The effects of nurse staffing on adverse events, morbidity, mortality, and medical costs

Optimizing Geriatric Venipuncture: A DRG-Compatible Team-Based Reengineering Strategy

Objective

This study evaluates a reengineered intervention aimed at improving the clinical management of intravenous indwelling needles in geriatric patients, focusing on cost-efficiency within the Diagnosis-Related Group (DRG) payment framework.

Methods

The intervention was assessed through a comparative study involving 387 elderly patients in the Geriatric Department of Xuanwu Hospital, between June 2021 and March 2022. The study contrasted outcomes between patients treated before and after implementing a new team-based management protocol in November 2021.

Results

Findings indicate enhanced first-attempt venipuncture success, reduced consumable costs, and decreased complication rates in the post-intervention group (P < 0.001), compared to controls.

Conclusion

The intervention demonstrates significant benefits in venipuncture efficiency, cost reduction, and patient safety, suggesting its potential for broader adoption in geriatric care.

Visibility-based layout of a hospital unit - An optimization approach

A patient fall is one of the adverse events in an inpatient unit of a hospital that can lead to disability and/or mortality. The medical literature suggests that increased visibility of patients by unit nurses is essential to improve patient monitoring and, in turn, reduce falls. However, such research has been descriptive in nature and does not provide an understanding of the characteristics of an optimal inpatient unit layout from a visibility-standpoint. To fill this gap, we adopt an interdisciplinary approach that combines the human field of view with facility layout design approaches. Specifically, we propose a bi-objective optimization model that jointly determines the optimal (i) location of a nurse in a nursing station and (ii) orientation of a patient's bed in a room for a given layout. The two objectives are maximizing the total visibility of all patients across patient rooms and minimizing inequity in visibility among those patients. We consider three different layout types, L-shaped, I-shaped, and Radial; these shapes exhibit the section of an inpatient unit that a nurse oversees. To estimate visibility, we employ the ray casting algorithm to quantify the visible target in a room when viewed by the nurse from the nursing station. The algorithm considers nurses' horizontal visual field and their depth of vision. Owing to the difficulty in solving the bi-objective model, we also propose a Multi-Objective Particle Swarm Optimization (MOPSO) heuristic to find (near) optimal solutions. Our findings suggest that the Radial layout appears to outperform the other two layouts in terms of the visibility-based objectives. We found that with a Radial layout, there can be an improvement of up to 50% in equity measure compared to an I-shaped layout. Similar improvements were observed when compared to the L-shaped layout as well. Further, the position of the patient's bed plays a role in maximizing the visibility of the patient's room. Insights from our work will enable understanding and quantifying the relationship between a physical layout and the corresponding provider-to-patient visibility to reduce adverse events.

Quantifying Workload and Stress in Intensive Care Unit Nurses: Preliminary Evaluation Using Continuous Eye-Tracking

OBJECTIVE

(1) To assess mental workloads of intensive care unit (ICU) nurses in 12-hour working shifts (days and nights) using eye movement data; (2) to explore the impact of stress on the ocular metrics of nurses performing patient care in the ICU.

BACKGROUND

Prior studies have employed workload scoring systems or accelerometer data to assess ICU nurses' workload. This is the first naturalistic attempt to explore nurses' mental workload using eye movement data.

METHODS

Tobii Pro Glasses 2 eye-tracking and Empatica E4 devices were used to collect eye movement and physiological data from 15 nurses during 12-hour shifts (252 observation hours). We used mixed-effect models and an ordinal regression model with a random effect to analyze the changes in eye movement metrics during high stress episodes.

RESULTS

While the cadence and characteristics of nurse workload can vary between day shift and night shift, no significant difference in eye movement values was detected. However, eye movement metrics showed that the initial handoff period of nursing shifts has a higher mental workload compared with other times. Analysis of ocular metrics showed that stress is positively associated with an increase in number of eye fixations and gaze entropy, but negatively correlated with the duration of saccades and pupil diameter.

CONCLUSION

Eye-tracking technology can be used to assess the temporal variation of stress and associated changes with mental workload in the ICU environment. A real-time system could be developed for monitoring stress and workload for intervention development.

Association between nurse staffing level in intensive care settings and hospital-acquired pneumonia among surgery patients: result from the Korea National Health Insurance cohort

This study examined the association between the number of nursing staff in intensive care units (ICUs) and hospital-acquired pneumonia (HAP) among surgical patients in South Korea. Data were obtained between 2008 and 2019 from the Korean National Health Insurance Service Cohort Database; 37,706 surgical patients who received critical care services were included in the analysis. Patients with a history of pneumonia 1 year prior to surgery or those who had undergone lung-related surgery were excluded. The ICU nursing management fee is an admission fee that varies based on the grading determined by nurse-to-bed ratio. Using this grading system, we classified four groups from the highest to the lowest level based on the proportion of beds to nurses (high, high-mid, mid-low, and low group). HAP was defined by the International Classification of Disease, 10th revision (ICD-10) code. Multilevel logistic regression was used to investigate the relationship between the level of ICU nurse staffing and pneumonia, controlling for variables at the individual and hospital levels. Lower levels of nurse staffing were associated with a greater incidence of HAP than higher levels of nurse staffing (mid-high, OR: 1.33, 95% CI: 1.12-1.57; mid-low, OR: 1.61, 95% CI: 1.27-2.04; low, OR: 2.13, 95% CI: 1.67-2.71). The intraclass correlation coefficient value was 0.177, and 17.7% of the variability in HAP was accounted for by the hospital. Higher ICU nursing management fee grades (grade 5 and above) in general and hospital settings were significantly associated with an increased risk of HAP compared to grade 1 admissions. Similarly, in tertiary hospitals, grade 2 and higher ICU nursing management fees were significantly associated with an increased risk of HAP compared to grade 1 admissions. Especially, a lower level of nurse staffing was associated with bacterial pneumonia but not pneumonia due to aspiration. In conclusion, this study found an association between the level of ICU nurse staffing and HAP among surgical patients. A lower level of nurse staffing in the ICU was associated with increased rates of HAP among surgical patients. This indicates that having fewer beds assigned to nurses in the ICU setting is a significant factor in preventing HAP, regardless of the size of the hospital.

Patient-to-nurse ratios: Balancing quality, nurse turnover, and cost

We consider the problem of setting appropriate patient-to-nurse ratios in a hospital, an issue that is both complex and widely debated. There has been only limited effort to take advantage of the extensive empirical results from the medical literature to help construct analytical decision models for developing upper limits on patient-to-nurse ratios that are more patient- and nurse-oriented. For example, empirical studies have shown that each additional patient assigned per nurse in a hospital is associated with increases in mortality rates, length-of-stay, and nurse burnout. Failure to consider these effects leads to disregarded potential cost savings resulting from providing higher quality of care and fewer nurse turnovers. Thus, we present a nurse staffing model that incorporates patient length-of-stay, nurse turnover, and costs related to patient-to-nurse ratios. We present results based on data collected from three participating hospitals, the American Hospital Association (AHA), and the California Office of Statewide Health Planning and Development (OSHPD). By incorporating patient and nurse outcomes, we show that lower patient-to-nurse ratios can potentially provide hospitals with financial benefits in addition to improving the quality of care. Furthermore, our results show that higher policy patient-to-nurse ratio upper limits may not be as harmful in smaller hospitals, but lower policy patient-to-nurse ratios may be necessary for larger hospitals. These results suggest that a "one ratio fits all" patient-to-nurse ratio is not optimal. A preferable policy would be to allow the ratio to be hospital-dependent.

The effects of physicians on operational and financial performance in United States hospitals: staffing, human capital and knowledge spillovers

Purpose

The authors examine how physician staffing, human capital and knowledge spillovers are related to multiple dimensions of hospital operational and financial performance at the organizational level.

Design/methodology/approach

The authors use a data set assembled from multiple sources for more than 1,300 US hospitals and employ hierarchical linear regression to test this study’s hypotheses. The authors use multiple quality, efficiency and financial measures of performance for these hospitals.

Findings

The authors find that higher levels of staffing, skills and knowledge spillovers associated with physicians were positively associated with multiple dimensions of hospital performance. The authors find linear and nonlinear relationships between experience and performance, with the relationships primarily negative, and nonlinear relationships between spillovers and quality performance.

Practical implications

Hospital managers should consider increasing physician staffing levels if possible. In addition, the overall Final MIPS Score from the Centers for Medicare and Medicaid Services might be included as a factor in determining which physicians practice in a hospital. Finally, if possible, encouraging physicians to practice at multiple hospitals will likely be beneficial to hospital performance.

Originality/value

This study’s findings are original in that they explore how physician-specific staffing and human capital, which have received comparatively little attention in the literature, are related to several different dimensions of hospital-level operational and financial performance. To the best of the authors’ knowledge, this paper is also the first to examine the relationship between the construct of physician knowledge spillovers and hospital-level operational and financial performance.

Healthcare Associated Infections, Nurse Staffing, and Financial Performance

Healthcare associated infections (HAIs) are a concern to patients, hospital administrators and policymakers. For over than a decade, efforts have been made to hold hospitals accountable for the costs of HAIs. This study uses contingency theory as a framework to examine the association between HAIs and hospital financial performance. We use publicly available data on 2059 hospitals in 2014 to 2016 that include HAIs, staffing financial performance, and hospital and hospital market characteristics. The key independent variables are available infection rates and nurse staffing. The dependent variables are indicators of financial performance: operating margin, total margin, and days cash on hand. We find nearly identical negative direct associations between infections and operating margins and total margins (-0.07%), and positive associations between the interaction of infections and nurse staffing (0.05%). A 10% higher infection rate would be predicted to be associated with only a 0.2% lower profit margin. The associations between HAIs, nurse staffing and days cash on hand were insignificantly different from zero.

Cost-quality tradeoff in nurse staffing: an exploration of USA hospitals facing market competition

Purpose

This research aims to explore the fine-grained relationships between nurse staffing and hospital operational performance with respect to care quality and operating costs. The authors also investigate the moderation effect of competition in local hospital markets on these relationships.

Design/methodology/approach

A six-year panel data is assembled from five separate sources to obtain information of 2,524 USA hospitals. Fixed-effect (FE) models are used to test the proposed hypotheses.

Findings

First, nurse staffing is initially associated with improved care quality until nurse staffing reaches a turning point, beyond which nurse staffing is associated with worse care quality. Second, a similar pattern applies to the relationship between nurse staffing and operating costs, although the turning point is at a much lower nurse staffing level. Third, market competition moderates the relationship between nurse staffing and care quality so that the turning point of nurse staffing will be higher when the degree of competition is higher. This shift of turning point is also observed in the relationship between nurse staffing and operating costs.

Practical implications

The study identifies three ranges of nurse staffing in which hospitals will likely experience simultaneous improvements, a tradeoff or simultaneous decline of care quality and operating costs when investing in more nursing capacity. Hospitals should adjust nurse staffing levels to the right directions to achieve better care or reduce operating costs.

Originality/value

Nurses constitute the largest provider group in hospitals and profoundly impact care quality and operating costs among all health care professionals. Optimizing the level of nurse staffing, therefore, can significantly impact the care quality and operating costs of hospitals.

Context specific realities and experiences of nurses and midwives in basic emergency obstetric and newborn care services in two district hospitals in Rwanda: a qualitative study

BACKGROUND

In low and middle-income countries, nurses and midwives are the frontline healthcare workers in obstetric care. Insights into experiences of these healthcare workers in managing obstetric emergencies are critical for improving the quality of care. This article presents such insights, from the nurses and midwives working in Rwandan district hospitals, who reflected on their experiences of managing the most common birth-related complications; postpartum hemorrhage (PPH) and newborn asphyxia. Rwanda has made remarkable progress in obstetric care. However, challenges remain in the provision of high-quality basic emergency obstetric and newborn care (BEmONC). This study is a qualitative part of a broader research project about implementation of an mLearning and mHealth decision support tool in BEmONC services in Rwanda.

METHODS

In this exploratory qualitative aspect of the research, four focus group discussions (FGDs) with 26 nurses and midwives from two district hospitals in Rwanda were conducted. Each FGD was made up of two parts. The first part focused on the participants' reflections on the research results (from the previous study), while the second part explored their experiences of delivering obstetric care services. The research results included: survey results reflecting their knowledge and skills of PPH management and of neonatal resuscitation (NR); and findings from a six-month record review of PPH management and NR outcomes, from the district hospitals under study. Data were analyzed using hybrid thematic analysis.

RESULTS

The analysis revealed three main themes: (1) reflections to the baseline research results, (2) self-reflection on the current practices, and (3) contextual factors influencing the delivery of BEmONC services. Nurses and midwives felt that the presented findings were a true reflection of the reality and offered diverse explanations for the results. The participants' narratives of lived experiences of providing BEmONC services are also presented.

CONCLUSION

The insights of nurses and midwives regarding the management of birth-related complications revealed multi-faceted factors that influence the quality of their obstetric care. Even though the study was focused on PPH management and NR, the resulting recommendations to improve quality of care could benefit the broader field of maternal and child health, particularly in low and middle-income countries.

Price and income effects of hospital reimbursements

Health insurance systems in many countries reimburse hospitals through fixed prices based on the diagnosis-related groups (DRGs) of patients. We quantify the effects of price and income changes for the full spectrum of hospital services as average and heterogeneous elasticities of quantities (number of admissions) and quality-related outcomes. For our empirical analysis, we use data on over 160 million hospital admissions, constituting the universe of hospital admissions in Germany between 2005 and 2016. Our identification strategy is based on instruments exploiting a two-year lag in regulatory price setting. The strategy lends itself to a placebo test demonstrating that our instruments do not have substantive anticipatory direct effects. We find that the compensated own-price elasticity of quantity is positive (0.2), while the income elasticity is negative (-0.15). On net, increasing all prices increases costs due to a behavioral response of larger quantities in addition to the mechanical increase.

Evolving Factors in Hospital Safety: A Systematic Review and Meta-Analysis of Hospital Adverse Events

OBJECTIVE

This study aimed to estimate the frequency of hospital adverse events (AEs) and explore the rate of AEs over time, and across and within hospital populations.

METHODS

Validated search terms were run in MEDLINE and EMBASE; gray literature and references of included studies were also searched. Studies of any design or language providing an estimate of AEs within the hospital were eligible. Studies were excluded if they only provided an estimate for a specific AE, a subgroup of hospital patients or children. Data were abstracted in duplicate using a standardized data abstraction form. Study quality was assessed using the Newcastle-Ottawa Scale. A random-effects meta-analysis estimated the occurrence of hospital AEs, and meta-regression explored the association between hospital AEs, and patient and hospital characteristics.

RESULTS

A total of 45,426 unique references were identified; 1,265 full-texts were reviewed and 94 studies representing 590 million admissions from 25 countries from 1961 to 2014 were included. The incidence of hospital AEs was 8.6 per 100 patient admissions (95% confidence interval [CI], 8.3 to 8.9; I2 = 100%, P < 0.001). Half of the AEs were preventable (52.6%), and a third resulted in moderate/significant harm (39.7%). The most evaluated AEs were surgical AEs, drug-related AEs, and nosocomial infections. The occurrence of AEs increased by year (95% CI, -0.05 to -0.04; P < 0.001) and patient age (95% CI = -0.15 to -0.14; P < 0.001), and varied by country income level and study characteristics. Patient sex, hospital type, hospital service, and geographical location were not associated with AEs.

CONCLUSIONS

Hospital AEs are common, and reported rates are increasing in the literature. Given the increase in AEs over time, hospitals should reinvest in improving hospital safety with a focus on interventions targeted toward the more than half of AEs that are preventable.

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 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.

Novice Nurses' Communication Skills When Addressing Aggression in Individuals Experiencing Psychosis: The Role of Emotional Regulation Capacity

Effective nursing practice is linked to a nurse's ability to regulate emotions and effectively communicate with patients. Novice nurses can feel unprepared when approaching individuals with psychosis who show aggressive behaviors. The current descriptive correlational study aimed to examine relationships among novice nurses' emotional regulation (ER) capacity, length of service, and communication skills, and investigate the predictive capacity of ER on communication skills in dealing with aggression among individuals with psychosis. A convenience sample of 133 novice nurses was obtained. Nurses who had been working for 19 to 24 months demonstrated significantly higher overall communication skills than those who had been working for 12 to 18 months and those who had been working <12 months (mean = 45.05 [SD = 10.89], mean = 41.43 [SD = 12.16], and mean = 38.44 [SD = 9.33], respectively; p = 0.03). In addition, a strong positive correlation was detected between ER strategies and communication skills. ER strategies were identified as independent precursors of novice nurses' communication skills. Incorporating ER and communication skills training in mental health nursing curricula is recommended. [Journal of Psychosocial Nursing and Mental Health Services, xx(xx), xx-xx.].

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.

Leader-member exchange fosters nurses' job and life satisfaction: The mediating effect of job crafting

This study aims to evaluate the effects of leader-member exchange (LMX) on job and life satisfaction among nurses in China and to examine the mediating effect of individual and collaborative job crafting between LMX and job and life satisfaction. The study recruited 263 nurses who worked in hospitals in Zhejiang province, China. A set of self-administered questionnaires were used to measure the variables of LMX, job crafting, job and life satisfaction. The data was analyzed using the partial least square structural equation modelling (PLS-SEM). The results reveal that LMX has a significant positive influence on job crafting and job satisfaction. Collaborative job crafting has a significant positive influence on the job satisfaction of nurses, whereas individual job crafting does not. Moreover, LMX will affect job satisfaction and life satisfaction through a partial mediating effect of both individual and collaborative job crafting. Finally, the article discusses the academically and practical implications, and also provide some suggestions and directions for the future research.

Staffing levels and nursing-sensitive patient outcomes: Umbrella review and qualitative study

Objective

To derive a comprehensive list of nursing‐sensitive patient outcomes (NSPOs) from published research on nurse staffing levels and from expert opinion.

Data Sources/Study Setting

Published literature reviews and their primary studies analyzing the link between nurse staffing levels and NSPOs and interviews with 16 experts on nursing care.

Study Design

Umbrella review and expert interviews.

Data Collection/Extraction Methods

We screened three electronic databases for literature reviews on the association between nurse staffing levels and NSPOs. After screening 430 potentially relevant records, we included 15 literature reviews, derived a list of 22 unique NSPOs from them, and ranked these in a systematic fashion according to the strength of evidence existing for their association with nurse staffing. We extended this list of NSPOs based on data from expert interviews.

Principal Findings

Of the 22 NSPOs discussed in the 15 included literature reviews, we rated the strength of evidence for four as high, for five as moderate, and for 13 outcomes as low. Four additional NSPOs that have not been considered in literature were identified through expert interviews.

Conclusions

We identified strong evidence for a significant association between nurse staffing levels and NSPOs. Our results may guide researchers in selecting NSPOs they might wish to prioritize in future studies. In particular, rarely studied NSPOs as well as NSPOs that were only identified through expert interviews but have not been considered in literature so far should be subject to further research.

Impact of the weekday of the first intensity-modulated radiotherapy treatment on the survival outcomes of patients with nasopharyngeal carcinoma: A multicenter cohort study

BACKGROUND

This study's purpose was to assess whether the weekday on which intensity-modulated radiotherapy (IMRT) is initiated influences survival outcomes in patients with nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

A total of 1440 patients with NPC who received IMRT were enrolled in this study between January 2010 and June 2016. The patients were divided into five groups according to the weekday of their first radiotherapy treatment. Group 1 (n = 322), Group 2 (n = 322), Group 3 (n = 286), Group 4 (n = 292) and Group 5 (n = 218) received first radiotherapy on Monday, Tuesday, Wednesday, Thursday and Friday respectively. Differences in the rates of overall survival (OS), disease-free survival (DFS), loco-regional relapse-free survival (LRRFS) and distant metastasis-free survival (DMFS) were compared among the five groups using the Kaplan-Meier method and Cox regression models.

RESULTS

No significant differences were found in OS, DFS, LRRFS or DMFS among the five groups. The Cox regression analysis showed that the weekday on which the radiotherapy was initiated was not an independent predictor of OS (Hazard Ratio [HR], 1.056; 95%CI: 0.959-1.164, P = 0.268), DFS (HR, 1.067; 95% CI: 0.980-1.161, P = 0.137), LRRFS (HR, 1.069; 95% CI: 0.914-1.249, P = 0.404) and DMFS (HR, 1.027; 95% CI: 0.929-1.134, P = 0.607). The subgroup analysis showed no significant differences among the five groups.

CONCLUSIONS

This study showed that the day of the week that patients with nasopharyngeal carcinoma begin radiotherapy has no effect on their survival outcomes.

Factors associated with length of stay and death in tube-fed patients: A cross-sectional multicentre study

OBJECTIVES

To analyse the factors associated with length of stay (LOS) and death in nasogastric/nasoenteric tube (NG/NET)-fed patients.

DESIGN

A cross-sectional multicentre study.

METHOD

Data collection took place from October 2017-April 2019, and the sample consisted of 365 participants from seven Brazilian hospitals. Demographic, clinical and therapeutic data were collected from the patients' medical records. Data analysis was performed using bivariate and multivariate tests, considering a significance level of p<.05.

RESULTS

Most patients were male, older adults, with high risk of death and highly dependent on nursing care. The LOS was associated with age, patient care complexity and length of NG/NET use. Death was associated with patient age. In the multivariate analysis, patients highly dependent on nursing care, and intensive and semi-intensive care had a greater chance of dying when compared with patients receiving minimal care. Screening for factors affecting LOS and death is important to plan effective nursing care.

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 Likert-Type scale for evaluating the “bottom line” of patient safety

The formally reported number of adverse events may be open to ambivalent interpretation – actual higher prevalence of adverse events versus a patient safety culture supporting reporting and learning. Many methods appearing in the literature that are not based on reporting systems struggle for adequately assess the precise level of prevalence of adverse events. Confronting this challenge in patient safety research, we suggest evaluating the perceived state of “almost no adverse events” in the ward, by using a short Likert- type scale we developed for this purpose. Some evidence for its reliability and validity are presented using two samples (99 head nurses, and 383 nurses). As was expected, leadership had a significant direct effect on the measured state of “almost no adverse events” as well as an indirect effect mediated successively by psychological safety, and safety behavior.

The effect of bed-to-nurse ratio on hospital mortality of critically ill children on mechanical ventilation: a nationwide population-based study

BACKGROUND

Despite the high workload of mechanical ventilation, there has been a lack of studies on the association between nurse workforce and mortality in mechanically ventilated patients. We evaluated the association of the bed-to-nurse ratio with mortality in ventilated pediatric patients admitted to an intensive care unit (ICU).

METHODS

We conducted a nationwide retrospective analysis by using the Korean National Health Insurance database, which categorizes the bed-to-nurse ratio into 9 grades according to the number of beds divided by the number of full-time equivalent registered nurses in a unit. Patients of ages between 28 days and 18 years were enrolled. Multiple admissions and transfers from other hospitals were excluded. We evaluated the odds ratios (ORs) of in-hospital mortality using 4 groups (Grade 1: bed-to-nurse < 0.50, Grade 2: < 0.63, Grade 3: < 0.77, Grade 4 or above > 0.77) with adjustment of patient factors, hospital factors, and treatment requirements.

RESULTS

Of the 27,849 patients admitted to ICU, 11,628 (41.8%) were on mechanical ventilation. The overall in-hospital mortality rates in Grade 1, Grade 2, Grade 3, and Grade 4 or above group were 4.5%, 6.8%, 6.9%, and 4.7%, respectively. The adjusted ORs (95% CI) for in-hospital mortality of mechanically ventilated patients in the Grade 2, Grade 3, and Grade 4 or above compared to those in Grade 1 were 2.73 (95% CI 1.51-4.95), 4.02 (95% CI 2.23-7.26), and 7.83 (4.07-15.07), respectively. However, for patients without mechanical ventilation, the adjusted ORs of in-hospital mortality were not statistically significant.

CONCLUSION

In mechanically ventilated patients, the adjusted mortality rate increased significantly, as the bed-to-nurse ratio of the ICU increased. Policies that limit the number of ventilated patients per nurse should be considered. Trial registration retrospectively registered.

The Association between Nursing Skill Mix and Mortality for Adult Medical and Surgical Patients: Protocol for a Systematic Review

Skill mix refers to the number and educational experience of nurses working in clinical settings. Authors have used several measures to determine the skill mix, which includes nurse-to-patient ratio and the proportion of baccalaureate-prepared nurses. Observational studies have tested the association between nursing skill mix and patient outcomes (mortality). To date, this body of research has not been subject to systematic review or meta-analysis. The aim of this study is to systematically review and meta-analyse observational and experimental research that tests the association between nursing skill mix and patient mortality in medical and surgical settings. We will search four key electronic databases—MEDLINE [OVID], EMBASE [OVID], CINAHL [EBSCOhost], and ProQuest Central (five databases)—from inception. Title, abstract, and full-text screening will be undertaken independently by at least two researchers using COVIDENCE review management software. We will include studies where the authors report an association between nursing skill mix and outcomes in adult medical and surgical inpatients. Extracted data from included studies will consist measures of nursing skill mix and inpatient mortality outcomes. A meta-analysis will be undertaken if there are at least two studies with similar designs, exposures, and outcomes. The findings will inform future research and workforce planning in health systems internationally.

The effect of different classification of hospitals on medical expenditure from perspective of classification of hospitals framework: evidence from China

Background

Different classification of hospitals (COH) have an important impact on medical expenditures in China. The objective of this study is to examine the impact of COH on medical expenditures with the hope of providing insights into appropriate care and resource allocation.

Methods

From the perspective of COH framework, using the Urban Employee Basic Medical Insurance (UEBMI) data of Chengdu City from 2011 to 2015, with sample size of 488,623 hospitalized patients, our study empirically analyzed the effect of COH on medical expenditure by multivariate regression modeling.

Results

The average medical expenditure was 5468.86 Yuan (CNY), the average expenditure of drug, diagnostic testing, medical consumables, nursing care, bed, surgery and blood expenditures were 1980.06 Yuan (CNY), 1536.27 Yuan (CNY), 500.01 Yuan (CNY), 166.23 Yuan (CNY), 221.98 Yuan (CNY), 983.18 Yuan (CNY) and 1733.21 Yuan (CNY) respectively. Patients included in the analysis were mainly elderly, with an average age of 86.65 years old. Female and male gender were split evenly. The influence of COH on total medical expenditures was significantly negative (p < 0.001). The reimbursement ratio of UEBMI had a significantly positive (p < 0.001) effect on various types of medical expenditures, indicating that the higher the reimbursement ratio was, the higher the medical expenditures would be.

Conclusions

COH influenced medical expenditures significantly. In consideration of reducing medical expenditures, the government should not only start from the supply side of healthcare services, but also focus on addressing the demand side.

Identifying optimal labor and delivery nurse staffing: The case of cesarean births and nursing hours

BACKGROUND

Numerous studies have identified a relationship between nurse staffing and adverse patient outcomes in medical / surgical patient populations. However, little is known about the impact of labor and delivery (L&D) nurse staffing and adverse birth outcomes, such as unintended cesarean delivery, in low-risk term-gestation women.

PURPOSE

We examined nurse staffing patterns on the likelihood of cesarean sections (C-sections) among low- risk, full gestation births and provided a testing framework to distinguish optimal from ineffective levels of nurse staffing.

METHODS

This retrospective descriptive study used hours of productive nursing time per delivery as the treatment variable to determine direct nursing time per delivery and its impact on the likelihood of a C-section. For comparisons, we also assessed the likelihood of augmentations and of inductions, as well as the number of neonatal intensive care unit (NICU) hours per birth. We limited our sample to those births between 37 and 42 weeks of gestation. Two complimentary models (the quadratic and piecewise regressions) distinguishing optimal staffing patterns from ineffective staffing patterns were developed. The study was implemented in eleven hospitals that are part of a large, integrated healthcare system in the Southwest.

DISCUSSION

While a simple linear regression of the likelihood of a C-section on nursing hours per delivery indicated no statistically distinguishable effect, our 'optimal staffing' model indicated that nurse staffing hours employed by using a large sample of hospitals were actually minimizing C-sections (robustness checks are provided using similar model comparisons for the likelihood of augmentation and induction, and NICU hours). Where the optimal staffing models did not appear to be effective for augmentations, inductions, and NICU hours, we found significant differences between facilities (i.e., significant fixed effects for hospitals). In all specifications, we also controlled for weeks of gestation, race, sex of the child, and mother's age.

Impacts of Occupational Cognitive Failure and Subjective Workload on Patient Safety Incidents among Intensive Care Units Nurses

BACKGROUND

Life-saving treatments and high-quality care techniques increase the opportunity for patient safety incidents in Intensive care unit.

AIMS

This descriptive correlation study aimed to determine the impacts of occupational cognitive failure and subjective workload on patient safety incidents among intensive care units nurses.

METHODS AND MATERIAL

One hundred seventy-six nurses working in intensive care units were included using census sampling. The data collection tools consisted of demographic and occupational data, standard questionnaires of subjective workload (NASA-TLX) and occupational cognitive failure (OCFQ), and a question about frequency of patient safety incidents. Data analysis was performed using Mann-Whitney and Kruskal-Wallis, Spearman rank correlation coefficient, and logistic regression tests.

RESULTS

Occupational cognitive failure (OR = 1.043), subjective workload in dimension of "performance" (OR = 0.982), age (OR = 0.947), and gender (OR = 3.726) were important predictive variables of patient safety incidents.

CONCLUSIONS

Nursing mangers and policymakers can consider the factors identified for staffing nurses and development of patient safety programs.

Number and Type of Complications Associated With Failure to Rescue in Trauma Patients

BACKGROUND

Failure to rescue (FTR) is becoming a ubiquitous metric of quality care. The aim of our study is to determine the type and number of complications associated with FTR after trauma.

METHODS

We reviewed the Trauma Quality Improvement Program including patients who developed complications after admission. Patients were divided as the following: "FTR" if the patient died or "rescued" if the patient did not die. Logistic regression was used to ascertain the effect of the type and number of complications on FTR.

RESULTS

A total of 25,754 patients were included with 972 identified as FTR. Logistic regression identified sepsis (odds ratio [OR] = 6.61 [4.72-9.27]), pneumonia (OR = 2.79 [2.15-3.64]), acute respiratory distress syndrome (OR = 4.6 [3.17-6.69]), and cardiovascular complications (OR = 24.22 [19.39-30.26]) as predictors of FTR. The odds ratio of FTR increased by 8.8 for every single increase in the number of complications.

CONCLUSIONS

Specific types of complications increase the odds of FTR. The overall complication burden will also increase the odds of FTR linearly.

LEVEL OF EVIDENCE

Level III Prognostic.

Improving practice and informing policy development: The impact of gerontological nursing research

Nurses have always approached the clinical care challenges they encounter with a combination of critical observation and a profound concern for human suffering. Beginning in earnest in the early 1980s, nurse researchers have pursued the answers to questions about the wellbeing of older adults, particularly those suffering from serious, chronic conditions. This paper offers three exemplars of nursing research domains that illustrate the creativity and commitment of nurse researchers seeking to understand and improve pervasive clinical problems experienced by older adults and to demonstrate the profound influence these activities have had on the evolution of the science and the quality of care for older adults. The impact of this work is reflected in practice protocols, institutional policies, government oversight, and improved outcomes for patients.

Greek hospital environments

PURPOSE

The purpose of this paper is three-fold: first, to assess nurse satisfaction levels with working environment (known as favourability) in five Greek public hospitals using the practice environment scale (PES); second, to compare perceptions among nurses employed in surgical and medical departments; and third, to examine relationships between perceptions and nurse educational level and experience.

DESIGN/METHODOLOGY/APPROACH

In total, 532 nurses from five major public hospitals in Greece completed the PES. Descriptive statistics, t-tests and Spearman correlations were employed to analyse the data.

FINDINGS

Nurses perceived their work settings as unfavourable in all five hospitals, with collegial nurse-physician relations emerging as the only positive factor. Compared to medical wards, surgical departments emerged as slightly more positive working environments. Work department notwithstanding, in some cases, education and experience levels affected their perceptions on management, poor care quality, limited nurse involvement in hospital affairs and nursing shortage.

PRACTICAL IMPLICATIONS

Hospital managers do not provide sufficient support for Greek nurses in their working environments.

ORIGINALITY/VALUE

The authors attempted to evaluate nursing practice environments in Greek hospitals, viewed from nurse perspectives. The authors identified insufficient support for nurses' working in these hospitals.

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.

Prevention of hospital-acquired pneumonia

PURPOSE OF REVIEW

Hospital-acquired pneumonia (HAP) is the leading cause of death from hospital-acquired infection. Little work has been done on strategies for prevention of HAP. This review aims to describe potential HAP prevention strategies and the evidence supporting them. Oral care and aspiration precautions may attenuate some risk for HAP. Oral and digestive decontamination with antibiotics may be effective but could increase risk for resistant organisms. Other preventive measures, including isolation practices, remain theoretical or experimental.

RECENT FINDINGS

Hospital-acquired pneumonia occurs because of pharyngeal colonization with pathogenic organisms and subsequent aspiration of these pathogens.

SUMMARY

Most potential HAP prevention strategies remain unproven.

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.

Disparities in the delivery of pediatric oncology nursing care by country income classification: International survey results

BACKGROUND

In 2014, a task force of the International Society of Paediatric Oncology (SIOP) Paediatric Oncology in Developing Countries Nursing Workgroup published six baseline standards to provide a framework for pediatric oncology nursing care in low- and lower-middle income countries (L/LMIC). We conducted an international survey in 2016-2017 to examine the association between country income level and nurses' resporting of conformity to the standards at their respective institutions.

PROCEDURE

Data from a cross-sectional web-based survey completed by nurses representing 54 countries were analyzed (N = 101). Responses were clustered by relevance to each standard and compared according to the 2017 World Bank-defined country income classification (CIC) of hospitals.

RESULTS

CIC and nurse-to-patient ratios in inpatient wards were strongly associated (P < 0.0001). Nurses in L/LMIC prepared chemotherapy more often (P < 0.0001) yet were less likely to have access to personal protective equipment such as nitrile gloves (P = 0.0007) and fluid-resistant gowns (P = 0.011) than nurses in high-resource settings. Nurses in L/LMIC were excluded more often from physician/caregiver meetings to discuss treatment options (P = 0.04) and at the time of diagnosis (P = 0.002). Key educational topics were missing from nursing orientation programs across all CICs. An association between CIC and the availability of written policies (P = 0.009) was found.

CONCLUSIONS

CIC and the ability to conform to pediatric oncology baseline nursing standards were significantly associated in numerous elements of the baseline standards, a likely contributor to suboptimal patient outcomes in L/LMIC. To achieve the goal of high-quality cancer care for children worldwide, nursing disparities must be addressed.

Variation in hospital charges in patients with external ventricular drains: comparison between the intensive care and surgical floor settings

OBJECTIVE

Placement of an external ventricular drain (EVD) is a common and potentially life-saving neurosurgical procedure, but the economic aspect of EVD management and the relationship to medical expenditure remain poorly studied. Similarly, interinstitutional practice patterns vary significantly. Whereas some institutions require that patients with EVDs be monitored strictly within the intensive care unit (ICU), other institutions opt primarily for management of EVDs on the surgical floor. Therefore, an ICU burden for patients with EVDs may increase a patient's costs of hospitalization. The objective of the current study was to examine the expense differences between the ICU and the general neurosurgical floor for EVD care.

METHODS

The authors performed a retrospective analysis of data from 2 hospitals within a single, large academic institution-the University of Washington Medical Center (UWMC) and Seattle Children's Hospital (SCH). Hospital charges were evaluated according to patients' location at the time of EVD management: SCH ICU, SCH floor, or UWMC ICU. Daily hospital charges from day of EVD insertion to day of removal were included and screened for days that would best represent baseline expenses for EVD care. Independent-samples Kruskal-Wallis analysis was performed to compare daily charges for the 3 settings.

RESULTS

Data from a total of 261 hospital days for 23 patients were included in the analysis. Ten patients were cared for in the UWMC ICU and 13 in the SCH ICU and/or on the SCH neurosurgical floor. The median values for total daily hospital charges were $19,824.68 (interquartile range [IQR] $12,889.73-$38,494.81) for SCH ICU care, $8,620.88 (IQR $6,416.76-$11,851.36) for SCH floor care, and $10,002.13 (IQR $8,465.16-$12,123.03) for UWMC ICU care. At SCH, it was significantly more expensive to provide EVD care in the ICU than on the floor (p < 0.001), and the daily hospital charges for the UWMC ICU were significantly greater than for the SCH floor (p = 0.023). No adverse clinical event related to the presence of an EVD was identified in any of the settings.

CONCLUSIONS

ICU admission solely for EVD care is costly. If safe EVD care can be provided outside of the ICU, it would represent a potential area for significant cost savings. Identifying appropriate patients for EVD care on the floor is multifactorial and requires vigilance in balancing the expenses associated with ICU utilization and optimal patient care.

The clinical significance of carbapenem-resistant Klebsiella pneumoniae rectal colonization in critically ill patients: from colonization to bloodstream infection

PURPOSE

To highlight the clinical significance of carbapenem-resistant Klebsiella pneumoniae (CRKP) rectal colonization by examining the risk factors for CRKP rectal colonization and subsequent bloodstream infection (BSI) in critically ill patients.

METHODOLOGY

Prospective study of CRKP rectal colonization in an intensive care unit (ICU) during a 39-month period. CRKP strains isolated from both the blood cultures and corresponding rectal specimens (n=96) of patients were screened by PCR for the presence of antibiotic resistance-associated genes. Molecular analyses were conducted to investigate the clonal relatedness of CRKP strains from the rectal and blood specimens.

RESULTS

Among the 498 patients, 226 were rectally colonized by CRKP, 48 of whom developed a CRKP BSI. The median time from hospital admission to the detection of CRKP rectal colonization was 8 days, while the median time from colonization to BSI was 4 days. The duration of ICU stay, patient/nurse ratio and prior use of antianaerobic antimicrobials were associated with CRKP rectal colonization. No specific factor was associated with BSIs in the colonized patients. The blaKPC-2 gene was detected in all 96 strains, which were all classified as sequence type ST-258. Representative pairs (n=48) of CRKP strains colonizing and infecting the same patient shared the same pulsotype.

CONCLUSION

Our results indicate that hospitalized patients become infected with their colonizing strains, supporting the strong association between colonization and BSI. Limiting antianaerobic antimicrobial administration, reducing the duration of ICU stay and maintaining a low patient/nurse ratio are possible strategies to restrict rectal CRKP colonization in ICUs.

Nurse staffing levels, missed vital signs and mortality in hospitals: retrospective longitudinal observational study

Background

Low nurse staffing levels are associated with adverse patient outcomes from hospital care, but the causal relationship is unclear. Limited capacity to observe patients has been hypothesised as a causal mechanism.

Objectives

This study determines whether or not adverse outcomes are more likely to occur after patients experience low nurse staffing levels, and whether or not missed vital signs observations mediate any relationship.

Design

Retrospective longitudinal observational study. Multilevel/hierarchical mixed-effects regression models were used to explore the association between registered nurse (RN) and health-care assistant (HCA) staffing levels and outcomes, controlling for ward and patient factors.

Setting and participants

A total of 138,133 admissions to 32 general adult wards of an acute hospital from 2012 to 2015.

Main outcomes

Death in hospital, adverse event (death, cardiac arrest or unplanned intensive care unit admission), length of stay and missed vital signs observations.

Data sources

Patient administration system, cardiac arrest database, eRoster, temporary staff bookings and the Vitalpac system (System C Healthcare Ltd, Maidstone, Kent; formerly The Learning Clinic Limited) for observations.

Results

Over the first 5 days of stay, each additional hour of RN care was associated with a 3% reduction in the hazard of death [hazard ratio (HR) 0.97, 95% confidence interval (CI) 0.94 to 1.0]. Days on which the HCA staffing level fell below the mean were associated with an increased hazard of death (HR 1.04, 95% CI 1.02 to 1.07), but the hazard of death increased as cumulative staffing exposures varied from the mean in either direction. Higher levels of temporary staffing were associated with increased mortality. Adverse events and length of stay were reduced with higher RN staffing. Overall, 16% of observations were missed. Higher RN staffing was associated with fewer missed observations in high-acuity patients (incidence rate ratio 0.98, 95% CI 0.97 to 0.99), whereas the overall rate of missed observations was related to overall care hours (RN + HCA) but not to skill mix. The relationship between low RN staffing and mortality was mediated by missed observations, but other relationships between staffing and mortality were not. Changing average skill mix and staffing levels to the levels planned by the Trust, involving an increase of 0.32 RN hours per patient day (HPPD) and a similar decrease in HCA HPPD, would be associated with reduced mortality, an increase in staffing costs of £28 per patient and a saving of £0.52 per patient per hospital stay, after accounting for the value of reduced stays.

Limitations

This was an observational study in a single site. Evidence of cause is not definitive. Variation in staffing could be influenced by variation in the assessed need for staff. Our economic analysis did not consider quality or length of life.

Conclusions

Higher RN staffing levels are associated with lower mortality, and this study provides evidence of a causal mechanism. There may be several causal pathways and the absolute rate of missed observations cannot be used to guide staffing decisions. Increases in nursing skill mix may be cost-effective for improving patient safety.

Future work

More evidence is required to validate approaches to setting staffing levels. Other aspects of missed nursing care should be explored using objective data. The implications of findings about both costs and temporary staffing need further exploration.

Trial registration

This study is registered as ISRCTN17930973.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 6, No. 38. See the NIHR Journals Library website for further project information.

Nurses' experiences of working in rural hospitals: An integrative review

AIM

To critically analyse the international literature describing the experiences of nurses working in rural hospitals.

BACKGROUND

Nursing shortages in rural areas is an ongoing issue. Given the significant role nurses play in the delivery of rural health care, a sufficient workforce is essential. However, maintaining this workforce is challenging. Understanding the experiences of nurses working in rural hospitals is essential to inform strategies around job satisfaction and staff retention.

EVALUATION

An integrative review was conducted. Six primary sources were included related to the experiences of nurses working in rural hospitals.

RESULTS

Four themes emerged, namely: (a) Professional Development; (b) Workplace stressors; (c) Teamwork; and (d) Community.

CONCLUSION

There is a need for further research exploring the experiences of nurses working in rural hospitals and its impact on job satisfaction, turnover intention and patient safety.

IMPLICATIONS FOR NURSING MANAGEMENT

This review highlights some key issues impacting nurses' working in rural hospitals. This understanding can be used by nurse managers to inform strategies for recruitment and retention of nurses in these areas.

A protocol to measure the impact of intentional changes to nurse staffing and skill-mix in medical and surgical wards

AIM

The aim of this research is to measure the impact that planned changes to nurse staffing and skill-mix have on patient, nurse, and organizational outcomes.

BACKGROUND

It has been highlighted that there are several design limitations in studies that explore the relationship between nurse staffing and patient, nurse and organizational outcomes; not least that the vast majority of research in this area emanates from studies that are predominantly observational in design. There are limited studies that measure nurse, patient, organizational, and economic outcomes using a longitudinal design following a planned change in nurse staffing.

DESIGN

The research will employ a longitudinal, multimethod approach to evaluate the impact that planned changes in nurse staffing and skill-mix have on wards in three pilot hospitals.

METHODS

Administrative data collection will take place on a shift-by-shift basis prospectively over a three-year period including the measurement of nursing sensitive outcomes: cross-sectional patient experience data and nurse outcomes (nursing work, job satisfaction, burnout, missed care) will be collected at intervals prior to, during and after the implementation of planned changes in nurse staffing and skill-mix. Data will be analysed using interrupted time-series models, adjusted for key hospital, ward and patient-level factors. An economic costing of the changes will further investigate the resources required for the intervention that can then be aggregated to a national level for future roll-out plans.

DISCUSSION

The study aims to provide evidence on the impact of planned changes to nurse staffing and skill-mix based on a systematic approach using a longitudinal design and to determine the extent to which the approach can be implemented at a national level.

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.

Faster clinical response to the onset of adverse events: A wearable metacognitive attention aid for nurse triage of clinical alarms

Objective

This study evaluates the potential for improving patient safety by introducing a metacognitive attention aid that enables clinicians to more easily access and use existing alarm/alert information. It is hypothesized that this introduction will enable clinicians to easily triage alarm/alert events and quickly recognize emergent opportunities to adapt care delivery. The resulting faster response to clinically important alarms/alerts has the potential to prevent adverse events and reduce healthcare costs.

Materials and methods

A randomized within-subjects single-factor clinical experiment was conducted in a high-fidelity 20-bed simulated acute care hospital unit. Sixteen registered nurses, four at a time, cared for five simulated patients each. A two-part highly realistic clinical scenario was used that included representative: tasking; information; and alarms/alerts. The treatment condition introduced an integrated wearable attention aid that leveraged metacognition methods from proven military systems. The primary metric was time for nurses to respond to important alarms/alerts.

Results

Use of the wearable attention aid resulted in a median relative within-subject improvement for individual nurses of 118% (W = 183, p = 0.006). The top quarter of relative improvement was 3,303% faster (mean; 17.76 minutes reduced to 1.33). For all unit sessions, there was an overall 148% median faster response time to important alarms (8.12 minutes reduced to 3.27; U = 2.401, p = 0.016), with 153% median improvement in consistency across nurses (F = 11.670, p = 0.001).

Discussion and conclusion

Existing device-centric alarm/alert notification solutions can require too much time and effort for nurses to access and understand. As a result, nurses may ignore alarms/alerts as they focus on other important work. There has been extensive research on reducing alarm frequency in healthcare. However, alarm safety remains a top problem. Empirical observations reported here highlight the potential of improving patient safety by supporting the meta-work of checking alarms.

Comparison of reports of missed nursing care: Registered Nurses vs. practical nurses in hospitals

BACKGROUND

Missed nursing care is an error of omission defined as standard, required nursing care that is not completed or is seriously delayed. Study findings from around the world show that missed nursing care is a global concern.

PURPOSE

The purpose of this study was to compare reports of missed nursing care by two types of nurses - registered nurses and practical nurses - in acute care hospitals in Iceland. Former studies in the USA indicate a variance in reports of missed nursing care by staff with different roles.

METHODS

This was a cross-sectional descriptive study using the MISSCARE Survey-Icelandic questionnaire for data collection. The questionnaire asks about the amount of missed nursing care on the unit for 24 nursing elements (Part A) and 17 reasons of care being missed (Part B). Participants were nursing staff from medical, surgical and intensive care units in all hospitals in Iceland.

FINDINGS

A t-test for independent groups showed a significant difference for the overall missed nursing care score (Part A) between registered nurses (M = 2.09, SD = 0.51) and practical nurses (M = 1.82, SD = 0.59) [t(541) = 5.703, p < 0.001]. A comparison of the overall mean score for reasons of missed nursing care (Part B) between registered nurses (M = 2.32, SD = 0.38) and practical nurses (M = 2.21, SD = 0.62) indicated a significant difference in their reporting [t(299) = 2.210, p = 0.028]. In spite of the overall significant difference in ratings of the elements and reasons for missed nursing care by registered nurses and practical nurses, a pattern is evident in the ranking of the elements of nursing care being missed and reasons.

CONCLUSIONS

The findings of this study point to the need to acknowledge certain aspects of missed nursing care and the different roles within nursing. They indicate a need to improve open, sincere and structured communication and mutual respect and trust within healthcare teams in Icelandic hospitals.

Seventy Years of RN Effectiveness: A Database Development Project to Inform Best Practice

BACKGROUND

The appropriate nursing staff mix is imperative to the provision of quality care. Nurse staffing levels and staff mix vary from country to country, as well as between care settings. Understanding how staffing skill mix impacts patient, organizational, and financial outcomes is critical in order to allow policymakers and clinicians to make evidence-informed staffing decisions.

AIMS

This paper reports on the methodology for creation of an electronic database of studies exploring the effectiveness of Registered Nurses (RNs) on clinical and patient outcomes, organizational and nurse outcomes, and financial outcomes.

METHODS

Comprehensive literature searches were conducted in four electronic databases. Inclusion criteria for the database included studies published from 1946 to 2016, peer-reviewed international literature, and studies focused on RNs in all health-care disciplines, settings, and sectors. Masters-prepared nurse researchers conducted title and abstract screening and relevance review to determine eligibility of studies for the database. High-level analysis was conducted to determine key outcomes and the frequency at which they appeared within the database.

RESULTS

Of the initial 90,352 records, a total of 626 abstracts were included within the database. Studies were organized into three groups corresponding to clinical and patient outcomes, organizational and nurse-related outcomes, and financial outcomes. Organizational and nurse-related outcomes represented the largest category in the database with 282 studies, followed by clinical and patient outcomes with 244 studies, and lastly financial outcomes, which included 124 studies.

LINKING EVIDENCE TO ACTION

The comprehensive database of evidence for RN effectiveness is freely available at https://rnao.ca/bpg/initiatives/RNEffectiveness. The database will serve as a resource for the Registered Nurses' Association of Ontario, as well as a tool for researchers, clinicians, and policymakers for making evidence-informed staffing decisions.

Predicting excess cost for older inpatients with clinical complexity: A retrospective cohort study examining cognition, comorbidities and complications

BACKGROUND

Hospital-acquired complications increase length of stay and contribute to poorer patient outcomes. Older adults are known to be at risk for four key hospital-acquired complications (pressure injuries, pneumonia, urinary tract infections and delirium). These complications have been identified as sensitive to nursing characteristics such as staffing levels and level of education. The cost of these complications compared to the cost of admission severity, dementia, other comorbidities or age has not been established.

METHOD

To investigate costs associated with nurse-sensitive hospital-acquired complications in an older patient population 157,178 overnight public hospital episodes for all patients over age 50 from one Australian state, 2006/07 were examined. A retrospective cohort study design with linear regression analysis provided modelling of length-of-stay costs. Explanatory variables included patient age, sex, comorbidities, admission severity, dementia status, surgical status and four complications. Extra costs were based on above-average length-of-stay for each patient's Diagnosis Related Group from hospital discharge data.

RESULTS

For adults over 50 who have length of stay longer than average for their diagnostic condition, comorbid dementia predicts an extra cost of A$874, (US$1,247); any one of four key complications predicts A$812 (US$1,159); each increase in admission severity score predicts A$295 ($US421); each additional comorbidity predicts A$259 (US$370), and for each year of age above 50 predicts A$20 (US$29) (all estimates significant at p<0.0001).

DISCUSSION

Hospital-acquired complications and dementia cost more than other kinds of inpatient complexity, but admission severity is a better predictor of excess cost. Because complications are potentially preventable and dementia care in hospitals can be improved, risk-reduction strategies for common complications, particularly for patients with dementia could be cost effective.

CONCLUSIONS

Complications and dementia were found to cost more than other kinds of inpatient complexity.

Nursing home prices and quality of care - Evidence from administrative data

There is widespread concern about the quality of care in nursing homes. On the basis of administrative data of a large health insurance fund, we investigate whether nursing home prices are associated with relevant quality of care indicators at the resident level. Our results indicate negative associations between price and both inappropriate and psychotropic medication. In contrast, we do not find any relationship between the price and impairments of physical health.

Job satisfaction, work environment and successful ageing: Determinants of delaying retirement among acute care nurses

AIM

To determine the relationships between job satisfaction, work environment and successful ageing and how these factors relate to Registered Nurses' intent to retire.

BACKGROUND

Although little studied, retention of older nurses by delaying early retirement, before age 65, is an important topic for research. Qualitative and quantitative studies have indicated that job satisfaction work environment and successful ageing are key motivators in acute care Registered Nurses retention and/or delaying retirement. This study was designed to provide information to administrators and policy makers about retaining older, experienced RNs longer and more productively.

DESIGN

This was a correlational, descriptive, cross-sectional study.

METHODS

An online survey of acute care Registered Nurses (N = 2,789) aged 40 years or older working in Florida was conducted from September - October 2013. Participants completed items related to job satisfaction, work environment, successful ageing and individual characteristics. Hypotheses derived from the modified Ellenbecker's Job Retention Model were tested using regression analysis.

RESULTS

Job satisfaction scores were high. Highest satisfaction was with scheduling issues and co-workers; lowest with advancement opportunities. Successful ageing scores were also high with 81% reporting excellent or good health. Work environment explained 55% of the variance in job satisfaction. Years to retirement were significantly associated with successful ageing (p < .001), age (p < .001) and income (p < .010).

CONCLUSIONS

This study provides quantitative evidence that environment and successful ageing are important areas that have an impact on job satisfaction and delay of retirement in older nurses and further studies in these areas are warranted to expand on this knowledge.