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

Exploring nurses' clinical judgment concerning the relative importance of fall risk factors: A mixed method approach using the Q Methodology

BACKGROUND

Nurses are pivotal in averting patient falls through their assessment of cues presented by patients and their environments, rendering clinical judgments regarding the risk of falling, and implementing tailored interventions. Despite the intricate cognitive processes entailed in nurses' judgment, no prior studies have explored their approach to assessing the risk of falling.

OBJECTIVE

This study aimed to examine how nurses judge the risk of falling among patients with different conditions, whether there are differences in the importance of risk factors as judged by nurses, how they justify their judgments, and what attributes of the nurses influence their judgments.

DESIGN

A mixed method approach using the Q Methodology was employed.

SETTING(S)

Three public and private hospitals in Japan.

PARTICIPANTS

Eighteen nurses participated in the study.

METHODS

Participants were tasked with ranking 36 patient scenarios, each featuring a distinct set of fall risk factors. Subsequently, post-sorting interviews were conducted to gather insights into their typical approach to assessing fall risk and the rationale behind their ranking decisions. A by-person principal component factor extraction was employed to examine differences in the rankings of the scenarios. The interview data were analyzed descriptively to elucidate the reasons behind these discrepancies.

RESULTS

Nurses engage in complex cognitive manipulations when evaluating the risk of patient falls, drawing extensively from their wealth of experience while utilizing assessment tools to support their judgments. In essence, nurses identify patients' tendency to act alone without calling a nurse, impaired gait and cognition, sedative use, drains, and limited information sharing among healthcare professionals as key fall risks. In addition, nurses vary in the importance they attribute to certain risk factors, leading to the discrimination of three distinct judgment profiles. One group of nurses judges patients with cognitive impairment and acting alone as high risk. Another group of nurses considers patients with unstable gait and acting alone as high risk. The last group of nurses sees patients wearing slippers as high risk. The post-sorting interviews revealed that their judgments are closely related to the healthcare context and patient population.

CONCLUSIONS

Nurses operate within diverse contexts, wherein they interact with patients of varying characteristics, collaborate with professionals from diverse disciplines, and have access to varying levels of human and physical resources. This nuanced understanding empowers the formulation of judgments that are finely attuned to the specific context at hand.

STUDY REGISTRATION

Not registered.

Identifying Nursing-Sensitive Indicators for Hospitals: A Modified Delphi Approach

BACKGROUND

Nursing-sensitive indicators (NSIs) play a crucial role in measuring the quality of care specific to nursing practice. Currently, hospitals monitor several NSIs which may vary between hospitals. Conducting research on NSIs can enhance the monitoring of nursing practice.

AIM

The aim is to identify NSIs for hospitals in Jordan.

METHODS AND MATERIAL

The Delphi approach was utilized to establish a consensus among a panel of national nursing experts (N=60). An initial list of 52 indicators was developed through a rigorous process and subsequently distributed to the panel members. The panelists provided their quantitative responses in three rounds. Consensus was determined based on the following criteria: agreement greater than 51.0%, interquartile range (IQR) below 1.5, standard deviation (SD) below 1, and moderate Kendall's coefficient of concordance (Kendall's W).

RESULTS

By the conclusion of the third round, a total of 42 indicators achieved group agreement. The agreed-upon indicators consisted of 10 structure, 16 process, and 16 outcome indicators.

CONCLUSION

This study successfully established a consensus and identified a comprehensive set of indicators that capture the distinct contributions of nursing in the hospital setting. The results demonstrate a wide range of agreed-upon indicators across the domains of structure, process, and outcome. These findings are valuable in enhancing the monitoring and evaluation of nursing practice in hospitals.

PRACTICAL IMPLICATIONS

 The findings of this study provide a solid foundation for monitoring and reporting the quality of nursing practice in hospitals. Nursing policymakers can utilize these findings to develop policies that promote the voluntary reporting of NSIs.

The Impact of Patient Education on Inpatient Fall Risk: A Review

» Patient falls in the hospital are one of the leading sentinel events identified by the Joint Commission.» Hospital falls affect orthopaedic patients of older age at higher rates, and up to 34% of falls lead to injury such as fractures.» Patients often misperceive their fall risk, and modalities aimed at educating patients to address the incongruence between perceived and actual fall risk significantly reduce fall rate and injurious fall rate.» Adequate communication with patients and their families with the goal of educating them may diminish the physical, psychological, and emotional detriment to orthopaedic patients.

Healthcare-associated infections in adult intensive care units: A multisource study examining nurses' safety attitudes, quality of care, missed care, and nurse staffing

OBJECTIVES

This study examined the association between safety attitudes, quality of care, missed care, nurse staffing levels, and the rate of healthcare-associated infection (HAI) in adult intensive care units (ICUs).

METHODS

A cross-sectional study was conducted in five hospitals. Nurses completed a validated survey on safety attitudes, quality of care, missed care, nurse staffing levels, and the frequency of HAIs. Secondary data were collected on the incidence of central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and ventilator-associated pneumonia (VAP) in participating units. Descriptive analysis and generalized linear models were performed.

RESULTS

A total of 314 nurses from eight ICUs participated in this study. The mean safety culture score was 60.85 (SD = 3.53). ICUs with strong job satisfaction had lower incidence and nurse-reported frequency of CLABSI, CAUTI, and VAP. Missed care was common, with 73.11% of nurses reporting missing at least one required care activity on their last shift. The mean patient-to-nurse ratio was 1.95. Increased missed care and higher workload were associated with higher HAIs. Nurses' perceptions of CLABSI and VAP frequency were positively associated with the actual occurrence of CLABSI and VAP in participating units.

CONCLUSION

Positive safety culture and better nurse staffing levels can lower the rates of HAIs in ICUs. Improvements to nurse staffing will reduce nursing workloads, which may reduce missed care, increase job satisfaction, and, ultimately, reduce HAIs.

IMPLICATIONS FOR CLINICAL PRACTICE

Higher levels of job satisfaction among ICU nurses, lower proportions of missed nursing care and higher nurse staffing are associated with lower rates of HAIs. Nurse-reported HAI frequency was positively associated with the incidence of HAIs; therefore, nurses provide reliable data on infection control outcomes in ICU settings.

Patient-level and organizational-level factors influencing in-hospital falls

AIM

In-hospital fall is one key safety issue in a healthcare setting. Although healthcare providers apply several strategies for preventing falls, falls still occur in hospitals. The aim of this study was to investigate patient-level and organizational-level factors influencing in-hospital falls.

DESIGN

A multicentre retrospective observational study.

METHODS

This study used the national healthcare database and supplemented with organizational data obtained through a survey. Data extraction and survey were conducted between July and August 2020. A mixed-effect logistic regression model was used to analyse factors influencing in in-hospital falls.

RESULTS

A total of 43,286 patients admitted in 86 hospitals were included in this study. Fall rate was 0.85 per 1000 days. Length of stay was significantly longer for fall patients than for no-fall patients. Patient-level factors (including age, mobility impairment and surgery) and organizational-level factors (including nurse staffing and proportion of new nurses) were significant factors influencing in-hospital falls.

CONCLUSION

Since in-hospital falls increase economic burden to patients, we should consider various fall prevention strategies to reduce falls. For a strategy to be applied stably to patients, organizational factors must be supported.

IMPACT

Proactive fall management in acute settings is essential to ensure patient safety. Considering that the number of patients with fall risk is increasing due to ageing, organizational factors should be supported to provide quality nursing care for fall risk patients. Therefore, nurse leaders should primarily ensure an appropriate level of nurse staffing. They also need to make efforts to strengthen clinical competency of nurses.

Identifying gaps in global evidence for nurse staffing and patient care outcomes research in low/middle-income countries: an umbrella review

OBJECTIVE

To identify nurse staffing and patient care outcome literature in published systematic reviews and map out the evidence gaps for low/middle-income countries (LMICs).

METHODS

We included quantitative systematic reviews on nurse staffing levels and patient care outcomes in regular ward settings published in English. We excluded qualitative reviews or reviews on nursing skill mix. We searched the Cochrane Register of Systematic Reviews, the Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Medline, Embase and Cumulative Index to Nursing and Allied Health Literature from inception until July 2021. We used the A Measurement Tool to Assess Systematic Reviews -2 (AMSTAR-2) criteria for risk of bias assessment and conducted a narrative synthesis.

RESULTS

From 843 papers, we included 14 in our final synthesis. There were overlaps in primary studies summarised across reviews, but overall, the reviews summarised 136 unique primary articles. Only 4 out of 14 reviews had data on LMIC publications and only 9 (6.6%) of 136 unique primary articles were conducted in LMICs. Only 8 of 23 patient care outcomes were reported from LMICs. Less research was conducted in contexts with staffing levels that are typical of many LMIC contexts.

DISCUSSION

Our umbrella review identified very limited data for nurse staffing and patient care outcomes in LMICs. We also identified data from high-income countries might not be good proxies for LMICs as staffing levels where this research was conducted had comparatively better staffing levels than the few LMIC studies. This highlights a critical need for the conduct of nurse staffing research in LMIC contexts.

LIMITATIONS

We included data on systematic reviews that scored low on our risk of bias assessment because we sought to provide a broad description of the research area. We only considered systematic reviews published in English and did not include any qualitative reviews in our synthesis.

PROSPERO REGISTRATION NUMBER

CRD42021286908.

The Impact of Nurse Staffing on Falls Performance within a Healthcare System: A Descriptive Study

AIM

The purpose of this study was to examine the impact of nurse staffing on inpatient falls performance across a multi-hospital system.

BACKGROUND

Evidence to support which staffing variables influence fall performance so that healthcare organizations can better allocate resources is lacking.

METHOD

A descriptive study design was used to analyze the impact of nurse staffing and falls performance, with units dichotomized as either high or low performing based on national benchmarking data. The impact was evaluated using 10 nurse staffing variables.

RESULTS

A total of 9 units were included (5 high and 4 low performing). Higher performing units showed less use of sitters and travelers, had fewer nurses working overtime hours, and employed more expert-level clinical nurses and combined nursing assistant/health unit coordinator positions, than lower performing units.

CONCLUSION

Findings provide evidence of how staffing variables affect a unit's falls performance. While significant relationships were found, further evaluation is needed to explore the relationship of staffing variables and quality outcomes.

IMPLICATIONS FOR NURSING MANAGEMENT

Nursing managers may consider trying to reduce use of sitters and travelers, and utilize innovative staffing models, such as using combined nursing assistant/health unit coordinator positions, to help improve their falls performance.

Moral and Professional Values of Nurses in Lebanon

BACKGROUND

Moral and professional values vary among cultures. The purpose of this study was to explore the moral and professional values of registered nurses at a university medical center in a Middle Eastern country and determine the relationship among formal ethics education, background variables (age, gender, nursing degree, regular daily prayer), and nurses' professional and moral values.

METHOD

A cross-sectional survey method with 123 nurses was used. Data on background variables, moral and professional values, and confidence in ethical decision-making were assessed.

RESULTS

Professional values were significantly higher among older nurses and nurses with master's degrees compared with younger nurses and nurses with bachelor's degrees. Daily prayer was related to higher mean scores for moral values. Nurses were confident in their ethical decision-making; however, formal education in ethics did not influence professional or moral values.

CONCLUSION

Although formal education in ethics did not influence the professional or moral values of nurses in Lebanon, this finding does not negate the need for future studies to investigate the content and duration of ethics education that is likely to affect professional or moral values. [J Contin Educ Nurs. 2021;52(9):429-437.].

Knowledge and attitudes of Turkish nursing students towards pressure injury prevention

AIM

Nurse educators are expected to teach nursing students the necessary knowledge and attitudes to prevent pressure injuries (Pİ) development. This study aims to assess the knowledge levels and attitudes of nursing students towards Pİ prevention and to analyze the relationship between their knowledge and attitudes.

MATERIAL AND METHODS

This study adopted a cross sectional, descriptive, and correlational research design. 259 students of the nursing department of a private university in the Turkish Republic of Northern Cyprus during the spring semester of the 2018-2019 academic year constituted the population of the study. Student information form, the Turkish version of Pİ prevention knowledge assessment instrument (PUPKAI-T), and attitude towards Pİ prevention instrument (APuP) were used for data collection. Data were analyzed by Kruskal-Wallis, Mann- Whitney U tests and Spearman's correlation. Ethics committee approval was received.

RESULTS

Mean PUPKAI-T score was 10.16 ± 2.44 (range: ≥ 16). Participants obtained the lowest score from the etiology and causes (32.3%) and classification and observation (33.5%) subscales of the PUPKAI-T. The mean score obtained by the participants from the APuP was 44.62 ± 3.54 (range; min; 13, max; 52). We found a positive, weak, and statistically significant correlation between the PUPKAI-T and the APuP scores (r = 0.131, p = 0.034).

CONCLUSION

The study found that the mean PUPKAI-T scores of the nursing students were low and their APuP scores indicated a positive attitude. The findings imply that the nursing curriculum might be revised and new courses might be introduced to increase the knowledge levels of nursing students on Pİ prevention.

Impact of nurse staffing on patient and nurse workforce outcomes in acute care settings in low- and middle-income countries: a systematic review

OBJECTIVE

The objective of this review was to determine the effect of nurse staffing on patient and nurse workforce outcomes in acute care settings within low- and middle-income countries.

INTRODUCTION

Health care systems in low- and middle-income countries experience a high proportion of the global burden of disease, which is aggravated by several health care constraints. The high rates of both communicable and non-communicable diseases, low numbers in the workforce, poor distribution of qualified professionals, and constraints in medical supplies and resources make the provision of quality health care challenging in low- and middle-income countries. Health care systems in low- and middle-income countries, however, are still expected to address universal health care access and provide high-quality health care. Systematic reviews examining nurse staffing and its effect on patient and nurse workforce outcomes are largely from the perspective of high-income countries. There is a need to understand the evidence on nurse staffing and its impact in the context of low- and middle-income countries.

INCLUSION CRITERIA

Empirical studies that addressed acute care nurse staffing levels, such as nurse-to-patient ratio or nurses' qualifications, experience, and skill mix, and their influence on patient and nurse workforce outcomes were included in the review. Studies conducted in a low- or middle-income country were included. Outcomes must have been measured objectively using validated tools.

METHODS

Studies published until July 2019 were identified from CINAHL, PubMed, Scopus, Embase, PsycINFO, Cochrane Library, Web of Science, and ProQuest Dissertations and Theses. The JBI approach to critical appraisal, study selection, data extraction, and data synthesis was used for this review. Narrative synthesis was conducted due to high heterogeneity of included studies. The level of evidence was determined using GRADEpro.

RESULTS

Twenty-seven studies were included in this review and the level of evidence was low, mainly due to the design of included studies. Low nurse-to-patient ratio or high nurse workload was associated with higher rates of in-hospital mortality, hospital-acquired infection, medication errors, falls, and abandonment of treatment. Findings on the effect of nurse staffing on length of hospital stay and incidence of pressure ulcers were inconsistent. Extended work hours, less experience, and working night or weekend shifts all significantly increased medication errors. Higher nurse workload was linked to higher levels of nurses' burnout, needlestick and sharps injuries, intent to leave, and absenteeism.

CONCLUSIONS

Lower nurse-to-patient ratios and higher nurse workload are linked to in-hospital mortality, hospital-acquired infections, and medication errors among patients, and high levels of burnout, needlestick and sharps injuries, absenteeism, and intention to leave their job among nurses in low- and middle-income countries. The results of this review show similarities with the evidence from high-income countries regarding poor outcomes for patients and nurses. These findings should be considered in light of the lower nurse-to-patient ratios in most low- and middle-income countries.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42018119428.

Intensive care nurse staffing and nurse outcomes: A systematic review

BACKGROUND

Intensive care units (ICU) are associated with significant work stress and exert continuous physical and emotional demand upon health care providers. The health and well-being of care providers, including ICU nurses, is a matter of great concern. However, to the researcher's knowledge, there have been no reviews synthesizing the evidence about the relationship between nurse staffing and nurse outcomes in the ICU.

PURPOSE

The purpose of this systematic review was to examine nurse staffing in the ICU and synthesize literature to examine the relationship with nurse outcomes such as job satisfaction, burnout, fatigue, and intent to leave.

METHODS

This review was reported based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Peer-reviewed articles published between January 2000 and September 2019 were identified via eight electronic bibliographic databases. Articles were included and reviewed if they were correlational studies examining the relationships between nurse staffing and nurse outcomes in the ICU, and were published in peer-reviewed journals written in either English or Korean. The Quality Assessment and Validity Tool for Correlation Studies was used for quality appraisal.

RESULTS

From 5086 articles, eight published between 2006 and 2019 were included in this review. Three studies found expected relationships between worse nurse staffing and adverse nurse outcomes (high burnout, fatigue state, emotional exhaustion, depersonalization, and stress). However, the relationships between nurse staffing and other adverse nurse outcomes were not significant. Perceived adequate staffing was negatively related to adverse nurse outcomes. However, a non-significant relationship also was found.

CONCLUSION

This study found limited evidence on relationships between nurse staffing and nurse outcomes in the ICU. More studies are needed to conduct to find a conclusive relationship.

RELEVANCE TO CLINICAL PRACTICE

Given high demands and workload in the ICU, nurse staffing levels should be closely monitored to prevent adverse nurse outcomes.

Relationship Between Prescription and Documentation of Pressure Injury Prevention Interventions and Their Implementation: An Exploratory, Descriptive Study

BACKGROUND

Formal assessment by nurses of a patient's pressure injury (PI) risk level is often highlighted as being key to PI prevention. However, if no action is taken to address the determined risk (i.e., if appropriate preventative interventions are not implemented), the patient remains vulnerable to PI development, and the assessment process is rendered pointless.

AIM

To explore the relationship between the prescription (planning) and implementation of PI preventative interventions by nurses following formal risk assessment.

METHODS

Using an exploratory, descriptive design, the charts and bedside areas of 200 adult patients admitted across four hospital wards were examined. Data collected included PI risk level, documented prescribed preventative interventions, and interventions for which there was evidence of implementation.

RESULTS

Of the final sample (n = 187), 66.8% of cases were categorized as being "at-risk" or above. As the risk category of patients increased, proportionately more patients in each category were prescribed each intervention. However, in most cases, significantly fewer interventions were actually implemented than were prescribed, except for several interventions that were implemented in more cases than were prescribed. There were 14 cases, including four at-risk and three high-risk patients, in which no preventative interventions were prescribed, while 88.7% of not at-risk patients had (unnecessary) preventative interventions prescribed.

DISCUSSION

These results indicate that intervention prescription increased relative to assessed level of risk; however, the rates of intervention prescription and actual implementation were suboptimal. The results indicate a significant mismatch between these two steps of PI prevention.

LINKING EVIDENCE TO ACTION

These results indicate that intervention prescription increased relative to assessed level of risk; however, the rates of intervention prescription and actual implementation were suboptimal. A significant mismatch between these two steps of PI prevention was evident. Following patient risk assessment, there should be a greater focus on appropriate preventative intervention prescription (planning) with regular review and audit to help ensure that interventions are implemented as prescribed. Improved implementation of preventative interventions should, in turn, help to reduce hospital-acquired pressure injuries.

whISOBAXTM Inhibits Bacterial Pathogenesis and Enhances the Effect of Antibiotics

As bacteria are becoming more resistant to commonly used antibiotics, alternative therapies are being sought. whISOBAX (WH) is a witch hazel extract that is highly stable (tested up to 2 months in 37 °C) and contains a high phenolic content, where 75% of it is hamamelitannin and traces of gallic acid. Phenolic compounds like gallic acid are known to inhibit bacterial growth, while hamamelitannin is known to inhibit staphylococcal pathogenesis (biofilm formation and toxin production). WH was tested in vitro for its antibacterial activity against clinically relevant Gram-positive and Gram-negative bacteria, and its synergy with antibiotics determined using checkerboard assays followed by isobologram analysis. WH was also tested for its ability to suppress staphylococcal pathogenesis, which is the cause of a myriad of resistant infections. Here we show that WH inhibits the growth of all bacteria tested, with variable efficacy levels. The most WH-sensitive bacteria tested were Staphylococcus epidermidis,Staphylococcus aureus, Enterococcus faecium and Enterococcus faecalis, followed by Acinetobacter baumannii, Klebsiella pneumoniae, Escherichia coli,Pseudomonas aeruginosa, Streptococcus agalactiae and Streptococcus pneumoniae. Furthermore, WH was shown on S. aureus to be synergistic to linezolid and chloramphenicol and cumulative to vancomycin and amikacin. The effect of WH was tested on staphylococcal pathogenesis and shown here to inhibit biofilm formation (tested on S. epidermidis) and toxin production (tested on S. aureus Enterotoxin A (SEA)). Toxin inhibition was also evident in the presence of subinhibitory concentrations of ciprofloxacin that induces pathogenesis. Put together, our study indicates that WH is very effective in inhibiting the growth of multiple types of bacteria, is synergistic to antibiotics, and is also effective against staphylococcal pathogenesis, often the cause of persistent infections. Our study thus suggests the benefits of using WH to combat various types of bacterial infections, especially those that involve resistant persistent bacterial pathogens.

Nurse staffing models in medical-surgical units of acute care settings: A cross-sectional study

BACKGROUND

Nurse staffing models have been developed across different countries to address nursing shortages and improve quality of nursing care. However, there is no published study that describes nurse staffing models in Ethiopian hospitals.

AIMS

To describe the existing staffing models for nursing practice in acute care units of two hospitals (one public and one private) in Ethiopia.

METHODS

A cross-sectional study was conducted from July to December 2018. A self-administered questionnaire was used to collect data such as shift patterns, hours worked, and number of patients cared for per shift. Unit-level data on nurse staffing were collected using a checklist developed specifically for this study.

RESULTS

Fifty-nine percent (59.9%) of participants reported that they worked six or seven days per week. On average, they worked 50 hours per week and 12% working over 60 hours per week. The number of patients they provided care for during their last shift ranged from four to 45 with an average of 13 patients.

CONCLUSION

This study demonstrates that nurses working in acute care settings in Ethiopia are typically working more than 40 hours per week and caring for many patients per shift, which has the potential to impact patient safety.

Multilevel factors influencing falls of patients in hospital: The impact of nurse staffing

AIM

The objective of this study was to investigate both individual and organizational factors influencing the falls of patients in hospitals.

BACKGROUND

Falls and fall-related injuries, which cause health problems and increase the economic burden to patients, are a critical issue for patient safety.

METHODS

This study retrospectively reviewed patient data and analysed factors influencing patient falls using a mixed-effect model.

RESULTS

The total number of patients in the study was 60,049, and the characteristics of the patients showed statistically significant differences according to the type of hospital where the fall occurred. The average rate of falls was 0.92 per 1,000 days. The rate of falls in general hospitals was the highest among all hospitals. Age, mobility impairment and hours per patient day for care delivered by registered nurses were factors influencing patients' falls.

CONCLUSION

Since the number of patient falls in an acute-care setting might increase in the future because of the growing elderly population, we should consider these risk factors for falls and construct preventative programs accordingly.

IMPLICATIONS FOR NURSING MANAGEMENT

An adequate level of nursing staff is an essential factor in the number of patient falls.