Nurse staffing and patient falls on acute care hospital units

Economic evaluation of the prevention of falls resulting from missed care in polish hospitals

Objectives

Falls are associated with increased morbidity, mortality, prolonged hospitalization and an increase in the cost of treatment in hospitals. They contribute to the deterioration of fitness and quality of life, especially among older patients, thus posing a serious social and economic problem. They increase the risk of premature death. Falls are adverse, costly, and potentially preventable. The aim of the study was to analyze the cost-effectiveness of avoiding one fall by nurse care provided by the nurses with higher education, from the perspective of the health service provider.

Methods

The economic analysis included and compared only the cost of nurse intervention measured by the hours of care provided with higher education in non-surgical departments (40.5%) with higher time spend by nurses with higher education level an increase in the number of hours by 10% (50.5%) to avoid one fall. The time horizon for the study is 1 year (2021). Cost-effectiveness and Cost-benefit analysis were performed. All registered falls of all hospitalized patients were included in the study.

Results

In the analyzed was based on the case control study where, 7,305 patients were hospitalized, which amounted to 41,762 patient care days. Care was provided by 100 nurses, including 40 nurses with bachelor's degrees and nurses with Master of Science in Nursing. Increasing the hours number of high-educated nurses care by 10% in non-surgical departments decreased the chance for falls by 9%; however, this dependence was statistically insignificant (OR = 1.09; 95% CI: 0.72-1.65; p = 0.65). After the intervention (a 10% increase in Bachelor's Degrees/Master of Science in Nursing hours), the number of additional Bachelor's Degrees/Master of Science hours was 6100.5, and the cost was USD 7630.4. The intervention eliminated four falls. The cost of preventing one fall is CER = USD 1697.1.

Conclusion

The results of these studies broaden the understanding of the relationship among nursing education, falls, and the economic outcomes of hospital care. According to the authors, the proposed intervention has an economic justification.

Travel nurses and patient outcomes: A systematic review

BACKGROUND

The unprecedented use of travel and temporary nurses in recent years requires further investigation of the impact on patient care.

PURPOSE

We conducted a systematic review of empirical research investigating the relationship between travel nurses and patient care to identify if consistent significant associations exist and how structural and process variables may influence such associations.

METHODS

A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses of six databases resulted in the identification of 21 relevant articles.

RESULTS

The existing research of travel nurse use differs widely in terms of the definition of travel nurse, study design, and included controls. The literature has failed to establish a consistent relationship between travel nurses and patient outcomes. Adverse associations between travel nursing and patient care may reflect staffing levels or work environments rather than the specific care by the travel nurses themselves.

PRACTICE IMPLICATIONS

Underlying structural and process variables, such as staffing levels and the practice work environment, may be confounding associations between travel nurse usage and quality patient care. Administrators and managers are urged to assess staffing and the work environment when employing travel nurses.

Nurse's experience working 12-hour shift in a tertiary level hospital in Qatar: a mixed method study

BACKGROUND

The use of 12-h shifts for nursing staff has become common in many healthcare settings, including tertiary hospitals, due to its potential benefits such as reduced handover time and increased continuity of care. However, there is limited research on the experiences of nurses working 12-h shifts, particularly in the context of Qatar, where the healthcare system and nursing workforce may have unique characteristics and challenges. This study aimed to explore the experiences of nurses working 12-h shifts in a tertiary hospital in Qatar, including their perceptions of physical health, fatigue, stress, job satisfaction, service quality, and patient safety.

METHODS

A mixed method study design was applied consisting of a survey and semi-structured interviews. Data was collected from 350 nurses through an online survey and from 11 nurses through semi-structured interviews. Data was analyzed using Shapiro-Wilk test and the difference between demographic variables and scores were examined using Whitney U test and Kruskal- Wallis test. Thematic analysis was used for qualitative interviews.

RESULTS

The results from quantitative study revealed nurses perception in working 12-h shift has negative impact in their wellbeing, satisfaction as well as patient care outcomes. Thematic analysis revealed real stress and burnout and experienced an enormous amount of pressure going for work.

CONCLUSIONS

Our study provides an understanding of the nurse's experience working 12-h shift in a tertiary level hospital in Qatar. A mixed method approach informed us that, nurses are not satisfied with the 12-h shift and interviews revealed high level of stress and burnout among nurses resulting in job dissatisfaction and negative health concerns. Nurses also reported that it is challenging to stay productive and focused throughout their new shift pattern.

High-Dimensional Fixed Effects Profiling Models and Applications in End-Stage Kidney Disease Patients: Current State and Future Directions

Profiling analysis aims to evaluate health care providers, including hospitals, nursing homes, or dialysis facilities among others with respect to a patient outcome, such as 30-day unplanned hospital readmission or mortality. Fixed effects (FE) profiling models have been developed over the last decade, motivated by the overall need to (a) improve accurate identification or "flagging" of under-performing providers, (b) relax assumptions inherent in random effects (RE) profiling models, and (c) take into consideration the unique disease characteristics and care/treatment processes of end-stage kidney disease (ESKD) patients on dialysis. In this paper, we review the current state of FE methodologies and their rationale in the ESKD population and illustrate applications in four key areas: profiling dialysis facilities for (1) patient hospitalizations over time (longitudinally) using standardized dynamic readmission ratio (SDRR), (2) identification of dialysis facility characteristics (e.g., staffing level) that contribute to hospital readmission, and (3) adverse recurrent events using standardized event ratio (SER). Also, we examine the operating characteristics with a focus on FE profiling models. Throughout these areas of applications to the ESKD population, we identify challenges for future research in both methodology and clinical studies.

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.

Quality and Safety in Health Care, Part LXXX: The National Database for Nursing Quality Indicators and the Practice Environment Scale of the Nursing Work Index

ABSTRACT

The National Database for Nursing Quality Indicators is an important source of information used to benchmark nursing by unit category in multiple areas related to not only structure and process but also outcome. It also provides some information regarding best practices and the cost to achieve certain results. The Practice Environment Scale of the Nursing Work Index is a frequently used way to measure the professional practice environment of nurses and the relationship of the latter to quality, safety, and other outcomes.

An app for predicting nurse intention to quit the job using artificial neural networks (ANNs) in Microsoft Excel

Background:

Numerous studies have identified factors related to nurses’ intention to leave. However, none has successfully predicted the nurse’s intention to quit the job. Whether the intention to quit the job can be predicted is an interesting topic in healthcare settings. A model to predict the nurse’s intention to quit the job for novice nurses should be investigated. The aim of this study is to build a model to develop an app for the automatic prediction and classification of nurses’ intention to quit their jobs.

Methods:

We recruited 1104 novice nurses working in 6 medical centers in Taiwan to complete 100-item questionnaires related to the nurse’s intention to quit the job in October 2018. The k-mean was used to divide nurses into 2 classes based on 5 items regarding leave intention. Feature variables were selected from the 100-item survey. Two models, including an artificial neural network (ANN) and a convolutional neural network, were compared across 4 scenarios made up of 2 training sets (n = 1104 and n = 804 ≅ 70%) and their corresponding testing (n = 300 ≅ 30%) sets to verify the model accuracy. An app for predicting the nurse’s intention to quit the job was then developed as a website assessment.

Results:

We observed that 24 feature variables extracted from this study in the ANN model yielded a higher area under the ROC curve of 0.82 (95% CI 0.80-0.84) based on the 1104 cases, the ANN performed better than the convolutional neural network on the accuracy, and a ready and available app for predicting the nurse’s intention to quit the job was successfully developed in this study.

Conclusions:

A 24-item ANN model with 53 parameters estimated by the ANN was developed to improve the accuracy of nurses’ intention to quit their jobs. The app would help team leaders take care of nurses who intend to quit the job before their actions are taken.

Key Points

Hospital-Acquired Conditions Reduction Program, Patient Safety, and Magnet Designation in the United States

OBJECTIVE

The aim of the study was to investigate the association between hospitals' nursing excellence accreditation and patient safety performance-measured by the Hospital-Acquired Conditions Reduction Program (HACRP).

METHODS

We linked data from the American Nursing Credentialing Center Magnet Recognition Program, Centers for Medicare and Medicaid Services HACRP, and the American Hospital Association annual survey from 2014 to 2016. We constrained the analysis to hospitals participating in Centers for Medicare and Medicaid Services' HACRP and deployed propensity score matching models to calculate the coefficients for our HACRP patient safety measures. These measures consisted of (a) patient safety indicator 90, (b) hospital-associated infection measures, and (c) total HAC scores. In addition, we used propensity score matching to assess HACRP scores between hospitals achieving Magnet recognition in the past 2 versus longer and within the past 5 years versus longer.

RESULTS

Our primary findings indicate that Magnet hospitals have an increased likelihood of experiencing lower patient safety indicator 90 scores, higher catheter-associated urinary tract infection and surgical site infection scores, and no different total HAC scores. Finally, when examining the impact of Magnet tenure, our analysis revealed that there were no differences in Magnet tenure.

CONCLUSIONS

Results indicate that the processes, procedures, and educational aspects associated with Magnet recognition seem to provide important improvements associated with care that is controlled by nursing practice. However, because these improvements do not differ when comparing total HAC scores nor Magnet hospitals with different tenure, there are likely opportunities for Magnet hospitals to continue process improvements focused on HACRP scores.

Nurse staffing and patient-perceived quality of nursing care: a cross-sectional analysis of survey and administrative data in German hospitals

OBJECTIVE

To examine the impact of nurse staffing on patient-perceived quality of nursing care. We differentiate nurse staffing levels and nursing skill mix as two facets of nurse staffing and use a multidimensional instrument for patient-perceived quality of nursing care. We investigate non-linear and interaction effects.

SETTING

The study setting was 3458 hospital units in 1017 hospitals in Germany.

PARTICIPANTS

We contacted 212 554 patients discharged from non-paediatric, non-intensive and non-psychiatric hospital units who stayed at least two nights in the hospital between January and October 2019. Of those, 30 174 responded, yielding a response rate of 14.2%. Our sample included only those patients. After excluding extreme values for our nurse staffing variables and removing observations with missing values, our final sample comprised 28 136 patients ranging from 18 to 97 years of age (average: 61.12 years) who had been discharged from 3458 distinct hospital units in 1017 hospitals.

PRIMARY AND SECONDARY OUTCOME MEASURES

Patient-perceived quality of nursing care (general nursing care, guidance provided by nurses, and patient loyalty to the hospital).

RESULTS

For all three dimensions of patient-perceived quality of nursing care, we found that they significantly decreased as (1) nurse staffing levels decreased (with decreasing marginal effects) and (2) the proportion of assistant nurses in a hospital unit increased. The association between nurse staffing levels and quality of nursing care was more pronounced among patients who were less clinically complex, were admitted to smaller hospitals or were admitted to medical units.

CONCLUSIONS

Our results indicate that, in addition to nurse staffing levels, nursing skill mix is crucial for providing the best possible quality of nursing care from the patient perspective and both should be considered when designing policies such as minimum staffing regulations to improve the quality of nursing care in hospitals.

The relationships between paediatric nurses' social support, job satisfaction and patient adverse events

AIMS

To explore the relationships of family, co-worker and manager support with paediatric nurses' satisfaction and their perception of adverse events. Furthermore, this study aimed to assess the job satisfaction, social support and the perceived patient adverse events.

DESIGN

This study used a cross-sectional correlational design.

METHODS

A convenient sample of 225 paediatric nurses was selected from nine hospitals in Jordan. Both the Pearson correlations and multiple regression tests were used in the analysis. The study was prepared and is reported according to the STROBE checklist.

RESULTS

Significant and positive correlations were found between paediatric nurses' job satisfaction and the social support they receive. Significant negative correlations were also found between adverse events and both family and manager support. The multiple regression results showed that manager support is a significant negative predictor of both pressure ulcers and patient falls, and family support significantly predicted paediatric nurses' job satisfaction.

The impact of nurse staffing levels on nursing-sensitive patient outcomes: a multilevel regression approach

The goal of this study is to provide empirical evidence of the impact of nurse staffing levels on seven nursing-sensitive patient outcomes (NSPOs) at the hospital unit level. Combining a very large set of claims data from a German health insurer with mandatory quality reports published by every hospital in Germany, our data set comprises approximately 3.2 million hospital stays in more than 900 hospitals over a period of 5 years. Accounting for the grouping structure of our data (i.e., patients grouped in unit types), we estimate cross-sectional, two-level generalized linear mixed models (GLMMs) with inpatient cases at level 1 and units types (e.g., internal medicine, geriatrics) at level 2. Our regressions yield 32 significant results in the expected direction. We find that differentiating between unit types using a multilevel regression approach and including postdischarge NSPOs adds important insights to our understanding of the relationship between nurse staffing levels and NSPOs. Extending our main model by categorizing inpatient cases according to their clinical complexity, we are able to rule out hidden effects beyond the level of unit types.

Nursing-sensitive indicators for nursing care: A systematic review (1997-2017)

AIM

To provide a systematic review of the literature from 1997 to 2017 on nursing-sensitive indicators.

DESIGN

A qualitative design with a deductive approach was used.

DATA SOURCES

Original and Grey Literature references from Cochrane Library, Medline/PubMed, Embase, and CINAHL, Google Scholar Original and Grey Literature.

REVIEW METHODS

Quality assessment was performed using the NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies.

RESULTS

A total of 3,633 articles were identified, and thirty-nine studies met the inclusion criteria. The quantitative assessment of investigated relationships in these studies suggests that nursing staffing, mortality, and nosocomial infections were the most frequently reported nursing-sensitive indicators.

CONCLUSION

This review provides a comprehensive list of nursing-sensitive indicators, their frequency of use, and the associations between these indicators and various outcome variables. Stakeholders of nursing research may use the findings to streamline the indicator development efforts and standardization of nursing-sensitive indicators.

IMPACT

This review provides evidence-based results that health organizations can benefit from nursing care quality.

A Novel 3-Part Approach to Tackle the Problem of Health Inequities in Early Childhood

The first 5 years of a child's life are crucial in laying the foundation for their health and developmental trajectory into adulthood. These early years are especially influenced by the surrounding environments in which children live and grow. A large international body of evidence demonstrates that children who experience disadvantage tend to fall increasingly behind over time. At the societal level, these inequities can cause substantial social burdens and significant costs across health, education, and welfare budgets. A contributing factor is that children experiencing adversity are less likely to have access to the environmental conditions that support them to thrive. Many of these factors are modifiable at the community or place level. We argue for three key-though not exhaustive-ideas that collectively could achieve more equitable outcomes for children facing disadvantage and experiencing adversity:We conclude that if adopted, these 3 ideas could contribute to the ability of local communities and networks to identify and respond to factors that address early childhood inequalities.

Incidence of falls in a cohort of critical adults: a cause for concerns?

OBJECTIVE

To describe the incidence and to report the cases of falls in a cohort of critical adults.

METHOD

A prospective cohort study, conducted in 2018 at an adult Intensive Care Unit (ICU) in the south of Brazil. The patients were followed up from admission to discharge; observations were made in the morning and afternoon. The clinical and care variables were evaluated. The descriptive analysis was performed followed by the reporting of the cases.

RESULTS

551 patients were monitored during 6 [3-12.7] days of hospitalization, generating 7,839 observations. There were four cases of falls, with an incidence rate of 5.1/10.000 observations/day - confidence interval of 99% [0.9 to 16] and density of incidence of 7/10.000 observations/day - confidence interval of 99% [1.2 to 22]. No serious harms were observed.

CONCLUSION

Falls occur less in the ICU, which can be explained by the use of safe care practices.

Association of US Dialysis Facility Staffing with Profiling of Hospital-Wide 30-Day Unplanned Readmission

Background

Unplanned hospital readmissions are a major source of morbidity among dialysis patients, in whom the risk of hospital readmission is exceptionally high. The contribution of dialysis facility staffing to hospital readmission has been largely overlooked.

Methods

Using annual data of dialysis patients from the United States Renal Data System from 2010 to 2013, we assessed dialysis facilities with a significantly worse (SW) and facilities with a nonsignificant (NS) standardized readmission ratio (SRR). SRR estimates were risk adjusted for patient factors, past year comorbidities, and index hospitalization characteristics. Facility staffing variables were compared between 2 exposure groups: facilities with SW and NS SRRs. Four measures of staffing, including patient-to-staffing ratio, were compared between SW and matched NS facilities.

Results

About 136,000-148,000 dialysis patients with 269,000-319,000 index hospital discharges were used to identify facilities with SW and facilities with NS SRR annually. Approximately 3-4% of facilities were identified as having SW SRR among > 5,000 facilities annually. The percent of nurses-to-total staff was significantly lower in 2010 for SW facilities than in matched NS facilities (42.5 vs. 45.6%, p = 0.012), but this disparity was attenuated by 2013 (44.8 vs. 44.7%, p = 0.949). There was a higher patient-to-nurse ratio for SW facilities than for NS facilities (mean 16.4 vs. 15.2, p = 0.038) in 2010 as well, and the disparity was reduced by 2013. The trends were similar for patient-to-total staff and patient-to-registered nurse, but not statistically significant.

Conclusions

This study found that dialysis facilities with SW 30-day readmission rates had lower proportions of nurses-to-total staff and higher patient-to-nurse ratios, but this disparity improved in recent years. Additional research is warranted focusing on how evidence-based staffing at dialysis facilities can contribute to reduction of hospital readmission, and this knowledge is needed to inform clinical practice guidelines and policy decisions regarding optimal dialysis patient staffing.

Evidence on Nurse Staffing Ratios and Patient Outcomes in a Low-Income Country: Implications for Future Research and Practice

BACKGROUND

Conclusive evidence on the effect of nurse staffing ratios on nurse-sensitive outcomes (NSOs) has not yet been achieved worldwide.

AIMS

To describe the relationship between nurse staffing and NSOs at a Magnet designated, university hospital a low-income country.

METHODS

A 48-month prospective study assessed the relationship between nurse staffing and six patient outcomes or NSOs in medical-surgical units and critical care units (CCUs). Nurse staffing was measured by nursing hours per patient day (NHPPD) and skill mix, whereas NSOs were total falls and injury falls per 1,000 patient days, percent of surveyed patients with hospital-acquired pressure injuries (HAPI), catheter-associated urinary tract infections, ventilator-associated pneumonia, and central line-associated bloodstream infections (CLABSI) per 1,000 central line days.

RESULTS

The odds for total falls, injury falls, HAPI, and CLABSI in the medical-surgical units were higher with lower NHPPD ratios, OR = 4.67, p = .000; OR = 4.33, p = .001; OR = 3.77, p = .004 and OR = 2.61, p = .006, respectively. For the CCUs, lower rates of NHPPD increased the odds for total falls, OR = 6.25, p = .0007, HAPIs OR = 3.91, p = .001 and CLABSI, OR = 4.78, p = .000. Skill mix was associated with total falls, OR = 2.40, p = .005 and HAPIs OR = 2.07, p = .03 in the medical-surgical units but had no effect in any NSOs in the CCUs.

LINKING EVIDENCE TO ACTION

Higher rates of nurses per patient were effective in improving some NSOs but not others. Skill mix had no effect on any of the six NSOs in the CCUs. As such, the results remain inconclusive as the benefits of the higher nurse to patient ratios in this low-income country warranting further multisite studies in different settings and countries.

Safety of Psychiatric Inpatients at the Veterans Health Administration

OBJECTIVE

Although reducing adverse events and medical errors has become a central focus of the U.S. health care system over the past two decades both within and outside the Veterans Health Administration (VHA) hospital systems, patients treated in psychiatric units of acute care general hospitals have been excluded from major research in this field.

METHODS

The study included a random sample of 40 psychiatric units from medical centers in the national VHA system. Standardized abstraction tools were used to assess the electronic health records from 8,005 hospitalizations. Medical record administrators screened the records for the presence of ten specific types of patient safety events, which, when present, were evaluated by physician reviewers to assess whether the event was the result of an error, whether it caused harm, and whether it was preventable.

RESULTS

Approximately one in five patients experienced a patient safety event. The most frequently occurring events were medication errors (which include delayed and missed doses) (17.2%), followed by adverse drug events (4.1%), falls (2.8%), and assault (1.0%). Most patient safety events (94.9%) resulted in little harm or no harm, and more than half (56.6%) of the events were deemed preventable.

CONCLUSIONS

Although patient safety events in VHA psychiatric inpatient units were relatively common, a great majority of these events resulted in little or no patient harm. Nevertheless, many were preventable, and the study provides data with which to target future initiatives that may improve the safety of this vulnerable patient population.

Case Analysis of Factors Contributing to Patient Falls

Falls are a constant risk for patients in acute-care hospitals, which can lead to serious consequences. The purpose of this study was to examine hospital fall case studies and to learn the contributing factors for patient falls. This was achieved by conducting a secondary analysis of 11 fall case studies obtained from two previous studies. The fall cases used the Senior Falls Investigative Methodology (SFIM) approach, which provided detailed analysis of the circumstances surrounding the falls. A total of 549 contributing factors were identified in the 11 case studies, where major categories were classified according to the four different layers of defenses using Reason's Swiss Cheese Model of Accident Causation (organizational factors, supervision, preconditions, and unsafe acts). Hospital policies, reduced supervision, disease processes, the environment, and patients transferring without assistance dominated the reasons for increased risk. Additional strategies were recommended for all layers of defense to reduce patient falls.

Relationships between Army nursing practice environments and patient outcomes

Favorable nursing practice environments have been associated with lower patient mortality, failure to rescue, nurse-administered medication errors, infections, patient complaints, and patient falls. Favorable environments have also been associated with higher nurse-reported care quality and patient satisfaction in civilian hospitals. However, limited information exists on the relationship between favorable nursing practice environments and positive outcomes in military facilities. Using 4 years of secondary data collected from 45 units in 10 Army hospitals, generalized estimating equations were used to test the associations between nurses' scores on the Practice Environment Scale of the Nursing Work Index (PES-NWI) and patient outcomes of falls with and without injury, medication administration errors with and without harm, and patient experience. Four significant associations were found between the PES-NWI subscales and the patient outcomes under study. The Staffing and Resource Adequacy subscale was significantly associated with patient falls, the Collegial Nurse Physician Relations subscale was significantly associated with the rate of nurse-administered medication errors, and the Nursing Foundations for Quality Care and Collegial Nurse Physician Relations subscales were both significantly associated with patient experience with nursing care. As in civilian hospitals, favorable nursing practice environment was associated with improved patient outcomes within these military nursing units.

Validation and reliability of Falls Risk for Hospitalized Older People (FRHOP): Taiwan version

A comprehensive fall risk assessment can provide information for effective prevention and intervention measures and reduce falls among hospitalized elderly people. The purpose of this study was to develop a Chinese version of an inpatient fall risk assessment tool and evaluate its validity and reliability.This study employed the Falls Risk for Hospitalised Older People (FRHOP) assessment to construct a FRHOP-Taiwan Version (Tw-FRHOP) through forward, synthesized, and backward translation. A face validation was conducted by 5 clinical nurses and a content validation was conducted by 5 specialists using the content validity index (CVI) to validate the proposed model. Thirty hospitalized older adults in an internal care unit were selected for an interrater reliability assessment, conducted separately by specialists in 4 disciplines (i.e., nurses, physicians, occupational therapists, and physiotherapists) by using Cohen kappa statistic and intraclass correlation coefficients (ICCs). Specifically, the assessment rating developed in the Tw-FRHOP was compared with the Morse Fall Scale (MFS), St. Thomas Risk Assessment Tool in Falling Elderly Inpatients (STRATIFY), and the Hendrich II Fall Risk Model (HIIFRM) for criterion validation.According to the analysis results, the CVI was 0.94, and the indexes of criterion-related validity for the FRHOP-Taiwan Version, MFS, STRATIFY, and HIIFRM were 0.49, 0.63, and 0.54 (all P < .001), respectively. In addition, after interrater reliability testing was conducted, the results indicated that the index of response consistency in each discipline was 86.7% to 100%, and the values of Cohen kappa were 0.651 to 1.000. The ICCs of the discipline-related subscale were 0.97 to 1.00.The Tw-FRHOP is a multidisciplinary comprehensive fall risk assessment that can serve as a satisfactorily valid and reliable reference tool for medical personnel with full professional training, as well as inpatient fall prevention interventions for multidisciplinary teams in hospitals.

A program evaluation of the Patient CaringTouch System: A pre- and postimplementation assessment

BACKGROUND

The Patient CaringTouch System (PCTS) is an innovative, strategic and patient-centric framework developed by the Army Nurse Corps for nursing care delivery that is designed to reduce nursing care variation and improve patient and nurse outcomes.

PURPOSE

This manuscript describes a program evaluation of the PCTS.

METHODS

A pre and post design was used to describe changes in patient and nursing measures following PCTS implementation.

DISCUSSION

Overall there was a good uptake of the PCTS; however, concurrent with initiation of the PCTS, declines in staffing levels and increases in patient acuity were noted. Medication administration error rates declined, but fall with injury rates increased. Pain reassessment following pain medication administration improved, as did several aspects of the nursing practice environment. Nurses' job dissatisfaction and intent to leave increased; however, potentially preventable losses decreased.

CONCLUSIONS

The program evaluation results will be used to target areas for improvement so that the PCTS may be sustained.

Understanding and managing the risk of "head impact" from in-hospital falls: A cross-sectional analysis of data from 166 public hospitals

BACKGROUND

Falls are a leading cause of preventable harm in the hospitalized elderly, and head impacts (HIs) can be a precursor to serious injury. The aim of this study was to examine if the risk of fall-related HI can be explained by incident characteristics.

METHODS

All reported falls across public hospital facilities in the state of Queensland, Australia, over a 2-year period were analyzed using univariate and multiple logistic regression.

RESULTS

In all, 650 instances of HI were reported across 24 218 falls. Falls due to fainting were associated with elevated HI odds (odds ratio [OR] = 2.00, 95% confidence interval [CI] = 1.30, 3.08). Similarly, falls while walking (OR = 1.48, 95% CI = 1.20, 1.81) and falls during certain time periods, namely, from 11:00 pm to midnight (OR = 1.79, 95% CI = 1.24, 2.59) and between 5:00 am and 6:00 am (OR = 1.50, 95% CI = 1.01, 2.22) were linked to increased HI odds. Falls among males were associated with lowered odds of HI (adjusted odds ratio [AOR] = 0.78, 95% CI = 0.64, 0.74).

CONCLUSIONS

Results confirm links between characteristics of inpatient falls and the likelihood of HI, and these data can assist risk managers to better target fall prevention strategies. Assisted mobility in high-risk patients and improved environmental lighting are advanced as foci for future research.

Association between Nurse Staffing and In-Hospital Bone Fractures: A Retrospective Cohort Study

OBJECTIVE

To determine if sufficient nurse staffing reduced in-hospital fractures in acute care hospitals.

DATA SOURCES/STUDY SETTING

The Japanese Diagnosis Procedure Combination inpatient (DPC) database from July 2010 to March 2014 linked with the Surveys for Medical Institutions.

STUDY DESIGN

We conducted a retrospective cohort study to examine the association of inpatient nurse-to-occupied bed ratio (NBR) with in-hospital fractures. Multivariable logistic regression with generalized estimating equations was performed, adjusting for patient characteristics and hospital characteristics.

DATA COLLECTION/EXTRACTION METHODS

We identified 770,373 patients aged 50 years or older who underwent planned major surgery for some forms of cancer or cardiovascular diseases. We used ICD-10 codes and postoperative procedure codes to identify patients with in-hospital fractures. Hospital characteristics were obtained from the "Survey of Medical Institutions and Hospital Report" and "Annual Report for Functions of Medical Institutions."

PRINCIPAL FINDINGS

Overall, 662 (0.09 percent) in-hospital fractures were identified. Logistic regression analysis showed that the proportion of in-hospital fractures in the group with the highest NBR was significantly lower than that in the group with the lowest NBR (adjusted odd ratios, 0.67; 95 percent confidence interval, 0.44-0.99; p = .048).

CONCLUSIONS

Sufficient nurse staffing may be important to reduce postsurgical in-hospital fractures in acute care hospitals.

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.

Lower Nurse Staffing Levels Are Associated With Occurrences of Inpatient Falls at a Large Pediatric Hospital

No previous research has been published regarding the relationship between nurse staffing levels and inpatient pediatric falls, and previous research in the adult population has yielded conflicting results, probably due in many instances to suboptimal study design. The objective of this study was to examine the relationship between nurse staffing levels and pediatric patient falls in a large children's hospital. A case-control study design was used to compare the nurse staffing level during the shift of patient falls to the staffing level in the same units on shifts when patient falls did not occur. Nurse staffing levels were significantly lower in units when patient falls occurred, particularly during night shift. Targeted nurse staffing interventions in high-risk units could reduce the incidence of inpatient pediatric falls.

Relación de la asignación de personal de enfermería con indicadores de resultado de la calidad de la atención en unidades de cuidados intensivos adulto

Objetivo: determinar la relación de la asignación de personal de enfermería con indicadores de resultado de la calidad de la atención en unidades de cuidados intensivos. Materiales y métodos: se hizo un estudio descriptivo con un componente correlacional, en el que se observaron 4006 turnos y se analizaron las variables de asignación de personal (estructura) y de resultado, en términos de casos de shock o paro, infecciones asociadas a la atención en salud, número de muertes y totalidad de eventos negativos en salud. Resultados: los resultados muestran que las enfermeras desarrollan un número reducido de actividades de cuidado directo al paciente, que se concentran en la administración de medicamentos y la supervisión de transfusiones, y otras tareas administrativas, mientras que el personal auxiliar se hace cargo del cuidado directo al paciente, incluidas las actividades complejas. La razón paciente/profesional de enfermería promedio fue de 5,4 pacientes por cada enfermera disponible en la unidad, y la razón paciente/auxiliar de enfermería promedio fue de 2,4. Las correlaciones no son concluyentes. Conclusiones: se sugiere estudiar con mayor profundidad el skill mix como una medida más sensible de asignación de personal, a la vez que se plantean recomendaciones en torno a la diferenciación de actividades entre profesionales y auxiliares de enfermería, y algunas consideraciones relativas a la asignación de personal.

The Safety of Hospital Beds: Ingress, Egress, and In-Bed Mobility

To explore the safety of the standard and the low hospital bed, we report on a microanalysis of 15 patients' ability to ingress, move about the bed, and egress. The 15 participants were purposefully selected with various disabilities. Bed conditions were randomized with side rails up or down and one low bed with side rails down. We explored the patients' use of the side rails, bed height, ability to lift their legs onto the mattress, and ability to turn, egress, and walk back to the chair. The standard bed was too high for some participants, both for ingress and egress. Side rails were used by most participants when entering, turning in bed, and exiting. We recommend that side rails be reconsidered as a means to facilitate in-bed movement, ingress, and egress. Furthermore, single deck height settings for all patients are not optimal. Low beds as a safety measure must be re-evaluated.

Nursing-sensitive indicators: a concept analysis

AIM

To report a concept analysis of nursing-sensitive indicators within the applied context of the acute care setting.

BACKGROUND

The concept of 'nursing sensitive indicators' is valuable to elaborate nursing care performance. The conceptual foundation, theoretical role, meaning, use and interpretation of the concept tend to differ. The elusiveness of the concept and the ambiguity of its attributes may have hindered research efforts to advance its application in practice.

DESIGN

Concept analysis.

DATA SOURCES

Using 'clinical indicators' or 'quality of nursing care' as subject headings and incorporating keyword combinations of 'acute care' and 'nurs*', CINAHL and MEDLINE with full text in EBSCOhost databases were searched for English language journal articles published between 2000-2012. Only primary research articles were selected.

METHODS

A hybrid approach was undertaken, incorporating traditional strategies as per Walker and Avant and a conceptual matrix based on Holzemer's Outcomes Model for Health Care Research.

RESULTS

The analysis revealed two main attributes of nursing-sensitive indicators. Structural attributes related to health service operation included: hours of nursing care per patient day, nurse staffing. Outcome attributes related to patient care included: the prevalence of pressure ulcer, falls and falls with injury, nosocomial selective infection and patient/family satisfaction with nursing care.

CONCLUSION

This concept analysis may be used as a basis to advance understandings of the theoretical structures that underpin both research and practical application of quality dimensions of nursing care performance.

Determinants of hospital fall rate trajectory groups: a longitudinal assessment of nurse staffing and organizational characteristics

BACKGROUND

Patient falls in acute care hospitals represent a significant patient safety concern. Although cross-sectional studies have shown that fall rates vary widely between acute care hospitals, it is not clear whether hospital fall rates remain consistent over time.

PURPOSE

The aim of this study was to determine whether hospitals can be categorized into fall rate trajectory groups over time and to identify nurse staffing and hospital characteristics associated with hospital fall rate trajectory groups.

METHODOLOGY/APPROACH

We conducted a 54-month (July 2006-December 2010) longitudinal study of U.S. acute care general hospitals participating in the National Database for Nursing Quality Indicators (2007). We used latent class growth modeling to categorize hospitals into groups based on their long-term fall rates. Nurse staffing and hospital characteristics associated with membership in the highest hospital fall rate group were identified using logistic regression.

FINDINGS

A sample of 1,529 hospitals (mean fall rate of 3.65 per 1,000 patient days) contributed data to the analysis. Latent class growth modeling findings classified hospital into three groups based on fall rate trajectories: consistently high (mean fall rate of 4.96 per 1,000 patient days), consistently medium (mean fall rate of 3.63 per 1,000 patient days), and consistently low (mean fall rate of 2.50 per 1,000 patient days). Hospitals with higher total nurse staffing (odds ratio [OR] = 0.92, 95% confidence interval [CI] [0.85, 0.99]), Magnet status (OR = 0.49, 95% CI [0.35, 0.70]), and bed size greater than 300 beds (OR = 0.70, 95% CI [0.51, 0.94]) were significantly less likely to be categorized in the "consistently high" fall rate group.

PRACTICE IMPLICATIONS

Over this 54-month period, hospitals were categorized into three groups based on long-term fall rates. Hospital-level factors differed among these three groups. This suggests that there may be hospitals in which "best practices" for fall prevention might be identified. In addition, administrators may be able to reduce fall rates by maintaining greater nurse staffing ratios as well as fostering an environment consistent with that of Magnet hospitals.

Shifting the paradigm: an assessment of the quality of fall risk reduction in Nebraska hospitals

PURPOSE

To assess the prevalence of evidence-based fall risk reduction structures and processes in Nebraska hospitals; whether fall rates are associated with specific structures and processes; and whether fall risk reduction structures, processes, and outcomes vary by hospital type--Critical Access Hospital (CAH) versus non-CAH.

METHODS

A cross-sectional survey of Nebraska's 83 general community hospitals, 78% of which are CAHs. We used a negative binomial rate model to estimate fall rates while adjusting for hospital volume (patient days) and the exact Pearson chi-square test to determine associations between hospital type and the structure and process of fall risk reduction.

FINDINGS

Approximately two-thirds or more of 70 hospitals used 6 of 9 evidence-based universal fall risk reduction interventions; 50% or more used 14 of 16 evidence-based targeted interventions. After adjusting for hospital volume, hospitals in which teams integrated evidence from multiple disciplines and reflected upon data and modified polices/procedures based upon data had significantly lower total and injurious fall rates per 1,000 patient days than hospitals that did not. Non-CAHs were significantly more likely than CAHs to perform 5 organizational-level fall risk reduction processes. CAHs reported significantly greater total (5.9 vs 4.0) and injurious (1.7 vs 0.9) fall rates per 1,000 patient days than did non-CAHs.

CONCLUSIONS

Hospital type was a significant predictor of fall rates. However, shifting the paradigm for fall risk reduction from a nursing-centric approach to one in which teams implement evidence-based practices and learn from data may decrease fall risk regardless of hospital type.

Developing a hospital-specific electronic inpatient fall surveillance program: phase 1

Patient falls in hospitals continue to exist as a serious societal problem. The purpose of this study was to analyze nurses' perceptions of patient fall risk factors that may be used to develop an electronic patient decision support system to prevent patient falls. A survey was distributed to 150 nurses in a moderate-size hospital system in Central Florida (200+ beds). Survey questions were developed to identify 3 fall risk factor categories: patient-centered, operational, and critical. Sixty-five surveys (43.3%) were returned. Descriptive statistics such as frequencies and percentages were calculated on all study variables. All participants indicated they were familiar with the circumstances that have contributed to falls or near-falls of patients. Findings included the majority of nurses perceived both patient-centered and operational factors increased the risks for patient falls, with pertinent results indicating a lack of appropriate ambulatory device (90.8%), low to very low nurse staffing levels (87.7%), and a history of a fall within the past year (73.8%) increased the risk for falls. The nurses' perceptions define a standard medical terminology that can be recorded in electronic progress notes and programmed to quickly link to additional sources of fall risk data (eg, laboratory work, medications) housed within the hospital's electronic health record. Further research is needed to assess the feasibility of an electronic health record-based system to prevent hospital falls using risk factors identified in this and other studies.

Postoperative prevention of falls in older adults with fragility fractures

The postoperative period after correction of a fragility fracture is usually associated with functional deconditioning. This deconditioning is caused by multiple factors associated with a higher risk of falls during the immediate postoperative period and after discharge. Identification of risk and appropriate fall prevention interventions in these patients are pivotal. In this article, an overview is presented of the strategies to identify falls risk in postoperative patients after suffering a fragility fracture. Evidence is presented favoring targeted multicomponent intervention for falls prevention rather than a single intervention in fractured older patients at high risk of new falls and fractures.

RN workgroup job satisfaction and patient falls in acute care hospital units

OBJECTIVE

The aim of this study was to examine the relationship between registered nurse (RN) workgroup job satisfaction and patient falls on 4 types of acute care hospital units.

BACKGROUND

Although a link has been found between nurse job satisfaction and quality of patient care, little research has been conducted to examine the effect of RN job satisfaction on patient clinical outcomes in acute care hospitals.

METHODS

Random-intercept negative binomial regression analyses were performed using 2009 unit-level data from 2,763 units in 576 National Database of Nursing Quality Indicators hospitals.

RESULTS

Controlling for unit (nurse staffing, RN education, and RN unit tenure) and hospital (Magnet® status, hospital size, and teaching status) characteristics, RN workgroup job satisfaction was inversely associated with patient falls (incident rate ratio, 0.941, 95% confidence interval, 0.911-0.972).

CONCLUSIONS

Higher RN workgroup job satisfaction is significantly related to fewer patient falls on acute care hospital units.

Pressure ulcers and prevention among acute care hospitals in the United States

BACKGROUND

Most pressure ulcers can be prevented with evidence-based practice. Many studies describe the implementation of a pressure ulcer prevention program but few report the effect on outcomes across acute care facilities.

METHODS

Data on hospital-acquired pressure ulcers and prevention from the National Database of Nursing Quality Indicators 2010 Pressure Ulcer Surveys were linked to hospital characteristics and nurse staffing measures within the data set. The sample consisted of 1,419 hospitals from across the United States and 710,626 patients who had been surveyed for pressure ulcers in adult critical care, step-down, medical, surgical, and medical/surgical units. Hierarchical logistic regression analysis was performed to identify study variables associated with hospital-acquired pressure ulcers among patients at risk for these ulcers.

RESULTS

The rate of hospital-acquired pressure ulcers was 3.6% across all surveyed patients and 7.9% among those at risk. Patients who received a skin and pressure ulcer risk assessment on admission were less likely to develop a pressure ulcer. Additional study variables associated with lower hospital-acquired pressure ulcer rates included a recent reassessment of pressure ulcer risk, higher Braden Scale scores, a recent skin assessment, routine repositioning, and Magnet or Magnet-applicant designation. Variables associated with a higher likelihood of hospital-acquired pressure ulcers included nutritional support, moisture management, larger hospital size, and academic medical center status.

CONCLUSIONS

Results provide empirical support for pressure ulcer prevention guideline recommendations on skin assessment, pressure ulcer risk assessment, and routine repositioning, but the 7.9% rate of hospital-acquired pressure ulcers among at-risk patients suggests room for improvement in pressure ulcer prevention practice.

Associations between rates of unassisted inpatient falls and levels of registered and non-registered nurse staffing

OBJECTIVE

To enhance understanding of how nurse staffing relates to unassisted falls by exploring non-linear associations between unassisted fall rates and levels of registered nurse (RN) and non-RN staffing on 5 nursing unit types, thereby enabling managers to improve patient safety by making better-informed decisions about staffing.

DESIGN

Cross-sectional analysis of routinely collected data using hierarchical negative binomial regression.

SETTING

8069 nursing units in 1361 U.S. hospitals participating in the National Database of Nursing Quality Indicators(®). Main outcome measure Rate of unassisted falls per inpatient day.

RESULTS

Associations between unassisted fall rates and nurse staffing varied by unit type. For medical-surgical units, higher RN staffing was weakly associated with lower fall rates. On step-down and medical units, the association between RN staffing and fall rates depended on the level of staffing: At lower staffing levels, the fall rate increased as staffing increased, but at moderate and high staffing levels, the fall rate decreased as staffing increased. Higher levels of non-RN staffing were generally associated with higher fall rates..

CONCLUSIONS

Increasing non-RN staffing seems ineffective at preventing unassisted falls. Increasing RN staffing may be effective, depending on the unit type and the current level of staffing.

Recent trends in hospital nurse staffing in the United States

OBJECTIVE

The aim of this study was to examine recent trends in nurse staffing levels and nursing staff composition.

BACKGROUND

Recent trends in hospital nurse staffing have not been well described, and the effects of the 2007 to 2012 recession and 2008 Centers for Medicare & Medicaid Services rule change are unknown.

METHODS

A longitudinal study of unit-level data from the National Database of Nursing Quality Indicators (NDNQI) and hospital-level data from the American Hospital Association (AHA) annual survey was conducted.

RESULTS

From 2004 to 2011, total nursing hours per patient day on general care units in NDNQI hospitals increased by 11.5%, and registered nurse (RN) hours per patient day by 22.9%. Trends were similar in AHA hospitals.

CONCLUSIONS

Hospitals have steadily increased total nurse staffing levels by increasing RN staffing. Use of temporary RNs in hospitals plummeted from mid-2008. There were no apparent changes in staffing levels due to the recession and/or CMS rule change.

Falls among adult patients hospitalized in the United States: prevalence and trends

OBJECTIVES

The purpose of this study was to provide normative data on fall prevalence in U.S. hospitals by unit type and to determine the 27-month secular trend in falls before the implementation of the Centers for Medicare and Medicaid Service (CMS) rule, which does not reimburse hospitals for care related to injury resulting from hospital falls.

METHODS

We used data from the National Database of Nursing Quality Indicators (NDNQI) collected between July 1, 2006, and September 30, 2008, to estimate prevalence and secular trends of falls occurring in adult medical, medical-surgical, and surgical nursing units. More than 88 million patient days (pd) of observation were contributed from 6100 medical, surgical, and medical-surgical nursing units in 1263 hospitals across the United States.

RESULTS

A total of 315,817 falls occurred (rate = 3.56 falls/1000 pd) during the study period, of which, 82,332 (26.1%) resulted in an injury (rate = 0.93/1000 pd). Both total fall and injurious fall rates were highest in medical units (fall rate = 4.03/1000 pd; injurious fall rate = 1.08/1000 pd) and lowest in surgery units (fall rate = 2.76/1000 pd; injurious fall rate = 0.67/1000 pd). Falls (0.4% decrease per quarter, P < 0.0001) and injurious falls (1% decrease per quarter, P < 0.0001) both decreased over the 27-month study.

CONCLUSIONS

In this large sample, fall and injurious fall prevalence varied by nursing unit type in U.S. hospitals. Over the 27-month study, there was a small, but statistically significant, decrease in falls (P < 0.0001) and injurious falls (P < 0.0001).

Moving healthcare quality forward with nursing-sensitive value-based purchasing

PURPOSE

To underscore the need for health system reform and emphasize nursing measures as a key component in our healthcare reimbursement system.

DESIGN AND METHODS

Nursing-sensitive value-based purchasing (NSVBP) has been proposed as an initiative that would help to promote optimal staffing and practice environment through financial rewards and transparency of structure, process, and patient outcome measures. This article reviews the medical, governmental, institutional, and lay literature regarding the necessity for, method of implementation of, and potential impact of NSVBP.

FINDINGS

Research has shown that adverse events and mortality are highly dependent on nurse staffing levels and skill mix. The National Database of Nursing Quality Indicators (NDNQI), along with other well-developed indicators, can be used as nursing-sensitive measurements for value-based purchasing initiatives. Nursing-sensitive measures are an important component of value-based purchasing.

CONCLUSIONS

Value-based purchasing is in its infancy. Devising an effective system that recognizes and incorporates nursing measures will facilitate the success of this initiative. NSVBP needs to be designed and incentivized to decrease adverse events, hospital stays, and readmission rates, thereby decreasing societal healthcare costs.

CLINICAL RELEVANCE

NSVBP has the potential for improving the quality of nursing care by financially motivating hospitals to have an optimal nurse practice environment capable of producing optimal patient outcomes by aligning cost effectiveness for hospitals to that of the patient and society.

Systematic review of evidence on the impact of nursing workload and staffing on establishing healthy work environments

Background  This systematic review set out to examine the impact, if any, of nursing workload and staffing on creating and maintaining healthy work environments. For the purposes of this review, the term 'healthy work environment' was defined as '. . . a practice setting that maximizes the health and well-being of nurses, quality patient outcomes and organizational performance'. This definition identifies nurse, patient and organisational outcomes as indicators of the establishment and maintenance of a healthy work environment. Objectives  The review sought to determine the impact of: • Patient characteristics, nurse characteristics, system characteristics and system processes on workload, scheduling and concepts of productivity and utilisation • Workload, scheduling and concepts of productivity and utilisation on the quality of outcomes for clients, nurses and the system/organisation Search strategy  The search strategy sought to find both published and unpublished studies and papers written in the English language. A three-step search strategy approach was used. An initial limited search of MEDLINE and CINAHL databases was undertaken to identify optimal search terms followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second extensive search using all identified keywords and index terms was then undertaken. The third step consisted of a search of the reference lists of all identified reports and articles for additional studies. Selection criteria  Types of studies: This review considered research papers that addressed the appropriateness and effectiveness of workload and staffing concepts in fostering a healthy work environment in healthcare. The types of papers to be considered included: meta-analysis, randomised controlled trials, quasi-randomised controlled trials, cohort studies, case-control studies, descriptive studies and correlational studies.

TYPES OF PARTICIPANTS

The review considered all participants involved or affected by workload and staffing concepts within the nursing workforce in a healthcare environment, including staff and patients. System and policy issues were also considered. Types of interventions: All workload and staffing strategies that impact on the work environment, patient and nurse outcomes were considered in this review. Types of outcome measures: Outcomes of interest were categorised into four groups: nursing staff outcomes, patient outcomes, organisational outcomes and system outcomes. Data collection and analysis  Following assessment of methodological quality, data were extracted using data extraction tools based on the work of the Cochrane Collaboration and the Centre for Reviews and Dissemination. Statistical pooling was not possible and findings were presented in narrative form. Results  Of the 2162 papers identified in the search, 171 were selected for full paper retrieval and assessed independently by two reviewers for methodological quality. A total of 40 papers were included in the review: one systematic review; one cohort study; and 38 correlational descriptive studies. Results were summarised in narrative form. The evidence suggests strong correlations between patient characteristics and work environments; and workload and staffing and the quality of outcomes for clients, nurses and the system/organisation. This gave rise to a number of recommendations for practice and for further research, such as: • A greater proportion of regulated staffing (i.e. registered nurses, enrolled nurses, practical or vocational nurses) is associated with improved outcomes related to the Functional Independence Measure score, the Short Form Health Survey (SF-36) vitality score, patient satisfaction with nursing care, patient adverse events (including atelectasis, decubitus ulcers, falls, pneumonia, postsurgical and treatment infection and urinary tract infections) • An increase in the number of registered nurse hours available is associated with improved patient outcomes in relation to falls, pneumonia, pressure ulcers, urinary tract infection, length of stay and postoperative infection rates.