This study deployed an integrative review method and used search terms such as "nursing law," "nurse ratio," "nurse," "nurse staffing," "health," and "staffing" to find articles published in English, Korean, German, or Japanese through Cumulative Index to Nursing and Allied Health Literature Plus with Full Text, the Westlaw (International Materials-Jurisdiction) site, US government and state sites (federal parliament, National Conference of State Legislatures), and Google Scholar.

RESULTS

Compared with medical laws in other advanced countries, Korean laws are quite crude and its nurse-to-patient ratio does not reflect patients' status. Korea also lacks strict penalties for nurse staffing ratio violations.

CONCLUSION

Korea requires a strong regulatory apparatus for nurse staffing in health-care organizations to improve the quality of its health-care services and patient safety.

Multilevel analysis exploring the relative importance of workplace resources in explaining nurses' workload perceptions: Are we setting the right focus?

BACKGROUND

Nurses' workload has become increasingly recognized as an important determinant of nurse turnover and shortage and has been also associated with poorer quality of care. Despite strong evidence that heavy workloads have negative consequences, we still lack a comprehensive understanding of the workplace characteristics that contribute most to improving nurses' workload, the relative importance of each in doing so, or indeed the workplace characteristics and other factors that drive nurses' perceptions of their workload.

PURPOSE

The aim of this study was to examine workplace resources as antecedents of nurses' perceptions of their workload and to investigate their relative importance in explaining workload perceptions. We considered workplace resources related to staffing, professional relationships, and technology.

METHODOLOGY

The study sample comprised nurse-reported and administrative data from U.S. Veterans Health Administration hospitals between 2014 and 2017. Our multilevel analyses are based on data from 20,330 nurses working in 273 work groups at 123 hospitals. We developed and empirically tested a theoretical model using multilevel mixed-effects linear regression. The relative importance of workplace resources was assessed by dominance analysis.

RESULTS

Staffing levels, relational climate, and information technology were significantly associated with nurses' workload perceptions. Dominance analysis indicated that relational resources are the most important measure in explaining nurses' workload perceptions.

PRACTICE IMPLICATIONS

This is the first study to examine the relative importance of workplace resources in explaining nurses' perceptions of their workload. Our results suggest that much might be gained by investing in interventions to boost relational resources. In turn, these findings could lead to more targeted, effective, and resource efficient interventions to improve nurses' workload.

Nurse staffing in large general hospitals in China: an observational study

BACKGROUND

The appropriate staffing of nurses not only reflects the situation of nursing management of human resource, but also is related to the nursing quality in hospitals. This study investigated the staffing of nurses in large general hospitals in China.

METHODS

In this study, a database established by the National Centre for Nursing Care Quality Control, which conducted a national survey of the staffing of nurses in China mainland in 2017, was analysed. The time-point survey data of 20 375 departments in 668 large general hospitals in China were obtained, including the information of nurses and patients during the day (10:00 am) and at night (10:00 pm). Then, the staffing of nurses was evaluated by calculating the nurse to patient ratio (the average number of patients assigned to a nurse, NTP ratio). The Kruskal-Wallis test was performed to compare the NTP ratios during the day and at night among different regions and departments.

RESULTS

In large general hospitals, a nurse takes care of eight patients (NTP ratio = 1:8.0) during the day and 23 patients at night (NTP ratio = 1:23) on average. There were significant differences between day and night. In terms of different regions, a nurse in the hospitals in the western region takes care of 7.8 patients during the day (NTP ratio = 1:7.8) on average, and the nursing resource in the western region is more adequate than that in the eastern (1:8.0) and central (1:8.0) regions. At night, the eastern region has a higher level of NTP (1:23.0). In terms of departments, a nurse working in the ICU takes care of two patients during the day (NTP ratio = 1:2.0) and 2.9 patients at night (NTP ratio = 1:2.9). The level of NTP in the oncology department is relatively higher: 9.3 during the day and 34.0 at night. Other departments including internal medicine, surgery, obstetrics and gynaecology, paediatrics, and geriatrics have NTP ratios of 1:7-8 during the day and 1:18-25 at night.

CONCLUSIONS

In China, the nurse staffing of large general hospitals has some regional and departmental patterns. The low level of nurse staffing at night may be a problem worthy of attention; the Chinese government needs to establish standards for different periods and departments to improve efficiency and quality of nursing.

Challenges of human resources management in nursing in Iran: A qualitative content analysis

Aim

Health service providers are appreciated among the vital components in a society wherein nurses are also considered as the main human resources. Thus, examining the existing challenges in managing these human resources through taking correct measures can contribute to identifying the priorities and consequently influence the quality of services provided. This study aims to investigate the challenges of human resources management in nursing from the perspective of professionals in Iran.

Design

Qualitative content analyses.

Methods

Present study is carried out using purposive sampling conducted on 12 nurses involved in different professional nursing positions. To this end, the participants' perceptions, opinions, beliefs and attitudes were collected via two focus group sessions. Data were collected during Febuary and March 2018.

Results

From the perspective of the professionals, the challenges could be observed in a wide variety of human resources management dimensions in nursing such as job analysis, recruitment, as well as development and retention of workforce.

[Hospital nursing personnel staffing and patient outcome]

OBJECTIVE

The purpose of this review is to comment on the association between hospital nursing personnel staffing and patient outcomes, including the avoidance of errors and complications.

METHODS

A literature search was carried out in the Medline database on publications from the last 10 years on nursing personnel staffing.

RESULTS

Only overviews and observational studies on the topic were available and no controlled or prospective surveys. Most investigators assumed that there was an inverse relationship between low nursing staff levels of hospital wards and intensive care and adverse outcomes, including higher mortality rates; however, there is no clear significance for this assumption and evidence-based definitive lower limits for nursing staff cannot be given due to a lack of randomized trials. The causes for unfavorable results in the case of inadequate nursing personnel staffing include hygiene deficiencies, orders not followed and unfulfilled nursing and monitoring measures. Furthermore, staff overload leads to staff dissatisfaction and burnout, which also has a negative impact on the results. Most studies required a maximum patient to nurse ratio of 2:1 for the intensive care unit and an average ratio of not more than 8:1 for surgical wards. With respect to these requirements, changing personnel needs must be considered depending on the current state of the patients being cared for, which enabled all investigators to require a flexible roster design; approval for fixed statutory lower limits for nursing staff was low. The level of education of the nursing staff also played an essential role as qualified nursing staff cannot be replaced at will by less qualified assistant staff.

CONCLUSION

The level of training and the number of the nursing personnel influence hospital mortality and adverse outcomes; however, there are no evidence-based lower levels for nursing staff for inpatient care and perhaps this cannot be the case due to the changing complexity of the patients admitted, the comorbidities and possible treatment complications. There is a considerable need for research.

Patient-Nurse Ratio is Related to Nurses' Intention to Leave Their Job through Mediating Factors of Burnout and Job Dissatisfaction

In healthcare settings, nurses’ workload, burnout, and job satisfaction are associated to the patient–nurse ratio. Whether this ratio also affects their intention to leave the nursing profession, along with the underlying stress pathway, remains unclear. This study aimed to investigate the effects of the patient–nurse ratio on nurses’ intention to leave and considering the mediating roles of burnout and job dissatisfaction. The study analyzed the data of two pooled cross-sectional surveys collected in 2013 and 2014. Measures were obtained by a structure questionnaire, which queried the average daily patient–nurse ratio (ADPNR), nurses’ personal burnout, client-related burnout, job dissatisfaction, intention to leave, and other demographics. ADPNRs were standardized according to hospital levels. Multiple regression models examined mediation hypotheses, and a percentile bootstrap confidence interval was applied to determine the significance of indirect effects. A total of 1409 full-time registered nurses in medical and surgical wards of 24 secondary or tertiary hospitals in Taiwan completed self-administered questionnaires. Most of the participants were female (97.2%), and the mean age was 29.9 years. The association between the standardized ADPNR and intention to leave their job was significantly mediated by personal burnout, client-related burnout, and job dissatisfaction. Higher standardized ADPNRs predicted higher levels of personal burnout, client-related burnout, and job dissatisfaction, each of which resulted in higher levels of intention to leave the current job. The results highlight that appropriate patient–nurse ratio standards may be further discussed by selecting personal burnout, client-related burnout, and job dissatisfaction as indicators.

A cross-sectional study exploring the relationship between burnout, absenteeism, and job performance among American nurses

Background

Studies suggest a high prevalence of burnout among nurses. The aim of this study was to evaluate the relationship between burnout among nurses and absenteeism and work performance.

Methods

A national sample of U.S. nurses was sent an anonymous, cross-sectional survey in 2016. The survey included items about demographics, fatigue, and validated instruments to measure burnout, absenteeism, and poor work performance in the last month.

Results

Of the 3098 nurses who received the survey, 812 (26.2%) responded. The mean age was 52.3 years (SD 12.5), nearly all were women (94.5%) and most were married (61.9%) and had a child (75.2%). Participating nurses had a mean of 25.7 (SD 13.9) years of experience working as nurse and most held a baccalaureate (38.2%) or masters of science (37.1%) degree in nursing. A quarter worked in the inpatient setting (25.5%) and the average hours worked per week was 41.3 (SD 14.1). Overall, 35.3% had symptoms of burnout, 30.7% had symptoms of depression, 8.3% had been absent 1 or more days in the last month due to personal health, and 43.8% had poor work performance in the last month. Nurses who had burnout were more likely to have been absent 1 or more days in the last month (OR 1.85, 95% CI 1.25–2.72) and have poor work performance (referent: high performer; medium performer, OR 2.68,95% CI 1.82–3.99; poor performer, OR 5.01, 95% CI 3.09–8.14). After adjusting for age, sex, relationship and parental status, highest academic degree, practice setting, burnout, depression, and satisfaction with work-life integration, nurses who were more fatigued (for each point worsening, OR 1.22, 95% CI 1.10–1.37) were more likely to have had absenteeism while those who worked more hours (for each additional hour OR 0.98, 95% CI 0.96–1.00) were less likely to have had absenteeism. Factors independently associated with poor work performance included burnout (OR 2.15, 95% CI 1.43–3.24) and fatigue (for each point of worsening, OR 1.22, 95% CI 1.12–1.33).

Conclusions

These findings suggest burnout is prevalent among nurses and likely impacts work performance.

Analysis of the Risk and Protective Roles of Work-Related and Individual Variables in Burnout Syndrome in Nurses

Aims: Burnout syndrome is a phenomenon that is becoming ever more widespread, especially in workers such as nurses who have heavy workloads and time pressures. The progression of burnout syndrome has been shown to be related to both individual and work-related variables. The objective of this study is to examine the risk and protective roles played by work-related and personal variables, both sociodemographic and psychological, in the development of burnout in nurses. Method: The sample was composed of 1236 nurses aged between 21 and 57 years, with a mean age of 31.50 years (SD = 6.18). Women accounted for 84.5% (n = 1044), and the remaining 15.5% (n = 192) were men. Exploratory tests were performed to understand the relationships between burnout and other variables, and a binary logistic regression was conducted to understand the roles of these variables in the incidence of this syndrome. Lastly, a regression tree was constructed. Results: The results show that the sociodemographic variables examined are not related to the level of burnout in nurses. However, certain work-related variables, such as spending more time with colleagues and patients and reporting good-quality relationships, exhibit a negative relationship with the occurrence of burnout. Of the psychological variables, the stress factors conflict-social acceptance and irritability-tension-fatigue, as well as informative communication, are shown to be risk factors for the appearance of burnout in nurses. In contrast, the communication skills factor, empathy, and energy-joy exert a protective function. Conclusion: Identifying the variables that influence the occurrence of burnout syndrome and understanding the manner in which they exert their influence are key elements in the development of effective prevention and intervention of burnout in nursing.

"You only have time for so much in 12 hours" unmet social needs of hospitalised patients: A qualitative study of acute care nurses

AIMS AND OBJECTIVES

To explore the experiences of nurses caring for socially at-risk patients and gain an understanding of the challenges nurses face when providing care.

BACKGROUND

Nurses play a pivotal role in caring for hospitalised patients with social risk factors and preparing them for discharge. Few studies have explored whether acute care nurses are adequately supported in their practice environments to address the unique needs of socially at-risk patients as they transition back into community settings.

DESIGN

A qualitative descriptive study of nurses working in a large urban academic medical centre.

METHODS

We conducted six semi-structured focus groups of nurses (n = 21). Thematic content analysis was performed to analyse the transcripts from the focus groups. We adhered to COREQ guidelines for reporting this qualitative study.

RESULTS

Six key themes emerged: (a) nurses' assessments of social risk factors, (b) experiences providing care, (c) barriers to care, (d) fear of "labelling" socially at-risk patients, (e) unmet social care needs and (f) recommendations to improve care.

CONCLUSIONS

Our findings suggest that nurses are able to identify social risk factors. However, prioritisation of medical needs during acute care hospitalisation and lack of organisational supports may deter nurses from fully addressing social concerns.

RELEVANCE TO CLINICAL PRACTICE

Acute care nurses should be involved in the development of future efforts to address the needs of socially at-risk patients and be provided with additional supports in their practice environments. This could include continuing education to build nursing competencies in community-based care and social vulnerability.

Use of the Worklife and Levels of Burnout Surveys to Assess the School Nurse Work Environment

Previous research regarding burnout in acute care settings revealed that positive work environments increase job satisfaction, decrease staff turnover, and improve patient outcomes. However, few studies address burnout among school nurses. The purpose of this study was to describe the relationship between the school nurse practice environment, school nurses’ levels of burnout, and perceived sources of work stress. A cross-sectional sample of 100 registered nurses completed a web-based version of the Maslach Burnout Inventory and Areas of Worklife Survey. Identified stressors were entered into regression models to determine associations with levels of burnout. Burnout is significantly associated with all Areas of Worklife subscales. School nurses who reported satisfactory work environments experienced little to no burnout. This study provides insights into the domains of work that can cause burnout among school nurses and provides evidence that can inform school leadership and policy makers on ways to promote healthy work environments.