Value-Added Care

The effect of practice environments and psychological empowerment perceptions of nurses on their care behaviours: A cross-sectional study

AIM

The aim of this study was to examine the effect of professional and individual characteristics, practice environments and psychological empowerment perceptions of nurses on their care behaviours.

DESIGN

The study used a cross-sectional research design following the STROBE guidelines.

METHODS

The sample of this descriptive and correlational study consisted of 584 nurses working in a university hospital in Turkey. The data were collected between January and June 2023 using the Nursing Information Form, the Practice Environment Scale of the Nursing Work Index (PES-NWI), the Psychological Empowerment Scale (PES), and the Caring Behaviours Scale-30, and analysed using descriptive statistics, Spearman's correlation and multiple linear regression.

RESULTS

It was determined that PES-NWI, PES and Caring Behaviours Scale (CBI-30) scores of nurses were higher than the average. The study revealed that certain professional and individual characteristics of nurses, practice environments and psychological empowerment perceptions had an effect on their care behaviours.

CONCLUSION

The results of the study showed that nurses' PES-NWI, PES and CBI-30 scores were higher than the average, and that certain professional and individual characteristics of nurses, practice environments and psychological empowerment perceptions had an effect on care behaviours. Nursing service managers, in particular, are required to understand the importance of this relationship and create appropriate working conditions which are integrated with psychological empowerment to improve caring behaviours of nurses.

Nurse Performance Metrics: A Scoping Review

OBJECTIVE

The purposes of this scoping review are: 1) to identify instances in the literature that describe measuring individual nurse performance and 2) characterize those metrics.

BACKGROUND

The impact of nurses on patient outcomes has been demonstrated at the unit or hospital level, with nurses measured in aggregate. There is an opportunity to evaluate individual nurse performance by creating metrics that capture it.

METHODS

A scoping review based on the framework published by the Joanna Briggs Institute was performed.

RESULTS

Researchers identified 12 articles. Three themes were trended: the emerging nature of these metrics in the literature, variability in their applications, and performance implications.

CONCLUSIONS

Individual nurse performance metrics is an emerging body of research with variability in the types of metrics developed. There is an opportunity for future researchers to work with nurse leaders and staff nurses to optimize these metrics and to use them to support nursing practice and patient care.

The Impact of Working Environment on Nurses' Caring Behavior in Sabah, Malaysia

Aims

This study aims to investigate 5 types of work environment influencing nurses' caring behavior, namely (i) participation in hospital affairs, (ii) foundations for quality of care, (iii) manager ability, leadership, and support of nurses, (iv) staffing and resource adequacy, and (v) nurse-physician relations.

Design

This research is a cross-sectional study using the survey method.

Methods

Data were collected from 3,532 nurses working in public hospitals and health clinics within Sabah, Malaysia in 2015. The hypothesized model was evaluated using partial least squares method.

Results

The findings reveal that all forms of work environment have a positive effect on nurses' caring behavior except for staffing and resource adequacy which shows a negative effect on caring behavior.

Conclusion

Overall, this study has added to theoretical contributions in the academic and research fields as well as in practical implications in the field of nursing practice by addressing the influence of work environments on caring behavior.

Implications for Nursing Management

The present research has provided convergent evidence on the role of the working environment in influencing the behavior of nurses working in hospitals and health clinics in Sabah, Malaysia.

Prevalence and reasons for non-nursing tasks as perceived by nurses: findings from a large cross-sectional study

AIM(S)

To describe the prevalence and reasons for non-nursing tasks as perceived by nurses.

BACKGROUND

Four types of non-nursing tasks have been identified to date: (a) auxiliary; (b) administrative, (c) expected by allied health care professionals; and (d) medical. However, no studies on a large scale have been performed with the aim of identifying the prevalence of all of these non-nursing tasks, and factors promoting or hindering their occurrence, given that they represent a clear waste of nurses' time.

METHOD(S)

A cross-sectional study in 2017, following The Strengthening the Reporting of Observational studies. All active nurses registered in an Italian provincial Nursing Board (=1331) willing to participate were involved. A questionnaire survey exploring the nature of the nursing-tasks performed in daily practice and the underlying reasons was administered via paper/pencil and e-mail.

RESULTS

733 nurses participated, of which 94.5% performed at least one type of non-nursing task, mainly administrative and auxiliary. Auxiliary tasks are less likely among nurses working in a community (Odds Ratio [OR] 0.43, 95% CI 0.29-0.63, p <0.01) or in a residential (OR 0.41, 95% CI 0.23-0.72, p <0.01) setting, in critical (OR 0.29, 95% CI 0.16-0.54, p <0.01) or surgical (OR 0.37, 95% CI 0.19-0.75, <p .01) hospital settings, and when they deal with unexpected clinical events (OR 0.58, 95% CI 0.44-0.77, p <0.01). Greater adequacy of nursing resources decreases the occurrence of auxiliary tasks (OR 0.98, 95% CI 0.97-0.99, p <0.01) while the need to compensate for a lack of resources (OR 1.44, 95% CI 1.07-1.93, p <0.01) increases it.

CONCLUSION(S)

Around one-third of shift time is devoted to non-nursing tasks; working in a hospital, in medical units, with lack of resources, and with patients with predictable clinical conditions might increase the occurrence of auxiliary tasks.

IMPLICATIONS FOR NURSING MANAGEMENT

Strategies to increase the time available for nursing care should consider the type of tasks performed by nurses, their antecedents, and the value-added to care in terms of patient' benefits.

How do nurses spend their time? A time and motion analysis of nursing activities in an internal medicine unit

Aim

To describe the nature and duration of nursing activities and how much time registered nurses allocate to the different dimensions of their scope of practice in a Swiss university hospital internal medicine ward.

Design

A single‐centre observational descriptive study.

Method

Using a time and motion study, two researchers shadowed healthcare workers (N = 21) during 46 complete work shifts in 2018. They recorded each activity observed in real time using a tablet computer with a pre‐registered list of 42 activities classified into 13 dimensions.

Results

A total of 507.5 work hours were observed. Less than one third of registered nurses’ work time was spent with patients. They allocated the most time to the dimensions of ‘communication and care coordination’ and ‘care planning’, whereas ‘optimizing the quality and safety of care’, ‘integrating and supervising staff’ and ‘client education’ were allocated the least time.

Conclusion

This study provided a reliable description of nurses’ time use at work. It highlighted suboptimal use of the full scope of nursing practice.

Impact

Both work organization and culture should be reconsidered to promote better use of nursing skills. Practice optimization should focus on the following three main areas: (1) greater involvement of registered nurses in building relationships and directly caring for patients and their families; (2) better use of registered nurses’ skills in the activities required of their proper roles, including nursing clinical assessments and patient education and (3) more systematically updating registered nurses’ knowledge.

A systematic review of the impact of health information technology on nurses' time

OBJECTIVE

Nursing time represents one of the highest costs for most health services. We conducted a systematic review of the literature on the impact of health information technology on nurses' time.

MATERIALS AND METHODS

We followed PRISMA guidelines and searched 6 large databases for relevant articles published between Jan 2004 and December 2019. Two authors reviewed the titles, abstracts, and full texts. We included articles that included a comparison group in the design, measured the time taken to carry out documentation or medication administration, documented the quantitative estimates of time differences between the 2, had nurses as subjects, and was conducted in either a care home, hospital, or community clinic.

RESULTS

We identified a total of 1647 articles, of which 33 met our inclusion criteria. Twenty-one studies reported the impact of 12 different health information technology (HIT) implementations on nurses' documentation time. Weighted averages were calculated for studies that implemented barcode medication administration (BCMA) and 2 weighted averages for those that implemented EHRs, as these studies used different sampling units; both showed an increase in the time spent in documentation (+22% and +46%). However, the time spent carrying out medication administration following BCMA implementation fell by 33% (P < .05). HIT also caused a redistribution of nurses' time which, in some cases, was spent in more "value-adding" activities, such as delivering direct patient care as well as inter-professional communication.

DISCUSSION AND CONCLUSIONS

Most of the HIT systems increased nursing documentation time, although time fell for medication administration following BCMA. Many HIT systems also resulted in nurses spending more time in direct care and "value-adding" activities.

The development of inpatient cost and nursing service weights in a tertiary hospital in Malaysia

Background

The current healthcare sector consists of diverse services to accommodate the high demands and expectations of the users. Nursing plays a major role in catering to these demands and expectations, but nursing costs and service weights are underestimated. Therefore, this study aimed to estimate the nursing costs and service weights as well as identify the factors that influence these costs.

Methods

A retrospective cross-sectional descriptive study was conducted at Universiti Kebangsaan Malaysia Medical Centre (UKMMC) using 85,042 hospital discharges from 2009 to 2012. A casemix costing method using the step-down approach was used to derive the nursing costs and service weights. The cost analysis was performed using the hospital data obtained from five departments of the UKMMC: Finance, Human Resource, Nursing Management, Maintenance and Medical Information. The costing data were trimmed using a low trim point and high trim point (L3H3) method.

Results

The highest nursing cost and service weights for medical cases were from F-4-13-II (bipolar disorders including mania - moderate, RM6,129; 4.9871). The highest nursing cost and service weights for surgical cases were from G-1-11-III (ventricular shunt - major, RM9,694; 7.8880). In obstetrics and gynaecology (O&G), the highest nursing cost and service weights were from O-6-10-III (caesarean section - major, RM2,515; 2.0467). Finally, the highest nursing cost and service weights for paediatric were from P-8-08-II (neonate birthweight > 2499 g with respiratory distress syndrome congenital pneumonia - moderate, RM1,300; 1.0582). Multiple linear regression analysis showed that nursing hours were significantly related to the following factors: length of stay (β = 7.6, p < 0.05), adult (β = − 6.0, p < 0.05), severity level I (β = − 3.2, p < 0.05), severity level III (β = 7.3, p < 0.05), male gender (β = − 4.2, p < 0.05), and the elderly (β = − 0.5, p < 0.05).

Conclusions

The results showed that nursing cost and service weights were higher in surgical cases compared to other disciplines such as medical, O&G and paediatric. This is possible as there are significant differences in the nursing activities and work processes between wards and specialities.

Registered nurses' knowledge, attitude and practice regarding their scope of practice in Botswana

BACKGROUND

The articulation of the scope of practice in nursing is important to provide boundaries for registered nurses in which to practice. Registered nurses in Botswana have frequently experienced challenges and raised concerns with their scope of practice. Research related to registered nurses' knowledge, attitudes and practice regarding their scope of practice appears to be limited in the African context, particularly in Botswana.

AIM

The aim of this study was to develop guidelines for professional nurses to explore and describe registered nurses' knowledge, attitude and practice regarding their scope of practice in Botswana.

METHODS

A convergent parallel mixed-methods design was employed using a three-tier sampling approach to ensure a representative sample of various settings, health facilities and nurses. For the purpose of this article, the data from the qualitative component are reported. Thirty registered nurses, working in the public health sector in Botswana, participated in semi-structured interviews. Data were analysed using thematic content analysis.

FINDINGS

Data analysis revealed that registered nurses' scope of their knowledge was lacking. Registered nurses' attitudes were reflected in the adaptation process to expanded practice, as demonstrated through emotive aspects, adjustments to practice beyond scope and the learning of new skills considered beyond scope. Participants reported implementing many skills deemed beyond their scope, whilst their motive to do so included their experience of a lack of control over practice, lack of resources or they were doing so out of consideration for the patient. Guidance in terms of their scope was found to be inadequate.

CONCLUSION

As in other resource-limited countries in Africa, registered nurses in Botswana experience challenges with their scope of practice. Inadequate boundaries may result in compromised nursing care and may have detrimental consequences for both the patient and the nurse.

Nurses' activities and time management during home healthcare visits

AIM

To describe nurses' activities and time management during HHC visits from the perspective of master's-level nursing students.

BACKGROUND

The shift from community-based hospitals to home-based, person-centred services for patients with a variety of acute or chronic health problems challenges nurses' professional competence and time management during home healthcare visits.

DESIGN AND METHODS

A cross-sectional study in accordance with STROBE guidelines. Observation sheets (n = 196) from two municipal home healthcare organisations were analysed with descriptive quantitative analysis.

ETHICAL ISSUES AND APPROVAL

While no external ethical committee evaluation was necessary for this quality improvement study, research ethical principles were followed.

RESULTS

The nurses spent 50% of each eight-hour shift on indirect patient contact activities and about 38% on direct patient contact activities. The majority of activities underlying the home visits could be linked to long-term illnesses: medication (57%), blood samples (23%), wound care (17%) or measurement of blood pressure (14%). Patient education was offered during only 3.5% of visits.

LIMITATIONS

The accuracy of the students' observations is related to their individual capacity to objectively and selectively observe.

CONCLUSIONS

There were a number of activities conducted for the patient, to promote continuous intra- and interprofessional patient care, but fewer nursing activities conducted with the patient. To ensure integrated, person-centred, safe patient care, vital reforms are needed.

RELEVANCE TO CLINICAL PRACTICE

The appropriate balance between indirect and direct patient contact activities should be discussed intra- and interprofessionally, delineated and made explicit in nurses' work plans and nursing documentation, alongside discussions pertaining to relevant resource allocation.

Intentionality in reducing health disparities: Caring as connection

OBJECTIVE

Inadequate health care quality may contribute to Native American health disparities through racial/ethnic discrimination by health care professionals. Nursing approaches to relationships and caring offer a means to understand health disparities through an unconventional lens. The study objective was to examine health disparities within the context of patient/nurse relationships.

DESIGN

A descriptive-qualitative method guided data collection and analysis. Eleven nurses who serve Native Americans were interviewed. They described attitudes, meaningful relationships, and nurse leadership.

RESULTS

Nurses discussed their perceptions of and experiences with Native American patients. Four themes emerged: shared patient/nurse values, patient-centered care, external forces, and stereotype-driven care.

CONCLUSIONS

Are we ready for the challenge to advocate for, build, and sustain organizational structures that support caring relationships? Implications for public health nursing include being intentional about recognizing implicit biases and ethnocentrism; examining nurses' complicit roles in perpetuating racism; and developing mechanisms to collectively advocate for improved Native American health.

Accounting for patient heterogeneity in nurse staffing using a queueing-theory approach

Evidence from observational studies suggests that inadequate nurse staffing in hospitals and heavy nurse workload may compromise patient safety and quality of care. There are recommended minimum nurse-to-patient ratios for different types of inpatient care settings. However, nursing-care intensity may vary across different patients within an inpatient unit depending on the severity of their medical condition, potentially rendering fixed nurse-to-patient ratios ineffective. This study aims at developing nurse-staffing strategies that explicitly account for patient heterogeneity. Using queueing theory, we develop a stochastic framework to model direct nursing care provided in inpatient-care units. The stochastic model is then used to measure different performance metrics that evaluate the efficiency and timeliness of inpatient-care delivery. The trade-off between those performance metrics and the nursing staff level is quantified, which can assist clinicians with determining minimum nursing staff levels that ensure timely delivery of nursing care to a given patient mix.

Increasing value-adding patient care by applying a modified TCAB program

Purpose The purpose of this study is to evaluate a development process aimed at increasing registered nurses' (RNs) working time use in value-adding patient care by applying a modified Transforming Care at the Bedside (TCAB) program at inpatient units of two tertiary hospitals. Design/methodology/approach Basic data for the development process were collected on RNs' working time use via external observation in 2011 (RNs = 113). Nursing work was redesigned and implemented by 12 multi-professional teams during 2012-2013. The development process was evaluated by repeating the collection of RNs' working time use data in 2013 (RNs = 95) and by analyzing the memos of the development teams via deductive content analysis ( N = 64). Findings RNs' working time use showed statistically significant increases in value-adding care and direct patient care but decreases in non-value-added work and miscellaneous work. Changes in the nursing work model, division of labor and the nursing work environment all affected RNs' working time use. Practical implications The development process progressed distinctively in each unit, as shown by the results of the development work. Clinical RNs had key roles as innovators and change agents, yet the engagement of nursing managers was most essential for the success of the development work. Originality/value Even minor changes in nurses' daily work profile can have considerable effects on RNs' work. The TCAB program was shown to be a useful method in developing RNs' work also in psychiatric units.

Sistematização do conhecimento sobre as metodologias empregadas para o dimensionamento da força de trabalho em saúde

A força de trabalho em saúde representa um fator de grande importância nos sistemas de saúde, sendo imprescindível à promoção e ao avanço da área, relacionada quantitativa e qualitativamente aos resultados alcançados. Esta revisão sistemática visa à identificação na literatura de metodologias que, empregadas, resultem em dimensionamento eficaz da força de trabalho em saúde. Os resultados indicam a necessidade de complementação da avaliação, sendo indispensável a identificação de metodologias que resultem em dimensionamento mais eficaz da força de trabalho em saúde para subsidiar decisões gerenciais no sistema de saúde.

Can real time location system technology (RTLS) provide useful estimates of time use by nursing personnel?

Accurate, precise, unbiased, reliable, and cost-effective estimates of nursing time use are needed to insure safe staffing levels. Direct observation of nurses is costly, and conventional surrogate measures have limitations. To test the potential of electronic capture of time and motion through real time location systems (RTLS), a pilot study was conducted to assess efficacy (method agreement) of RTLS time use; inter-rater reliability of RTLS time-use estimates; and associated costs. Method agreement was high (mean absolute difference = 28 seconds); inter-rater reliability was high (ICC = 0.81-0.95; mean absolute difference = 2 seconds); and costs for obtaining RTLS time-use estimates on a single nursing unit exceeded $25,000. Continued experimentation with RTLS to obtain time-use estimates for nursing staff is warranted.

Weighted staffing plans for better prediction of staffing needs

OBJECTIVE

The aim of this study was to examine the effect of patient turnover and acuity on worked hours per patient day (WHPPD).

BACKGROUND

An examination of staffing plans publically posted by Massachusetts hospitals with more than 300 beds revealed that less than 40% were within 5% of their planned versus actual WHPPD.

METHODS

Three years of WHPPD data collected from 14 adult acute care units were correlated with patient turnover and acuity data. A weight factor was retrospectively added to 8 paired units' planned WHPPD where correlations were identified.

RESULTS

Twelve units (86%) showed significant correlations between WHPPD and patient turnover. Correlations between patient acuity and WHPPD were significant only at the aggregate level. After weighting WHPPD, the 8 paired units demonstrated a decreased variance between planned and actual WHPPD.

CONCLUSION

Using a weight factor added to WHPPD to right size acute care medical-surgical units may be useful for accurate staff planning and budgeting.

The making of an education day in a canadian health care facility

The benefits of an education day have been documented within a variety of disciplines; however, there is a paucity of up-to-date knowledge on the implementation and planning phases, and these phases are addressed in this article. Having knowledge of what form of delivery education can take can affect employer-provided education throughout health care. This article will benefit staff development educators by addressing issues in staff development and the role that an education day can have in health care facilities.

Measuring actual scope of nursing practice: a new tool for nurse leaders

OBJECTIVE

: This project describes the development and testing of the actual scope of nursing practice questionnaire.

BACKGROUND

: Underutilization of the skill sets of registered nurses (RNs) is a widespread concern. Cost-effective, safe, and efficient care requires support by management to facilitate the implementation of nursing practice at the full scope.

METHODS

: Literature review, expert consultation, and face validity testing were used in item development. The instrument was tested with 285 nurses in 22 medical units in 11 hospitals in Canada.

RESULTS

: The 26-item, 6-dimension questionnaire demonstrated validity and reliability. The responses suggest that nurses practice at less than their optimal scope, with key dimensions of professional practice being implemented infrequently.

CONCLUSIONS

: This instrument can help nurse leaders increase the effective use of RN time in carrying out the full scope of their professional practice.

Nurse staffing in critical access hospitals: structural factors linked to quality care

Evidence links the amount of registered nurse care to improved patient outcomes in large hospitals, but little is known about registered nurse staffing in small critical access hospitals, which comprise 30% of all US hospitals. Our study findings show that the unique work environment of critical access hospitals means registered nurses are often overextended, reassigned from inpatient care, and/or interrupted creating potential safety and quality risks. Further research is needed to understand what critical access hospitals consider "safe" levels of nurse staffing and what processes are implemented to mitigate these risks.

A holistic framework for nursing time: implications for theory, practice, and research

TOPIC

Nursing time has relevance for those who produce it, those who receive it, and those who must pay for it. Although the term nursing time may be commonly used, a common understanding of the concept within the fields of nursing and healthcare administration is lacking.

PURPOSE

The purposes of this paper are to explore the concept of nursing time and to identify implications for theory development, clinical and administrative practice, and research.

DISCUSSION

Both physical and psychological forms of time are viewed as fundamental to our experience of time as social beings. Nursing time has significant intrinsic and instrumental value in nursing and health care. A holistic approach incorporating the physical, psychological, and sociological aspects and dimensions of nursing time is advocated.

CONCLUSIONS

Multiple strategies to enhance the patient experience of nursing time are warranted and should address how much time nurses spend with patients as well as how they spend that time. Patterns of overlapping and competing time structures for nurses should be identified and evaluated for their effect on physical time available for patient care and the psychological experiences of time by nurses and patients.

Costing nursing care: using the clinical care classification system to value nursing intervention in an acute-care setting

The purpose of this study was to combine an established methodology for coding nursing interventions and action types using the Clinical Care Classification System with a reliable formula (relative value units) to cost nursing services. Using a flat per-diem rate to cost nursing care greatly understates the actual costs and fails to address the high levels of variability within and across units. We observed nurses performing commonly executed nursing interventions and recorded these into an electronic database with corresponding Clinical Care Classification System codes. The duration of these observations was used to calculate intervention costs using relative value unit calculation formulas. The costs of the five most commonly executed interventions were nursing care coordination/manage-refer ($2.43), nursing status report/assess-monitor ($4.22), medication treatment/perform-direct ($6.33), physical examination/assess-monitor ($3.20), and universal precautions/perform-direct ($1.96). Future studies across a variety of nursing specialties and units are needed to validate the relative value unit for Clinical Care Classification System action types developed for use with the Clinical Care Classification System nursing interventions as a method to cost nursing care.

Transforming nursing workflow, part 2: the impact of technology on nurse activities

OBJECTIVE

To assess the impact of new technology on nurse workflow, nurses at 2 hospitals were observed before and after implementation of an electronic medication charting system. In part 1 (September 2010 issue), we discussed the chaotic nature of nurse activities and its implications on transforming workflow.

BACKGROUND

Numerous studies have documented the impact of technology on performance and satisfaction, but technology's impact on the frequency, duration, and pattern of activities is less understood. These patterns are important to the development of new care models.

METHODS

Observers shadowed nurses at 2 hospitals before and after the implementation of an electronic medication charting system. A total of 196 hours of observation was recorded at one site, and 185 hours at the other site.

RESULTS

Analysis of variance revealed a number of significant differences in the time spent on a variety of activities, but the duration and frequency of nurse activities were not drastically altered by the additional technology.

CONCLUSIONS

Computer use increased; however, the impact was evenly distributed among other activities. More importantly, time with patients and verbal communication remained unchanged as nurses seemed to incorporate the new requirements into their normal routine.

Using clinical data to capture nurse workload: implications for staffing and safety

The purpose of this project was to demonstrate how a hospital clinical database can be utilized to calculate individual nursing unit activities that affect nurses' workload. While research has established that staffing is associated with patient safety, few studies have examined ways to measure nurse workload and its impact on patient safety. The widely used midnight census does not account for the number of patients who occupy a bed in a 24-hour period. In this study, a hospital clinical data repository was used to calculate workload measures such as total treated patients, midnight census, and admission, discharges, and transfers, as well as a unit activity index. Unit activity indexes for intensive care and medical-surgical units were compared over time, by shift, day of week, and month. Admission, discharges, and transfers varied according to unit type. During 1994 to 2006, unit activity index increased. Fluctuations in unit activity index were noted according to shift, day of week, and month. Hospital clinical data repositories can be used to calculate workload measures, and these measures should be incorporated with other traditional measures in making staffing decisions.

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

TOPIC

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

PURPOSE

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

SOURCES OF INFORMATION

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

CONCLUSIONS

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

Nurse staffing levels revisited: a consideration of key issues in nurse staffing levels and skill mix research

AIM

This paper revisits the published evidence relating to how nurse staffing levels impact on patient, nurse and service outcomes and considers the implications of this body of research for nurse managers in their quest to determine optimum nursing numbers.

BACKGROUND

Within the context of the recognized global nursing shortage and particular local pressures within international health services, questions of appropriate nurse staffing levels and skill mix are once again becoming increasingly important. It would seem that the determination of optimum nurse staffing levels and skill mix is a central issue in relation to health service governance, service user involvement, as well as in the recruitment, retention and well-being of nursing staff across the service sectors.

METHODS

A review of published evidence was carried out, applying key principles of the systematic method, in order to facilitate the identification of current factors and issues in nurse staffing levels research. The review did not seek to address a specific research question. The search covered 10 years from 1998 to 2008 and identified more than 500 relevant papers, giving a wide international perspective.

KEY ISSUES

The majority of research in the field relates to the acute service sector and there are considerable similarities in issues that transcend international boundaries. Much of the research focuses on the impact on patients and nurses of 'poor' nurse staffing levels. More recent studies have explored the impact of nurse staffing levels on the service organization itself. However, while there may be an association between models of nurse staffing and outcomes, there is insufficient evidence to establish a causal relationship between these factors. In this context it is perhaps time to reconsider how nursing outcomes are defined and measured. IMPLICATIONS FOR NURSING MANAGEMENT AND CONCLUSION: Nurse managers, commissioners of services and workforce planners need to be cognisant of key issues and analyses in the consideration of nurse staffing levels. Not least of these is the need for a healthy degree of caution regarding the supposed objectivity, scientific basis, or evidence base, for rational calculation of optimum nurse staffing levels.

Unit-Related Factors That Affect Nursing Time with Patients: Spatial Analysis of the Time and Motion Study

Objective:

The primary goal of this study was to test the hypothesis that nurses adopt distinct movement strategies based on features of unit topology and nurse assignments. The secondary goal was to identify aspects of unit layout or organization that influence the amount of time nurses spend in the patient room.

Background:

Previous research has demonstrated a link between nursing hours and patient outcomes. Unit layout may affect direct patient care time by determining aspects of nurse behavior, such as the amount of time nurses spend walking. The recent nurses' Time and Motion study employed multiple technologies to track the movements and activities of 767 medical-surgical nurses. With regard to unit layout, initial analysis of the data set did not detect differences between types of units and time spent in the patient room. The analysis reported here applies novel techniques to this data set to examine the relationship between unit layout and nurse behavior.

Methods:

Techniques of spatial analysis, borrowed from the architectural theory of spatial syntax, were applied to the Time and Motion data set. Motion data from radio-frequency identification tracking of nurses was combined with architectural drawings of the study units and clinical information such as nurse-patient assignment. Spatial analytic techniques were used to determine the average integration or centrality of nurse assignments for each shift.

Results:

Nurse assignments with greater average centrality to all assigned rooms were associated with a higher number of entries to patient rooms, as well as to the nurse station. Number of entries to patient rooms was negatively correlated with average time per visit, but positively correlated with total time spent in patient rooms. The data describe two overall strategies of nurse mobility patterns: fewer, longer visits versus more frequent, shorter visits.

Conclusions:

Results suggest that the spatial qualities of nurse assignments and unit layout affect nurse strategies for moving through units and affect how frequently nurses enter patient rooms and the nurse station.