UK ward design: Patient dependency, nursing workload, staffing and quality—An observational study

Association of nursing hours with cognitive function, balance, and dependency level of stroke patients

AIMS

To examine the association of nursing hours given to patients with stroke with clinical characteristics to predict the nursing care needs.

DESIGN

Twenty-four-hour observational study METHODS: Nursing hours per patient day (NHPPD) of 171 stroke patients were measured by 146 nursing personnel who worked on the day of the observation. Cognitive function, balance ability and dependency level were assessed using the Korean version of the Mini-Mental State Examination (K-MMSE), the Korean version of the Berg Balance Scale (K-BBS) and the Korean version of the Modified Barthel Index (K-MBI), respectively.

RESULTS

The NHPPD were moderately correlated with K-MMSE (r = -.450), K-BBS (r = -.529) and K-MBI (r = -.549). The worse the cognitive function, balance ability and dependency level, the more were the nursing hours given to the patients. Therefore, these factors can be considered to be factors that predict nursing care needs for patients with stroke.

Factors associated with nursing needs and nursing hours in acute care hospital settings: A cross-sectional study

AIM

To identify the patient and hospital characteristics related to nursing needs and nursing hours in acute hospital settings.

BACKGROUND

To determine appropriate staffing levels, accumulating empirical data through direct observation and surveys reflecting the actual situation is necessary.

METHODS

In this cross-sectional study, we conducted direct observations of nurses in acute care hospitals from May 1 to August 31, 2020. Twenty-six hospitals in five cities participated, and 747 nursing personnel collected 1,681 patients' data while performing nursing activities. The data of 1,605 individuals were analyzed using descriptive statistics, t-tests, analysis of variance, and linear regression.

RESULTS

Hospital size, admission day, patients' dependence level, high fall risk, and disease diagnoses were variables associated with nursing needs (F = 73.49, P < 0.001) and nursing hours (F = 57.7, P < 0.001). Comparing the correlates of nursing needs and nursing hours revealed that, unlike nursing needs, nursing hours were not significantly associated with surgery and certain diagnoses.

CONCLUSION

This study confirmed the variables associated with nursing needs and nursing hours in acute hospitals; based on this, determining appropriate staffing levels, which is an important step in improving inpatients' health outcomes, is necessary.

IMPLICATIONS FOR NURSING MANAGEMENT

In acute hospitals, an increased number of nurse staffing should be employed based on the number of newly hospitalized patients, patients with high dependence levels and specific diagnoses, and those at high risk of falling.

Patients' and Nurses' Experiences of All Single-Room Hospital Accommodation: A Scoping Review

AIM AND OBJECTIVE

To identify, examine, and map literature on the experiences of single-room hospital accommodation, exploring what is known about how single-room accommodation in hospitals is viewed by patients and nurses.

BACKGROUND

Worldwide, hospital design is changing to mainly single-room accommodation. However, there is little literature exploring patients' and nurses' experiences of single-room designs.

DESIGN

Scoping review following the Joanna Briggs Institute guidance on scoping reviews.

METHODS

We conducted the search in medical databases for scientific and gray literature. The four authors independently used a data extraction tool to include sources from the searches. The sources were discussed during the process, and in case of a disagreement between two reviewers, the third and fourth reviewer would be invited to participate in the discussion until consensus was achieved.

RESULTS

We included 22 sources published during the period 2002-2020, with a majority (n = 16) during the period 2013-2020. The sources were distributed on 10 different countries; however, England dominated with 14 publications. We found three main maps for reporting on patients' experiences: (1) personal control, (2) dignity, and (3) by myself. For the nurses' experiences, we found four main maps: (1) the working environment, (2) changes of nursing practice, (3) privacy and dignity, and (4) patient safety.

CONCLUSION

We suggested that patients' and nurses' experiences are predominantly interdependent and that the implications of single-room accommodation is a large and complex issue which goes beyond hospital design.

Clinical frailty as a key characteristic of the patient population of the NHS Nightingale North West COVID-19 temporary emergency field hospital: cohort study April to June 2020

Objectives

COVID-19 temporary emergency ‘field’ hospitals have been established in the UK to support the surge capacity of the National Health Service while protecting the community from onward infection. We described the population of one such hospital and investigated the impact of frailty on clinical outcomes.

Design

Cohort study.

Setting

NHS Nightingale Hospital North West, April–June 2020.

Participants

All in-patients with COVID-19.

Main Outcome Measures

Mortality and duration of admission.

Methods

We analysed factors associated with mortality using logistic regression and admission duration using Cox's regression, and described trends in frailty prevalence over time using linear regression.

Results

A total of 104 COVID-19 patients were admitted, 74% with moderate-to-severe frailty (clinical frailty score, CFS > 5). A total of 84 were discharged, 14 transferred to other hospitals, and six died on site. High C-reactive protein (CRP) > 50 mg/dL predicted 30-day mortality (adjusted odds ratio 11.9, 95%CI 3.2–51.5, p < 0.001). Patients with CFS > 5 had a 10-day median admission, versus 7-day for CFS ≤ 5 and half the likelihood of discharge on a given day (adjusted hazard ratio 0.51, 95%CI 0.29–0.92, p  =  0.024). CRP > 50 mg/dL and hospital-associated COVID-19 also predicted admission duration. As more frail patients had a lower rate of discharge, prevalence of CFS > 5 increased from 64% initially to 90% in the final week (non-zero slope p < 0.001). Conclusions: The NNW population was characterized by high levels of frailty, which increased over the course of the hospital's operation, with subsequent operational implications. Identifying and responding to the needs of this population, and acknowledging the risks of this unusual clinical context, helped the hospital to keep patients safe.

Risk Factors Preventing Immediate Fall Detection: A Study Using Zero-Inflated Negative Binomial Regression

PURPOSE

Falls are the most common accidents in healthcare facilities, and timely intervention can have a positive effect on the hazards and trauma experienced by patients after a fall. This study determined the factors affecting the time taken to detect a fall.

METHODS

A total of 3,470 cases of falls reported through the Korea Patient Safety Reporting and Learning System were included in the analysis. A zero-inflated negative binomial regression method was used for this retrospective secondary data analysis study.

RESULTS

There were 537 patients whose falls were not detected immediately; the count model was used to predict risk factors that delayed fall detection. Women aged 60-69 years-compared to those below 60 years and an evening nursing shift, compared to a day shift-were identified as significant factors. The fall detection time of about 2,933 patients was zero; therefore, the logit model was applied to predict a patient's possibility of belonging to the group whose fall was detected immediately. Comparisons of tertiary hospitals with general hospitals and hospitals, of the evening shift with the day shift, and of the day shift with the night shift indicated significant influencing factors.

CONCLUSIONS

These findings can assist nurses in recognizing patient and hospital characteristics related to delayed fall detection. Strategies to improve patient safety in healthcare facilities that focus on patient characteristics such as age can be recommended. Furthermore, nurse staffing requires improvement to detect fall incidents immediately.

Initial testing of the use of the Safer Nursing Care Tool in a Canadian acute care context

Aim

Initial testing of England's Safer Nursing Care Tool for adult in‐patient acute care wards in a university‐affiliated Canadian hospital.

Background

Safe‐nursing staffing decisions have significant impacts on patients' safety and quality of care. The Safer Nursing Care Tool was developed in England to provide managers with a validated formula for making appropriate nursing staffing decisions. The tool has been widely used and studied in the UK but has yet to be tested in a Canadian context.

Method

Ten high service quality acute care wards from a university‐affiliated Canadian hospital tested the use of the Safer Nursing Care Tool. Service quality, patients' dependency/acuity and staff activity data were benchmarked against information collected in 726 comparable UK wards.

Results

Higher bed occupancy and patient dependency/acuity mix were found in the 10 Canadian wards compared to their UK counterparts. Overall staff activity was comparable between UK and Canadian wards.

Conclusion

The Safer Nursing Care Tool can be applied in this Canadian hospital, and further testing in other hospitals and specialties is required.

Implication for Nursing Management

The Safer Nursing Care Tool is a valid staffing tool to use that, when combined with professional judgement, can help managers to properly establish nursing staff in acute care wards.

The Prevention of Delirium system of care for older patients admitted to hospital for emergency care: the POD research programme including feasibility RCT

Background

Delirium is a distressing, common and serious condition in older people in hospital. Evidence suggests that it could be prevented in about one-third of patients using multicomponent interventions targeting delirium risk factors, but these interventions are not yet routinely available in the NHS.

Objective

The objective was to improve delirium prevention for older people admitted to the NHS.

Design

Project 1 comprised case studies employing qualitative methods (observation, interviews, workshops) in three NHS hospitals to develop the Prevention of Delirium system of care. Project 2 comprised case studies using mixed methods in five NHS hospitals to test the Prevention of Delirium implementation, feasibility and acceptability, and to modify the Prevention of Delirium system of care. Project 3 comprised a multicentre, cluster randomised, controlled, pragmatic feasibility study in eight hospitals, with embedded economic evaluation, to investigate the potential clinical effectiveness and cost-effectiveness of the Prevention of Delirium system of care, compared with standard care, among older patients admitted to hospital for emergency care. The primary objectives related to gathering information to design a definitive trial. Criteria for progression to a definitive trial were as follows: a minimum of six wards (75%) completing the Prevention of Delirium manual milestone checklist and an overall recruitment rate of at least 10% of the potential recruitment pool.

Setting

This study was set in NHS general hospitals.

Participants

In project 1, participants were staff, volunteers, and patient and carer representatives. In project 2, participants were staff, volunteers, patients and carers. In project 3, participants were older patients admitted to elderly care and orthopaedic trauma wards.

Intervention

The developed intervention (i.e. the Prevention of Delirium system of care).

Main outcome measures

For the feasibility study (project 3), the primary outcome measure was the Confusion Assessment Method. The secondary outcome measures were the Nottingham Extended Activities of Daily Living scale, the Clinical Anxiety Scale and the Geriatric Depression Scale Short Form.

Results

Project 1: understanding of delirium prevention was poor. Drawing on evidence, and working with ward teams, we developed the Prevention of Delirium system of care, which targeted 10 delirium risk factors. This multicomponent intervention incorporated systems and mechanisms to introduce and embed delirium prevention into routine ward practices. Project 2: five out of six wards implemented or partially implemented the Prevention of Delirium intervention. A prominent role for hospital volunteers was intended, but most wards were unable to recruit or sustain the numbers needed. We identified four conditions necessary to implement and deliver the Prevention of Delirium intervention: (1) commitment of senior nurse, (2) a named person to drive implementation forward, (3) dedicated time (1 day per week) of an experienced nurse to lead implementation and (4) adequate ward staffing levels. Overall, the intervention was acceptable to staff, volunteers, patients and carers, and did not increase nursing staff workload. In the light of these findings, the Prevention of Delirium system of care was modified for use in project 3. Project 3: 16 wards in eight hospitals (two wards per hospital) were recruited. Out of 4449 patients screened, 3274 (73.6%) were eligible and 713 were registered, resulting in a recruitment rate of 16.0%. Thirty-three (4.6%) participants withdrew. The screened and registered participants were similar, but some between-treatment group imbalances were noted among those registered to the trial. All eight wards allocated to the intervention group completed the Prevention of Delirium manual milestone checklist and delivered the Prevention of Delirium intervention (median time 18.6 weeks for implementation). Overall, fidelity to the intervention was assessed as being high in two wards, medium in five wards and low in one ward. Of the expected 5645 Confusion Assessment Method delirium assessments, 5065 (89.7%) were completed during the first 10 days of admission. The rates of return of the patient-reported questionnaire booklets were 98.0% at baseline, 81.8% at 30 days and 70.5% at 3 months. The return rate of the EuroQol-5 Dimensions questionnaire was 98.6% at baseline, 77.5% at 1 month and 65.3% at 3 months (94–98% fully completed). The completion rate of the resource use questionnaire was lower (48.7%). The number of people with new-onset delirium at 10 days was 24 (7.0%) in the Prevention of Delirium group and 33 (8.9%) in the control group. Multilevel logistic regression analysis showed that participants in the Prevention of Delirium group had non-significant lower odds of developing delirium (odds ratio 0.68, 95% confidence interval 0.37 to 1.26; p = 0.2225). The average cost of the Prevention of Delirium intervention was estimated as £10.98 per patient and the mean costs for the Prevention of Delirium and usual-care groups were £5332 and £4412, respectively, with negligible between-group differences in quality-adjusted life-years. There was conflicting evidence from the trial- and model-based analyses relating to the cost-effectiveness of the Prevention of Delirium intervention. Given this, and in view of issues with the data (e.g. high levels of missingness), the results from the economic evaluation are highly uncertain. The criteria for continuation to a future definitive randomised controlled trial were met. Such a trial would need to recruit 5200 patients in 26 hospital clusters (200 patients per cluster).

Conclusions

The Prevention of Delirium system of care was successfully developed, and a multicentre feasibility study showed that the intervention is capable of implementation and delivery in routine care, with acceptable intervention fidelity and preliminary estimate of effectiveness.

Limitations

A prominent role for volunteers was originally intended in the Prevention of Delirium system of care, but only three of the eight wards allocated to the trial intervention group involved volunteers.

Future work

The findings indicate that a definitive multicentre evaluation of the Prevention of Delirium system of care should be designed and conducted to obtain robust estimates of clinical effectiveness and cost-effectiveness.

Trial registration

Current Controlled Trials ISRCTN28213290 (project 1), ISRCTN65924234 (project 2) and ISRCTN01187372 (project 3).

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 4. See the NIHR Journals Library website for further project information.

Objective measures of workload in healthcare: a narrative review

PURPOSE

Workload is a critical concept in the evaluation of performance and quality in healthcare systems, but its definition relies on the perspective (e.g. individual clinician-level vs unit-level workload) and type of available metrics (e.g. objective vs subjective measures). The purpose of this paper is to provide an overview of objective measures of workload associated with direct care delivery in tertiary healthcare settings, with a focus on measures that can be obtained from electronic records to inform operationalization of workload measurement.

DESIGN/METHODOLOGY/APPROACH

Relevant papers published between January 2008 and July 2018 were identified through a search in Pubmed and Compendex databases using the Sample, Phenomenon of Interest, Design, Evaluation, Research Type framework. Identified measures were classified into four levels of workload: task, patient, clinician and unit.

FINDINGS

Of 30 papers reviewed, 9 used task-level metrics, 14 used patient-level metrics, 7 used clinician-level metrics and 20 used unit-level metrics. Key objective measures of workload include: patient turnover (n=9), volume of patients (n=6), acuity (n=6), nurse-to-patient ratios (n=5) and direct care time (n=5). Several methods for operationalization of these metrics into measurement tools were identified.

ORIGINALITY/VALUE

This review highlights the key objective workload measures available in electronic records that can be utilized to develop an operational approach for quantifying workload. Insights gained from this review can inform the design of processes to track workload and mitigate the effects of increased workload on patient outcomes and clinician performance.

Performance of the Safer Nursing Care Tool to measure nurse staffing requirements in acute hospitals: a multicentre observational study

OBJECTIVES

The best way to determine nurse staffing requirements on hospital wards is unclear. This study explores the precision of estimates of nurse staffing requirements made using the Safer Nursing Care Tool (SNCT) patient classification system for different sample sizes and investigates whether recommended staff levels correspond with professional judgements of adequate staffing.

DESIGN

Observational study linking datasets of staffing requirements (estimated using a tool) to professional judgements of adequate staffing. Multilevel logistic regression modelling.

SETTING

81 medical/surgical units in four acute care hospitals.

PARTICIPANTS

22 364 unit days where staffing levels and SNCT ratings were linked to nurse reports of "enough staff for quality".

PRIMARY OUTCOME MEASURES

SNCT-estimated staffing requirements and nurses' assessments of staffing adequacy.

RESULTS

The recommended minimum sample of 20 days allowed the required number to employ (the establishment) to be estimated with a mean precision (defined as half the width of the CI as a percentage of the mean) of 4.1%. For most units, much larger samples were required to estimate establishments within ±1 whole time equivalent staff member. When staffing was lower than that required according to the SNCT, for each hour per patient day of registered nurse staffing below the required staffing level, the odds of nurses reporting that there were enough staff to provide quality care were reduced by 11%. Correspondingly, the odds of nurses reporting that necessary nursing care was left undone were increased by 14%. No threshold indicating an optimal staffing level was observed. Surgical specialty, patient turnover and more single rooms were associated with lower odds of staffing adequacy.

CONCLUSIONS

The SNCT can provide reliable estimates of the number of nurses to employ on a unit, but larger samples than the recommended minimum are usually required. The SNCT provides a measure of nursing workload that correlates with professional judgements, but the recommended staffing levels may not be optimal. Some important sources of systematic variations in staffing requirements for some units are not accounted for. SNCT measurements are a potentially useful adjunct to professional judgement but cannot replace it.

TRIAL REGISTRATION NUMBER

ISRCTN12307968.

The Safer Nursing Care Tool as a guide to nurse staffing requirements on hospital wards: observational and modelling study

Background

The Safer Nursing Care Tool is a system designed to guide decisions about nurse staffing requirements on hospital wards, in particular the number of nurses to employ (establishment). The Safer Nursing Care Tool is widely used in English hospitals but there is a lack of evidence about how effective and cost-effective nurse staffing tools are at providing the staffing levels needed for safe and quality patient care.

Objectives

To determine whether or not the Safer Nursing Care Tool corresponds to professional judgement, to assess a range of options for using the Safer Nursing Care Tool and to model the costs and consequences of various ward staffing policies based on Safer Nursing Care Tool acuity/dependency measure.

Design

This was an observational study on medical/surgical wards in four NHS hospital trusts using regression, computer simulations and economic modelling. We compared the effects and costs of a ‘high’ establishment (set to meet demand on 90% of days), the ‘standard’ (mean-based) establishment and a ‘flexible (low)’ establishment (80% of the mean) providing a core staff group that would be sufficient on days of low demand, with flexible staff re-deployed/hired to meet fluctuations in demand.

Setting

Medical/surgical wards in four NHS hospital trusts.

Main outcome measures

The main outcome measures were professional judgement of staffing adequacy and reports of omissions in care, shifts staffed more than 15% below the measured requirement, cost per patient-day and cost per life saved.

Data sources

The data sources were hospital administrative systems, staff reports and national reference costs.

Results

In total, 81 wards participated (85% response rate), with data linking Safer Nursing Care Tool ratings and staffing levels for 26,362 wards × days (96% response rate). According to Safer Nursing Care Tool measures, 26% of all ward-days were understaffed by ≥ 15%. Nurses reported that they had enough staff to provide quality care on 78% of shifts. When using the Safer Nursing Care Tool to set establishments, on average 60 days of observation would be needed for a 95% confidence interval spanning 1 whole-time equivalent either side of the mean. Staffing levels below the daily requirement estimated using the Safer Nursing Care Tool were associated with lower odds of nurses reporting ‘enough staff for quality’ and more reports of missed nursing care. However, the relationship was effectively linear, with staffing above the recommended level associated with further improvements. In simulation experiments, ‘flexible (low)’ establishments led to high rates of understaffing and adverse outcomes, even when temporary staff were readily available. Cost savings were small when high temporary staff availability was assumed. ‘High’ establishments were associated with substantial reductions in understaffing and improved outcomes but higher costs, although, under most assumptions, the cost per life saved was considerably less than £30,000.

Limitations

This was an observational study. Outcomes of staffing establishments are simulated.

Conclusions

Understanding the effect on wards of variability of workload is important when planning staffing levels. The Safer Nursing Care Tool correlates with professional judgement but does not identify optimal staffing levels. Employing more permanent staff than recommended by the Safer Nursing Care Tool guidelines, meeting demand most days, could be cost-effective. Apparent cost savings from ‘flexible (low)’ establishments are achieved largely by below-adequate staffing. Cost savings are eroded under the conditions of high temporary staff availability that are required to make such policies function.

Future work

Research is needed to identify cut-off points for required staffing. Prospective studies measuring patient outcomes and comparing the results of different systems are feasible.

Trial registration

Current Controlled Trials ISRCTN12307968.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 8, No. 16. See the NIHR Journals Library website for further project information.

Methods used to examine technology in relation to the quality of nursing work in acute care: A systematic integrative review

AIMS AND OBJECTIVES

To systematically locate, assess and synthesise research to describe methods used to examine technology in relation to the quality of nursing work in acute care. Specific objectives were to (a) describe the types of nursing work examined; (b) describe methods used to examine technology in nursing work; (c) identify outcomes used to evaluate technology in relation to the quality of nursing work; and (d) make recommendations for future research.

BACKGROUND

New technologies can offer numerous benefits to nurses; however, it is challenging to evaluate health information technologies in relation to the quality of nurses' complex day-to-day work.

DESIGN

A systematic integrative review using a five-step process.

METHODS

Five databases were searched using search terms "nurs*," "workload," "task," "time." Data screening, extraction and interpretation were conducted independently by at least two authors and agreement verified by discussion. Data extraction followed PRISMA guidelines.

RESULTS

Of the 41 studies included, most (87.8%, n = 36) examined physical dimensions of nursing work; 31.7% (n = 13) organisational dimensions; 17.1% (n = 8) cognitive dimensions; and only 12.2% (n = 5) emotional dimensions. More than half (58.5%, n = 24) examined only one dimension; one captured all four dimensions. Most frequently examined technologies were electronic medical/health records (36.5%) and electronic medication management (19.5%). Direct observation (58.8%, n = 28) and multiple methods (19.5%, n = 8) were the most common methods; nurse tasks, frequency, duration and time distribution were variables most often measured.

CONCLUSIONS

Examinations of technology in nursing work often failed to capture the multiple dimensions of this work nor did they recognise the complexity of day-to-day nursing work in acute care. There is a paucity of literature to inform how and what technology should be measured in relation to the quality of nursing care.

RELEVANCE TO CLINICAL PRACTICE

The outcomes inform useful research methods to comprehensively examine technology to enhance the quality of complex nursing work.

Key Components of the Safe Surgical Ward: International Delphi Consensus Study to Identify Factors for Quality Assessment and Service Improvement

OBJECTIVE

The aim of this study was to prioritize key factors contributing to safety on the surgical ward BACKGROUND:: There is a variation in the quality and safety of postoperative care between institutions. These variations may be attributed to a combination of process-related issues and structural factors. The aim of this study is to reach a consensus, by means of Delphi methodology, on the most influential of these components that may determine safety in this environment.

METHODS

The Delphi questionnaire was delivered via an online questionnaire platform. The panel were blinded. An international panel of safety experts, both clinical and nonclinical, and safety advocates participated. Individuals were selected according to their expertise and extent of involvement in patient safety research, regulation, or patient advocacy.

RESULTS

Experts in patient safety from the UK, Europe, North America, and Australia participated. The panel identified the response to a deteriorating patient and the care of outlier patients as error-prone processes. Prioritized structural factors included organizational and environmental considerations such as use of temporary staff, out-of-hours reduction in services, ward cleanliness, and features of layout. The latter includes dedicated areas for medication preparation and adequate space around the patient for care delivery. Potential quality markers for safe care that achieved the highest consensus include leadership, visibility between patients and nurses, and nursing team skill mix and staffing levels.

CONCLUSION

International consensus was achieved for a number of factors across process-related and structural themes that may influence safety in the postoperative environment. These should be championed and prioritized for future improvements in patient safety at the ward-level.

Assessment of pressure pain threshold at the cervical and lumbar spine region in the group of professionally active nurses: A cross-sectional study

OBJECTIVES

The problem of spinal pain among nurses and lack of compliance with workplace ergonomy is increasing. The study aimed to assess the pressure pain threshold (PPT) at the cervical and lumbar spine in nursing staff.

METHODS

The sample of this prospective and observational study consisted of 30 female nurses with a mean age of 38.6 ± 11.1 years. The standardized Oswestry (ODI) and the Neck Disability Index (NDI) were used, as well as the Authors' Designed Questionnaire (ADQ) was used to assess compliance with ergonomic principles. The PPT analysis using a computerized pressure algometer (CPA) was performed to examine the level of PPT.

RESULTS

A mild disability was found in 56% of nurses (NDI and ODI). A value of <4 kg/cm2 (CPA), indicating musculoskeletal overload was observed in 57% of subjects. Also, 60% of nurses work with a lying patient; 73.4% grabs the patient's armpits while transferring in bed; 16.7% never adjusts the height of the bed, and only 13.4% choose specialist footwear for work. There is a correlation between PPT values for trapezius and erector spinae muscles on the same side of the body in nurses with mild and moderate disability (P < .05).

CONCLUSIONS

Pain complaints are associated with lower PPT of trapezius and erector spinae muscles and asymmetry of muscle tension. Also, it was noted that the lack of implementation of ergonomic principles by nursing staff affects their degree of disability.

Process of implementing and delivering the Prevention of Delirium system of care: a mixed method preliminary study

BACKGROUND

Delirium is a frequent complication of hospital admission among older people. Multicomponent interventions which can reduce incident delirium by ≈one-third are recommended by the National Institute of Health and Care Excellence. Currently, a standardised delirium prevention system of care suitable for adoption in the UK National Health Service does not exist. The Prevention of Delirium (POD) system of care is a theory informed, multicomponent intervention and systematic implementation process which includes a role for hospital volunteers. We report POD implementation and delivery processes in NHS hospital wards, as part of a feasibility study.

METHODS

A comparative case study design and participatory, multi-method evaluation was performed with sequential six month preparatory and six month delivery stages. Six wards in five hospitals in Northern England were recruited. Methods included: facilitated workshops; observation of POD preparatory activities; qualitative interviews with staff; collection of ward organisational and patient profiles; and structured observation of staff workload.

RESULTS

POD implementation and delivery was fully accomplished in four wards. On these wards, implementation strategies informed by Normalization Process Theory operated synergistically and cumulatively. An interactive staff training programme on delirium and practices that might prevent it among those at risk, facilitated purposeful POD engagement. Observation of practice juxtaposed to action on delirium preventive interventions created tension for change, legitimating new ways of organising work around it. Establishing systems, processes and documentation to make POD workable in the ward setting, enhanced staff ownership. 'Negotiated experimentation' to involve staff in creating, appraising and modifying systems and practices, helped integrate the POD care system in ward routines. Activating these change mechanisms required a particular form of leadership: pro-active 'steer', and senior ward 'facilitator' to extend 'reach' to the staff group. Organisational discontinuity (i.e. ward re-location and re-modelling) disrupted and extended POD implementation; staff shortages adversely affected staff capacity to invest in POD. Findings resulted in the development of 'site readiness' criteria without which implementation of this complex intervention was unlikely to occur.

CONCLUSIONS

POD implementation and delivery is feasible in NHS wards, but a necessary context for success is 'site readiness.'

Nursing workload, nurse staffing methodologies and tools: A systematic scoping review and discussion

Background

The importance of nurse staffing levels in acute hospital wards is widely recognised but evidence for tools to determine staffing requirements although extensive, has been reported to be weak. Building on a review of reviews undertaken in 2014, we set out to give an overview of the major approaches to assessing nurse staffing requirements and identify recent evidence in order to address unanswered questions including the accuracy and effectiveness of tools.

Methods

We undertook a systematic scoping review. Searches of Medline, the Cochrane Library and CINAHL were used to identify recent primary research, which was reviewed in the context of conclusions from existing reviews.

Results

The published literature is extensive and describes a variety of uses for tools including establishment setting, daily deployment and retrospective review. There are a variety of approaches including professional judgement, simple volume-based methods (such as patient-to-nurse ratios), patient prototype/classification and timed-task approaches. Tools generally attempt to match staffing to a mean average demand or time requirement despite evidence of skewed demand distributions. The largest group of recent studies reported the evaluation of (mainly new) tools and systems, but provides little evidence of impacts on patient care and none on costs. Benefits of staffing levels set using the tools appear to be linked to increased staffing with no evidence of tools providing a more efficient or effective use of a given staff resource. Although there is evidence that staffing assessments made using tools may correlate with other assessments, different systems lead to dramatically different estimates of staffing requirements. While it is evident that there are many sources of variation in demand, the extent to which systems can deliver staffing levels to meet such demand is unclear. The assumption that staffing to meet average need is the optimal response to varying demand is untested and may be incorrect.

Conclusions

Despite the importance of the question and the large volume of publication evidence about nurse staffing methods remains highly limited. There is no evidence to support the choice of any particular tool. Future research should focus on learning more about the use of existing tools rather than simply developing new ones. Priority research questions include how best to use tools to identify the required staffing level to meet varying patient need and the costs and consequences of using tools.

Tweetable abstract

Decades of research on tools to determine nurse staffing requirements is largely uninformative. Little is known about the costs or consequences of widely used tools.

NHS managers’ use of nursing workforce planning and deployment technologies: a realist synthesis

Background

Policy and reviews of health-care safety and quality emphasise the role of NHS managers in ensuring safe, good-quality patient care through effective staffing. Guidance requires that NHS managers combine professional judgement with evidence-based workforce planning and deployment tools and technologies (WPTs). Evidence has focused on the effectiveness of WPTs, but little is known about supporting their implementation, or the impact of using WPTs across settings.

Objectives

The review answered the following question: ‘NHS managers’ use of workforce planning and deployment technologies and their impacts on nursing staffing and patient care: what works, for whom, how and in what circumstances?’.

Design

A realist synthesis was conducted. A programme theory was formulated and expressed as hypotheses in the form of context, mechanisms and outcomes; this considered how, through using WPTs, particular conditions produced responses to generate outcomes. There were four phases: (1) development of a theoretical territory to understand nurse workforce planning and deployment complexity, resulting in an initial programme theory; (2) retrieval, review and synthesis of evidence, guided by the programme theory; (3) testing and refinement of the programme theory for practical application; and (4) actionable recommendations to support NHS managers in the implementation of WPTs for safe staffing.

Participants

NHS managers, patient and public representatives and policy experts informed the programme theory in phase 1, which was validated in interviews with 10 NHS managers. In phase 3, 11 NHS managers were interviewed to refine the programme theory.

Results

Workforce planning and deployment tools and technologies can be characterised functionally by their ability to summarise and aggregate staffing information, communicate about staffing, allocate staff and facilitate compliance with standards and quality assurance. NHS managers need to combine local knowledge and professional judgement with data from WPTs for effective staffing decisions. WPTs are used in a complex workforce system in which proximal factors (e.g. the workforce satisfaction with staffing) can influence distal factors (e.g. organisational reputation and potential staff recruitment). The system comprises multiple organisational strategies (e.g. professional and financial), which may (or may not) align around effective staffing. The positive impact of WPTs can include ensuring that staff are allocated effectively, promoting the patient safety agenda within an organisation, learning through comparison about ‘what works’ in effective staffing and having greater influence in staffing work. WPTs appear to have a positive impact when they visibly integrate data on needs and resources and when there is technical and leadership support. A collaborative process appears to be best for developing and implementing WPTs, so that they are fit for purpose.

Limitations

The evidence, predominantly from acute care, often lacked detail on how managers applied professional judgement to WPTs for staffing decisions. The evidence lacked specificity about how managers develop skills on communicating staffing decisions to patients and the public.

Conclusions and recommendations

The synthesis produced initial explanations of the use and impact of WPTs for decision-making and what works to support NHS managers to use these effectively. It is suggested that future research should further evaluate the programme theory.

Study registration

This study is registered as PROSPERO CRD42016038132.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The emergency department landscape in The Netherlands: an exploration of characteristics and hypothesized relationships

BACKGROUND

Nationwide optimization of the emergency department (ED) landscape is being discussed in The Netherlands. The emphasis is put mostly on the number of EDs actually present at the time versus a proposed minimum number of EDs needed in the future. The predominant idea in general is that by concentrating emergency care in less EDs costs would be saved and quality of care would increase. However, structural insight into similarities as well as differences of ED characteristics is missing. This knowledge and fact interpretation is needed to provide better steering information which could contribute to strategies aiming to optimize the ED landscape. This study provides an in-depth insight in the ED landscape of The Netherlands by presentation of providing an overview of the variation in ED characteristics and by exploring associations between ED volume characteristics on one side and measures of available ED and hospital resources on the other side. Obtained insight can be a starting point towards a more well-founded future optimization policy.

METHODS

This is a nationwide cross-sectional observational study. All 24/7 operational EDs meeting the IFEM definition in The Netherlands in December 2016 were identified, contacted and surveyed. Requested information was retrieved from local hospital information systems and entered into a database. Till August 1, 2017, data have been collected.

RESULTS

All 87 eligible EDs in The Netherlands participated in this study (100%). All of them were hospital based. These were 8 EDs in universities (9%), 27 EDs in teaching hospitals (31%) and 52 EDs in general hospitals (60%). On average, 22,755 patients were seen per ED (range 6082-53,196). On average, 85% (range 44-99%) was referred versus 15% self-referred (range 1-56%). Further subdivision of the referred patients showed 17% 'emergency call' (range 0.5-30%), 52% by GPC (range 16-77%) and 15% other referral (range 1-52%). On average, 38% of patients per ED (range 13-76%) were hospitalized. ED treatment bays ranged from 4 to 36 and added nationally up to 1401 (mean and median of 16 per ED). The number of hospital beds behind these EDs ranged from 104 to 1339 and added up to 36,630 beds nationally (mean of 421 and median of 375 behind each ED). Information about ED nurse workforce was available for 83 of 87 EDs and ranged from 11 to 65, adding up to 2348 fulltime-equivalent nationally (mean of 28 and median of 27 per ED). We found positive and significant correlations, confirming all formulated hypotheses. The strongest correlation was seen between the number of patients seen in the ED and ED nurse workforce, followed by the number of patients seen in the ED and ED treatment bays. The other hypotheses showed less positive significant correlations.

CONCLUSION

Our study shows that the ED landscape is still pluriform by numbers and specifications of individual ED locations. This study identifies associations between patient and hospitalization volumes on a national level on one side and number of ED treatment bays, ED nurse workforce capacity and available hospital beds on the other side. These findings might be useful as input for the development of an ED resource allocation framework and a more targeted optimization policy in the future.

The Impact of Operating Room Layout on Circulating Nurse’s Work Patterns and Flow Disruptions: A Behavioral Mapping Study

Aim:

To assess how the adjacencies of functionally different areas within operating rooms (ORs) can influence the circulating nurse’s (CN) workflow patterns and disruptions.

Background:

The CN plays a significant role in promoting patient safety during surgical procedures by observing, monitoring, and managing potential threats at and around the surgical field. Their work requires constant movement to different parts of the OR to support team members. The layout of the OR and crowded and cluttered environment might impact the CN’s workflow and cause disruptions during the surgery.

Method:

A convenience sample of 25 surgeries were video recorded and thematically coded for CN’s activities, locations, and flow disruptions. The OR layout was categorized into transitional zones and functional zones (workstations, supply zones, support zones, and sterile areas around the surgical table). CN’s activities were classified into patient-, equipment-, material-, and information-related activities. Flow disruptions included those related to environmental hazards and layout.

Results:

The CN traveled through multiple zones during 91% of the activities. The CN’s workstation acted as a main hub from which the CN made frequent trips to both sides of the surgical table, the foot of the OR table, supply zones, and support zones. Transitional zones accounted for 58.3% of all flow disruption that the CN was involved in whereas 28% occurred in areas surrounding the OR bed.

Conclusion:

The similarity of the movement and flow disruption patterns, despite variations in OR layout, highlighted the adjacencies required between major zones that CNs regularly visit. These optimum adjacencies should be considered while designing ORs such that they are more efficient and safer.

Tecnologia móvel para coleta de dados de pesquisas em saúde

Resumo Objetivo: Descrever o desenvolvimento de aplicativo de tecnologia móvel para coleta de dados em pesquisa de tempo e movimento dos profissionais de saúde do Programa Estratégia de Saúde da Família, na realização das intervenções/atividades de cuidado. Métodos: Pesquisa aplicada de produção tecnológica fundamentada no conceito de prototipagem e nas fases de definição, desenvolvimento e manutenção, para construção e validação de aplicativo do “instrumento de medida de carga de trabalho dos profissionais de saúde na atenção primária”, para dispositivo móvel tablet Motorola® com sistema operacional Android® 3.2, com a finalidade de coletar dados em pesquisa de tempo e movimento, por meio da técnica de amostragem do trabalho e identificar a carga de trabalho de profissionais de saúde, lotados em unidades de saúde da família, localizadas nas cinco regiões geográficas do Brasil, consideradas de ótimo desempenho pelo Programa de Melhoria do Acesso e da Qualidade da Atenção Básica - ciclo 1. Resultados: O aplicativo potencializou a coleta de dados e facilitou as seguintes etapas: registro e armazenamento dos dados; manutenção da integridade da informação; transmissão e armazenamento dos dados; organização e processamento das informações e maior segurança na análise dos resultados. A transmissão e a extração dos dados foram realizadas diariamente, através da sincronização dos arquivos no Dropbox®. O aplicativo eletrônico foi utilizado durante as observações dos 418 profissionais de saúde das 27 unidades de saúde da família, no total foram registrados 85.398 observações de intervenções/atividades. Conclusão: O aplicativo possibilitou uma coleta de dados mais dinâmica; manteve a integridade da informação; auxiliou a transmissão e o armazenamento de dados; facilitou a organização e o processamento das informações e proporcionou maior segurança na análise dos resultados.

Geographical thinking in nursing inquiry, part two: performance, possibility, and non-representational theory

Part one in this two paper series reviewed the nature of geographical thinking in nursing research thus far. The current paper builds on it by looking forwards and providing a particular vision for future research. It argues that it is time to once again look to the parent discipline of human geography for inspiration, specifically to its turn towards non-representational theory, involving an emphasis on life that onflows prior to meaning, significance, and full cognition; on life's 'taking-place'. The paper introduces this way of viewing and animating the world. Some potential connections to nursing research and practice are suggested, as are some specific avenues for future inquiry. Explained is how, through non-representational theory, nursing might be re-imagined as something that reveals space-time.

Re-conceiving building design quality: A review of building users in their social context

Considerable overlap exists between post-occupancy research evaluating building design quality and the concept of 'social value', popularised by its recent application to issues of the public realm. To outline this potential research agenda, the paper reviews design quality research on buildings in relation to users and their social context where the term 'social context' refers to building user group dynamics, a combination of organisational cultures, management strategies, and social norms and practices. The review is conducted across five key building types, namely housing, workplaces, healthcare, education, and the retail/service sector. Research commonalities and gaps are identified in order to build a more comprehensive picture of the design quality literature and its handling of users in their social context. The key findings concerning each building type are presented visually. It is concluded that the design quality field comprises a patchwork of relatively isolated studies of various building types, with significant potential for theoretical and empirical development through interdisciplinary collaboration. Users tend to be conceived as anonymous and autonomous individuals with little analysis of user identity or interaction. Further, the contextual impact of user group dynamics on the relationship between building design and building user is rarely addressed in the literature. Producing a more nuanced understanding of users in situ is proposed as an important area for future design quality research.

One size fits all? Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience, safety and costs

BACKGROUND AND OBJECTIVES

There is little strong evidence relating to the impact of single-room accommodation on healthcare quality and safety. We explore the impact of all single rooms on staff and patient experience; safety outcomes; and costs.

METHODS

Mixed methods pre/post 'move' comparison within four nested case study wards in a single acute hospital with 100% single rooms; quasi-experimental before-and-after study with two control hospitals; analysis of capital and operational costs associated with single rooms.

RESULTS

Two-thirds of patients expressed a preference for single rooms with comfort and control outweighing any disadvantages (sense of isolation) felt by some. Patients appreciated privacy, confidentiality and flexibility for visitors afforded by single rooms. Staff perceived improvements (patient comfort and confidentiality), but single rooms were worse for visibility, surveillance, teamwork, monitoring and keeping patients safe. Staff walking distances increased significantly post move. A temporary increase of falls and medication errors in one ward was likely to be associated with the need to adjust work patterns rather than associated with single rooms per se. We found no evidence that single rooms reduced infection rates. Building an all single-room hospital can cost 5% more with higher housekeeping and cleaning costs but the difference is marginal over time.

CONCLUSIONS

Staff needed to adapt their working practices significantly and felt unprepared for new ways of working with potentially significant implications for the nature of teamwork in the longer term. Staff preference remained for a mix of single rooms and bays. Patients preferred single rooms.

Using workload measurement tools in diverse care contexts: the experience of staff in mental health and learning disability inpatient settings

ACCESSIBLE SUMMARY

What is known on the subject? Difficulties with the recruitment and retention of qualified nursing staff have resulted in nursing shortages worldwide with a consequential impact on the quality of care. It is increasingly recommended that evidence-based staffing levels are central to the development of workforce plans. Due to a paucity of empirical research in mental health and learning disability services the staffing needs and requirements for these settings are undefined and the availability of tools to aid staffing decisions is limited. What this paper adds to existing knowledge? This paper provides a valuable insight into the practical uses of these tools as perceived by staff members with day-to-day experience of the requirements of mental health and learning disability wards. It reveals that while workload measurement tools are considered a valuable aid for the development of workforce plans, they are limited in their ability to capture all aspects of care provision in these settings. It further emphasizes the inapplicability of a one-shoe-fits-all approach for determining nurse staffing levels and the need for individual and customized workforce plans. What are the implications for practice? This study demonstrates that the development of tools for use in mental health and learning disability services is in its infancy, yet no tool that has been validated as such. It highlights the potential for workload measurement tools to aid staffing decisions; however, a more holistic approach that considers additional factors is needed to ensure robust workforce planning models are developed for these services.

INTRODUCTION

The critical challenge of determining the correct level and skill mix of nursing staff required to deliver safe and effective health care has become an international concern. It is recommended that evidence-based staffing decisions are central to the development of future workforce plans. Workforce planning in mental health and learning disability nursing is largely under-researched with few tools available to aid the development of evidence-based staffing levels in these environments.

AIM

It was the aim of this study to explore the experience of staff using the Safer Nursing Care Tool and the Mental Health and Learning Disability Workload Tool in mental health and learning disability environments.

METHOD

Following a 4-week trial period of both tools, a survey was distributed via Qualtrics online survey software to staff members who used the tools during this time.

RESULTS

The results of the survey revealed that the tools were considered a useful resource to aid staffing decisions; however, specific criticisms were highlighted regarding their suitability to psychiatric intensive care units and learning disability wards.

DISCUSSION

This study highlights that further development of workload measurement tools is required to support the implementation of effective workforce planning strategies within mental health and learning disability services.

IMPLICATIONS FOR PRACTICE

With increasing fiscal pressures, the need to provide cost-effective care is paramount within the services of the National Health Service. Evidence-based workforce planning is therefore necessary to ensure that appropriate levels of staff are determined. This is of particular importance within mental health and learning disability services due to the reduction in the number of available beds and an increasing focus on purposeful admission and discharge.

Research on nursing unit layouts: an integrative review

Purpose

– This paper aims to present an integrative review of the research studies on nursing unit layouts.

Design/methodology/approach

– Studies selected for review were published between 1956 and 2014. For the purpose of this review, a framework for integrative review was developed using research orientations. The three primary dimensions – technical, psychological and social – of the designed environment and various combinations of these dimensions were used to define the research orientations of these studies.

Findings

– Of all the publications reviewed for the paper, 21 presented technical orientations, 16 psychological orientations, 3 social orientations, 20 psychotechnical orientations, 10 sociotechnical orientations, 2 psychosocial orientations and 13 presented psychosociotechnical orientations. With only a few exceptions, several issues related to nursing unit layouts were investigated no more than one time in any one category of research orientations. Several other seemingly important issues including patient and family behavior and perception, health outcomes and social and psychosocial factors in relation to unit layouts have not been studied adequately.

Research limitations/implications

– Future studies on nursing unit layouts will need to focus on patient and family behavior and perception, health outcomes and social and psychosocial factors in different units. They will also need to focus on developing theories concerning the effects of layouts on the technical, psychological and social dimensions of nursing units.

Originality/value

– Despite a long history of research on nursing unit layouts, an integrative review of these studies is still missing in the literature. This review fills in the gap using a novel framework for integrative review developed based on research orientations.

Evaluating a major innovation in hospital design: workforce implications and impact on patient and staff experiences of all single room hospital accommodation

Background

New hospital design includes more single room accommodation but there is scant and ambiguous evidence relating to the impact on patient safety and staff and patient experiences.

Objectives

To explore the impact of the move to a newly built acute hospital with all single rooms on care delivery, working practices, staff and patient experience, safety outcomes and costs.

Design

(1) Mixed-methods study to inform a pre-/post-‘move’ comparison within a single hospital, (2) quasi-experimental study in two control hospitals and (3) analysis of capital and operational costs associated with single rooms.

Setting

Four nested case study wards [postnatal, acute admissions unit (AAU), general surgery and older people’s] within a new hospital with all single rooms. Matched wards in two control hospitals formed the comparator group.

Data sources

Twenty-one stakeholder interviews; 250 hours of observation, 24 staff interviews, 32 patient interviews, staff survey (n = 55) and staff pedometer data (n = 56) in the four case study wards; routinely collected data at ward level in the control hospitals (e.g. infection rates) and costs associated with hospital design (e.g. cleaning and staffing) in the new hospital.

Results

(1) There was no significant change to the proportion of time spent by nursing staff on different activities. Staff perceived improvements (patient comfort and confidentiality), but thought the new accommodation worse for visibility and surveillance, teamwork, monitoring, safeguarding and remaining close to patients. Giving sufficient time and attention to each patient, locating other staff and discussing care with colleagues proved difficult. Two-thirds of patients expressed a clear preference for single rooms, with the benefits of comfort and control outweighing any disadvantages. Some patients experienced care as task-driven and functional, and interaction with other patients was absent, leading to a sense of isolation. Staff walking distances increased significantly after the move. (2) A temporary increase in falls and medication errors within the AAU was likely to be associated with the need to adjust work patterns rather than associated with single rooms, although staff perceived the loss of panoptic surveillance as the key to increases in falls. Because of the fall in infection rates nationally and the low incidence at our study site and comparator hospitals, it is difficult to conclude from our data that it is the ‘single room’ factor that prevents infection. (3) Building an all single room hospital can cost 5% more but the difference is marginal over time. Housekeeping and cleaning costs are higher.

Conclusions

The nature of tasks undertaken by nurses did not change, but staff needed to adapt their working practices significantly and felt ill prepared for the new ways of working, with potentially significant implications for the nature of teamwork in the longer term. Staff preference remained for a mix of single rooms and bays. Patients preferred single rooms. There was no strong evidence that single rooms had any impact on patient safety but housekeeping and cleaning costs are higher. In terms of future work, patient experience and preferences in hospitals with different proportions of single rooms/designs need to be explored with a larger patient sample. The long-term impact of single room working on the nature of teamwork and informal learning and on clinical/care outcomes should also be explored.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Comparing the monitoring of patients transferred from a critical care unit to hospital wards at after-hours with day transfers: an exploratory, prospective cohort study

AIMS

To investigate possible factors related to patient monitoring to explain the higher mortality rates associated with after-hours transfers compared with daytime transfers from critical care units to the wards.

BACKGROUND

International research suggests that patients transferred from critical care units after-hours have a higher mortality rate than transfers during daytime, although the reasons remain unknown.

DESIGN

A prospective exploratory study.

METHODS

Twenty-nine patients transferred from a UK critical care unit to a ward within the same hospital after-hours for 10 weeks beginning April 2009 were compared with 29 transfers during daytime hours matched on potentially confounding characteristics. UK Critical Care Unit transfer guidelines have remained unchanged since data collection. Outcomes were as follows: (i) frequency of nursing observations; (ii) time periods from transfer to first medical review; (iii) time period from transfer to first clinical observations; (iv) frequency of transfer to an inappropriate ward; (v) delayed transfers from Critical Care Unit to ward.

RESULTS

Using Wilcoxon's Rank test (two tail) to compare paired data from the matched groups, observations were recorded significantly less frequently within the first 12 hours for after-hours transfers. Time from transfer to first clinical observations was significantly longer for after-hour transfer patients. The delay from when the patient was ready for ward care and actual transfer was also longer for the after-hours transfer group.

CONCLUSIONS

Surveillance differences, including time to the first set of observations and frequency of observations in the first 12 hours, are potential factors that may explain the differential mortality associated with after-hours transfers.

Factors influencing patients' dignity: A qualitative study

Dignity represents the essence of nursing care; hence, nurses are professionally responsible for promoting understanding about the promotion, provision, and preservation of every patient's dignity, while considering contextual differences. The aim of this study was to explore the factors that influence, promote, or compromise patient dignity. A purposeful sample of 14 participants with hospitalization experience was chosen, and individual in-depth semi-structured interviews were conducted for data collection. Using inductive content analysis, the themes and subthemes related to factors influencing patients' dignity were explored: "persona" ("personal beliefs" and "personal characteristics"), "communication behaviors" ("verbal interaction," "body language," "compassionate behavior," and "devoting enough time"), and "staff conduct" ("professional commitment," "adequate human resources," and "staff's proficiency and competency"). The findings revealed that it is essential to expand nurses' insights and knowledge about preserving patients' dignity and the factors that influence these. Recognizing and focusing on these factors will help nurses to establish practical measures for preserving and promoting patients' dignity and providing more dignified care at the bedside.

Evaluating palliative care ward staffing using bed occupancy, patient dependency, staff activity, service quality and cost data

BACKGROUND

Palliative care staffing has remained unchallenged for decades while service provision has changed markedly, bringing new workforce demands. There is little evidence to inform hospice workforce structures, which strive to deliver the highest-quality holistic care.

AIM

The study had three main aims, to: (i) adapt the acuity-quality workforce planning method used extensively in the UK National Health Service (NHS) for use in hospices; (ii) compare hospice and NHS palliative care staffing establishments and their implications; and (iii) create ward staffing benchmarks and formulae for hospice managers.

DESIGN

A method adapted from a widely used nursing workforce planning and development (WP&D) study was used to collect data in hospice and palliative care wards.

SETTING

Twenty-three palliative care and hospice wards, geographically representing England, were studied.

RESULTS

A dataset, which profiles and benchmarks hospice and NHS palliative care ward occupancy, patient dependency, staff activity, ward establishments, quality and costs in 23 palliative care and hospice wards has been created. The database reveals large differences between hospice and palliative care wards. For example, hospice wards are better staffed and more expensive to run but staff deliver higher-quality care (measured using an established service quality audit) despite facing heavier workloads. Consequently, staffing multipliers are created to help managers estimate workload-based ward staffing.

CONCLUSIONS

This dataset provides evidence-based recommendations to inform palliative care nursing workforce modelling, including deciding future nursing workforce size and mix based on rising workloads. The new dataset is suitable for use in UK hospice wards and may be appropriate for future international use.

The ventilation of multiple-bed hospital wards in the tropics: A review

Hospital and healthcare facilities have diverse indoor environment due to the different comfort and health needs of its occupants. Currently, most ventilation studies revolve around specialised areas such as operating rooms and isolation rooms. This paper focuses on the ventilation of multiple-bed hospital wards in the tropical climate, taking into account the design, indoor conditions and engineering controls. General ward layouts are described briefly. The required indoor conditions such as temperature, humidity, air movements and indoor air quality in the ward spaces are summarized based on the current guidelines and practices. Also, recent studies and engineering practices in the hospital indoor environment are elaborated. Usage of computational fluid dynamics tools for the ventilation studies is discussed as well. As identified during the review, there is an apparent knowledge gap for ventilation studies in the tropics compared with temperate climates, as fact studies have only been published for hospital wards in countries with a temperate climate. Therefore, it is highlighted that specific tropical studies along with novel engineering controls are required in addressing the ventilation requirements for the tropics.

Nurse staffing levels revisited: a consideration of key issues in nurse staffing levels and skill mix research

AIM

This paper revisits the published evidence relating to how nurse staffing levels impact on patient, nurse and service outcomes and considers the implications of this body of research for nurse managers in their quest to determine optimum nursing numbers.

BACKGROUND

Within the context of the recognized global nursing shortage and particular local pressures within international health services, questions of appropriate nurse staffing levels and skill mix are once again becoming increasingly important. It would seem that the determination of optimum nurse staffing levels and skill mix is a central issue in relation to health service governance, service user involvement, as well as in the recruitment, retention and well-being of nursing staff across the service sectors.

METHODS

A review of published evidence was carried out, applying key principles of the systematic method, in order to facilitate the identification of current factors and issues in nurse staffing levels research. The review did not seek to address a specific research question. The search covered 10 years from 1998 to 2008 and identified more than 500 relevant papers, giving a wide international perspective.

KEY ISSUES

The majority of research in the field relates to the acute service sector and there are considerable similarities in issues that transcend international boundaries. Much of the research focuses on the impact on patients and nurses of 'poor' nurse staffing levels. More recent studies have explored the impact of nurse staffing levels on the service organization itself. However, while there may be an association between models of nurse staffing and outcomes, there is insufficient evidence to establish a causal relationship between these factors. In this context it is perhaps time to reconsider how nursing outcomes are defined and measured. IMPLICATIONS FOR NURSING MANAGEMENT AND CONCLUSION: Nurse managers, commissioners of services and workforce planners need to be cognisant of key issues and analyses in the consideration of nurse staffing levels. Not least of these is the need for a healthy degree of caution regarding the supposed objectivity, scientific basis, or evidence base, for rational calculation of optimum nurse staffing levels.

Identifying thresholds for relationships between impacts of rationing of nursing care and nurse- and patient-reported outcomes in Swiss hospitals: a correlational study

BACKGROUND

In the Rationing of Nursing Care in Switzerland Study, implicit rationing of care was the only factor consistently significantly associated with all six studied patient outcomes. These results highlight the importance of rationing as a new system factor regarding patient safety and quality of care. Since at least some rationing of care appears inevitable, it is important to identify the thresholds of its influences in order to minimize its negative effects on patient outcomes.

OBJECTIVES

To describe the levels of implicit rationing of nursing care in a sample of Swiss acute care hospitals and to identify clinically meaningful thresholds of rationing.

DESIGN

Descriptive cross-sectional multi-center study.

SETTINGS

Five Swiss-German and three Swiss-French acute care hospitals.

PARTICIPANTS

1338 nurses and 779 patients.

METHODS

Implicit rationing of nursing care was measured using the newly developed Basel Extent of Rationing of Nursing Care (BERNCA) instrument. Other variables were measured using survey items from the International Hospital Outcomes Study battery. Data were summarized using appropriate descriptive measures, and logistic regression models were used to define a clinically meaningful rationing threshold level.

RESULTS

For the studied patient outcomes, identified rationing threshold levels varied from 0.5 (i.e., between 0 ('never') and 1 ('rarely') to 2 ('sometimes')). Three of the identified patient outcomes (nosocomial infections, pressure ulcers, and patient satisfaction) were particularly sensitive to rationing, showing negative consequences anywhere it was consistently reported (i.e., average BERNCA scores of 0.5 or above). In other cases, increases in negative outcomes were first observed from the level of 1 (average ratings of rarely).

CONCLUSIONS

Rationing scores generated using the BERNCA instrument provide a clinically meaningful method for tracking the correlates of low resources or difficulties in resource allocation on patient outcomes. Thresholds identified here provide parameters for administrators to respond to whenever rationing reports exceed the determined level of '0.5' or '1'. Since even very low levels of rationing had negative consequences on three of the six studied outcomes, it is advisable to treat consistent evidence of any rationing as a significant threat to patient safety and quality of care.