Licensed nurse staffing and adverse events in hospitals

Impact of Variations in the Nursing Care Supply-Demand Ratio on Postoperative Outcomes and Costs

INTRODUCTION

Improving surgical outcomes is a priority during the last decades because of the rising economic health care burden. The adoption of enhanced recovery programs has been proven to be part of the solution. In this context, the impact of variations in the nursing care supply-demand ratio on postoperative complications and its economic consequences is still not well elucidated. Because patients require different amounts of care, the present study focused on the more accurate relationship between demand and supply of nursing care rather than the nurse-to-patient ratio.

METHODS

Through a 3-year period, 838 patients undergoing elective and emergent colorectal and pancreatic surgery within the institutional enhanced recovery after surgery (ERAS) protocol were retrospectively investigated. Nursing demand and supply estimations were calculated using a validated program called the Projet de Recherche en Nursing (PRN), which assigns points to each patient according to the nursing care they need ( estimated PRN) and the actual care they received ( real PRN), respectively. The real/estimated PRN ratio was used to create 2 patient groups: one with a PRN ratio higher than the mean (PRN+) and a second with a PRN ratio below the mean (PRN-). These 2 groups were compared regarding their postoperative complication rates and cost-revenue characteristics.

RESULTS

The mean PRN ratio was 0.81. A total of 710 patients (84.7%) had a PRN+ ratio, and 128 (15.3%) had a PRN- ratio. Multivariable analysis focusing on overall complications, severe complications, and prolonged length of stay revealed no significant impact of the PRN ratio for all outcomes ( P > 0.2). The group PRN- had a mean margin per patient of U.S. dollars 1426 (95% confidence interval, 3 to 2903) compared with a margin of U.S. dollars 676 (95% confidence interval, -2213 to 3550) in the PRN+ group ( P = 0.633).

CONCLUSIONS

A PRN ratio of 0.8 may be sufficient for patients treated following enhanced recovery after surgery guidelines, pending the adoption of an accurate nursing planning system. This may contribute to better allocation of nursing resources and optimization of expenses on the long run.

Self-reported survey on infection prevention and control structures in healthcare facilities part of a national level healthcare associated infection surveillance network in India, 2019

BACKGROUND

Healthcare associated infections (HAIs) are prevalent and difficult to treat worldwide. Most HAIs can be prevented by effective implementation of Infection Prevention and Control (IPC) measures. A survey was conducted to assess the existing IPC practices across a network of Indian Hospitals using the World Health Organization designed self-assessment IPC Assessment Framework (IPCAF) tool.

METHODS

This was a cross sectional observation study. Thirty-two tertiary care public and private facilities, part of the existing Indian HAI surveillance network was included. Data collected was analyzed by a central team at All India Institute of Medical Sciences, New Delhi, a tertiary care hospital of India. The WHO questionnaire tool was used to understand the capacity and efforts to implement IPC practices across the network.

RESULTS

The overall median score of IPCAF across the network was 620. Based on the final IPCAF score of the facilities; 13% hospitals had basic IPC practices, 28% hospitals had intermediate and 59% hospitals had advanced IPC practices. The component multimodal strategies had the broadest range of score while the component IPC guidelines had the narrowest one.

CONCLUSIONS

Quality improvement training for IPC nurses and healthcare professionals are needed to be provided to health facilities.

Translation and psychometric properties of the MISSCARE survey-Persian version

Background

Providing safe and high-quality nursing care is an essential task of nursing. Nurses may be unable to provide patients with all of the necessary care for numerous reasons, such as an increase in the number of patients and a low number of nursing staff. Moreover, they may have to omit, postpone, or incompletely perform a series of care, referred to as missed nursing care. The purpose of this study was to translate and conduct psychometric testing of the MISSCARE Survey.

Method

In this study, we accurately translated the MISSCARE Survey. Its acceptability, construct validity, and internal consistency were analyzed. This cross-sectional study was conducted in the summer of 2020 in educational hospitals in Ardabil, Iran. The participants were 300 nurses who worked in educational hospitals and were randomly selected.

Results

Participants in this study included 300 nurses from five units, including general medicine (13.3%), COVID-19 (45.0%), surgery (18.7%), critical care unit (6.3%), and intensive care unit (16.7%), who worked various shifts, of whom 84.7% were female. The total content validity in Part A was 0.944, and that in Part B was 0.969. Part A was divided into three domains (necessary care, secondary care, and supportive care), and Part B was divided into five domains (communication, labor resources, material resources, responsibility, and unpredictable situations). In both parts, the chi-square index was < 3, and the RMSEA index was < 0.08. The internal consistency measured by Cronbach’s alpha was 0.933 for Part A and 0.910 for Part B for the Persian version of the MISSCARE Survey.

Conclusion

Based on the outcomes of this research, it can be concluded that the Persian version of the MISSCARE Survey is valid for use in Iranian hospitals and can be used to identify missed care and the reasons behind it. Nursing managers can also use it to improve the situation and provide the highest-quality care.

Nurses' view of implementation evidence-based fall prevention interventions: A qualitative study

AIM

The purpose of this descriptive qualitative study was to evaluate nurses' views of implementation evidence-based fall prevention interventions.

METHODS

The study was conducted with participation of nurses who worked in a training and research hospital after evidence-based fall prevention interventions had been implemented. Interviews were done with 17 nurses who participated in all training courses.

RESULTS

The evaluation of the interventions was examined, and three themes were extracted through analysis: 'effectiveness of training programme', 'barriers' and 'suggestions'.

CONCLUSION

Nurses emphasized that evidence-based fall prevention interventions are usable in hospital, but team collaboration and administrative support are required for better outcomes.

IMPLICATIONS FOR NURSING MANAGEMENT

The study result shows that fall prevention interventions should be introduced to all health care professionals, through the use of various training methods. Training should be given to patients and their caregivers, and barriers that nurses stated like understaffing, lack of materials and tools that ensure patient safety and internet (research/scientific information) access restriction should be reduced.

Exploring clinical leadership in long-term care: An integrative literature review

AIM

The aim of this study is to understand the concept of clinical leadership and clinical leadership development for nurses working with older adults in long-term care health care facilities.

BACKGROUND

In Canada, clinical care within long-term care is undertaken by registered nurses and licenced practical nurses working with health care aides. Effective clinical leadership is essential for providing quality nursing care.

EVALUATION

An integrative literature review using the framework of Whittemore and Knafl (2005). All selected articles were quality appraised using the Critical Appraisal Skills Program and the accuracy, authority, coverage, objectivity, date and significance checklist.

KEY ISSUES

The analysis resulted in four themes: ambiguous definitions, practice-based and value-driven care, the impact of clinical leadership and clinical leadership development for Canadian nurses.

CONCLUSION

The findings suggest that ambiguity surrounds the concept of clinical leadership, with the term denoting both 'management' as a formal administrative role and 'leadership' in general. More recently, the clinical leadership focus has been on informal leadership by nurses at the bedside, where personal and professional values align with clinical action.

IMPLICATIONS FOR NURSING MANAGEMENT

Effective clinical leadership can have a positive impact on quality care and employee job satisfaction.

Does continuity in nursing staff matter? A pilot study on correlation of central line-associated bloodstream infections and employee turnover

BACKGROUND

Understaffing has been previously reported as a risk factor for central line-associated bloodstream infections (CLABSI). No previous study addressed the question whether fluctuations in staffing have an impact on CLABSI incidence. We analyzed prospectively collected CLABSI surveillance data and data on employee turnover of health care workers (HCW) to address this research question.

METHODS

In January 2016, a semiautomatic surveillance system for CLABSI was implemented at the University Hospital Zurich, a 940 bed tertiary care hospital in Switzerland. Monthly incidence rates (CLABSI/1000 catheter days) were calculated and correlations with human resources management-derived data on employee turnover of HCWs (defined as number of leaving HCWs per month divided by the number of employed HCWs) investigated.

RESULTS

Over a period of 24 months, we detected on the hospital level a positive correlation of CLABSI incidence rates and turnover of nursing personnel (Spearman rank correlation, r = 0.467, P = 0.022). In more detailed analyses on the professional training of nursing personnel, a correlation of CLABSI incidence rates and licensed practical nurses (Spearman rank correlation, r = 0.26, P = 0.038) or registered nurses (r = 0.471, P = 0.021) was found. Physician turnover did not correlate with CLABSI incidence (Spearman rank correlation, r =  -0.058, P = 0.787).

CONCLUSIONS

Prospectively determined CLABSI incidence correlated positively with the degree of turnover of nurses overall and nurses with advanced training, but not with the turnover of physicians. Efforts to maintain continuity in nursing staff might be helpful for sustained reduction in CLABSI rates.

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.

Effect of Nursing Workload in Intensive Care Units

Nursing work efforts are important in providing sound healthcare services, especially in the intensive care units (ICU). Complications and adverse events are more liable to occur among patients in the ICU and these patients require more attention and nursing care. Most of the research in this field is mainly focused on the effect of staffing and its correlation to patient safety and satisfaction. Previous studies also showed that reduced nursing staffing was significantly associated with the development of pneumonia in ICU patients who needed more nursing requirements. An increase in nursing workload is also significantly associated with an increased incidence rate of nosocomial infections. The association between nursing workload in ICU patients and increased incidence rates of mortality is also supported by previous studies. The nurse-to-patient ratio has been previously used to evaluate patient safety correlation with the nursing workload as reported by previous reports. However, previous research shows that the nursing workload is a more complex correlation and can not be determined by a simple ratio as the nurse-to-patient one. Evidence shows that many adverse events may occur with patients in the ICU secondary to reduced nursing care such as increased mortality, length of hospital stay, and catching in-hospital infections. In the current study, we aim to review the outcomes from previous investigations to further emphasize the effect of nursing workload on ICU patient outcomes and safety.

A quantitative systematic review of the association between nurse skill mix and nursing-sensitive patient outcomes in the acute care setting

AIMS

To examine the association between nurse skill mix (the proportion of total hours provided by Registered Nurses) and patient outcomes in acute care hospitals.

DESIGN

A quantitative systematic review included studies published in English between January 2000 - September 2018.

DATA SOURCES

Cochrane Library, CINAHL Plus with Full Text, MEDLINE, Scopus, Web of Science and Joanna Briggs Institute were searched. Observational and experimental study designs were included. Mix-methods designs were included if the quantitative component met the criteria.

REVIEW METHODS

The Systematic Review guidelines of the Joanna Briggs Institute and its critical appraisal instrument were used. An inverse association was determined when seventy-five percent or more of studies with significant results found this association.

RESULTS

Sixty-three articles were included. Twelve patient outcomes were inversely associated with nursing skill mix (i.e., higher nursing skill mix was significantly associated with improved patient outcomes). These were length of stay; ulcer, gastritis and upper gastrointestinal bleeds; acute myocardial infarction; restraint use; failure-to-rescue; pneumonia; sepsis; urinary tract infection; mortality/30-day mortality; pressure injury; infections and shock/cardiac arrest/heart failure.

CONCLUSION

Nursing skill mix affected 12 patient outcomes. However, further investigation using experimental or longitudinal study designs are required to establish causal relationships. Consensus on the definition of skill mix is required to enable more robust evaluation of the impact of changes in skill mix on patient outcomes.

IMPACT

Skill mix is perhaps more important than the number of nurses in reducing adverse patient outcomes such as mortality and failure to rescue, albeit the optimal staffing profile remains elusive in workforce planning.

Association of registered nurse and nursing support staffing with inpatient hospital mortality

Background

The association of nursing staffing with patient outcomes has primarily been studied by comparing high to low staffed hospitals, raising concern other factors may account for observed differences. We examine the association of inpatient mortality with patients’ cumulative exposure to shifts with low registered nurse (RN) staffing, low nursing support staffing and high patient turnover.

Methods

Cumulative counts of exposure to shifts with low staffing and high patient turnover were used as time-varying covariates in survival analysis of data from a three-campus US academic medical centre for 2007–2012. Staffing below 75% of annual median unit staffing for each staff category and shift type was characterised as low. High patient turnover per day was defined as admissions, discharges and transfers 1 SD above unit annual daily averages.

Results

Models included cumulative counts of patient exposure to shifts with low RN staffing, low nursing support staffing, both concurrently and high patient turnover. The HR for exposure to shifts with low RN staffing only was 1.027 (95% CI 1.002 to 1.053, p<0.001), low nursing support only, 1.030 (95% CI 1.017 to 1.042, p<0.001) and shifts with both low, 1.025 (95% CI 1.008 to 1.043, p=0.035). For a model examining cumulative exposure over the second to fifth days of an admission, the HR for exposure to shifts with low RN staffing only was 1.048 (95% CI 0.998 to 1.100, p=0.061), low nursing support only, 1.032 (95% CI 1.008 to 1.057, p<0.01) and for shifts with both low,1.136 (95% CI 1.089 to 1.185, p<0.001). No relationship was observed for high patient turnover and mortality.

Conclusion

Low RN and nursing support staffing were associated with increased mortality. The results should encourage hospital leadership to assure both adequate RN and nursing support staffing.

Hospital Staffing and Health Care-Associated Infections: A Systematic Review of the Literature

BACKGROUND

Previous literature has linked the level and types of staffing of health facilities to the risk of acquiring a health care-associated infection (HAI). Investigating this relationship is challenging because of the lack of rigorous study designs and the use of varying definitions and measures of both staffing and HAIs.

METHODS

The objective of this study was to understand and synthesize the most recent research on the relationship of hospital staffing and HAI risk. A systematic review was undertaken. Electronic databases MEDLINE, PubMed, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched for studies published between January 1, 2000, and November 30, 2015.

RESULTS

Fifty-four articles were included in the review. The majority of studies examined the relationship between nurse staffing and HAIs (n = 50, 92.6%) and found nurse staffing variables to be associated with an increase in HAI rates (n = 40, 74.1%). Only 5 studies addressed non-nurse staffing, and those had mixed results. Physician staffing was associated with an increased HAI risk in 1 of 3 studies. Studies varied in design and methodology, as well as in their use of operational definitions and measures of staffing and HAIs.

CONCLUSION

Despite the lack of consistency of the included studies, overall, the results of this systematic review demonstrate that increased staffing is related to decreased risk of acquiring HAIs. More rigorous and consistent research designs, definitions, and risk-adjusted HAI data are needed in future studies exploring this area.

Performance Measurement of Nursing Care

Concerns about nurse staffing in hospitals, nursing's influence on patient safety and health care outcomes, and nurses' work environment (e.g., equipment failures, documentation burden) have led to increased interest in measuring and reporting nursing's performance. This article reviews recent efforts and issues involved in identifying a set of nursing-sensitive performance measures. Sustaining and strengthening current efforts requires developing measures that address all the domains of nursing, addressing technical issues needed to analyze the impact of nursing on patient safety and health care outcomes, developing data systems that provide the information needed to implement the model system, regularly improving the set of endorsed standards to reflect the most current science and empirical evidence, and persuading all health care stakeholders that measurement and reporting nursing-sensitive standards make a difference in the care and quality that are delivered. Each of these tasks requires substantial development work and construction and maintenance of the infrastructure to sustain the performance measurement efforts.

Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care

OBJECTIVES

To determine the association of hospital nursing skill mix with patient mortality, patient ratings of their care and indicators of quality of care.

DESIGN

Cross-sectional patient discharge data, hospital characteristics and nurse and patient survey data were merged and analysed using generalised estimating equations (GEE) and logistic regression models.

SETTING

Adult acute care hospitals in Belgium, England, Finland, Ireland, Spain and Switzerland.

PARTICIPANTS

Survey data were collected from 13 077 nurses in 243 hospitals, and 18 828 patients in 182 of the same hospitals in the six countries. Discharge data were obtained for 275 519 surgical patients in 188 of these hospitals.

MAIN OUTCOME MEASURES

Patient mortality, patient ratings of care, care quality, patient safety, adverse events and nurse burnout and job dissatisfaction.

RESULTS

Richer nurse skill mix (eg, every 10-point increase in the percentage of professional nurses among all nursing personnel) was associated with lower odds of mortality (OR=0.89), lower odds of low hospital ratings from patients (OR=0.90) and lower odds of reports of poor quality (OR=0.89), poor safety grades (OR=0.85) and other poor outcomes (0.80<OR<0.93), after adjusting for patient and hospital factors. Each 10 percentage point reduction in the proportion of professional nurses is associated with an 11% increase in the odds of death. In our hospital sample, there were an average of six caregivers for every 25 patients, four of whom were professional nurses. Substituting one nurse assistant for a professional nurse for every 25 patients is associated with a 21% increase in the odds of dying.

CONCLUSIONS

A bedside care workforce with a greater proportion of professional nurses is associated with better outcomes for patients and nurses. Reducing nursing skill mix by adding nursing associates and other categories of assistive nursing personnel without professional nurse qualifications may contribute to preventable deaths, erode quality and safety of hospital care and contribute to hospital nurse shortages.

Improving Nurse Staffing Measures: Discharge Day Measurement in “Adjusted Patient Days of Care”

Previous research cannot account for the discrepancy between registered nurse (RN) reports of understaffing and studies showing slight improvement. One reason may be that “adjusted patient days of care”(APDC) underestimates patient load. Using data from all Pennsylvania acute care general hospitals for the years 1994 through 1997, we found that APDC is underestimated by two hours. After adjusting APDC, we examined the difference in nurse staffing over the period 1991–2000 before and after the adjustment. We found a significant difference between unadjusted and adjusted measures. However, when applied to the changes in nurse staffing between 1991 and 2000, the difference was not enough to account for the discrepancy between reports and data. Other measurement and conceptual problems may exist in terms of patients' increasing acuity levels, patients' declining lengths of stay and the associated greater proportion of nurse time devoted to admission and discharge, and lack of recent data in some empirical studies.

Hospital Finances and Patient Safety Outcomes

Hospitals recently have experienced greater financial pressures. Whether these financial pressures have led to more patient safety problems is unknown. Using the Healthcare Cost and Utilization Project (HCUP) State Inpatient Data for Florida from 1996 to 2000, this study examines whether financial pressure at hospitals is associated with increases in the rate of patient safety events (e.g., medical errors) for major surgeries. Findings show that patients have significantly higher odds of having adverse patient safety events (nursing-related patient safety events, surgery-related patient safety events, and all likely preventable patient safety events) when hospital profit margins decline over time. The finding that a within-hospital erosion of hospital operating profits increases the rate of adverse patient safety events suggests that any cost-cutting efforts be carefully designed and managed.

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.

Predictors of Gaps in Patient Safety and Quality in U.S. Hospitals

OBJECTIVE

To explore predictors of gaps between observed and best possible Hospital Compare scores in U.S. hospitals.

DATA SOURCES

American Hospital Association Annual Survey; Area Resource Files; Centers for Medicare and Medicaid Services Medicare Provider and Analysis Review; and Hospital Compare data.

STUDY DESIGN

Using Stochastic Frontier Analysis and secondary cross-sectional data, gaps between the best possible and actual scores of Hospital Compare quality measures were estimated. Poisson regressions were used to ascertain financial, organizational, and market predictors of those gaps.

DATA EXTRACTION

Data were cleaned and matched based on hospital Medicare IDs. All U.S. hospitals that matched on analysis variables in 2007 were in the study (1,823-2,747, depending upon gap variable).

PRINCIPAL FINDINGS

Most hospitals have a greater than 10 percent gap in quality indicators. Payer mix, registered nurse staffing, size, case mix index, accreditation, being a teaching hospital, market competition, urban location, and region were strong predictors of gaps, although the direction of the association with gaps was not uniform across outcomes.

CONCLUSIONS

A significant percentage of hospitals have gaps between their best possible and observed quality scores. It may be better to use gap scores than observed scores in payments systems. More SFA research is needed to know how to lower gaps through changes in hospital and market characteristics.

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.

Associations of hospital characteristics with nosocomial pneumonia after cardiac surgery can impact on standardized infection rates

To identify hospital-level factors associated with post-cardiac surgical pneumonia for assessing their impact on standardized infection rates (SIRs), we studied 43 691 patients in a cardiac surgery registry (2001–2011) in 16 hospitals. In a logistic regression model for pneumonia following cardiac surgery, associations with hospital characteristics were quantified with adjustment for patient characteristics while allowing for clustering of patients by hospital. Pneumonia rates varied from 0·7% to 12·4% across hospitals. Seventy percent of variability in the pneumonia rate was attributable to differences in hospitals in their long-term rates with the remainder attributable to within-hospital differences in rates over time. After adjusting for patient characteristics, the pneumonia rate was found to be higher in hospitals with more registered nurses (RNs)/100 intensive-care unit (ICU) admissions [adjusted odds ratio (aOR) 1·2, P = 0·006] and more RNs/available ICU beds (aOR 1·4, P < 0·001). Other hospital characteristics had no significant association with pneumonia. SIRs calculated on the basis of patient characteristics alone differed substantially from the same rates calculated on the basis of patient characteristics and the hospital characteristic of RNs/100 ICU admissions. Since SIRs using patient case-mix information are important for comparing rates between hospitals, the additional allowance for hospital characteristics can impact significantly on how hospitals compare.

Studies on nurse staffing and health care-associated infection: methodologic challenges and potential solutions

BACKGROUND

Researchers have been studying hospital nurse staffing in relation to health care-associated infections (HAIs) for >2 decades, and the results have been mixed. We summarized published research examining these issues, critically analyzed the commonly used approaches, identified methodologic challenges, proposed potential solutions, and suggested the possible benefits of applying an electronic health record (EHR) system.

METHODS

A scoping review was conducted using MEDLINE and CINAHL from 1990 onward. Original research studies examining relationships between nurse staffing and HAIs in the hospital setting and published in peer-reviewed English-language journals were selected.

RESULTS

A total of 125 articles and abstracts were identified, and 45 met inclusion criteria. Findings from these studies were mixed. The methodologic challenges identified included database selection, variable measurement, methods to link the nurse staffing and HAI data, and temporality. Administrative staffing data were often not precise or specific. The most common method to link staffing and HAI data did not assess the temporal relationship. We proposed using daily staffing information 2-4 days prior to HAI onset linked to individual patient HAI data.

CONCLUSION

To assess the relationships between nurse staffing and HAIs, methodologic decisions are necessary based on what data are available and feasible to obtain. National efforts to promote an EHR may offer solutions for future studies by providing more comprehensive data on HAIs and nurse staffing.

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.

Models of care choices in today’s nursing workplace: where does team nursing sit?

This paper provides an overview of the developmental history of models of care (MOC) in nursing since Florence Nightingale introduced nurse training programs in a drive to make nursing a discipline-based career option. The four principal choices of models of nursing care delivery (primary nursing, individual patient allocation, team nursing and functional nursing) are outlined and discussed, and recent MOC literature reviewed. The paper suggests that, given the ways work is being rapidly reconfigured in healthcare services and the pressures on the nursing workforce projected into the future, team nursing seems to offer the best solutions.

Modeling hospital-acquired pressure ulcer prevalence on medical-surgical units: nurse workload, expertise, and clinical processes of care

OBJECTIVE

This study modeled the predictive power of unit/patient characteristics, nurse workload, nurse expertise, and hospital-acquired pressure ulcer (HAPU) preventive clinical processes of care on unit-level prevalence of HAPUs.

DATA SOURCES

Seven hundred and eighty-nine medical-surgical units (215 hospitals) in 2009.

STUDY DESIGN

Using unit-level data, HAPUs were modeled with Poisson regression with zero-inflation (due to low prevalence of HAPUs) with significant covariates as predictors.

DATA COLLECTION/EXTRACTION METHODS

Hospitals submitted data on NQF endorsed ongoing performance measures to CALNOC registry.

PRINCIPAL FINDINGS

Fewer HAPUs were predicted by a combination of unit/patient characteristics (shorter length of stay, fewer patients at-risk, fewer male patients), RN workload (more hours of care, greater patient [bed] turnover), RN expertise (more years of experience, fewer contract staff hours), and processes of care (more risk assessment completed).

CONCLUSIONS

Unit/patient characteristics were potent HAPU predictors yet generally are not modifiable. RN workload, nurse expertise, and processes of care (risk assessment/interventions) are significant predictors that can be addressed to reduce HAPU. Support strategies may be needed for units where experienced full-time nurses are not available for HAPU prevention. Further research is warranted to test these finding in the context of higher HAPU prevalence.

Remodeling a broken system through hospital-payer partnerships

One way to fix our broken system is to strengthen hospital-payer partnerships, which will help shift caregiver focus from volume to value.

Concurrent and lagged effects of registered nurse turnover and staffing on unit-acquired pressure ulcers

OBJECTIVE

We examined the concurrent and lagged effects of registered nurse (RN) turnover on unit-acquired pressure ulcer rates and whether RN staffing mediated the effects.

DATA SOURCES/SETTING

Quarterly unit-level data were obtained from the National Database of Nursing Quality Indicators for 2008 to 2010. A total of 10,935 unit-quarter observations (2,294 units, 465 hospitals) were analyzed.

METHODS

This longitudinal study used multilevel regressions and tested time-lagged effects of study variables on outcomes.

FINDINGS

The lagged effect of RN turnover on unit-acquired pressure ulcers was significant, while there was no concurrent effect. For every 10 percentage-point increase in RN turnover in a quarter, the odds of a patient having a pressure ulcer increased by 4 percent in the next quarter. Higher RN turnover in a quarter was associated with lower RN staffing in the current and subsequent quarters. Higher RN staffing was associated with lower pressure ulcer rates, but it did not mediate the relationship between turnover and pressure ulcers.

CONCLUSIONS

We suggest that RN turnover is an important factor that affects pressure ulcer rates and RN staffing needed for high-quality patient care. Given the high RN turnover rates, hospital and nursing administrators should prepare for its negative effect on patient outcomes.

Using theory and evidence to drive measurement of patient, nurse and organizational outcomes of professional nursing practice

An evolving body of literature suggests that the implementation of evidence based clinical and professional guidelines and strategies can improve patient care. However, gaps exist in our understanding of the effect of implementation of guidelines on outcomes, particularly patient outcomes. To address this gap, a measurement framework was developed to assess the impact of an organization-wide implementation of two nursing-centric best-practice guidelines on patient, nurse and organizational level outcomes. From an implementation standpoint, we anticipate that our data will show improvements in the following: (i) patient satisfaction scores and safety outcomes; (ii) nurses ability to value and engage in evidence based practice; and (iii) organizational support for evidence-informed nursing care that results in quality patient outcomes. Our measurement framework and multifaceted methodological approach outlined in this paper might serve as a blueprint for other organizations in their efforts to evaluate the impacts associated with implementation of clinical and professional guidelines and best practices.

The effects of nurse staffing on hospital financial performance: competitive versus less competitive markets

BACKGROUND

Hospitals facing financial uncertainty have sought to reduce nurse staffing as a way to increase profitability. However, nurse staffing has been found to be important in terms of quality of patient care and nursing-related outcomes. Nurse staffing can provide a competitive advantage to hospitals and as a result of better financial performance, particularly in more competitive markets.

PURPOSE

In this study, we build on the Resource-Based View of the Firm to determine the effect of nurse staffing on total profit margin in more competitive and less competitive hospital markets in Florida.

METHODOLOGY/APPROACH

By combining a Florida statewide nursing survey with the American Hospital Association Annual Survey and the Area Resource File, three separate multivariate linear regression models were conducted to determine the effect of nurse staffing on financial performance while accounting for market competitiveness. The analysis was limited to acute care hospitals.

FINDINGS

Nurse staffing levels had a positive association with financial performance (β = 3.3, p = .02) in competitive hospital markets, but no significant association was found in less competitive hospital markets.

PRACTICE IMPLICATIONS

Hospitals in more competitive hospital markets should reconsider reducing nursing staff, as these cost-cutting measures may be inefficient and negatively affect financial performance.

Evaluation of nurse staffing levels and outcomes under the government--recommended staffing levels in Korea

AIM

This study aimed to evaluate registered nurse staffing levels and outcomes enforced by the current Korean nursing regulations.

BACKGROUND

Registered nurse staffing levels are closely related to patient and nurse outcomes. Thus, the government's policy regarding nursing staffing has a practical impact, and better policies could lead to more appropriate nurse staffing. The actual evaluation of the government-recommended staffing levels in Korea is paramount for the establishment of a realistic and effective system that promotes quality care and patient safety.

METHOD

The participating hospital operated under the government-recommended staffing levels (Grade 2 of the Graded Fee of Nursing Management Inpatient System). For unit-level evaluations, one surgical unit was chosen and its staffing level was changed by assigning one additional registered nurse for 6 months. Length of hospitalisation, incidents of death, overtime hours and nursing job performance were measured prior to and after the addition of the extra staff.

RESULT

After 6 months, the length of patient hospitalisation and registered nurse overtime hours reduced and nurse job performance scores in the unit analysed improved.

CONCLUSIONS AND IMPLICATIONS FOR NURSING MANAGEMENT

The results demonstrated that increasing the number of registered nurses beyond the current government-recommended staffing level improves patient and nurse outcomes. This indicates the importance and value of empirically assessing the need for changes in the recommended nurse staffing levels to develop appropriate, realistic and effective policies.

Workload as a Determinant of Staff Injury in Intermediate Care

Care aides (CAs) and licensed practical nurses (LPNs) in intermediate care (IC) facilities experience high risks of injury. Workload measures were examined in eight IC facilities to ascertain their relationships with musculoskeletal injury rates, pain, burnout, and self-reported health. Workload was measured using (1) focus groups and telephone interviews to obtain CA/LPN perceptions; (2) systematic observation (numbers of tasks performed in shift); and (3) CA-to-resident staffing ratios. Controlling for resident dependency and facility funding, all workload measures were correlated with staff injury rates and burnout. Facilities with low injury rates had better CA/LPN-to-resident staffing ratios and fewer tasks. The differences in staffing reflected differences in how organizations prioritized and allocated resources. Thus, workload is an important determinant of injuries and increased staffing levels correlate with decreased injuries.

Successful reduction of hospital-acquired methicillin-resistant Staphylococcus aureus in a urology ward: a 10-year study

BACKGROUND

To eradicate hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) using a stepwise infection control strategy that includes an avoidance of antimicrobial prophylaxis (AMP) based on surgical wound classification and an improvement in operative procedures in gasless single-port urologic surgery.

METHODS

The study was conducted at an 801-bed university hospital. Since 2001, in the urology ward, we have introduced the stepwise infection control strategy. In 2007, surveillance cultures for MRSA in all urological patients were commenced. The annual incidence of MRSA was calculated as a total number of newly identified MRSA cases per 1,000 patient days. Trend analysis was performed using a Poisson regression.

RESULTS

Over the study period, 139,866 patients, including 10,201 urology patients, were admitted to our hospital. Of these patients, 3,719 patients, including 134 ones in the urology ward, were diagnosed with MRSA throughout the entire hospital. Although the incidence of MRSA increased throughout the entire hospital (p = 0.002), it decreased significantly in the urology ward (p < 0.0001). Of the 134 cases, 45 (33.6%) were classified as "imported," and 89 (66.4%) as "acquired." In the urology ward, the incidence of acquired MRSA decreased significantly over time (p < 0.0001), whereas the incidence of imported MRSA did not change over time (p = 0.66). A significant decrease (p < 0.0001) in the incidence of clinically significant MRSA infection over time was found.

CONCLUSIONS

Stepwise infection control strategy that includes a reduction or avoidance of antimicrobial prophylaxis in minimally invasive surgery can contribute to a reduction in hospital-acquired MRSA.

TRIAL REGISTRATION

Current study has approved by the institutional ethical review board (No.1141).

Relationship between structural characteristics and outcome quality indicators at health care facilities for the elderly requiring long-term care in Japan from a nationwide survey

AIM

To clarify the performance situation of selected quality indicators: falls, pressure ulcers and dehydration, at health care facilities for the elderly in Japan, and what structural characteristics are related to them.

METHODS

The operational population consisted of 1057 institutionalized users (approximately 10 randomly selected per facility) from a survey answered by the care staff. The facilities were divided into two groups according to their prevalence of negative outcomes (falls, pressure ulcers, dehydration): the best 25% (the very good performers) and the remaining 75% (not so good performers). Logistic regression analysis was carried out to examine the relationship between the structure characteristics of the facilities and their performance regarding each quality indicator.

RESULTS

After controlling for sex, years of operation and average age of the users, our results showed a beneficial significant relationship between falls and the total number of nurses per 100 users with an adjusted odds ratio (AOR) of 0.77 (95% CI 0.59-0.98); In contrast, for pressure ulcers, harmful associations between a higher number of registered nurses (AOR 1.23, 95% CI 1.01-1.05) and the availability of 24-h nurse staffing (AOR 4.95, 95% CI 1.19-24.91) were found; regarding dehydration, we did not find any related staffing characteristics.

CONCLUSION

Nursing staff might be considered as a potentially related variable in the quality of care in health care facilities for the elderly. The present study is the first to show a relationship between structural characteristics and quality outcomes in health care facilities for the elderly.

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.