Beyond ratios - flexible and resilient nurse staffing options to deliver cost-effective hospital care and address staff shortages: A simulation and economic modelling study

Call to Action: Quality and Simulation Professionals Should Collaborate

SUMMARY STATEMENT

Simulation is underutilized as a tool to improve healthcare quality and safety despite many examples of its effectiveness to identify and remedy quality and safety problems, improve teamwork, and improve various measures of quality and safety that are important to healthcare organizations, eg, patient safety indicators. We urge quality and safety and simulation professionals to collaborate with their counterparts in their organizations to employ simulation in ways that improve the quality and safety of care of their patients. These collaborations could begin through initiating conversations among the quality and safety and simulation professionals, perhaps using this article as a prompt for discussion, identifying one area in need of quality and safety improvement for which simulation can be helpful, and beginning that work.

Bottleneck factors impacting nurses' workflow and the opportunity to prioritize improvement efforts: factor analysis

PURPOSE

Minimizing delays in delivering nursing care is paramount for enhancing the overall quality of care. Certain bottleneck variables restrict the workflow of nurses, resulting in extended shift times. This study is designed to pinpoint and analyze the principal factors contributing to bottleneck issues in nursing workflow, to direct improvement endeavors. This study seeks to provide insights into the key variables contributing to nurses' extended shift times, with the ultimate goal of prioritizing efforts for improvement.

METHODS

A descriptive multicenter cross-sectional study was conducted. A scale was developed for this study by the authors after conducting a literature review, subsequently validated, and its reliability was assessed.

RESULTS

Among the 31 bottleneck variables, 29 were retained under three persistent bottleneck factors: (1) Nurse staffing- This pertains to the availability of sufficient nursing staff at all times across the continuum of care; (2) Working environment and quality of care-This refers to the availability of necessary skills and resources for nurses to perform their duties effectively and; (3) Medical devices- This factor concerns the availability of fully functional medical devices required for providing care.

CONCLUSION

Efforts aimed at enhancing the overall healthcare system should concentrate on addressing persistent bottleneck factors. This may involve the implementation of a healthcare workforce management system, the establishment of standards for a conducive and supportive working environment, and the utilization of a standardized system for the management of medical equipment. The outcomes of this study can be utilized by nurses and policymakers to devise comprehensive strategies for improvement.

American Psychiatric Nurses Association Position: Staffing Inpatient Psychiatric Units

OBJECTIVE

An American Psychiatric Nurses Association (APNA) task force reviewed current staffing research to revise and update the 2011 APNA "Staffing inpatient psychiatric units" position paper and provide recommendations to the APNA Board of Directors on how psychiatric mental health (PMH) nurses might champion the staffing needs of inpatient psychiatric units.

METHODS

Current research on staffing and nursing practice in inpatient psychiatric units was reviewed as well as variables believed to influence staffing and nursing practice, such as consumer needs and workplace culture. Since current nurse staffing principles emphasize nursing value and how that value is connected to outcomes, the literature search included a focus on staffing and related patient outcomes.

RESULTS

PMH nurses are critical to the safety and quality of care in inpatient psychiatric units. However, there are little existing data on the relationship between staffing levels and even common adverse events such as staff injury and restraint of patients. Furthermore, there is scant research conducted on inpatient psychiatric units that informs optimal staffing models or establishes links between staffing and patient outcomes.

CONCLUSIONS

Consistent with current evidence, the universal use of a single method or model of determining staffing needs (e.g., nursing hours per, case mix index, or mandatory ratios) is not recommended. PMH nurses should champion systematic evaluation of staffing on their inpatient units against select patient, nurse, and system outcomes. A data repository of PMH nurse-sensitive outcomes is necessary to benchmark unit performance and staffing.

Relevant factors affecting nurse staffing: a qualitative study from the perspective of nursing managers

Objective

To understand the current situation of nursing manpower allocation, explore the factors affecting nurse staffing, improve nurse staffing level, and provide reference for better formulation of nursing human resources staffing standards.

Methods

A descriptive research method was used to conduct semi-structured interviews with 14 nursing managers. The data were analyzed and refined by content analysis. The sample size was subject to content saturation.

Results

Nine themes and twenty sub-themes of influencing factors for nursing staffing were identified across four levels: hospital level, department level, patient level, and nurse level.

Conclusion

Hospital and department managers need to comprehensively consider the factors of affecting nurse staffing. Adopting multidimensional optimization measures, improving relevant systems, optimizing nurse structure, and establishing flexible and mobile nurse database to cope with public emergencies, so as to effectively improve nurse staffing and nursing service quality.

Hospital Nurse Staffing Legislation: Mixed Approaches In Some States, While Others Have No Requirements

Legislative agendas aimed at regulating nurse staffing in US hospitals have intensified after acute workforce disruptions triggered by COVID-19. Emerging evidence consistently demonstrates the benefits of higher nurse staffing levels, although uncertainty remains regarding whether and which legislative approaches can achieve this outcome. The purpose of this study was to provide a comprehensive updated review of hospital nurse staffing requirements across all fifty states. As of January 2024, seven states had laws pertaining to staffing ratios for at least one hospital unit, including California and Oregon, which had ratios pertaining to multiple units. Eight states required nurse staffing committees, of which six specified a percentage of committee members who must be registered nurses. Eleven states required nurse staffing plans. Five states had pending legislation, and one state, Idaho, had passed legislation banning minimum nurse staffing requirements. The variety of state regulations provides an opportunity for comparative evaluations of efficacy and feasibility to inform new legislation on the horizon.

Nursing Team Composition and Mortality Following Acute Hospital Admission

Importance

Many studies show the adverse consequences of insufficient nurse staffing in hospitals, but safe and effective staffing is unlikely to be just about staff numbers. There are considerable areas of uncertainty, including whether temporary staff can safely make up shortfalls in permanent staff and whether using experienced staff can mitigate the effect of staff shortages.

Objective

To explore the association of the composition of the nursing team with the risk of patient deaths.

Design, Setting, and Participants

This patient-level longitudinal observational study was conducted in 185 wards in 4 acute hospital trusts in England between April 2015 and March 2020. Eligible participants were patients with an overnight stay and nursing staff on adult inpatient wards. Data analysis was conducted from month April 2022 to June 2023.

Exposure

Naturally occurring variation during the first 5 days of hospital admission in exposure to days of low staffing from registered nurses (RNs) and nursing support (NS) staff, the proportion of RNs, proportion of senior staff, and proportion of hospital-employed (bank) and agency temporary staff.

Main Outcomes and Measures

The primary outcome was death within 30 days of admission. Mixed-effect Cox proportional hazards survival models were used.

Results

Data from 626 313 admissions (319 518 aged ≥65 years [51.0%]; 348 464 female [55.6%]) were included. Risk of death was increased when patients were exposed to low staffing from RNs (adjusted hazard ratio [aHR], 1.08; 95% CI 1.07-1.09) and NS staff (aHR, 1.07; 95% CI, 1.06-1.08). A 10% increase in the proportion of temporary RNs was associated with a 2.3% increase in the risk of death, with no difference between agency (aHR, 1.023; 95% CI, 1.01-1.04) and bank staff (aHR, 1.02; 95% CI, 1.01-1.04). A 10% increase in the proportion of agency NS was associated with a 4% increase in risk of death (aHR, 1.04; 95% CI, 1.02-1.06). Evidence on the seniority of staff was mixed. Model coefficients were used to estimate the association of using temporary staff to avoid low staffing and found that risk was reduced but remained elevated compared with baseline.

Conclusions and Relevance

This cohort study found that having senior nurses in the nursing team did not mitigate the adverse outcomes associated with low nurse staffing. These findings indicate that while the benefits of avoiding low staffing may be greater than the harms associated with using temporary staff, particularly for RNs, risk remains elevated if temporary staff are used to fill staffing shortages, which challenges the assumption that temporary staff are a cost-effective long-term solution to maintaining patient safety.

Alternative Models of Nurse Staffing May Be Dangerous in High-Stakes Hospital Care

BACKGROUND

Hospitals are resurrecting the outdated "team nursing" model of staffing that substitutes lower-wage staff for registered nurses (RNs).

OBJECTIVES

To evaluate whether reducing the proportion of RNs to total nursing staff in hospitals is in the best interest of patients, hospitals, and payers.

RESEARCH DESIGN

Cross-sectional, retrospective.

SUBJECTS

In all, 6,559,704 Medicare patients in 2676 general acute-care US hospitals in 2019.

MEASURES

Patient outcomes: in-hospital and 30-day mortality, 30-day readmission, length of stay, and patient satisfaction. Avoidable Medicare costs associated with readmissions and cost savings to hospitals associated with shorter stays are projected.

RESULTS

A 10 percentage-point reduction in RNs was associated with 7% higher odds of in-hospital death, 1% higher odds of readmission, 2% increase in expected days, and lower patient satisfaction. We estimate a 10 percentage-point reduction in RNs would result in 10,947 avoidable deaths annually and 5207 avoidable readmissions, which translates into roughly $68.5 million in additional Medicare costs. Hospitals would forgo nearly $3 billion in cost savings annually because of patients requiring longer stays.

CONCLUSIONS

Reducing the proportion of RNs in hospitals, even when total nursing personnel hours are kept the same, is likely to result in significant avoidable patient deaths, readmissions, longer lengths of stay, and decreased patient satisfaction, in addition to excess Medicare costs and forgone cost savings to hospitals. Estimates represent only a 10 percentage-point dilution in skill mix; however, the team nursing model includes much larger reductions of 40-50 percentage-points-the human and economic consequences of which could be substantial.

How much do we know about nursing care delivery models in a hospital setting? A mapping review

To deal with the upcoming challenges and complexity of the nursing profession, it is deemed important to reflect on our current organization of care. However, before starting to rethink the organization of nursing care, an overview of important elements concerning nursing care organization, more specifically nursing models, is necessary. The aim of this study was to conduct a mapping review, accompanied by an evidence map to map the existing literature, to map the field of knowledge on a meta-level and to identify current research gaps concerning nursing models in a hospital setting. Next to nursing models, two other organizational correlates seem to be of importance when looking at the organization of nursing care: nurse staffing and skill mix. Although it seems that in recent research, the theoretical focus on the organization of nursing care has been left behind, the increasingly complex healthcare environment might gain from the use of nursing theory, or in this case, care delivery models. As almost no fundamental studies have been done toward the combination of care delivery models, nurse staffing, and skill mix, those elements should be taken into account to fully capture the organization of nursing care in future research.

A Qualitative Study of Systems-Level Factors That Affect Rural Obstetric Nurses' Work During Clinical Emergencies

BACKGROUND

Maternal morbidity and mortality is rising in the United States. Previous studies focus on patient attributes, and most of the national data are based on research performed at urban tertiary care centers. Although it is well understood that nurses affect patient outcomes, there is scant evidence to understand the nurse work system, and no studies have specifically studied rural nurses. The authors sought to understand the systems-level factors affecting rural obstetric nurses when their patients experience clinical deterioration.

METHODS

The research team used a qualitative descriptive approach, including a modified critical incident technique, in interviews with bedside nurses (n = 7) and physicians (n = 4) to understand what happens when patients experience clinical deterioration. Physicians were included to better understand the systems in which nurses work. Clinicians were interviewed at three rural hospitals in New England, with a mean births per year of 190.

FINDINGS

Six systems-level factors/themes were identified: (1) shortages of resources; (2) need for teamwork; (3) physicians' multiple conflicting and simultaneous responsibilities, such as seeing patients in the office while women labor on the hospital floor; (4) need for all team members to be at the top of their game; (5) process issues during high-acuity patient transfer, including difficulty finding available beds at tertiary care centers; and (6) insufficient policies that take low-resource contexts into account, such as requiring two registered nurses to remove emergency medications from the medication cabinet.

CONCLUSION

Rural nurses need policies and protocols that are written with their hospital context in mind. Hospitals may need outside support for content expertise, but policies should be co-created with clinicians with rural practice experience.

Diverse perspectives on unit-level nurse staffing ratios in medical-surgical units: A Delphi policy analysis

BACKGROUND

Appropriate staffing is essential to acute care delivery. Staffing ratio policy generates controversy.

PURPOSE

This study examines perspectives on unit-level nurse-to-patient ratio policy in adult medical-surgical units.

METHOD

Delphi methodology uses an invited diverse panel to analyze a policy's effects. Panelists completed iterative surveys about the impact they expect from unit-level ratio policy.

FINDINGS

Panelists demonstrated moderate agreement that the proposed policy could increase staffing levels, decrease patient length of stay, and reduce nurse attrition. Other potential outcomes included reducing staffing in units above the minimum and increasing short-term costs. Panelists agreed that the policy could increase patient safety and nurse satisfaction and did not agree about the effect on long-term cost and innovation. Panelists also anticipated a mostly positive effect on patients and nurses.

DISCUSSION

Policies that set unit-level nurse-to-patient ratios offer a potential strategy to improve medical-surgical staffing. Policy design should consider the range of expected outcomes.

Relationship Between Unit Characteristics and Fall Incidence: A Cross-Sectional Survey Using Administrative Data in Japan

BACKGROUND

Falls are the most frequent accident experienced by inpatients in hospitals. As falls affect patient outcomes, high fall risk factors should be studied to prevent falls and improve patient safety. However, the relationship between hospital unit characteristics and fall risk has never been assessed.

PURPOSE

This study was designed to identify the unit characteristics significantly related to fall risk.

METHODS

A cross-sectional study was conducted on the medical records of patients hospitalized in a Japanese academic hospital between 2018 and 2019. This study quantified unit activities and utilized Diagnosis Procedure Combination data to examine unit characteristics related to falls based on unit day.

RESULTS

Data on 16,307 patients were included in the analysis, and 355 unit days were certified as fall events. Based on patient condition and medical treatment, the results identified antineoplastic injections, radiation therapy, aseptic treatment room, and functional status of partly assisted transfers, meals, and oral care as unit characteristics associated with increased fall events. Decreased nursing time per patient at night (odds ratio [OR] = 0.75, p = .04) and higher numbers of partially assisted transfer patients were also identified as unit characteristics associated with higher fall incidence rates (OR = 5.56, p = .01).

CONCLUSIONS

The results of this study are expected to assist nurses to predict falls based on unit characteristics; reducing nursing time in the units was found to be a factor associated with higher fall risk. Nurse managers must understand the unit-related fall risk factors, appropriately assign nurse staffing numbers, and demonstrate nursing leadership to prevent falls in their units.

An examination of the usefulness of a quantitative appraisal method in nursing human resource management in primary hospital operating rooms: An example of integrated collaborative scheduling

In recent years, China medical and health services have made great development. However, the management of nursing human resources in operating room of primary hospitals still faces a series of challenges. In the nursing work of operating room, high-quality nursing human resource management is important for improving the efficiency of operating room and ensuring the safety of patients. From January 2022 to December 2022, comprehensive collaborative scheduling and quantitative scoring evaluation methods were carried out in our hospital, and relevant data were collected. The flexible scheduling combined quantitative scoring performance appraisal system and the traditional scheduling plus average distribution performance appraisal system were statistically analyzed and compared in terms of annual surgical cases, annual overtime hours, annual back work hours, annual compensatory rest hours, and average daily working hours. This study was based on 30 medical staff (27 females and 3 males) in the operating room of a primary hospital. The annual operation volume increased by 387 cases compared with before, and the attitudes of patients to the service attitude and preoperative waiting time were significantly improved, reaching more than 95%. In addition, in the survey of surgeons, it was found that their satisfaction with preoperative preparation and operation time was significantly higher than that of the traditional scheduling method, and reached more than 95%. In the survey of nursing staff, it was found that the satisfaction with the traditional scheduling method was about 80%, and the satisfaction directly reached 100% after the comprehensive collaborative scheduling system. Based on the above survey, the satisfaction of nurses, doctors and patients with the new comprehensive collaborative scheduling system has improved compared with before. After the implementation of the comprehensive collaborative scheduling system, the annual surgical volume has increased significantly, and the average daily working hours of nursing staff have decreased. Comprehensive collaborative scheduling is an effective method of nursing human resource management in operating room, which can effectively improve the work efficiency of nurses and the satisfaction of patients, doctors and nurses. In practice, this method needs to be continuously explored and refined to adapt to different application scenarios and requirements.

Consistently Exploring Nurse Staffing and Neurocritical Care Unit Turnover

ABSTRACT

BACKGROUND: Staffing models within nursing units have long been a hot topic of discussion. The COVID-19 pandemic exacerbated this discussion by straining the national nursing environment and workforce. Before the pandemic, the neuroscience intensive care unit (NSICU) primarily used an acuity-adjusted staffing model and aimed for a nurse-to-patient ratio of 1:1.5. During and after the pandemic, the NSICU was forced to primarily use a centralized staffing model because of the increased turnover in the hospital at large and a rise in patient census. METHODS : Unit census data in an NSICU were tracked before, during, and after the pandemic alongside utilization of a centralized staffing model in the hospital at large. RESULTS : During this time, the NSICU saw a statistically significant increase in average nurse-to-patient ratio and incidences of both floating and tripled assignments. The NSICU simultaneously saw a 180% increase in nursing turnover. CONCLUSION : Although we cannot prove that a centralized staffing model is directly responsible for higher nursing turnover, its utilization led to greater incidence of poor staffing-reflected in deviation from the nurse-to-patient ratio goal of the unit. Nurse staffing concerns play a large role in nurse satisfaction in the workforce: staffing shortages have been described both as a precursor to and as a consequence of increased nursing turnover.

The association between midwifery staffing and reported harmful incidents: a cross-sectional analysis of routinely collected data

BACKGROUND

Independent inquiries have identified that appropriate staffing in maternity units is key to enabling quality care and minimising harm, but optimal staffing levels can be difficult to achieve when there is a shortage of midwives. The services provided and how they are staffed (total staffing, skill-mix and deployment) have been changing, and the effects of workforce changes on care quality and outcomes have not been assessed. This study aims to explore the association between daily midwifery staffing levels and the rate of reported harmful incidents affecting mothers and babies.

METHODS

We conducted a cross-sectional analysis of daily reports of clinical incidents in maternity inpatient areas matched with inpatient staffing levels for three maternity services in England, using data from April 2015 to February 2020. Incidents resulting in harm to mothers or babies was the primary outcome measure. Staffing levels were calculated from daily staffing rosters, quantified in Hours Per Patient Day (HPPD) for midwives and maternity assistants. Understaffing was defined as staffing below the mean for the service. A negative binomial hierarchical model was used to assess the relationship between exposure to low staffing and reported incidents involving harm.

RESULTS

The sample covered 106,904 maternal admissions over 46 months. The rate of harmful incidents in each of the three services ranged from 2.1 to 3.0 per 100 admissions across the study period. Understaffing by registered midwives was associated with an 11% increase in harmful incidents (adjusted IRR 1.110, 95% CI 1.002,1.229). Understaffing by maternity assistants was not associated with an increase in harmful incidents (adjusted IRR 0.919, 95% 0.813,1.039). Analysis of specific types of incidents showed no statistically significant associations, but most of the point estimates were in the direction of increased incidents when services were understaffed.

CONCLUSION

When there is understaffing by registered midwives, more harmful incidents are reported but understaffing by maternity assistants is not associated with higher risk of harms. Adequate registered midwife staffing levels are crucial for maintaining safety. Changes in the profile of maternity service workforces need to be carefully scrutinised to prevent mothers and babies being put at risk of avoidable harm.

Transforming health care systems towards high-performance organizations: qualitative study based on learning from COVID-19 pandemic in the Basque Country (Spain)

BACKGROUND

The COVID-19 pandemic is one of the worst health catastrophes of the last century, which caused severe economic, political, and social consequences worldwide. Despite these devastating consequences, lessons learned provide a great opportunity that can drive the reform of health systems to become high-performing, effective, equitable, accessible, and sustainable organisations. This work identifies areas in which changes must be encouraged that will enable health systems to deal effectively with current and future challenges, beyond COVID-19.

METHODS

A realist design was chosen, based on qualitative data collection techniques, content analysis and triangulation to identify key domains of organizational interventions behind the changes implemented to react to the COVID-19 pandemic in the Basque Country. Twenty key informants were used as an expert source of information. Thematic analysis was done using the Framework Method.

RESULTS

The analysis of the interviews resulted in the identification of 116 codes, which were reviewed and agreed upon by the researchers. Following the process of methodological analysis, these codes were grouped into domains: seven themes and 23 sub-themes. Specifically, the themes are: responsiveness, telehealth, integration, knowledge management, professional roles, digitisation, and organisational communication. The detailed description of each theme and subtheme is presented.

CONCLUSIONS

The findings of this work pretend to guide the transformation of health systems into organisations that can improve the health of their populations and provide high quality care. Such a multidimensional and comprehensive reform encompasses both strategic and operational actions in diverse areas and requires a broad and sustained political, technical, and financial commitment.

Exploring factors that affect nurse staffing: a descriptive qualitative study from nurse managers' perspective

BACKGROUND

The appropriate nurse staffing reflects the situation of nursing management of human resources. Nurse managers have a pivotal role in determining a competent and sufficient number of nurses. It is important to understand the factors influencing nurse staffing to promote appropriate staffing levels. The study aimed to explore the factors affecting nurse staffing from the perspective of nursing managers.

METHODS

Purposive sampling was adopted to recruit 14 nurse managers from secondary and tertiary hospitals located in the central region of China, and semi-structured interviews via telephone were conducted from April to May 2022. Interview transcripts were analyzed and collated using thematic analysis.

RESULTS

This research identified four themes and ten subthemes influencing nurse staffing. Extracted themes include: government level (inadequacy of mandatory policies, budgetary constraints), hospital level (hospital characteristics, the control of nurse labor costs, inadequate support on nursing), patient level (patient characteristics, increasing care needs), and nurse level (nurse shortage, skill-mix, individual high-level needs).

CONCLUSION

The findings indicate that it is crucial for decision-makers or policymakers to legislate for safe nurse staffing and establish effective supervision and funding incentives. Tailored interventions are also needed to improve the organizational context, address the nurse workforce and balance the structure of nurse staff.

Floating to intensive care units: Nurses' messages for instant action to promote patient safety

BACKGROUND

The overwhelming number of patients admitted to intensive care units (ICUs) combined with a nursing staff deficit sometimes requires the redeployment of nurses from other areas, meaning non-critical care nurses are asked to assist in treating critically ill patients. This may affect patient safety, especially in poorly resourced ICUs with financial constraints, such as in some developing countries. Nurses and nurse managers need specific strategies to address this issue and ensure patient safety.

AIM

To explore ICU and floating nurses' perspectives of the floating experience and describe how the use of floating nurses could threaten the safety of patients in Egyptian ICUs.

STUDY DESIGN

This was a qualitative descriptive study. Data were collected in in-depth interviews and analysed using Colaizzi's method of analysis. Forty-seven interviews were conducted, 22 with ICU nurses/managers and 25 with floating nurses.

RESULTS

Two main themes were extracted: (1) Lived work experience of floating and ICU nurses during the floating period which included three subthemes: Being a floating nurse: living a double experience of a professional role, Being an ICU nurse: feeling overloaded, and small failures leading to bigger, more serious issuses; and (2) Messages for patient safety from floating and ICU nurses' perspectives which also comprised three subthemes: education and training, putting the patient in the safety zone, and poilcy reform.

CONCLUSIONS

Promising strategies for ICUs to ensure patient safety when transferring nurses from other units include providing ongoing education and appropriate training for floating nurses to put patients in the safety zone.

RELEVANCE TO CLINICAL PRACTICE

Our findings provide a foundation for nursing practitioners, managers, and policymakers to prevent medical errors and optimize nursing workforce allocation. Nursing managers should consider floating nurses' competence levels when assigning ICU patients. Moreover, teamwork and communication between ICU nurses/managers and floating nurses should be strengthened. Close supervision and use of technology to minimize medical errors are potential strategies to ensure patient safety when using floating nurses.

Costs and cost-effectiveness of improved nurse staffing levels and skill mix in acute hospitals: A systematic review

BACKGROUND

Extensive research shows associations between increased nurse staffing levels, skill mix and patient outcomes. However, showing that improved staffing levels are linked to improved outcomes is not sufficient to provide a case for increasing them. This review of economic studies in acute hospitals aims to identify costs and consequences associated with different nurse staffing configurations in hospitals.

METHODS

We included economic studies exploring the effect of variation in nurse staffing. We searched PubMed, CINAHL, Embase Econlit, Cochrane library, DARE, NHS EED and the INAHTA website. Risk of bias was assessed using a framework based on the NICE guidance for public health reviews and Henrikson's framework for economic evaluations. Inclusion, data extraction and critical appraisal were undertaken by pairs of reviewers with disagreements resolved by the entire review team. Results were synthesised using a hierarchical matrix to summarise findings of economic evaluations.

RESULTS

We found 23 observational studies conducted in the United States of America (16), Australia, Belgium, China, South Korea, and the United Kingdom (3). Fourteen had high risk of bias and nine moderate. Most studies addressed levels of staffing by RNs and/or licensed practical nurses. Six studies found that increased nurse staffing levels were associated with improved outcomes and reduced or unchanged net costs, but most showed increased costs and outcomes. Studies undertaken outside the USA showed that increased nurse staffing was likely to be cost-effective at a per capita gross domestic product (GDP) threshold or lower. Four studies found that increased skill mix was associated with improved outcomes but increased staff costs. Three studies considering net costs found increased registered nurse skill mix associated with net savings and similar or improved outcomes.

CONCLUSION

Although more evidence on cost-effectiveness is still needed, increases in absolute or relative numbers of registered nurses in general medical and surgical wards have the potential to be highly cost-effective. The preponderance of the evidence suggests that increasing the proportion of registered nurses is associated with improved outcomes and, potentially, reduced net cost. Conversely, policies that lead to a reduction in the proportion of registered nurses in nursing teams could give worse outcomes at increased costs and there is no evidence that such approaches are cost-effective. In an era of registered nurse scarcity, these results favour investment in registered nurse supply as opposed to using lesser qualified staff as substitutes, especially where baseline nurse staffing and skill mix are low.

REGISTRATION

PROSPERO (CRD42021281202).

TWEETABLE ABSTRACT

Increasing registered nurse staffing and skill mix can be a net cost-saving solution to nurse shortages. Contrary to the strong policy push towards a dilution of nursing skill mix, investment in supply of RNs should become the priority.

Understanding the workflow of nurses in acute and subacute medical wards: A time and motion study

AIMS AND OBJECTIVES

The aim of this study was to determine how much time nurses spend on direct and indirect patient care in acute and subacute hospital settings.

BACKGROUND

Quantifying direct and indirect nursing care provided during inpatient stay is vital to optimise the quality of care and manage resources.

DESIGN

Time and motion cross-sectional observational study and reported the study according to the STROBE guideline.

METHODS

Nurses working in an acute or subacute medical wards of a single health service participated. Nurses were observed twice for 2 h on the same day with an observer break in between sessions. Real-time task-related data were digitally recorded using the Work Observation Method By Activity Timing (WOMBAT) tool by a single research assistant. Frequency and time spent on pre-determined tasks were recorded and included direct care, indirect care, documentation, medication-related tasks, communication (professional) and other tasks. Task interruptions and multitasking were also recorded.

RESULTS

Twenty-one nurses (acute n = 12, subacute n = 9) were observed during shifts between 7 AM and 9 PM in May-July 2021. A total of 7240 tasks were recorded. Nurses spent a third of their time on direct patient care (27% direct care and 3% medication administration). A total of 556 task interruptions occurred, mostly during documentation, and medication-related tasks. A further 1385 tasks were performed in parallel with other tasks, that is multitasking.

CONCLUSIONS

Time spent on tasks was similar regardless of the setting and was consistent with previous research. We found differences in the distribution of tasks throughout the day between settings, which could have implications for workforce planning and needs to be investigated further. Interruptions occurred during documentation, direct care and medication-related tasks. Local-level strategies should be in place and regularly revised to reduce interruptions and prevent errors. Relevance to clinical practice The association between interruption and increased risk of error is well-established and should be an ongoing area of attention including observations and education provided in local settings.

Wake-up Call: Night Shifts Adversely Affect Nurse Health and Retention, Patient and Public Safety, and Costs

The purpose of this mini review is to (1) summarize the findings on the impact of night shift on nurses' health and wellness, patient and public safety, and implications on organizational costs and (2) provide strategies to promote night shift nurses' health and improve organizational costs. The night shift, compared with day shift, results in poorer physical and mental health through its adverse effects on sleep, circadian rhythms, and dietary and beverage consumption, along with impaired cognitive function that increases nurse errors. Nurse administrators and health care organizations have opportunities to improve nurse and patient safety on night shifts. Low-, moderate-, and higher-cost measures that promote night nurses' health and well-being can help mitigate these negative outcomes. The provided individual and organizational recommendations and innovations support night shift nurses' health, patient and public safety, and organizational success.

Patient Outcomes and Hospital Nurses’ Workload: A Cross-Sectional Observational Study in Slovenian Hospitals Using the RN4CAST Survey

Introduction

Higher nursing workload increases the odds of patient deaths, as the work environment has a significant effect on patient outcomes. The aim of the study was to explore the relation between patient outcomes and nurses’ working conditions in hospitals.

Methods

Administrative data on discharges of surgical patients for the year 2019 in eight general hospitals and two university medical centres in Slovenia were collected to determine in-hospital mortality within 30 days of admission. The RN4CAST survey questionnaire was used to gather data from nurses in these hospitals, with 1,010 nurses participating. Data was collected at the beginning of 2020. The number of nurses per shift and the nurse-to-patient ratio per shift were calculated. Univariate, bivariate and multivariate statistical methods were used to analyse the data.

Results

The 30-day in-hospital mortality for surgical patients was 1.00% in the hospitals sampled and ranged from 0.27% to 1.62%. The odds ratio for staffing suggests that each increase of one patient per RN is associated with a 6% increase in the likelihood of a patient dying within 30 days of admission. The mean patient-to-RN ratio was 15.56 (SD=2.50) and varied from 10.29 to 19.39. Four of the 13 tasks checked were not performed on patients during the last shift.

Conclusion

The results are not encouraging, with an extremely critical shortage of RNs and thus a high RN workload. The number of patients per RN is the highest in Europe and also higher than in some non-European countries, and represents an extreme risk to the quality of nursing and healthcare as a whole. The recommendation for acute non-emergency internal medicine and surgery departments is four patients per RN per shift.

Improving hospital nurse staffing during the pandemic: Implementation of the 2019 Fund for Health Care Staff in Belgium

Chronic hospital nurse understaffing is a pre-existing condition of the COVID-19 pandemic. With nurses on the frontline against the pandemic, safe nurse staffing in hospitals is high on the political agenda of the responsible ministers of Health. This paper presents a recent Belgian policy reform to improve nurse staffing levels. Although the reform was initiated before the pandemic, its roll-out took place from 2020 onwards. Through a substantial increase of the hospital budget, policy makers envisaged to improve patient-to-nurse ratios. Yet, this ambition was considerably toned down during the implementation. Due to a shortage of nurses in the labour market, hospital associations successfully lobbied to allocate part of the budget to hire non-nursing staff. Moreover, other healthcare settings claimed their share of the pie. Elements of international best-practice examples such as ward managers supernumerary to the team and increasing the transparency on staffing decisions were adopted. Other measures, such as mandated patient-to-nurse ratios, nurse staffing committees, or the monitoring or public reporting of ratios, were not retained. Additional measures were taken to safeguard that bedside staffing levels would improve, such as the requirement to demonstrate a net increase in staff to obtain additional budget, staffing plan's approval by local work councils and recommendation to base staff allocation on patient acuity measures. This policy process makes clear that the engagement of budgets is only a first step towards safe staffing levels, which needs to be embedded in a comprehensive policy plan. Future evaluation of bedside nurse staffing levels and nurse wellbeing is needed to conclude about the effectiveness of these measures and the intended and unintended effects they provoked.

Integrating Fuzzy Multiobjective Programming and System Dynamics to Develop an Approach for Talent Retention Policy Selection: Case on Health-Care Industry

The demand for medical services has been increasing yearly in aging countries. Medical institutions must hire a large number of staff members to provide efficient and effective health-care services. Because of high workload and pressure, high turnover rates exist among health-care staff members, especially those in nonurban areas, which are characterized by limited resources and a predominance of elderly people. Turnover in health-care institutions is influenced by complex factors, and high turnover rates result in considerable direct and indirect costs for such institutions (Lo and Tseng 2019). Therefore, health-care institutions must adopt appropriate strategies for talent retention. Because institutions cannot determine the most effective talent retention strategy, many of them simply passively adopt a single human resource (HR) policy and make minor adjustments to the selected policy. In the present study, system dynamics modeling was combined with fuzzy multiobjective programming to develop a method for simulating HR planning systems and evaluating the suitability of different HR policies in an institution. We also considered the external insurance policy to be the parameter for the developed multiobjective decision-making model. The simulation results indicated that reducing the turnover rate of new employees in their trial period is the most effective policy for talent retention. The developed procedure is more efficient, effective, and cheaper than the traditional trial-and-error approaches for HR policy selection.

Adaptation and validation of an adult patient classification instrument with emphasis on the family dimension

Objectives:

to adapt and validate an instrument for classifying adult patients that emphasizes the family support network in the demand for nursing care.

Methods:

methodological study, carried out in three phases: adaptation of an instrument considering the reality of adult patients; content validation with seven experts and assessment of measurement properties (construct validity and internal consistency) with 781 hospitalized patients.

Results:

in content validation, the indicators reached the values established for the Content Validity Index (0.85-1.00). In the confirmatory factor analysis, the 11 indicators were distributed in three domains and presented average variance extracted and factor loading greater than 0.5. Composite reliability was greater than 0.7.

Conclusions:

the present study adapted and made available, with evidence of validity and reliability, an instrument for classifying adult patients that considers the family support network in the demand for nursing care.

Adaptação e validação de instrumento de classificação de paciente adulto com ênfase na dimensão familiar

RESUMO Objetivos: adaptar e validar um instrumento para classificação de pacientes adultos que enfatiza a rede de suporte familiar na demanda de cuidados de enfermagem. Métodos: estudo metodológico, realizado em três fases: adaptação de um instrumento considerando a realidade de pacientes adultos; validação de conteúdo com sete especialistas e avaliação das propriedades de medida (validade de construto e consistência interna) com 781 pacientes internados. Resultados: na validação de conteúdo, os indicadores alcançaram os valores estabelecidos para o Índice de Validade de Conteúdo (0,85-1,00). Na análise fatorial confirmatória, os 11 indicadores foram distribuídos em três domínios e apresentaram variância média extraída e carga fatorial superiores a 0,5. A confiabilidade composta foi superior a 0,7. Conclusões: o presente estudo adaptou e disponibilizou, com evidências de validade e confiabilidade, um instrumento para classificação de pacientes adultos que considera a rede de suporte familiar na demanda de cuidados de enfermagem.

International recruitment of mental health nurses to the national health service: a challenge for the UK

The UK's National Health Service (NHS) has been dealing with a shortage in the nursing workforce for the past few decades. With the ongoing COVID-19 pandemic and post-Brexit effects, it is important now more than ever to concentrate on recruiting new staff and retaining current staff in the National Health Service. The increasing demand for mental health services stresses the importance of prioritising recruitment of mental health nurses. One of the main strategies being implemented to combat this shortage is the recruitment of internationally trained mental health nurses. Whilst this is a favourable solution, the multiple challenges this proposal brings makes it hard for the National Health Service to practically implement this to increase staff numbers. In this discursive position paper, we consider the difficulties the National Health Service is currently facing in terms of recruiting mental health nurses and then discuss the importance of and need for international recruitment including the strategies that are currently being implemented. The challenges and obstacles associated with this proposed resolution will also be addressed.

Beyond patient classification: the "hidden" face of nursing workload

This is a theoretical-reflective essay, which aimed to reflect on the centralization of Patient Classification Systems in workload and hospital nursing staff sizing. The reflexive interpretations were guided by two axes: Patient Classification Systems : constitution and utilities; and "Hidden" nursing activities in workload measurement. The first evidences the importance and the role of these instruments in workload identification and in hospital nursing staff sizing, exemplifying several possibilities to be used by nurses. On the other hand, with the second axis, it is clear that there are many nursing activities that are not sensitive to the application (even if systematic) of these means of patient assessment. Therefore, nursing workload measurement may be underestimated. It was inferred that the complexity of practice environments requires a macro and micro institutional look at the nursing workload measurement, especially when considered for workforce planning/sizing purposes.

Cost-Effectiveness Analysis of Improving Nurses' Education Level in the Context of In-Hospital Mortality

(1) Background: an assessment of the cost-effectiveness of employing an increased number of nurses with higher education from the perspective of the service provider. (2) Methods: Based on a year-long study results and data collected from a large hospital, we conducted of the costs of preventing one death. The study involved intervention by 10% increase in the percentage of nursing care hours provided by nurses with higher education. The measure of health effects was the cost of avoiding one death (CER). The cost-effectiveness analysis (CEA) was used as the evaluation method. (3) Results: The cost of employing a larger percentage of nurses with higher education amounts to a total of amounts to a USD 11,730.62 an increase of 3.02% as compared to the base costs. The estimated number of deaths that could be prevented was 44 deaths. Mortality per 1000 patient days was 9.42, mortality after intervention was 8.41. The cost of preventing one death by the 10% increase in BSN/MSN NCH percentage in non-surgical wards USD 263.92. (4) Conclusions: increasing the percentage of care hours provided by nurses with tertiary education is a cost-effective method of reducing in-hospital mortality.

Além da classificação do paciente: a face “oculta” da carga de trabalho da enfermagem

RESUMO Ensaio teórico-reflexivo, que objetivou refletir acerca da centralização dos Sistemas de Classificação de Pacientes na aferição da carga de trabalho e dimensionamento de pessoal de enfermagem hospitalar. As interpretações reflexivas foram norteadas por dois eixos: Sistemas de Classificação de Pacientes: constituição e utilidades; e Atividades de enfermagem “ocultas” na aferição da carga de trabalho. O primeiro evidencia a importância e o protagonismo desses instrumentos na identificação da carga de trabalho e no dimensionamento de pessoal de enfermagem hospitalar, exemplificando-se diversas possibilidades a serem utilizadas pelos enfermeiros. Em contrapartida, com o segundo eixo, percebe-se que existem muitas atividades de enfermagem que não são sensíveis à aplicação (mesmo que sistemática) destes meios de avaliação do paciente. Logo, a mensuração da carga de trabalho da enfermagem pode ser subestimada. Inferiu-se que a complexidade dos ambientes de prática requer um olhar macro e micro institucional à aferição da carga de trabalho da enfermagem, especialmente quando considerada para fins de planejamento/dimensionamento da força de trabalho.

An Innovative Nurse Staffing Model: Nurses Are Happy2Help and Strike the Right Balance

OBJECTIVE

The aim of this study was to develop a flexible nurse reallocation solution.

BACKGROUND

Successful nurse reallocation supports appropriate staffing and may enhance workforce flexibility.

METHODS

An innovative program incentivizing regular nursing staff to volunteer for extra shifts systemwide was implemented at a large healthcare organization.

RESULTS

Nurses' perceptions of appropriate staffing improved, and nursing care quality was not compromised. The program primed the organization to respond to the pandemic.

CONCLUSIONS

The staffing model has been sustained for 3+ years.

The effect of data aggregation on estimations of nurse staffing and patient outcomes

OBJECTIVE

To examine how estimates of the association between nurse staffing and patient length of stay (LOS) change with data aggregation over varying time periods and settings, and statistical controls for unobserved heterogeneity.

DATA SOURCES/STUDY SETTING

Longitudinal secondary data from October 2002 to September 2006 for 215 intensive care units and 438 general acute care units at 143 facilities in the Veterans Affairs (VA) health care system.

RESEARCH DESIGN

This retrospective observational study used unit-level panel data to analyze the association between nurse staffing and LOS. This association was measured over both a month-long and a year-long period, with and without fixed effects.

DATA COLLECTION

We used VA administrative data to obtain patient data on the severity of illness and LOS, as well as labor hours and wages for each unit by month.

PRINCIPAL FINDINGS

Overall, shorter LOS was associated with higher nurse staffing hours and lower proportions of hours provided by licensed professional nurses (LPNs), unlicensed personnel, and contract staff. Estimates of the association between nurse staffing and LOS changed in magnitude when aggregating data over years instead of months, in different settings, and when controlling for unobserved heterogeneity.

CONCLUSIONS

Estimating the association between nurse staffing and LOS is contingent on the time period of analysis and specific methodology. In future studies, researchers should be aware of these differences when exploring nurse staffing and patient outcomes.

Nursing staff ratio and skill mix in Swedish emergency departments: A national cross-sectional benchmark study

AIM

The aim of this study is to describe ratio and skill mix for nursing staff in Swedish emergency departments over a specific 24-h period.

BACKGROUND

The link between number of patients per nursing staff and missed nursing care is well described within the in-hospital setting, showing association with negative outcomes such as increased mortality. Potential association within the emergency department setting is still unexplored.

METHOD

This is a national descriptive cross-sectional benchmark study.

RESULTS

The majority (n = 54; 89%) of Swedish emergency departments participated. The patients-per-registered nurse ratio varied between the shifts, from 0.3 patients to 8.8 patients (mean 3.2). The variation of patients per licenced practical nurse varied, from 1.5 to 23.5 patients (mean 5.0). The average skill mix was constant at around 60% registered nurses and 40% licenced practical nurses.

CONCLUSION

The varying ratios for patient per registered nurse and licenced practical nurse in Swedish emergency departments are noteworthy. Furthermore, the patient flow and nursing staff numbers did not match one another, resulting in higher nursing staff ratios during the evening shift.

IMPLICATIONS FOR NURSING MANAGEMENT

Findings can be used to improve rosters in relation to crowding, to manage the challenging recruitment and retention situation for nursing staff and to improve patient safety.