The role of theory in improving patient safety and quality health care

Nonlinear Analysis to Detect if Excellent Nursing Work Environments Have Highest Well-Being

PURPOSE

To detect potentially nonlinear associations between nurses' work environment and nurse staffing on the one hand and nurse burnout on the other hand.

DESIGN

A cross-sectional multicountry study for which data collection using a survey of 33,731 registered nurses in 12 European countries took place during 2009 to 2010.

METHODS

A semiparametric latent variable model that describes both linear and potentially nonlinear associations between burnout (Maslach Burnout Inventory: emotional exhaustion, depersonalization, personal accomplishment) and work environment (Practice Environment Scale of the Nursing Work Index: managerial support for nursing, doctor-nurse collegial relations, promotion of care quality) and staffing (patient-to-nurse ratio).

FINDINGS

Similar conclusions are reached from linear and nonlinear models estimating the association between work environment and burnout. For staffing, an increase in the patient-to-nurse ratio is associated with an increase in emotional exhaustion. At about 15 patients per nurse, no further increase in emotional exhaustion is seen.

CONCLUSIONS

Absence of evidence for diminishing returns of improving work environments suggests that continuous improvement and achieving excellence in nurse work environments pays off strongly in terms of lower nurse-reported burnout rates. Nurse staffing policy would benefit from a larger number of studies that identify specific minimum as well as maximum thresholds at which inputs affect nurse and patient outcomes.

CLINICAL RELEVANCE

Nurse burnout is omnipresent and has previously been shown to be related to worse patient outcomes. Additional increments in characteristics of excellent work environments, up to the highest possible standard, correspond to lower nurse burnout.

Are Patient Falls and Pressure Ulcers Sensitive to Nurse Staffing?

Research has demonstrated an association between more nurses and more qualified nursing staff in hospitals and better patient outcomes. Patient falls and pressure ulcers have been advanced as nursing-sensitive outcomes. This article evaluates the state of the science linking nurse staffing to falls and pressure ulcers. Studies that employed multivariate analysis to discern the effect of nurse staffing on patient falls and pressure ulcers in hospitals were evaluated. Eleven studies that met inclusion criteria were contrasted on their data sources and measures, data analysis, risk adjustment, and results. The evidence of an effect of nursing hours or skill mix on patient falls and pressure ulcers is equivocal. Substantial differences in research methods across studies may account for the mixed findings. Two study types were identified based on the level at which nurse staffing was measured, hospital or nursing unit, which exhibited systematic differences in measures and methods. Improvements in measurement and methods are suggested.

Organization of Hospital Nursing, Provision of Nursing Care, and Patient Experiences With Care in Europe

This study integrates previously isolated findings of nursing outcomes research into an explanatory framework in which care left undone and nurse education levels are of key importance. A moderated mediation analysis of survey data from 11,549 patients and 10,733 nurses in 217 hospitals in eight European countries shows that patient care experience is better in hospitals with better nurse staffing and a more favorable work environment in which less clinical care is left undone. Clinical care left undone is a mediator in this relationship. Clinical care is left undone less frequently in hospitals with better nurse staffing and more favorable nurse work environments, and in which nurses work less overtime and are more experienced. Higher proportions of nurses with a bachelor's degree reduce the effect of worse nurse staffing on more clinical care left undone.

The relationship between nurse staffing and inpatient complications

AIM

To compare characteristics of hospitalizations with and without complications and examine the impact of nurse staffing on inpatient complications across different unit types.

BACKGROUND

Studies investigating the relationship between nurse staffing and inpatient complications have not shown consistent results. Methodological limitations have been cited as the basis for this lack of uniformity. Our study was designed to address some of these limitations.

DESIGN

Retrospective longitudinal hospitalization-level study.

METHOD

Adult hospitalizations to high intensity, general medical and general surgical units at three metropolitan tertiary hospitals were included. Data were sourced from Western Australian Department of Health administrative data collections from 2004-2008. We estimated the impact of nurse staffing on inpatient complications adjusted for patient and hospital characteristics and accounted for patients with multiple hospitalizations.

RESULTS

The study included 256,984 hospitalizations across 58 inpatient units. Hospitalizations with complications had significantly different demographic characteristics compared with those without. The direction of the association between nurse staffing and inpatient complications was not consistent for different inpatient complications, nurse skill mix groups or for hospitalizations with different unit movement patterns.

CONCLUSION

Our study design addressed limitations noted in the field, but our results did not support the widely held assumption that improved nurse staffing levels are associated with decreased patient complication rates. Despite a strong international focus on improving nurse staffing to reduce inpatient complications, our results suggest that adding more nurses is not a panacea for reducing inpatient complications to zero.

A realist logic model of the links between nurse staffing and the outcomes of nursing

Background:

There has been a long-standing debate over the definition and nature of the quality of healthcare and factors that influence and enhance quality. Within nursing, the challenge is to identify the outcomes that are measurable and amenable to change as a result of nursing care. Arising originally from concerns over potential nurse staffing shortages and nurse retention within the United States, an extensive literature has developed in the acute sector, exploring nurse staffing and its consequences. All of these studies raise the generic question of what potential causal mechanisms might link nurse staffing levels and skill mix to issues of patient safety and outcome.

Objectives:

To generate a tentative logic model to understand existing findings and to elucidate possible ways in which nurse staffing and skill mix may affect patient and nurse outcomes.

Methods:

This study was grounded within the principles of realist evaluation, realist review and logic modelling. The existing literature was reviewed to bring to light the underlying rationale suggested by the authors of this study on how nursing care might affect patient outcomes. A step-by-step process was followed to demonstrate the generation of a tentative logic model of how nurse staffing might influence patient, and nursing, outcomes.

Results:

The final logic model depicts staffing adequacy as having a complex link with patient outcomes. This is mediated at a general level through factors in the process of care (for example, nurse surveillance, clinical judgement, level of education, level of nurse training and length of nursing experience) and tasks left undone. These operate in conjunction with working with other nurses who are clinically competent, having good nurse–physician relationships and communication, supportive nurse manager/supervisor and good teamwork.

Conclusions:

This study extends the understanding of the mechanisms through which nurse staffing levels may result in adverse patient outcomes in the acute sector. Key intervening variables are the application of nurse intuition, operation of clinical judgement and missed nursing care/tasks left undone. The tentative logic model can be used to draw up areas and hypotheses to guide the direction of future research and to aid interpretation of existing research.

Nursing intellectual capital theory: testing selected propositions

AIMS

To test the selected propositions of the middle-range theory of nursing intellectual capital.

BACKGROUND

The nursing intellectual capital theory conceptualizes nursing knowledge's influence on patient and organizational outcomes. The theory proposes nursing human capital, nurses' knowledge, skills and experience, is related to the quality of patient care and nurse recruitment and retention of an inpatient care unit. Two factors in the work environment, nurse staffing and employer support for nurse continuing professional development, are proposed to influence nursing human capital's association with patient and organizational outcomes.

DESIGN

A cross-sectional survey design.

METHODS

The study took place in 2008 in six Canadian acute care hospitals. Financial, human resource and risk data were collected from hospital departments and unit managers. Clearly specified empirical indicators quantified the study variables. The propositions of the theory were tested with data from 91 inpatient care units using structural equation modelling.

RESULTS

The propositions associated with the nursing human capital concept were supported. The propositions associated with the employer support for nurse continuing professional development concept were not. The proposition that nurse staffing's influences on patient outcomes was mediated by the nursing human capital of an inpatient unit, was partially supported.

CONCLUSION

Some of the theory's propositions were empirically validated. Additional theoretical work is needed to refine the operationalization and measurement of some of the theory's concepts. Further research with larger samples of data from different geographical settings and types of hospitals is required to determine if the theory can withstand empirical scrutiny.

Economic theory and nursing administration research--is this a good combination?

TOPIC

Economic theory is used to describe and explain decision making in the context of scarce resources.

PURPOSE

This paper presents two applications of economic theory to the delivery of nursing services in acute care hospitals and evaluates its usefulness in guiding nursing administration research.

SOURCES OF INFORMATION

The description of economic theory and the proposed applications for nursing are based on current nursing, healthcare, and economic literature. Evaluation of the potential usefulness of economic theory in guiding nursing administration research is based on the criteria of significance and testability as described by Fawcett and Downs.

CONCLUSIONS

While economic theory can be very useful in explaining how decisions about nursing time allocation and nursing care production are made, it will not address the issue of how they should be made. Normative theories and ethical frameworks also must be incorporated in the decision-making process around these issues. Economic theory and nursing administration are a good fit when balanced with the values and goals of nursing.

The relationship between nursing leadership and patient outcomes: a systematic review

AIM

The purpose of this review was to describe findings of a systematic review of studies that examine the relationship between nursing leadership and patient outcomes.

BACKGROUND

With recent attention directed to the creation of safer practice environments for patients, nursing leadership is called on to advance this agenda within organizations. However, surprisingly little is known about the actual association between nursing leadership and patient outcomes.

METHODS

Published English-only research articles that examined formal nursing leadership and patient outcomes were selected from computerized databases and manual searches. Data extraction and methodological quality assessment were completed for the final seven quantitative research articles.

RESULTS

Evidence of significant associations between positive leadership behaviours, styles or practices and increased patient satisfaction and reduced adverse events were found. Findings relating leadership to patient mortality rates were inconclusive.

CONCLUSION

The findings of this review suggest that an emphasis on developing transformational nursing leadership is an important organizational strategy to improve patient outcomes.

Methodological issues in nurse staffing research

The purpose of this article is to identify and describe four issues in nurse staffing research that must be addressed before the evidence base for the relationship between nurse staffing and quality of care can be said to be theoretically and empirically sufficient. The issues are the need to build well-developed theory, use valid and reliable databases, appropriate risk-adjustment systems, and address issues of causal inference in nonexperimental research.