Nurse staffing and post-surgical complications using the present on admission indicator

Factors Affecting the Field Adaptation of Early-Stage Nurses in South Korea

Supporting early-stage nurses to adapt to the field and become proficient in nursing is important to improve the quality of patient care. This study aimed to determine the effects of the nursing work environment, nursing practice readiness, and optimism on the field adaptation of early-stage nurses. A descriptive survey was conducted among 209 early-stage nurses with ≤3 years of work experience at hospitals. The collected data were analyzed using descriptive statistics, the t-test, ANOVA, Pearson's correlation coefficients, and regression analysis with the SPSS Program. The participating nurses' mean field adaptation score was 2.90 ± 0.40 (total score = 5) and a significant positive correlation was found between nursing work environment (r = 0.61, p < 0.001), nursing practice readiness (r = 0.41, p < 0.001), and optimism (r = 0.26, p < 0.001). The regression analysis revealed that the nursing work environment (β = 0.38, p < 0.001), job satisfaction (β = 0.33, p < 0.001), nursing practice readiness (β = 0.24, p < 0.001), and turnover intention (β = 0.17, p = 0.001) significantly affect the field adaptation of early stage nurses; the explanatory power was 56.1% (F = 27.55, p < 0.001). The results suggest that to facilitate the field adaptation of early-stage nurses, the nursing work environment, job satisfaction, and nursing practice readiness should be improved. Improvement in the nursing work environment and the development of additional training for field adaptation would enhance the ability of early-stage nurses to adapt to the field and, consequently, improve the quality of nursing care.

Midwifery and nurse staffing of inpatient maternity services - A systematic scoping review of associations with outcomes and quality of care

OBJECTIVE

To undertake a scoping literature review of studies examining the quantitative association between staffing levels and outcomes for mothers, neonates, and staff. The purpose was to understand the strength of the available evidence, the direction of effects, and to highlight gaps for future research.

DATA SOURCES

Systematic searches were conducted in Medline (Ovid), Embase (Ovid), CINAHL (EBCSCO), Cochrane Library, TRIP, Web of Science and Scopus.

STUDY SELECTION AND REVIEW METHODS

To be eligible, staffing levels had to be quantified for in-patient settings, such as ante-natal, labour/delivery or post-natal care. Staff groups included midwives, nurse midwives or equivalent, and assistant staff working under the supervision of professionals. Studies of the quality of care, patient outcomes and staff outcomes were included from all countries. All quantitative designs were included, including controlled trials, time series, cross-sectional, cohort studies and case controlled studies. Data were extracted and sources of bias identified by considering the study design, measurement of exposure and outcomes, and risk adjustment. Studies were grouped by outcome noting the direction and significance of effects.

RESULTS

The search yielded a total of 3280 records and 21 studies were included in this review originating from ten countries. There were three randomised controlled trials, eleven cohort studies, one case control study and six cross sectional studies. Seventeen were multicentre studies and nine of them had over 30,000 participants. Reduced incidence of epidural use, augmentation, perineal damage at birth, postpartum haemorrhage, maternal readmission, and neonatal resuscitation were associated with increased midwifery staff. Few studies have suggested a negative impact of increasing staffing rates, although a number of studies have found no significant differences in outcomes. Impact on the mode of birth was unclear. Increasing midwifery assistants was not associated with improved patient outcomes. No studies were found on the impact of low staffing levels for the midwifery workforce.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Although there is some evidence that higher midwifery staffing is associated with improved outcomes, current research is insufficient to inform service planning. Studies mainly reported outcomes relating to labour, highlighting a gap in research evidence for the antenatal and postnatal periods. Further studies are needed to assess the costs and consequences of variations in maternity staffing, including the deployment of maternity assistants and other staff groups.

Are hospital nurse staffing practices associated with postoperative cardiac events and death? A systematic review

INTRODUCTION

Postoperative cardiac events are frequent complications of surgery, and their occurrence could be associated with suboptimal nurse staffing practices, but the existing evidence remains scattered. We systematically reviewed studies linking nurse staffing practices to postoperative cardiac events and two related outcomes, all-cause mortality and failure-to-rescue.

METHODS

A systematic search of the English/French literature was undertaken in the CINAHL, PsychInfo, and Medline databases. Studies were included if they: a) were published between 1996 and 2018; b) used a quantitative design; c) examined the association between at least one of seven staffing practices of interest (i.e., staffing levels, skill mix, work environment characteristics, levels of education and experience of the registered nurses, and overtime or temporary staff use) and postoperative cardiac events, mortality or failure-to-rescue; and d) were conducted among surgical patients. Data extraction, analysis, and synthesis, along with study methodological quality appraisal, were performed by two authors. High methodological heterogeneity precluded a formal meta-analysis.

RESULTS

Among 3,375 retrieved articles, 44 studies were included (39 cross-sectional, 3 longitudinal, 1 case-control, 1 interrupted time series). Existing evidence shows that higher nurse staffing levels, a higher proportion of registered nurses with an education at the baccalaureate degree level, and more supportive work environments are related to lower rates of both 30-day mortality and failure-to-rescue. Other staffing practices were less often studied and showed inconsistent associations with mortality or failure-to-rescue. Similarly, few studies (n = 10) examined the associations between nurse staffing practices and postoperative cardiac events and showed inconsistent results.

CONCLUSION

Higher nurse staffing levels, higher registered nurse education (baccalaureate degree level) and more supportive work environments were cross-sectionally associated with lower 30-day mortality and failure-to-rescue rates among surgical patients, but longitudinal studies are required to corroborate these associations. The existing evidence regarding postoperative cardiac events is limited, which warrants further investigation.

Safety and satisfaction of patients with nurse's care in the perioperative

OBJECTIVE

to investigate the safety and satisfaction of patients and their relationship with nurse's care in the perioperative period.

METHOD

cross-sectional, multi-level, correlational study with 105 nurses in the surgical area and 150 patients operated in a Spanish tertiary hospital. For the nurses the sociodemographic variables, the perception of the work environment, the professional burnout and the satisfaction in the work were collected. For patients, the safety of adverse events and level of satisfaction, through the application of questionnaires. Univariate and multivariate analysis were used.

RESULTS

job satisfaction, professional commitment, and participation in hospital issues were negative predictors for adverse events related to the patient, while postoperative nurse care was a positive predictor.

CONCLUSION

there is an increase in adverse events when nurses are dissatisfied at work, less professional commitment and low availability to participate in the subjects of their unit. On the other hand, adverse events decrease when nurses perform the care in the postoperative period. Satisfaction was good and there was no association with the characteristics of nurses' attention. It is recommended to improve these predictors to increase the safety of surgical patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effects of work environment on patient and nurse outcomes

BACKGROUND

Several parameters of the nurse's work environment lead to fewer patient complications and lower nurse burnout. The aim of this systematic review was the analysis of research data related to the effect of nurses' work environments on outcomes for both patients and nurses.

METHODS

Medline was searched by using keywords: 'working conditions', 'work environment', 'nurses', 'nursing staff', 'patients', 'outcomes'.

RESULTS

In total, 10 studies were included, of which 4 were cross-sectional and the remaining were descriptive correlational studies. Patients who were hospitalised in units with good work environments for the nurses were more satisfied with the nursing care than the patients in units with poor work environments. Nurses who perceived their work environment to be good experienced higher job satisfaction and lower rates of burnout syndrome.

CONCLUSIONS

A good work environment constitutes a determinant factor for high care quality and, at the same time, relates to improved outcomes for the nurses.

Transcending Competency Testing in Hospital-Based Simulation

Simulation is a frequently used method for training students in health care professions and has recently gained acceptance in acute care hospital settings for use in educational programs and competency testing. Although hospital-based simulation is currently limited primarily to use in skills acquisition, expansion of the use of simulation via a modified Quality Health Outcomes Model to address systems factors such as the physical environment and human factors such as fatigue, reliance on memory, and reliance on vigilance could drive system-wide changes. Simulation is an expensive resource and should not be limited to use for education and competency testing. Well-developed, peer-reviewed simulations can be used for environmental factors, human factors, and interprofessional education to improve patients' outcomes and drive system-wide change for quality improvement initiatives.

The relationship between nurse staffing and length of stay in acute-care: a one-year time-series data

AIM

To examine the relationship between nurse staffing and patient length of stay in an acute-care hospital over a 1-year period.

BACKGROUND

Although there has been prior research on the relationship between nurse staffing and length of stay in acute-care hospitals, there is a need for more information on how nurse staffing is related to length of stay longitudinally.

METHODS

Retrospective time-series registry data from 20 acute-care inpatient units of a Finnish university hospital as a monthly time series in 2008 were analysed by linear mixed models.

RESULTS

The ratio of registered nurses to all nurses was 72.4%. Nurses worked mainly (96%) full time, and 63% had permanent employment contracts. Statistically significant variation was found in time series of five variables. Statistically significant relationships were found between length of stay and patient acuity, diagnosis-related group-volume, census and nursing hours per patient day at the unit level. Nursing hours per patient day had the strongest correlation with length of stay.

CONCLUSION AND IMPLICATIONS FOR NURSING MANAGEMENT

A rational response to the variations in patient care needs and intensity in the complex care environment is flexible nurse staffing. Increasing nursing hours per patient day to achieve shorter length of stays is not the only solution, well-functioning care processes are also essential.

Comparison of Nurse Staffing Measurements in Staffing-Outcomes Research

BACKGROUND

Investigators have used a variety of operational definitions of nursing hours of care in measuring nurse staffing for health services research. However, little is known about which approach is best for nurse staffing measurement.

OBJECTIVE

To examine whether various nursing hours measures yield different model estimations when predicting patient outcomes and to determine the best method to measure nurse staffing based on the model estimations.

DATA SOURCES/SETTING

We analyzed data from the University HealthSystem Consortium for 2005. The sample comprised 208 hospital-quarter observations from 54 hospitals, representing information on 971 adult-care units and about 1 million inpatient discharges.

METHODS

We compared regression models using different combinations of staffing measures based on productive/nonproductive and direct-care/indirect-care hours. Akaike Information Criterion and Bayesian Information Criterion were used in the assessment of staffing measure performance.

RESULTS

The models that included the staffing measure calculated from productive hours by direct-care providers were best, in general. However, the Akaike Information Criterion and Bayesian Information Criterion differences between models were small, indicating that distinguishing nonproductive and indirect-care hours from productive direct-care hours does not substantially affect the approximation of the relationship between nurse staffing and patient outcomes.

CONCLUSIONS

This study is the first to explicitly evaluate various measures of nurse staffing. Productive hours by direct-care providers are the strongest measure related to patient outcomes and thus should be preferred in research on nurse staffing and patient outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The relationship between nurse staffing and inpatient complications

AIM

To compare characteristics of hospitalizations with and without complications and examine the impact of nurse staffing on inpatient complications across different unit types.

BACKGROUND

Studies investigating the relationship between nurse staffing and inpatient complications have not shown consistent results. Methodological limitations have been cited as the basis for this lack of uniformity. Our study was designed to address some of these limitations.

DESIGN

Retrospective longitudinal hospitalization-level study.

METHOD

Adult hospitalizations to high intensity, general medical and general surgical units at three metropolitan tertiary hospitals were included. Data were sourced from Western Australian Department of Health administrative data collections from 2004-2008. We estimated the impact of nurse staffing on inpatient complications adjusted for patient and hospital characteristics and accounted for patients with multiple hospitalizations.

RESULTS

The study included 256,984 hospitalizations across 58 inpatient units. Hospitalizations with complications had significantly different demographic characteristics compared with those without. The direction of the association between nurse staffing and inpatient complications was not consistent for different inpatient complications, nurse skill mix groups or for hospitalizations with different unit movement patterns.

CONCLUSION

Our study design addressed limitations noted in the field, but our results did not support the widely held assumption that improved nurse staffing levels are associated with decreased patient complication rates. Despite a strong international focus on improving nurse staffing to reduce inpatient complications, our results suggest that adding more nurses is not a panacea for reducing inpatient complications to zero.

Nursing-sensitive indicators: a concept analysis

AIM

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

BACKGROUND

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

DESIGN

Concept analysis.

DATA SOURCES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

DATA SOURCES/SETTING

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

METHODS

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

FINDINGS

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

CONCLUSIONS

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

Recent trends in hospital nurse staffing in the United States

OBJECTIVE

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

California's minimum nurse staffing legislation: results from a natural experiment

OBJECTIVE

To determine whether, following implementation of California's minimum nurse staffing legislation, changes in acuity-adjusted nurse staffing and quality of care in California hospitals outpaced similar changes in hospitals in comparison states without such regulations.

DATA SOURCES/STUDY SETTING

Data from the American Hospital Association Annual Survey of Hospitals, the California Office of Statewide Health Planning and Development, the Hospital Cost Report Information System, and the Agency for Healthcare Research and Quality's Health Care Cost and Utilization Project's State Inpatient Databases from 2000 to 2006.

STUDY DESIGN

We grouped hospitals into quartiles based on their preregulation staffing levels and used a difference-in-difference approach to compare changes in staffing and in quality of care in California hospitals to changes over the same time period in hospitals in 12 comparison states without minimum staffing legislation.

DATA COLLECTION/EXTRACTION METHODS

We merged data from the above data sources to obtain measures of nurse staffing and quality of care. We used Agency for Healthcare Research and Quality's Patient Safety Indicators to measure quality.

PRINCIPAL FINDINGS

With few exceptions, California hospitals increased nurse staffing levels over time significantly more than did comparison state hospitals. Failure to rescue decreased significantly more in some California hospitals, and infections due to medical care increased significantly more in some California hospitals than in comparison state hospitals. There were no statistically significant changes in either respiratory failure or postoperative sepsis.

CONCLUSIONS

Following implementation of California's minimum nurse staffing legislation, nurse staffing in California increased significantly more than it did in comparison states' hospitals, but the extent of the increases depended upon preregulation staffing levels; there were mixed effects on quality.

Reliability of the nursing care hour measure: a descriptive study

BACKGROUND

The nursing care hour has become an international standard unit of measure in research where nurse staffing is a key variable. Until now, there have been no studies verifying whether nursing care hours obtained from hospital data sources can be collected reliably.

OBJECTIVES

To examine the processes used by hospitals to generate nursing care hour data and to evaluate inter-rater reliability and guideline compliance with standards of the National Database of Nursing Quality Indicators(®) (NDNQI(®)) and the National Quality Forum.

DESIGN AND SETTING

Two-phase descriptive study of all NDNQI hospitals that submitted data in third quarter of 2007.

METHODS

Data for phase I came from an online survey created by the authors to ascertain the processes used by hospitals to collect nursing care hours and their compliance with standardized data collection guidelines. In phase II, inter-rater reliability was measured using intra-class correlations between nursing care hours generated from clock hour files submitted to the study team by participants' payroll/accounting departments and aggregated data submitted previously.

RESULTS

Phase I data were obtained from a total of 714 respondents. Nearly half (48%) of all sites use payroll records to obtain nursing care hour data and 70% use one of the standardized methods for converting the bi-weekly hours into months. Unit secretaries were reportedly included in NCH by 17.4% of respondents and only 26.2% of sites could accurately identify the point at which newly hired nurses should be included. The phase II findings (n=11) support the ability of two independent raters to obtain similar results when calculating total nursing care hours according to standard guidelines (ICC=0.76-0.99).

CONCLUSIONS

Although barriers exist, this study found support for hospitals' abilities to collect reliable nursing care hour data.

Evaluating nurse staffing patterns and neonatal intensive care unit outcomes using Levine's Conservation Model of Nursing

AIMS

To explore the influences of intensity of nursing care and consistency of nursing caregivers on health and economic outcomes using Levine's Conservation Model of Nursing as the guiding theoretical framework.

BACKGROUND

Professional nursing practice models are increasingly being used although limited research is available regarding their efficacy.

METHOD

A structural equation modelling approach tested the influence of intensity of nursing care (direct care by professional nurses and patient-nurse ratio) and consistency of nursing caregivers on morbidity and resource utilization in a neonatal intensive care unit (NICU) setting using primary nursing.

RESULTS

Consistency of nursing caregivers served as a powerful mediator of length of stay and the duration of mechanical ventilation, supplemental oxygen therapy and parenteral nutrition. Analysis of nursing intensity indicators revealed that a mix of professional nurses and assistive personnel was effective.

CONCLUSIONS

Providing consistency of nursing caregivers may significantly improve both health and economic outcomes. New evidence was found to support the efficacy of the primary nursing model in the NICU.

IMPLICATIONS FOR NURSING MANAGEMENT

Designing nursing care delivery systems in acute inpatient settings with an emphasis on consistency of nursing caregivers could improve health outcomes, increase organizational effectiveness, and enhance satisfaction of nursing staff, patients, and families.

Adjusting for patient acuity in measurement of nurse staffing: two approaches

BACKGROUND

Researchers who examine the relationship between nurse staffing and quality of care frequently rely on the Medicare case mix index to adjust for patient acuity, even though it was developed originally based on medical diagnoses and may not accurately reflect patients' needs for nursing care.

OBJECTIVES

The aim of this study was to examine the differences between unadjusted measures of nurse staffing (registered nurses per 1,000 adjusted patient days) and case mix adjusted nurse staffing and nurse staffing adjusted with nursing intensity weights, which were developed to reflect patients' needs for nursing care.

METHOD

Secondary data were used from 579 hospitals in 13 states from 2000 to 2006. Included were three measures of nurse staffing and hospital characteristics including ownership, geographic location, teaching status, hospital size, and percent Medicare inpatient days.

RESULTS

Measures of nurse staffing differed in important ways. The differences between the measures were related systematically to ownership, geographic location, teaching status, hospital size, and percentage Medicare inpatient days.

DISCUSSION

Without an accurate method to incorporate acuity into measurement of nurse staffing, research on the relationship between staffing and quality of care will not reach the full potential to inform practice.