Costs and cost-effectiveness of improved nurse staffing levels and skill mix in acute hospitals: A systematic review

Barriers and enablers in nurses implementing light sedation in intubated and ventilated children: A qualitative exploratory descriptive study

OBJECTIVE

To explore barriers and enablers in nurses implementing light sedation in mechanically ventilated children.

DESIGN

A qualitative exploratory descriptive study.

SETTING

The study was conducted in a quaternary paediatric intensive care unit in Queensland, Australia.

METHODS

Focus groups (n = 4) were conducted with nurses (n = 32) caring for children requiring mechanical ventilation and sedation. The Capability, Opportunity and Motivation model of Behaviour change (COM-B) provided the conceptual framework for this study. Qualitative data were thematically analysed.

FINDINGS

Nurse reported challenges in balancing sedation needs with patient safety. Knowledge and experience with sedation management in mechanically ventilated children, and continuity of care, positively influenced light sedation. Resources in both the physical and social environment, including family engagement, play a positive role in enhancing the practice of light sedation. Light sedation in the younger paediatric population, and those with delirium, was identified as challenging. Nonpharmacological measures facilitated management of lightly sedated patients whereas inconsistent practice among physicians and lack of nursing autonomy were identified as barriers.

CONCLUSIONS

The practice of light sedation is most effectively promoted when it is prioritized at the organisational level. Ensuring adequate human resources, modifying the physical environment, and fostering collaboration among multidisciplinary teams, including family, are all likely to enhance its implementation. Nurses' knowledge and experience in sedation management, alongside continuity of care and utilising nonpharmacological interventions, can further promote its practice. However, factors such as nurses' concerns for their own professional and patient safety, high acuity levels in the unit, and a lack of support may hinder the adoption of light sedation practices.

IMPLICATIONS FOR CLINICAL PRACTICE

The findings from this study suggest engaging multidisciplinary team to support light sedation practice. Likewise, training and skill development of nurses in the assessment and management of sedation may help implement light sedation. Continuity of care, adequate staffing, patient visibility and minimising stimulation should be considered to support the same. Nurses need to be empowered to practice light sedation, and sedation protocols may be helpful in this regard.

Personnel shortages and the provision of long-term care: an empirical analysis of German nursing homes

Amidst demographic shifts, advanced economies are facing critical nursing shortages. This study analyzes how long-term care in German nursing homes relate to these shortages using administrative data for the period 2007 to 2017. Our analysis reveals that higher nursing shortages correlate with decreased nurse-to-resident ratios, changes in the qualification mix of nurse personnel, and reduced occupancy rates. These findings suggest that nurse shortages might be a threat to the quality of care and the financial sustainability of nursing homes at the margin of being profitable.

Cost-effectiveness of eliminating hospital understaffing by nursing staff: a retrospective longitudinal study and economic evaluation

BACKGROUND

Understaffing by nursing staff in hospitals is linked to patients coming to harm and dying unnecessarily. There is a vicious cycle whereby poor work conditions, including understaffing, can lead to nursing vacancies, which in turn leads to further understaffing. Is hospital investment in nursing staff, to eliminate understaffing on wards, cost-effective?

METHODS

This longitudinal observational study analysed data on 185 adult acute units in four hospital Trusts in England over a 5-year period. We modelled the association between a patient's exposure to ward nurse understaffing (days where staffing was below the ward mean) over the first 5 days of stay and risk of death, risk of readmission and length of stay, using survival analysis and linear mixed models. We estimated the incremental cost-effectiveness of eliminating understaffing by registered nurses (RN) and nursing support (NS) staff, estimating net costs per quality-adjusted life year (QALY). We took a hospital cost perspective.

FINDINGS

Exposure to RN understaffing is associated with increased hazard of death (adjusted HR (aHR) 1.079, 95% CI 1.070 to 1.089), increased chance of readmission (aHR 1.010, 95% CI 1.005 to 1.016) and increased length of stay (ratio 1.687, 95% CI 1.666 to 1.707), while exposure to NS understaffing is associated with smaller increases in hazard of death (aHR 1.072, 95% CI 1.062 to 1.081) and length of stay (ratio 1.608, 95% CI 1.589 to 1.627) but reduced readmissions (aHR 0.994, 95% CI 0.988 to 0.999). Eliminating both RN and NS understaffing is estimated to cost £2778 per QALY (staff costs only), £2685 (including benefits of reduced staff sickness and readmissions) or save £4728 (including benefits of reduced lengths of stay). Using agency staff to eliminate understaffing is less cost-effective and would save fewer lives than using permanent members of staff. Targeting specific patient groups with improved staffing would save fewer lives and, in the scenarios tested, cost more per QALY than eliminating all understaffing.

INTERPRETATION

Rectifying understaffing on inpatient wards is crucial to reduce length of stay, readmissions and deaths. According to the National Institute for Health and Care Excellence £10 000 per QALY threshold, it is cost-effective to eliminate understaffing by nursing staff. This research points towards investing in RNs over NS staff and permanent over temporary workers. Targeting particular patient groups would benefit fewer patients and is less cost-effective.

Evaluating the Implementation of Strategies to Improve Evidence-Based Surgical Care: A Focus Group Study

AIM

To evaluate healthcare professionals' perspectives on factors that lead to success in the implementation of strategies to strengthen evidence-based surgical nursing care.

DESIGN

A qualitative study design with focus group interviews, according to Krueger and Casey in a surgical department at a university hospital in Sweden.

METHODS

Four focus groups were conducted with 18 participants, including specialist nurses in surgical care, registered nurses and assistant nurses. Data were collected in February-March 2024. A semi-structured interview guide was used, and data were analysed using qualitative content analysis.

RESULTS

Three themes with seven subthemes were developed to capture the evaluation of health care professionals' perspectives of the implementation strategies to strengthen evidence-based surgical nursing care. The themes were (1) Roles and leadership, (2) Engagement in the implementation, and (3) Facilitators and barriers to implementation. The implementation has meant the transition from theory to practice and integrating new routines into the surgical department. It was a learning process where the health care professionals needed to familiarise themselves with new concepts and working methods. The positive outcome of the project and support from the nursing leadership were important facilitators in the implementation process.

CONCLUSIONS

The implementation of new ways of working was a complex process with both resistance and learning, but it ultimately led to positive changes in the surgical care environment.

IMPLICATIONS FOR THE PROFESSION AND IMPACT

The project has entailed that specialist nurses in surgical care have increased nursing power in the department and extended responsibilities. Support from the head of the department and the management team has been crucial to being able to carry out the project, and the implementation of activities in small steps has been successful.

REPORTING METHOD

Adhered to the SRQR guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Optimising Nurse-Patient Assignments: The Impact of Machine Learning Model on Care Dynamics-Discursive Paper

BACKGROUND

Machine learning (ML) models can enhance patient-nurse assignments in healthcare organisations by learning from real data and identifying key capabilities. Nurses must develop innovative ideas for adapting to the dynamic environment, managing staffing and establishing flexible workforce solutions.

AIM

This discursive paper discusses the application of ML in optimising patient-nurse assignments within healthcare settings, considering various factors such as staff skill mix, patient acuity, cultural competencies and language considerations.

METHODS

A discursive approach was used to optimise nurse-patient assignments and the impact of ML models. Through a review of traditional and emerging perspectives, factors such as staff skill mix, patient acuity, cultural competencies and language-related challenges were emphasised.

RESULTS

Machine learning models can potentially enhance healthcare patient-nurse assignments by considering skill integration, acuity level assessment and cultural and language barrier awareness. Thus, models have the potential to optimise patient care through dynamic adjustments.

CONCLUSION

The application of ML models in optimising patient-nurse assignments presents significant opportunities for improving healthcare delivery. Future research should focus on refining algorithms, ensuring real-time adaptability, addressing ethical considerations, evaluating long-term patient outcomes, fostering cooperative systems, and integrating relevant data and policies within the healthcare framework. No patient or public contribution.

Nurse Staffing Configurations and Nurse Absence Due to Sickness

Importance

Rates of work-related stress and sickness absence are high among nurses. The consequences of sickness absence are severe for health systems' efficiency and productivity.

Objective

To examine the association between nurse staffing configurations and sickness absence in hospital inpatient unit nursing teams.

Design, Setting, and Participants

This retrospective longitudinal case-control study using routinely collected hospital data among 4 general acute care hospitals in England examined 18 674 registered nurses (RNs) and nursing support (NS) staff working in 116 hospital units. Data were analyzed from April 1, 2015, to February 29, 2020.

Exposure

Nursing team skill mix, temporary staffing hours, understaffing, proportion of long shifts (≥12 hours) worked, and full-time or part-time work status in the previous 7 days.

Main Outcome and Measure

The main outcome was the number of episodes of sickness absence, which was defined as a sequence of sickness days with no intervening days of work.

Results

There were 2 690 080 shifts and 43 097 sickness episodes. The incident rates for starting a sickness episode were 2.0% for NSs and 1.4% for RNs. In total, there were 18 674 members of staff; 2 188 562 (81.6%) were shifts by staff classified as working full time and 493 400 (18.4%) by staff classified as working part time. A skill mix composed of more RNs was associated with a 2% reduction in the odds of RN sickness absence for each 10% change in the proportion of RN hours (odds ratio [OR], 0.98; 95% CI, 0.96-0.99). Moving from the lower quartile skill mix (ie, approximately 55% of the nursing hours worked by RNs) to the upper quartile (ie, approximately 75% of the nursing hours worked by RNs) was associated with a 4% reduction in odds of sickness absence. Working only long shifts in the prior 7 days was associated with a 26% increase in the odds of sickness absence for RNs compared with working no long shifts (OR, 1.26; 95% CI, 1.19-1.33). Part-time work for RNs was associated with higher sickness absence (OR, 1.09; 95% CI, 1.03-1.15). For RNs, there was a significant interaction between part-time work and RN understaffing, whereby short staffing in the previous week increased sickness absence for full-time staff but not among those working part time. NS understaffing was not associated with sickness absence for any staffing group.

Conclusions and Relevance

This retrospective case-control study found that exposure to RN understaffing increased the risk of sickness absence in nursing teams. Adverse working conditions for nurses, already known to pose a risk to patient safety, may also create risks for nurses and the possibility of further exacerbating staff shortages.

Evaluation of an intervention package developed to reduce pre-registration nursing student attrition rates: A mixed method study

BACKGROUND

Higher educational institutions strive to recruit and retain student nurses into pre-registration programmes to support a sustainable nursing workforce. Attrition rates for student nurses are high and escalating, with around one in three nursing students in the United Kingdom failing to complete their degree programmes. Risk factors for student attrition include the attributes students bring to their study environment, as well as their behaviours and academic outputs. Modern learning analytics engagement tool can monitor attrition risk through tracking students as they engage with learning resources and other institutional opportunities.

AIM

To evaluate the effectiveness of an intervention package aimed at reducing pre-registration nursing student attrition rates at a Higher Education Institute in South East England.

DESIGN AND METHODS

Our mixed methods study design had three phases. Phase 1: design of an intervention package and its planned implementation. Phase 2: piloted the intervention with 1198 student nurses. Phase 3: semi-structured interviews with five student nurses.

RESULTS

The learning analytics engagement tool was able to identify 144 students who were struggling and/or disengaging with their academic studies. 17 % (n = 24) students responding to the initial email contact. Of these 24 students, 67 % (n = 16) did not want a meeting with the Intervention Officer, who they were unfamiliar with, and only one attended a meeting.

CONCLUSION

Our evaluation of the effectiveness of an intervention package in reducing pre-registration nursing student attrition rates revealed valuable insights. Findings revealed that a lack of trusting relationships with intervention facilitators is likely to diminish engagement with such interventions.

The effect of registered nurse staffing and skill mix on length of stay and hospital costs

BACKGROUND

Sepsis is a common cause of hospitalization among Medicare beneficiaries, often leading to prolonged hospital stays and high costs.

PURPOSE

To estimate the impact of registered nurse (RN) staffing and skill mix on hospital lengths of stay and associated costs for Medicare beneficiaries with sepsis.

METHODS

A retrospective, cross-sectional analysis was conducted using 2018 data from 2,107 acute care hospitals, including 653,496 patients with sepsis.

FINDINGS

A one-unit increase in RN hours per patient day and a 1% increase in RN skill mix reduced hospital stays by 2% and 1%, respectively. Enhancing staffing to nine RN hours per patient day and an 80% RN skill mix could save 63,580 inpatient days annually, reducing costs by $152.9 million. Further increases to 11 RN hours and an 85% skill mix could save $331.9 million.

DISCUSSION

Better RN staffing and skill mix can improve patient outcomes and yield significant cost savings.

Are we making the most of safe staffing research

INTRODUCTION

The uptake of research evidence on staffing issues in nursing by nursing leadership, management and into organizational policies seems to vary across Europe. This study wants to assess this uptake of research evidence.

DESIGN

Scoping survey.

METHOD

The presidents of twelve country specific Sigma Chapters within the European Region answered written survey questions about work organisation, national staffing levels, national skill mix levels, staff characteristics, and education.

RESULTS

Seven of the 12 chapters could not return complete data, reported that data was unavailable, there was no national policy or only guidance related to some settings.

CONCLUSION

Enhancing the awareness of nursing research and of nursing leaders and managers regarding staffing level evidence is not enough. It seems necessary to encourage nurse leaders to lobby for staffing policies.

CLINICAL RELEVANCE

Research evidence on staffing issues in nursing and how it benefits health care is available. In Europe this evidence should be used more to lobby for change in staffing policies.

'Entanglement of nursing care': A theoretical proposition to understand the complexity of nursing work and division of labour

Ongoing challenges in the provision of care, driven by growing care complexity and nursing shortages, prompt us to reconsider the basis for efficient division of nursing labour. In organising nursing work, traditionally the focus has been on identifying nursing tasks that can be delegated to other less expensive and less highly educated staff, in order to make best use of scarce resources. We argue that nursing care activities are connected and intertwined. As such 'entanglement' is a hallmark of nursing work, it needs to be understood to identify optimal and sustainable options for division of labour in nursing. We elaborate the value of entanglement as a theoretical proposition to shift the focus away from old models of task-oriented nursing and put forward a model of labour division that acknowledges the importance of entangled nursing care activities. We build on the work of Jackson, Anderson, and Maben (2021) in which nursing work was conceptualised as a combination of cognitive, emotional, organisational, and physical labour. We assert that just allocating labour based on the type of work will not do the trick. The complexity of nursing work also needs to be considered. This is commonly framed as the combination of care activities required in the interest of patients and the complexity of each of these activities ('task complexity'). Integrating the concept of entanglement brings to light that even 'simple' care activities contribute to the complexity of work, as activities are potentially bound up with other activities ('entangled care activities'). That is to say, nursing work is not simply a function of the tasks undertaken. Based on our conceptualisation, we propose that the existence and nature of entangled care activities ('task entanglement') should be taken into account, to express what is needed in dividing the labour ('labour complexity'). This should in turn underpin future staffing and skill mix decisions. In the pursuit of guaranteeing high quality of care, further research on 'ideal' mixes of skills and optimal team compositions in various health care contexts is necessary. For nursing practice, our theoretical proposition can be used to explicate the complexity of daily work. Hereby, giving nurses something to demonstrate their added value in providing the best care to patients. Tweetable abstract: Nursing work is more than the accumulation of care activities; to comprehend its complexity care entanglement (intertwining) should be acknowledged.

Association Between Nurse Staffing Coverage and Patient Outcomes in a Context of Prepandemic Structural Understaffing: A Patient-Unit-Level Analysis

Objective: To evaluate the association between nurse staffing coverage and patient outcomes in a context of structural understaffing. Design: This is a population-based, cross-sectional, multicenter study, including patient and staffing data from eight public hospitals from Catalonia, Spain. Participants: A total of 183,085 adult in-patients admitted to hospital wards and step-down units during 2016 and 2017. Outcomes: In-hospital mortality, 30-day hospital readmission, and three cluster nurse-sensitive adverse events: healthcare-acquired infections, failure to maintain, and avoidable critical complications. The study factor is safe nursing staffing equivalent to nurse staffing coverage > 90%. Results: Average patient acuity was equivalent to 4.5 required nursing hours per patient day. The mean available nursing hours per patient day was 2.6. The average nurse staffing coverage reached 65.5%. Overall, 1.9% of patients died during hospitalization, 5% were readmitted within 30 days, and 15.9% experienced one or more adverse events. Statistically significant differences were identified for all patient outcomes when comparing patients safely covered (nurse staffing coverage > 90%) and under-covered (nurse staffing coverage < 90%). Increasing nurse staffing coverage to a safe level (> 90%) is associated with a reduction of the risk of death (RR: 0.41, 95% CI: 0.37-0.45), a decrease in the risk of hospital readmission (RR: 0.93, 95% CI: 0.89-0.97), and a reduction of nurse-sensitive adverse events (RR: 0.67, 95% CI: 0.66-0.69). Conclusion: Safe nurse staffing coverage acts as a protective factor for detrimental patient outcomes, significantly reducing the risk of in-hospital mortality, 30-day hospital readmission, healthcare-associated infections, failure to maintain, and avoidable critical complications. Further policy efforts are needed to guarantee a safe registered nurse staffing coverage.

Demonstration of sizing nursing staff methods in intensive care

OBJECTIVE

to demonstrate the sizing of intensive care nursing staff estimated by two calculations, using the Nursing Activities Score as one of its central components.

METHOD

descriptive, retrospective study that compiled the Nursing Activities Score scores of patients in five Intensive Care Units of a hospital in southern Brazil. Two calculations were used to size the nursing staff. In addition to other components, calculation I converted the Nursing Activities Score into minutes and hours; and calculation II used this score on a denominator corresponding to one nursing professional/day, considering two types of work shifts. In both equations, the proportion of 52% of nurses was respected.

RESULTS

in the 9,610 evaluations, the mean of Nursing Activities Score was 85.9% (80.8% to 96.4%). While calculation I estimated 164 professionals, calculation II projected 176 and 140 workers for five and four shifts, respectively. The difference in nurses between the methods was 18 professionals.

CONCLUSION

the choice of the calculation and the number of work shifts substantially interfere in the estimation of intensive care nursing staff. This may support a methodological review in the standardization of nursing sizing in this area.

Hypoxemia and Postoperative Monitoring After Anesthesia: A Prospective Observational Study Using Portable Pulse Oximetry in a Resource-Limited Setting in Guatemala

Pulse oximetry is a critical component of patient monitoring to ensure adequate oxygenation in the perioperative period. However, its use remains limited in low- and middle-income countries due to device scarcity, limited funding, and lack of training. This prospective observational study describes the incidence of early postoperative hypoxemia (EPH) with newly implemented portable pulse oximetry and associated factors that impact postoperative management at the Hospital Nacional de Coatepeque (HNC), a primary referral public hospital in Guatemala. Semi-structured interviews were conducted with perioperative medical staff to explore perspectives regarding postoperative monitoring and patient safety in a resource-limited setting. One hundred patients were included, of which 10% experienced EPH. Patient age was significantly associated with EPH. The average duration in the recovery area of 14 minutes, with a lack of subsequent monitoring, was a primary concern of the 14 interviewed medical personnel. The greatest perceived needs include enhanced monitoring, increased staffing, and a dedicated post-anesthesia care unit. Pulse oximetry is essential to detect previously unrecognized EPH. Improved postoperative monitoring and increased recovery time and staffing are priorities to enhance patient safety at public hospitals in Guatemala.

Time spent on activities that can be delegated and reasons for not delegating among acute care nurses: A mixed-methods study

AIM

To describe the activities nurses perceived to be delegable to other staff (delegable activities) in order to estimate the time nurses spend on delegable activities and explore nurses' reasons for not delegating these activities.

DESIGN

Mixed-methods explanatory sequential.

METHODS

In total, 236 nurses from 27 medical and surgical wards of five hospitals in northern Italy completed a web-based survey during a single shift between June and July 2022. Minutes spent on delegable activities, staff member to whom participants could have delegated and reason(s) for not delegating were reported. Chief nurses provided specific wards' characteristics using a paper-and-pencil questionnaire. Twenty semi-structured interviews were conducted to explore delegable activities and reasons for not delegating. Quantitative and qualitative results were merged using joint displays.

RESULTS

Participants spent approximately one-quarter of their time performing delegable activities, mainly delegable to nurse aides or nurse clerks, and performed due to a lack/shortage of staff or their concurrent participation in other activities. Participants recognized that activities requiring clinical assessment and decision-making skills cannot be delegated, whereas technical activities and indirect care should be delegated. Organizational, structural and cultural factors, as well as patient characteristics, available staff and experience affected delegation, leading nurses to perform delegable activities to ensure patient care.

CONCLUSION

Nurses spend a considerable part of their time on delegable activities due to a lack of staff or support services and suboptimal organization, which could be addressed by optimal staff management, but also to the complexity of the contexts, including individual and cultural factors that should be addressed through policy interventions.

IMPACT

This study estimates the time nurses spend on delegable activities in acute care settings. Our findings highlighted the reasons that sustain the decision not to delegate that policymakers, healthcare managers, and nurse educators should consider to promote nurses' delegation skills.

REPORTING METHODS

MMR checklist.

PATIENT/PUBLIC CONTRIBUTION

None.

The Nursing Human Capital Value Model

Nursing's economic value is presently framed within the dominant "outcomes-over-cost" value framework. Within this context, organizations employing nurses often use nursing budget reductions as a cost-minimization strategy, with the intent of retaining high quality outcomes. However, persistent issues such as nurse understaffing, burnout, and turnover threaten healthcare systems' capacity to deliver the quality, equitable, affordable patient care that the public requires. In this paper, we propose a new conceptual model and definition of nursing's economic value. The model development is guided by the convergence of three classic economic frameworks: human capital theory, production theory, and value theory. Grounded in these theories, we envision nursing as a value-adding human capital asset and explicitly link nursing staff characteristics and allocation to the production of healthcare services and organizational financial outcomes. We redefine nursing's economic value as the return on investment (ROI) in nursing human capital reflected in the improvement of consumer, nurse, and organizational outcomes. This new conceptual model, termed the Nursing Human Capital Value Model, presents a cycle of value creation that starts with investments in growing, developing and sustaining an organization's nursing human capital. Nurses, as a human capital asset, deliver nursing care-a foundational ingredient to the production of healthcare services and consumer outcomes. Improved outcomes, subsequently, drive organizational revenue growth. Finally, the accrued revenue is reinvested in nursing, further propelling the cycle's continuation. This innovative model, which is applicable across health systems financed through both governmental and private/non-governmental payor sources, highlights that investment in nursing human capital development is essential for sustainable value generation, identifying opportunities for optimizing nurses' contributions to the value cycle. By directly incorporating economic theories of human capital, production, and value, our model paves the way for future research on the dynamic scope of nursing's economic contribution within healthcare organizations and systems and underscores its necessity for the long-term sustainability and growth of the nursing profession. Tweetable abstract: The economic value of nursing lies in the return on investment in nursing human capital. #nurses #ROI #healthcare.

The Healthcare Workforce Shortage of Nurses and Physicians: Practice, Theory, Evidence, and Ways Forward

The healthcare sector is ubiquitously plagued by workforce shortages in economies around the globe. The fragility of this structural shortage becomes apparent when external shocks, such as the COVID-19 pandemic, exacerbate the lack of workers in clinical practice. In this article, we summarize current trends in healthcare workforce development across the globe, review theoretical concepts of workforce shortages, and discuss policies to address them. In practice, developed countries often address workforce shortages with targeted migration policies. However, targeted workforce migration policies only intensify workforce shortages in low-and middle-income countries. Theoretical macroeconomic models suggest that supply shortages may result from too low wages, supply lagging behind demand, and social perception. Changes in the wage rate cannot sufficiently increase the supply of health professionals as scholars find inelastic wages for physicians and nurses. Nonpecuniary factors such as working conditions, job satisfaction, and intrinsic motivation are at least equally important as financial incentives. In conclusion, increased wages can only be part of a heterogeneous policy plan to address shortages. Migration and retirement levels of health professionals can temporarily mitigate workforce shortages but rarely change the underlying systemic issues. Increasing the number of places available in medical and nursing schools while also improving, both, financial and nonfinancial incentives for employees are long-term structural policy options.

The Scheduling Mode of Anesthesia Nurses Affects Postanesthesia Care Unit Efficiency: A Single-Center Retrospective Study From China

PURPOSE

Anesthesia nurses play an important postsurgical role during the anesthesia recovery period, which is characterized by a high incidence of complications related to anesthesia and surgery. Strengthening staff allocation and skill management in the postanesthesia care unit (PACU) is therefore particularly important in managing length of stay. We aimed to investigate the effect of two schedule modes for anesthesia nurses on PACU efficiency.

DESIGN

A retrospective observational cohort study.

METHODS

We conducted a retrospective study in a large tertiary academic medical center. In 2018, the PACU operated with traditional scheduling and the nurse-to-patient ratio was 1.2:1. The PACU implemented intensive scheduling and this ratio was adjusted to 1:1 in 2019 by adjusting the anesthesia nurse allocation scheme. We compared the number of admitted patients, length of PACU stay, the incidence of anesthesia-related complications, and nurse satisfaction with the two modes.

FINDINGS

The total number of admitted patients was 10,531 in 2018 and 10,914 in 2019. PACU admitted 401 more patients in 2019 than in 2018, even with two fewer nurses per day. Nevertheless, the median length of PACU stay in 2019 was statistically significantly shorter than in 2018 (29 [22-40] vs 28 [21-39], P < .001], while the incidence of anesthesia-related complications including postoperative pain, nausea and vomiting, hypertension, and shivering were comparable in the 2 years (P > .091). The intensive scheduling implemented in 2019 received more satisfaction from nurses than the traditional scheduling applied in 2018 (P < .01).

CONCLUSIONS

The scheduling of anesthesia nurses affects PACU efficiency. The intensive scheduling mode implemented in 2019 resulted in a comparable number of admitted patients, a better quality of care, and higher nurse satisfaction than those under the traditional scheduling mode.

The Impact of Assessment of Nurses' Experiences in Thoracic Surgery in Onco-Hematological Patients

Background: Nowadays, Thoracic Surgery is technologically advanced; therefore, it also focuses its attention on nursing care. The aim of the study is to evaluate the effect of the assessment of a dedicated team of nurses (DTN) in all onco-hematological patients undergoing VATS lobectomy for lung cancer on the outcome of the patient, preventing pressure injuries, reducing perioperative stress, duration of operations, complications, and hospital stay times. Methods: We performed a single-center observational retrospective study, including 31 DTN and 760 onco-hematological patients who underwent thoracic surgery between 30 October 2018 and 30 June 2023 at "Vanvitelli" University of Naples. Results: DTN ensures good nursing care before, during, and after surgery. Operative time was reduced by approximately 20 min, decreasing hospital infections in the DNT period and reducing intraoperative complications such as bleeding and hospital costs (p < 0.05). Conclusions: Thoracic surgery nurses require more specialized training to adapt to the development of sophisticated.

Nurse understaffing associated with adverse outcomes for surgical admissions

BACKGROUND

Nurses play a crucial role in maintaining the safety of surgical patients. Few nurse staffing studies have looked specifically at surgical patients to examine the impact of exposure to low staffing on patient outcomes.

METHODS

A longitudinal patient analysis was conducted in four organizations in England using routine data from 213 910 admissions to all surgical specialties. Patients' staffing exposures were modelled as counts of understaffed registered nurse and nurse assistant days in the first 5 inpatient days. Understaffing was identified when staffing per patient-day was below the mean for the ward. Cox models were used to examine mortality within 30 days of admission and readmission within 30 days of discharge. Generalized linear models were used to investigate duration of hospital stay and occurrence of hospital-acquired conditions.

RESULTS

Increased exposure to registered nurse understaffing was associated with longer hospital stay and increased risk of deep vein thrombosis, pneumonia, and pressure ulcers. This was also true for nurse assistant understaffing, but the effect sizes tended to be smaller. In the Cox models, there were similarly increased hazards of death for registered nurse understaffing (HR 1.09, 95% c.i. 1.07 to 1.12) and nurse assistant understaffing (HR 1.10, 1.08 to 1.13), whereas the effect size of registered nurse understaffing for readmission (HR 1.02, 1.02 to 1.03) was greater than that seen with nurse assistants (HR 1.01, 1.01 to 1.02).

CONCLUSION

Understaffing by both registered nurses and nursing assistants is associated with increased risks of a range of adverse events, and generally larger effects are seen with registered nurse understaffing.

Nursing Team Composition and Mortality Following Acute Hospital Admission

Importance

Many studies show the adverse consequences of insufficient nurse staffing in hospitals, but safe and effective staffing is unlikely to be just about staff numbers. There are considerable areas of uncertainty, including whether temporary staff can safely make up shortfalls in permanent staff and whether using experienced staff can mitigate the effect of staff shortages.

Objective

To explore the association of the composition of the nursing team with the risk of patient deaths.

Design, Setting, and Participants

This patient-level longitudinal observational study was conducted in 185 wards in 4 acute hospital trusts in England between April 2015 and March 2020. Eligible participants were patients with an overnight stay and nursing staff on adult inpatient wards. Data analysis was conducted from month April 2022 to June 2023.

Exposure

Naturally occurring variation during the first 5 days of hospital admission in exposure to days of low staffing from registered nurses (RNs) and nursing support (NS) staff, the proportion of RNs, proportion of senior staff, and proportion of hospital-employed (bank) and agency temporary staff.

Main Outcomes and Measures

The primary outcome was death within 30 days of admission. Mixed-effect Cox proportional hazards survival models were used.

Results

Data from 626 313 admissions (319 518 aged ≥65 years [51.0%]; 348 464 female [55.6%]) were included. Risk of death was increased when patients were exposed to low staffing from RNs (adjusted hazard ratio [aHR], 1.08; 95% CI 1.07-1.09) and NS staff (aHR, 1.07; 95% CI, 1.06-1.08). A 10% increase in the proportion of temporary RNs was associated with a 2.3% increase in the risk of death, with no difference between agency (aHR, 1.023; 95% CI, 1.01-1.04) and bank staff (aHR, 1.02; 95% CI, 1.01-1.04). A 10% increase in the proportion of agency NS was associated with a 4% increase in risk of death (aHR, 1.04; 95% CI, 1.02-1.06). Evidence on the seniority of staff was mixed. Model coefficients were used to estimate the association of using temporary staff to avoid low staffing and found that risk was reduced but remained elevated compared with baseline.

Conclusions and Relevance

This cohort study found that having senior nurses in the nursing team did not mitigate the adverse outcomes associated with low nurse staffing. These findings indicate that while the benefits of avoiding low staffing may be greater than the harms associated with using temporary staff, particularly for RNs, risk remains elevated if temporary staff are used to fill staffing shortages, which challenges the assumption that temporary staff are a cost-effective long-term solution to maintaining patient safety.

Addressing the Nursing Workforce Crisis Through Nurse-Physician Collaboration

This Viewpoint explores root causes of the nurse staffing shortages in the US and proposes solutions that involve physicians.

Transcultural Adaptation and Psychometric Properties of the Persian Version of the Nursing Student Competence Scale (NSCS)

Introduction

The competency of a nurse in integrating knowledge, skills, attitudes, and values in various healthcare areas depends on their ability to apply these elements. It is a basic indicator of performance in nursing, and its assessment is a necessity among nursing students.

Objective

The present study was conducted to determine the psychometric properties of the Persian version of the nursing competence tool for Iranian nursing students in 2023.

Methods

This is a methodological study in which the Nursing Student Competence Scale (NSCS) was translated into Persian using the forward-backward translation method. A total of 321 nursing students were selected for construct validity by the exploratory factor analysis (EFA) (the first 190 nursing students) and confirmatory factor analysis (CFA) by convenience sampling method. Cronbach's alpha coefficient was used to evaluate the internal consistency, and the test-retest method was used to check the instrument's reliability.

Results

The results of EFA and CFA confirmed the instrument with six factors and 28 items. The results showed that the fit indices of the model in CFA included (CFI = .91, NNFI = .90, goodness of fit index = .83, root mean square error of approximation = .075, standardized root mean square residual = .047). Pearson's correlation coefficient between items and subscales showed a direct and significant relationship with the main scale. Also, Cronbach's alpha coefficient (0.9) and test-retest (0.88) confirmed the reliability of the Persian version of (NSCS).

Conclusion

Generally, the Persian version of the NSCS with 28 items and six factors is a valid and reliable scale. This instrument has good internal consistency, validity, and reliability, which can be used to evaluate nursing students' competence in bachelor training.