Defining the nursing contribution to patient outcome: lessons from a review of the literature examining nursing outcomes, skill mix and changing roles

Nursing Interventions in Neurocritical Care

Highly educated and skilled nursing care is critical to improving patient outcomes in general and in specialties like neurocritical care. Nursing interventions reflect nursing knowledge, critical thinking, and decision-making and is generally rooted in the nursing process. Nursing interventions are also a key focus of research to better understand how nursing care influences patient outcomes. This review describes the literature regarding nursing interventions in key neurocritical diagnoses and contextualizes it within the broader discussion about the nursing process and nursing interventions research. Publications about nursing interventions in neurocritical care emphasize key themes, including managing neurophysiologic parameters, providing psychosocial support, managing the environmental milieu, and interventions to prevent complications. Further study of how to best support nurses in collecting and interpreting data to form nursing interventions is needed, as is understanding the benefits and limitations of the nursing process in low- and middle-income countries.

Associated factors of nurse-sensitive patient outcomes: A multicentred cross-sectional study in psychiatric inpatient hospitals

WHAT IS ALREADY KNOWN?: The nurse-patient relationship in mental health care is an important focus of mental health nursing theories and research. There is limited evidence about which factors influence nurse-sensitive patient outcomes of the nurse-patient relationship. This hinders the development, planning, delivering, and quality assurance of the nurse-patient relationship in nursing practice and nursing education. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: To our best knowledge, this is the first study to examine associations between nurse-sensitive patient outcomes of the nurse-patient relationship and a range of patient characteristics and relationship-contextual factors. In this study, we found that gender, age, hospital characteristics, nurse availability when needed, nurse contact, and nurse stimulation were associated with the scores on the nurse-sensitive patient outcome scale. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Having insight into the factors associated with nurse-sensitive patient outcomes of the nurse-patient relationship can help nurses, nursing students, nursing management and also patients to enhance the nurse-patient relationship, trying to influence outcomes of nursing care. ABSTRACT: Introduction The lack of evidence on patient characteristics and relational-contextual factors influencing nurse-sensitive patient outcomes of a nurse-patient relationship is a possible threat to the quality and education of the nurse-patient relationship. Aim To measure nurse-sensitive patient outcomes of the nurse-patient relationship and to explore the associations between nurse-sensitive patient outcomes and a range of patient characteristics and relational-contextual factors. Method In a multicenter cross-sectional study, 340 inpatients from 30 units in five psychiatric hospitals completed the Mental Health Nurse-Sensitive Patient Outcome Scale. Descriptive, univariate and Linear Mixed Model analyses were conducted. Results Overall, patient-reported outcomes were moderate to good. Female participants, nurse availability when needed, more nurse contact and nurse stimulation were associated with higher outcomes. Age differences were observed for some of the outcomes. Outcomes also varied across hospitals but were not related to the number of times patients were hospitalized or to their current length of stay in the hospital. Discussion The results may help nurses to become more sensitive and responsive to factors associated with nurse-sensitive patient outcomes of the nurse-patient relationship. Implications The nurse-sensitive results can support nurses in designing future nurse-patient relationships.

Diversity in radiation therapist/therapeutic radiographer (RTT) advanced practice (AP) roles delivering on the four domains

INTRODUCTION

Advanced practice roles are well documented, and continue to respond to the changing landscape in radiotherapy and oncology. In the UK the highest level of AP for the therapeutic radiographer/radiation therapist (RTT) is the consultant radiographer. These posts should meet the four domains of practice, as set out in national guidance. Here we aim to describe well established roles that meet this criteria, and provide subgroups of examples.

METHODOLOGY

Three AP post holders with over 10 years AP experience completed a questionnaire adapted from the consultant radiographer toolkit. These were completed in conjunction with guidance and framework documents. The examples were to demonstrate how they achieve a high level of practice in clinical and expert practice; professional leadership and consultancy; education, training and development; and practice and service development, research and evaluation. Participants then categorised results to add subgroups to each domain.

RESULTS

The questionnaire was completed by three RTTs specialising as a lung consultant radiographer (LCR), a neuro-oncology consultant radiographer (NCR) and a lead research radiographer (RR). Each post holder described how they meet the criteria by discussing the benefit they make to their profession, department and patients. All posts had examples for all criteria, achieving consultant practice. Clinical and expert practice was the dominant domain for the clinical specialist posts, and professional leadership and research evaluation was the strongest domains for the RR.

CONCLUSION

All three consultant RTTs have demonstrated expert practice with clear and transparent examples of their professional practice which evidence the four domains of consultant practice. Following two decades of AP practice for RTTs there is a need to be strategic in the development of future posts with a prospective view on succession planning that safeguards their longevity.

The Therapeutic Engagement Questionnaire (TEQ): a service user-focused mental health nursing outcome metric

BACKGROUND

Therapeutic engagement (TE) has been described as the crux of mental health nursing but despite its perceived importance, to date, there is no measurement tool that captures it. As a result, there is no way of determining the contribution of mental health nursing interaction to service user recovery, in acute inpatient mental health settings or the wider care quality agenda.

METHODS

To develop and validate a TE measurement tool in partnership with Service Users (SUs) and Registered Mental Health Nurses (RMHNs). The TEQ was developed in 3 stages: 1) item generation (and pre-testing), 2) item reduction using Principal Component Analysis (PCA), and 3) validation across Mental Health Trusts in England.

RESULTS

The final questionnaire has two versions, (SU and RMHN version), each scored within two contexts (1-1 SU-RMHN interactions and overall environment and atmosphere of the ward) and includes 20 items with two sub-scales (care interactions and care delivery). Psychometric evaluation of the TEQ shows high inter-scale correlations (0.66-0.95 SU; 0.57-0.90 RMHN), sound sub-scale internal consistency (> 0.95), concurrent validity (> 0.60) and adequate score variability for both versions of the TEQ. In summary, the TEQ behaves well as a measurement tool.

CONCLUSIONS

The TEQ can determine the collaborative and empathic nature of RMHN-SU interactions, capture if SUs are treated with dignity and respect and recognise that the principles of the recovery approach are being respected. The TEQ can also provide robust monitoring of nursing activity, offer opportunity for transparency of activity, feed into healthcare organizations' key performance indicators and provide reassurance about the nature and quality of nurses' work.

Effects of the Care Certificate on healthcare assistants' ability to identify and manage deteriorating patients

The Care Certificate, launched in England in 2015, safeguards patients by ensuring all new healthcare assistants (HCAs) undertake a structured educational programme so that they can provide appropriate, safe and high standards of care in clinical settings. This article describes a service evaluation that aimed to identify the effects of the Care Certificate on HCAs' confidence and ability to identify, and initiate management of, unwell patients independently.

Hospital nurse-staffing models and patient- and staff-related outcomes

BACKGROUND

Nurses comprise the largest component of the health workforce worldwide and numerous models of workforce allocation and profile have been implemented. These include changes in skill mix, grade mix or qualification mix, staff-allocation models, staffing levels, nursing shifts, or nurses' work patterns. This is the first update of our review published in 2011.

OBJECTIVES

The purpose of this review was to explore the effect of hospital nurse-staffing models on patient and staff-related outcomes in the hospital setting, specifically to identify which staffing model(s) are associated with: 1) better outcomes for patients, 2) better staff-related outcomes, and, 3) the impact of staffing model(s) on cost outcomes.

SEARCH METHODS

CENTRAL, MEDLINE, Embase, two other databases and two trials registers were searched on 22 March 2018 together with reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included randomised trials, non-randomised trials, controlled before-after studies and interrupted-time-series or repeated-measures studies of interventions relating to hospital nurse-staffing models. Participants were patients and nursing staff working in hospital settings. We included any objective reported measure of patient-, staff-related, or economic outcome. The most important outcomes included in this review were: nursing-staff turnover, patient mortality, patient readmissions, patient attendances at the emergency department (ED), length of stay, patients with pressure ulcers, and costs.

DATA COLLECTION AND ANALYSIS

We worked independently in pairs to extract data from each potentially relevant study and to assess risk of bias and the certainty of the evidence.

MAIN RESULTS

We included 19 studies, 17 of which were included in the analysis and eight of which we identified for this update. We identified four types of interventions relating to hospital nurse-staffing models:- introduction of advanced or specialist nurses to the nursing workforce;- introduction of nursing assistive personnel to the hospital workforce;- primary nursing; and- staffing models.The studies were conducted in the USA, the Netherlands, UK, Australia, and Canada and included patients with cancer, asthma, diabetes and chronic illness, on medical, acute care, intensive care and long-stay psychiatric units. The risk of bias across studies was high, with limitations mainly related to blinding of patients and personnel, allocation concealment, sequence generation, and blinding of outcome assessment.The addition of advanced or specialist nurses to hospital nurse staffing may lead to little or no difference in patient mortality (3 studies, 1358 participants). It is uncertain whether this intervention reduces patient readmissions (7 studies, 2995 participants), patient attendances at the ED (6 studies, 2274 participants), length of stay (3 studies, 907 participants), number of patients with pressure ulcers (1 study, 753 participants), or costs (3 studies, 617 participants), as we assessed the evidence for these outcomes as being of very low certainty. It is uncertain whether adding nursing assistive personnel to the hospital workforce reduces costs (1 study, 6769 participants), as we assessed the evidence for this outcome to be of very low certainty. It is uncertain whether primary nursing (3 studies, > 464 participants) or staffing models (1 study, 647 participants) reduces nursing-staff turnover, or if primary nursing (2 studies, > 138 participants) reduces costs, as we assessed the evidence for these outcomes to be of very low certainty.

AUTHORS' CONCLUSIONS

The findings of this review should be treated with caution due to the limited amount and quality of the published research that was included. We have most confidence in our finding that the introduction of advanced or specialist nurses may lead to little or no difference in one patient outcome (i.e. mortality) with greater uncertainty about other patient outcomes (i.e. readmissions, ED attendance, length of stay and pressure ulcer rates). The evidence is of insufficient certainty to draw conclusions about the effectiveness of other types of interventions, including new nurse-staffing models and introduction of nursing assistive personnel, on patient, staff and cost outcomes. Although it has been seven years since the original review was published, the certainty of the evidence about hospital nurse staffing still remains very low.

Conceptualizing skill mix in nursing and health care: An analysis

AIM

This paper aims to unpack the concept of "skill mix" into its constituent parts to achieve a better understanding and reduce confusion associated with the term.

BACKGROUND

Skill mix is a topic that is widely debated and is foremost on the health policy agenda due to specific local pressures within international health services. At present, however, there is large variation in terms of what is understood by the concept of "skill mix" and there is a paucity of research that attempts to analyse this concept.

EVALUATION

Using Rodgers' evolutionary method of concept analysis, this paper provides an analysis of definitions of skill mix, its attributes and associated terms in the literature.

KEY ISSUE

Definitions of skill mix are often vague and ambiguous and may refer to one or more attributes of skill mix.

CONCLUSION

A lack of understanding of the concept can lead to an ad hoc interpretation of policy recommendations related to skill mix at local level.

IMPLICATIONS FOR NURSING MANAGEMENT

A better understanding of the concept of "skill mix" and its attributes can assist both policy makers and stakeholders, including nurse management, to ensure that the potential of skill mix is maximized.

Development and Testing of the Family Structure and Family Functions Scale for Parents Providing Adolescent Reproductive Health Based on the Friedman Family Assessment Model

Background and Purpose:

To describe the development and testing of a psychometric of Family Structure and Functions (FSF) that measures parents’ ability to provide adolescent reproductive health (ARH).

Methods:

A cross-sectional study of Indonesian parents (n = 525). Multifactors FSF-ARH were examined using construct validity (exploratory factor analysis [EFA] and confirmatory factor analysis [CFA]) and content validity (Content Validity Index [CVI]). Internal consistency was explored using Cronbach’s α coefficient.

Results:

EFA revealed nine factors with 26 items accounting for 61.64% of explained variance and CFA validity testing fit for the construct validity of FSF-ARH. The CVI indicated adequate content validity (0.80–0.10) and acceptable internal consistency (0.70).

Conclusions:

FSF-ARH contains valid, reliable, and robust measures although some subscales performed moderate reliability, establishing the purpose for further research.

Service user involvement in the coproduction of a mental health nursing metric: The Therapeutic Engagement Questionnaire

Service users' involvement in mental health service research is increasingly acknowledged as important, yet, whilst involving users of mental health services as research participants is commonplace, seeking out their experience and indeed their "expertise" to facilitate the development of tools to be used within mental health services is in its infancy. This article describes the involvement and views of service users in the development of a nursing metric-the Therapeutic Engagement Questionnaire. It presents their role in the three stages of development: generation, statement reduction and authentication.

Practice development: a concept analysis

Exploration of the term `practice development' is required for the discipline of infection control nursing. Improved understanding of the term would allow practitioners to approach practice development in a more constructive and measurable fashion. A concept analysis based on the model of Walker and Avant is therefore presented. The analysis includes the definition of the term `practice development' and discussion of how it is presented in the literature. Illustrative cases are used to achieve clarification of the concept, culminating in identification of the empirical referents, these being: (1) identified patient need and (2) a change in nursing practice and demonstrably improved care.

Making claims on nursing work

Throughout the NHS, the traditional boundaries between professional groups are breaking down to promote more flexible ways of working to deliver patient-centred care. Registered nurses (RNs) have responded to changing care demands through the development of innovative roles and extended roles and responsibilities. However, there are increasing numbers of healthcare assistants (HCAs) being employed by the National Health Service (NHS) in the UK to support RNs in providing nursing care. To date, little is known about the make-up of the health care assistant workforce and the changing nature of their role. This paper reports the findings of a single case study using mixed methods (survey, interviews, participant observations, focus groups and documentary analysis) to generate an in-depth account of HCAs' work in one UK hospital setting. The study is built upon what HCAs say they do, compared with what they actually do in practice and RNs’ perceptions of the HCA role. It explores how and whether the work of HCAs is adequately supervised, tensions between the work of HCAs and RNs and the subsequent effects on teamwork and patient care. There are policy expectations associated with the work of HCAs. However, this study reveals significant deviations from these goals. The workplace arena, and the informal negotiations between HCAs and RNs that take place within it, actively shape the HCAs’ work. The changing roles of RNs have direct implications for the roles of HCAs: as RNs take on extra duties and responsibilities they are conceding some of their roles to HCAs. An important element of the RNs’ role must now be to consider how HCAs can best be deployed, to assess their competence for carrying out nursing work, and to monitor and supervise their work so as to maximise, and further develop, the HCAs’ contribution to patient care and to ensure quality standards.

Stakeholders’ experience of teledermatology in a nurse-led community clinic: a case study

Dermatology is regarded as especially suitable for the application of telemedicine because it relies to a large extent on visual information for diagnosis and holds promise as an alternative means of delivering healthcare. Interest in teledermatology has come at a time when there is an increased demand for dermatological services and has been advocated as a mode of delivery that may diminish inequalities in the provision of an overstretched service and improve access to dermatological care. A qualitative case study based on interviews and observations was undertaken to explore the perceptions of stakeholders (nurses, patients, GPs, consultants) when interacting with a nurse-led teledermatology service in primary care. The study found that the delineation of roles and changing professional boundaries were important issues for stakeholders. It has provided further evidence that teledermatology is more than images and diagnostics.

Does radiography advanced practice improve patient outcomes and health service quality? A systematic review

OBJECTIVE

To investigate the impact of radiographer advanced practice on patient outcomes and health service quality.

METHODS

Using the World Health Organization definition of quality, this review followed the Centre for Reviews and Dissemination guidance for undertaking reviews in healthcare. A range of databases were searched using a defined search strategy. Included studies were assessed for quality using a tool specifically developed for reviewing studies of diverse designs, and data were systematically extracted using electronic data extraction pro forma.

RESULTS

407 articles were identified and reviewed against the inclusion/exclusion criteria. Nine studies were included in the final review, the majority (n = 7) focusing on advanced radiography practice within the UK. Advanced practice activities considered were radiographer reporting, leading patient review clinics and barium enema examinations. The articles were generally considered to be of low-to-moderate quality, with most evaluating advanced practice within a single centre. With respect to specific quality dimensions, the included studies considered cost reduction, patient morbidity, time to treatment and patient satisfaction. No articles reported data relating to time to diagnosis, time to recovery or patient mortality.

CONCLUSION

Radiographer advanced practice is an established activity both in the UK and internationally. However, evidence of the impact of advanced practice in terms of patient outcomes and service quality is limited.

ADVANCES IN KNOWLEDGE

This systematic review is the first to examine the evidence base surrounding advanced radiography practice and its impact on patient outcomes and health service quality.

Sufficient competence in community elderly care? Results from a competence measurement of nursing staff

Background

Multi-morbidity, poly-pharmacy and cognitive impairment leave many old patients in a frail condition with a high risk of adverse outcomes if proper health care is not provided. Knowledge about available competence is necessary to evaluate whether we are able to offer equitable and balanced health care to older persons with acute and/or complex health care needs. This study investigates the sufficiency of nursing staff competence in Norwegian community elderly care.

Methods

We conducted a cross-sectional survey of 1016 nursing staff in nursing homes and home care services with the instrument “Nursing Older People – Competence Evaluation Tool”. Statistical analyses were ANOVA and multiple regression.

Results

We found that nursing staff have competence in all areas measured, but that the level of competence was insufficient in the areas nursing measures, advanced procedures, and nursing documentation. Nursing staff in nursing homes scored higher than staff in home care services, and older nursing staff scored lower than younger nursing staff.

Conclusions

A reason for the relatively low influence of education and training on competence could be the diffuse roles that nursing staff have in community elderly care, implying that they have poor standards against which to judge their own competence. Clearer role descriptions for all groups of nursing staff are recommended as well as general competence development in geriatric nursing care.

Nursing Job Rotation Stress Scale development and psychometric evaluation

AIM

The aim of this study was to develop and assess the reliability and validity of the Nurse Job Rotation Stress Scale (NJRS).

METHODS

A convenience sampling method was utilized to recruit two groups of nurses (n = 150 and 253) from a 2751 bed medical center in southern Taiwan. The NJRS scale was developed and used to evaluate the NJRS.

RESULTS

Explorative factor analysis revealed that three factors accounted for 74.11% of the explained variance. Confirmatory factor analysis validity testing supported the three factor structure and the construct validity. Cronbach's alpha for the 10 item model was 0.87 and had high linearity.

CONCLUSION

The NJRS can be considered a reliable and valid scale for the measurement of nurse job rotation stress for nursing management and research purposes.

Is there a relationship between personality and choice of nursing specialty: an integrative literature review

Background

Personality is deemed to play a part in an individual’s choice of work, with individuals’ preferencing a profession or field of work that will satisfy their personal needs. There is limited research exploring the personality characteristics of nurses within clearly defined nursing specialty areas. Retaining nurses within specialty areas has workforce implications when vacancies are unable to be filled by appropriately experienced staff.

The aim of the review was to determine the current state of knowledge regarding the personality profiles of nurses in specialty areas of nursing practice.

Methods

An integrative literature review was undertaken.

Five electronic databases were searched using personality and nursing based keywords. No date limit or research design restriction was applied. Rigorous screening and quality appraisal was undertaken considering the research design, methods and limitations of each manuscript.

Results

A review of the 13 included articles demonstrated some variability in the personality characteristics of the nursing specialty groups studied. A relationship was identified between personality characteristics and levels of nursing stress and burnout.

Conclusion

There is some evidence to suggest a relationship between personality characteristics and nursing specialty choice, burnout and job satisfaction. The published literature is limited and the effect of personality on retention is not well established.

Electronic supplementary material

The online version of this article (doi:10.1186/s12912-014-0040-z) contains supplementary material, which is available to authorized users.

What is a nurse? Is there an international consensus?

BACKGROUND

Historical experience and health service modernization partly account for the variation seen in definitions of what a 'nurse' is from country to country. It is unclear if international disparities in nursing provision, apparent in health data for developed countries, demonstrate real differences in staffing patterns or simply reflect the wide variations in understanding and use of terms for different categories of nurse.

AIM

This paper is an opinion piece of international interest discussing the need for standardization in definitions of different categories of nurse internationally.

DISCUSSION

The International Council for Nurses (ICN), the World Health Organization and the Organisation for Economic Cooperation and Development (OECD) all have different ways of defining a nurse. The wide variation in terms is particularly apparent from OECD countries however, where nursing density data present wide disparities, not readily accounted for by gross national product. Skill mix and clinical role developments may account for these better.

CONCLUSION

Until proper consensus is reached on what a nurse is and does, any skill mix or clinical role developments will only have limited international relevance, especially in OECD countries. If nursing qualifications are to be valid even across the European Union, then recommended standards such as those of the ICN, must be specified in terms of what different categories of nurses actually can do, and their responsibilities and roles within that scope of practice. Standardization of definitions of categories of nurse internationally should reduce confusion and promote better understanding of patterns of nurse staffing and the effect these may have on patient outcomes.

The skill mix model: a preliminary study of changing nurse role functions in Taiwan

BACKGROUND

: Nursing shortage is a critical problem worldwide. Using nurse aides (NAs) within a skill mix model has been applied in the healthcare delivery system as a strategy to improve nursing workforce shortages.

PURPOSE

: The purpose of this study was to investigate changes in nurse perceptions of their role functions under the skill mix model in Taiwan.

METHODS

: This was a cross-sectional designed study that employed a structured questionnaire. Participants included 38 registered nurses from three medical wards in three hospitals that had implemented the skill mix model for 6 months. The questionnaire gathered data on participant demographics, perceptions on the role functions, role and job satisfaction of nurses, and patient care quality. Nurses' role functions were grouped into independent, dependent, and interdependent categories.

RESULTS

: Results demonstrate that nurses' perceptions of independent and interdependent role function have changed since the implementation of the skill mix model. The most significant role changes in the independent function category included the nurse as educator of NAs, supervisor for patient care, and evaluator for nursing care outcomes. The most significant role changes in the interdependent function category included the nurse as integrator of nursing work and coordinator of the healthcare team. Nurses' perceived changes increase in repetitive confirmation of patient conditions and patient care quality.

CONCLUSIONS

: This study revealed that nurses working in skill mix model environments need more authority to delegate and educate NAs and to supervise and integrate nursing care. Study results may serve as a reference for hospital nursing practice in Taiwan.

Does nursing leadership affect the quality of care in the community setting?

AIM

To examine perceptions about how nursing leadership affects quality of care in the community setting.

BACKGROUND

Quality care is considered an essential component of nursing work and recent policy has emphasized the role of leadership in meeting the quality agenda. As shifting the balance of nursing care from the hospital to the community occurs in the UK, there is an imperative to confirm more effectively the quality of care that patients and families receive from nurses working in the community.

METHODS

A qualitative study involving community nurse leaders (n = 12) and community nurses (n = 27) in semi-structured individual interviews (n = 31) and three focus groups (n = 13).

RESULTS

Tensions exist between 'leading' for quality care and 'delivering' for quality care. Organisational decision making is challenged by limited measures of quality of care in the diverse roles of community nursing.

CONCLUSIONS

Frontline community nurses and nurse leaders need to articulate how they intend quality of nursing care to be appreciated and actively indicate ways to show this.

IMPLICATIONS FOR NURSING MANAGEMENT

Mechanisms to monitor patient safety, a key aspect of the policy agenda for quality care and other technical aspects of care are important for nurse leaders to develop with frontline community nurses.

Hospital nurse staffing models and patient and staff-related outcomes

BACKGROUND

Nurse staffing interventions have been introduced across countries in recent years in response to changing patient requirements, developments in patient care, and shortages of qualified nursing staff. These include changes in skill mix, grade mix or qualification mix, staffing levels, nursing shifts or nurses' work patterns. Nurse staffing has been closely linked to patient outcomes, organisational outcomes such as costs, and staff-related outcomes.

OBJECTIVES

Our aim was to explore the effect of hospital nurse staffing models on patient and staff-related outcomes.

SEARCH STRATEGY

We searched the following databases from inception through to May 2009: Cochrane/EPOC resources (DARE, CENTRAL, the EPOC Specialised Register), PubMed, EMBASE, CINAHL Plus, CAB Health, Virginia Henderson International Nursing Library, the Joanna Briggs Institute database, the British Library, international theses databases, as well as generic search engines.

SELECTION CRITERIA

Randomised control trials, controlled clinical trials, controlled before and after studies and interrupted time series analyses of interventions relating to hospital nurse staffing models. Participants were patients and nursing staff working in hospital settings. We included any objective measure of patient or staff-related outcome.

DATA COLLECTION AND ANALYSIS

Seven reviewers working in pairs independently extracted data from each potentially relevant study and assessed risk of bias.

MAIN RESULTS

We identified 6,202 studies that were potentially relevant to our review. Following detailed examination of each study, we included 15 studies in the review. Despite the number of studies conducted on this topic, the quality of evidence overall was very limited. We found no evidence that the addition of specialist nurses to nursing staff reduces patient death rates, attendance at the emergency department, or readmission rates, but it is likely to result in shorter patient hospital stays, and reductions in pressure ulcers. The evidence in relation to the impact of replacing Registered Nurses with unqualified nursing assistants on patient outcomes is very limited. However, it is suggested that specialist support staff, such as dietary assistants, may have an important impact on patient outcomes. Self-scheduling and primary nursing may reduce staff turnover. The introduction of team midwifery (versus standard care) may reduce medical procedures in labour and result in a shorter length of stay without compromising maternal or perinatal safety. We found no eligible studies of educational interventions, grade mix interventions, or staffing levels and therefore we are unable to draw conclusions in relation to these interventions.

AUTHORS' CONCLUSIONS

The findings suggest interventions relating to hospital nurse staffing models may improve some patient outcomes, particularly the addition of specialist nursing and specialist support roles to the nursing workforce. Interventions relating to hospital nurse staffing models may also improve staff-related outcomes, particularly the introduction of primary nursing and self-scheduling. However, these findings should be treated with extreme caution due to the limited evidence available from the research conducted to date.

Psychometric testing of the Spanish version of the practice environment scale of the nursing work index in a primary healthcare context

AIM

This paper is a report of psychometric testing of the Spanish version of the Practice Environment Scale of the Nursing Work Index for use in a primary health care.

BACKGROUND

The Practice Environment Scale of the Nursing Work Index has been widely used in different studies and contexts. However, there is no validated version for primary care nursing staff in Spain.

METHODS

A descriptive, multicentre, cross-sectional study for transcultural adaptation and psychometric validation purposes. Data were collected from October 2009 to January 2010. To test the reliability of the factors in the measurement model, Cronbach's alpha was used. To study the measurement model, different structural models were tested, using exploratory and confirmatory factor analyses. 377 completed questionnaires were obtained from a total of 553 nurses working for the Public Health Service in the Balearic Islands (Spain). This represents a response rate of 68·2%.

RESULTS

For overall reliability, a Cronbach alpha of 0·91 was obtained. The confirmatory analysis upholds the original five-factor structure.

CONCLUSION

The excellent goodness of fit of the confirmatory analysis corroborates the validity of this adapted version in primary healthcare contexts.

A review of nursing workforce policies in five European countries: Denmark, Finland, Ireland, Portugal and United Kingdom*/England

AIM

Review nursing workforce policies in five European countries: Denmark, Finland, Ireland, Portugal and the United Kingdom*.

BACKGROUND

Imbalances in registered nurse (RN) supply and demand is a global, significant and recurring issue that impacts on healthcare systems, organizations, staff and patients.

METHOD

Policy Review using resources located by a systematic search of relevant healthcare databases and policies in Danish, English, Finnish and Portuguese over the time period 2003-2007. Content analysis was used to identify themes and compare policies.

RESULTS

Common nursing workforce policy themes were identified across the five countries: (1) improving retention through effective human resource management, improving the practice environment and nurses' working lives and (2) improving recruitment through attracting more new recruits and RNs back to practice, and international recruitment. The present study also identified methodological issues relating to data quality and quantity. Lack of an agreed definition and standardized measures of nursing need and shortage makes comparison and evaluation of policy effectiveness and impact difficult.

IMPLICATIONS FOR NURSING MANAGEMENT

Healthcare systems and organizations need to identify and implement effective policies that promote the retention of RNs in the workforce, or risk threats to healthcare system sustainability, as well as patient care quality and safety.

Partnerships in intensive care unit (ICU): a new model of nursing care delivery

AIM

The purpose of this project was to explore an alternate nursing workforce model in major public hospital in Melbourne, Australia. Drivers for this project included improving patient care, facilitating access to intensive care (ICU) beds and managing the changing nursing workforce challenges.

METHODS

Using an exploratory descriptive design completed over two stages, a nursing partnership model with Enrolled Nurses (ENs) and experienced ICU nurses was piloted over a nine month period from May 2006.

FINDINGS

Overall the partnership model was not sustainable. The positive outcomes included an improved focus on standards of patient care, maintaining access to ICU beds, skill enhancement for participating nurses and a general acceptance by staff to pilot alternate models of care in ICU. The challenges identified included managing changing patient acuity and patient allocation, staff turnover, and barriers to effectively transitioning the appointed Enrolled Nurses into this ICU setting.

CONCLUSION

The resources and leadership required to implement the pilot were immense and the requirement did not lessen over time resulting in the pilot being unsustainable after nine months.

Evidence-based nursing-sensitive indicators for patients hospitalized with depression in Thailand

The aim of this study was to develop and validate nursing-sensitive indicators for patients hospitalized with depression in Thailand. The initial draft, consisting of 12 categories with 37 subcategories, was then evaluated by experts in the US and Thailand. Hospital records were then utilized to evaluate the feasibility and efficacy of the indicators. The finalized instrument consisted of 11 categories with 43 items with a validity of .98 and internal consistency of .88. This is the first set of indicators developed to evaluate nursing-sensitivity for patients hospitalized with a diagnosis of depression in Thailand. Having nursing indicators for depressed patients provides nurses with concrete tools to evaluate their work with depressed patients, allowing these staff to assess their work in a very specific, methodical, and consistent manner. When problems are discovered, both the staff and administration can work to address these issues through training, procedural changes, and departmental shifts.

A systematic review of what factors attract and retain nurses in aged and dementia care

AIM

To present evidence-based factors for the recruitment and retention of licensed nurses caring for older people and persons with dementia.

BACKGROUND

The international nurse shortage crisis is intensified in the aged and dementia care sector. Strategies to address this crisis rely on qualitative, quasi-experimental, anecdotal and unsubstantiated literature.

DESIGN

Systematic literature review.

METHOD

Search terms 'nurse''nurses''nursing''clinical supervision''staff''staffing''staff mix''staff levels''recruitment''retention''aged care''gerontology''gerontological''dementia care''residential''nursing home,' were used in all possible combinations and applied in a wide range of relevant academic databases, with secondary hand searches of selected bibliographies.

RESULTS

Two hundred and twenty-six papers were retrieved and scanned, with 105 chosen for closer examination that were relevant to recruitment and retention strategies for dementia and aged care nursing. Twenty-five of the papers chosen for review were rated at level 2++ to 3, according to the guidelines of the National Institute for Health and Clinical Excellence (The NICE Guidelines Manual, National Institute for Health and Clinical Excellence, London). The 25 critically reviewed papers are organised as promising strategies for (1) nurse recruitment and (2) nurse retention.

CONCLUSIONS

The intrinsic rewards of the caring role attract nurses to dementia and aged care. Essential strategies linking recruitment with retention are: careful selection of student nurse clinical placements and their ongoing supervision and education, training for skills, leadership and teamwork for new and existing nurses, increased staffing levels, pay parity across different health settings and family friendly policies.

RELEVANCE TO CLINICAL PRACTICE

A family-friendly, learning environment that values and nurtures its nursing staff, in the same way as nurses are expected to value and care for their patients and residents, is critical in ensuring their retention in dementia and aged care.

The Irish Nursing Minimum Data Set for mental health--a valid and reliable tool for the collection of standardised nursing data

AIMS AND OBJECTIVES

To test the validity and reliability of the newly developed Irish Nursing Minimum Data Set for mental health (I-NMDS (MH)) to ensure its clinical usability.

BACKGROUND

Internationally, difficulties exist in defining the contribution mental health nursing makes to patient care. Structured information systems, like the Nursing Minimum Data Set, have been developed internationally to gather standardised information to increase the visibility of nursing in the health care system.

DESIGN

This study employed a quantitative, longitudinal research design.

METHOD

A convenience sample of mental health nurses (n = 184) collected data on the nursing care of patients (n = 367) from care settings attached to 11 hospitals across Ireland. Exploratory factor analysis (EFA), ridit analysis and Cronbach's alpha coefficient were used to establish the construct and discriminative validity and scale score reliability of the I-NMDS (MH).

RESULTS

Goodness of Fit scores indicated that the I-NMDS (MH) possesses good construct validity. Alpha coefficients for each factor were above the recommended 0.7 level. Ridit analysis inferred that the I-NMDS (MH) discriminated between elements of nursing care across acute inpatient and community based care settings.

CONCLUSIONS

The I-NMDS (MH) possesses a sound theoretical base, has scale score reliability and possesses good discriminative validity. The valid and reliable I-NMDS (MH) is the first NMDS to be developed specifically for mental health.

RELEVANCE TO CLINICAL PRACTICE

Data collected using the I-NMDS (MH) will increase the visibility of the contribution mental health nurses make to healthcare delivery. In addition, it will support evidence based practice in mental health to improve further the effectiveness of nursing care in the future.

Cascade iatrogenesis: factors leading to the development of adverse events in hospitalized older adults

Older adults are at particular risk for injuries associated with hospitalization and the rate of adverse events increases significantly with age. The purpose of this paper is to review factors associated with the development of adverse events in hospitalized older adults, especially those factors that contribute to cascade iatrogenesis. Cascade iatrogenesis is the serial development of multiple medical complications that can be set in motion by a seemingly innocuous first event [Rothschild, J.M., Bates, D.W., Leape, L.L., 2000. Preventable medical injuries in older patients. Archieves of Internal Medicine 160 (October), 2717-2728]. Research has examined how patient characteristics may lead to cascade iatrogenesis, but existing conceptual models and research have not considered the role of nursing care. Using the outcome postoperative respiratory failure as an example, we expand on existing knowledge about factors associated with older adults' risk for developing this complication by presenting a conceptual model of events that may trigger the initial cascade and the nursing care variables that may prevent or mitigate these risks. We believe that this model will help guide research in this area and enable clinicians to identify systemic failures and develop targeted interventions to prevent their occurrence.

Registered nurse staffing mix and quality of care in nursing homes: a longitudinal analysis

PURPOSE

To examine the relationship between registered nurse (RN) staffing mix and quality of nursing home care measured by regulatory violations.

DESIGN AND METHODS

A retrospective panel data study (1999-2003) of 2 groups of California freestanding nursing homes. One group was 201 nursing homes that consistently met the state's minimum standard for total nurse staffing level over the 5-year period. The other was 210 nursing homes that consistently failed to meet the standard over the period. All facility and market variables were drawn from California's cost report data and state licensing and certification data, as well as 3 other databases.

RESULTS

The RN to total nurse staffing ratio was negatively related to serious deficiencies in nursing homes that consistently met the staffing standard, whereas the ratio was negatively associated with total deficiencies in nursing homes that consistently failed to meet the standard over the 5-year period. As the RN to licensed vocational nurse ratios increased, total deficiencies and serious deficiencies decreased in both groups of nursing homes.

IMPLICATIONS

A higher RN mix is positively related to quality of care, but the relationship is affected by overall nurse staffing levels in nursing homes. Further studies are necessary for a better understanding of RNs' unique contributions to the quality of care in nursing homes.

Health care assistants' and mental attendants' daily work tasks in acute hospital care

To describe the work and the everyday activities of health care assistants (HCAs) and mental attendants (MAs) in acute hospital care. Several caring duties have been delegated from registered nurses to HCAs and MAs the last decade. Their tasks can either be rather demanding and qualified or be quite unqualified. Both a qualitative and quantitative design was used. Data collection comprised diaries written by 26 HCAs and MAs in 10 wards during a week in April 2006. Content analysis was used for data analysis. The study shows that the participants on average spend half of their working time on direct care (bedside). The HCAs in the geriatric wards spend more time on bedside than all the others. There can be several explanations as to the difference between wards. The MAs appear to have more authority and influence on psychiatric care in contrast to the HCAs. From this study is that the HCAs and MAs carry out quite demanding work tasks and particularly the MAs are responsible for qualified patient care, which raises questions about their formal education and competence.

Advanced nursing practice and Newton's three laws of motion

This article considers the reasons for the development of advanced practice roles among nurses and other healthcare professions. It explores the implications of financial constraints, consumer preferences and the development of new healthcare services on the reorganization of professional boundaries. It makes use of Sir Isaac Newton's three laws of motion to demonstrate how professional development in nursing has taken place in response to a number of external influences and demands. It also considers the significance of skill mix for the nursing profession, in particular the development and likely expansion of the physician assistant role. The application of different professionals and grades within a healthcare team or organization is central to the Government's Agenda for Change proposals and nurses have successfully adopted a number of roles traditionally performed by doctors. Nurses have demonstrated that they are capable of providing high quality care and contributing directly to positive patient outcome. Advanced nursing roles should not only reflect the changing nature of healthcare work, they should also be actively engaged in reconstructing healthcare boundaries.

Nurses' attitudes toward their role in patient discharge medication education and toward collaboration with hospital pharmacists: a staff development issue

This qualitative pilot study explored nurses' attitudes toward their role in patients' discharge medication education and collaboration with pharmacists. Purposive sampling was used, and data were collected by a focus group interview. The findings give a clear indication of the need for extensive staff development. It is unfortunate that nurses in this study appeared not to value their role in educating patients on medications prior to discharge. They were somewhat resistant to collaboration with pharmacists, and they tended to accept limited responsibility for improving patient discharge medication adherence or compliance. Although the findings are of concern, they do provide clear evidence of the need for intensive staff development.

Nursing skill mix and outcomes: a Singapore perspective

AIM

To summarize key evidence on nursing skill mix in acute care hospitals and their limitations; and identify the gaps in current literature vis-à-vis Singapore's nursing workforce.

BACKGROUND

Nursing skill mix has been theorized to be a factor influencing patient, nurse and organizational outcomes. While there is a growing body of literature explicating associations between nursing skill mix and positive outcomes, the evidence does not as yet provide firm directions in determining the best configuration. In addition, differences in nursing workforce characteristics also make it difficult to apply findings from one healthcare setting to another.

CONCLUSIONS

In reviewing key evidence from the United States of America and Canada, this paper highlights three critical gaps in the nursing skill mix literature when examined in the context of Singapore's nursing workforce. Issues related to the interface between local and foreign nurses, the impact of speciality education, and the possible effects that work roles and distribution may have on quality of care need to be further examined. This knowledge should provide a robust evidence base with which to inform national policy on skill mix and maximize nursing resources in order to achieve optimal outcomes.

Perioperative Clinical Nurse Specialist Role Delineation: A Systematic Review

A CLEARLY DEFINED ROLE for the perioperative clinical nurse specialist (CNS) has not been identified or established. USING ROLE THEORY as a framework, a systematic review of the literature was conducted to provide recommendations for a delineated CNS role and to compare this role with other nursing roles. SEVERAL FACTORS CONTRIBUTE to CNS role confusion, including the versatility of the position, lack of certification examinations, and variance of state recognition. FUTURE RESEARCH should investigate merging of CNS and nurse practitioner titles, perioperative CNS functions, spheres of influence, and patient outcomes.

The clinical nursing competences and their complexity in Belgian general hospitals

AIM

This paper reports a study whose aim was to chart clinical nursing competences and their complexity in Belgian general hospitals.

BACKGROUND

Competence is an essential factor for assuring quality, safety and cost-effective health care. As clinical competence cannot be evaluated separately from the clinical context in which decisions are made, competence is defined as functional adequacy and the capacity to integrate knowledge and skills with attitudes and values into the specific contexts of practice.

METHOD

The study took place in 2003 and focused on basic care, specialized care and elder care. Head nurses of 176 departments processed 521 patient situations. Experts selected 50 situations per area. In a Delphi procedure 100 experts described the nursing competences required in each situation necessary to provide quality acceptable care. The experts determined the global complexity of each of these competences as well as the complexity of the cognitive, psychomotor and affective aspects.

FINDINGS

The global complexity of the various care areas was similar. Cognitive and affective aspects of competences scored higher than psychomotor aspects. Simple and average situations did not show any significant difference with regard to complexity and were less complex than difficult situations, which obtained the highest complexity score. The complexity of emergency situations did not differ from that of difficult situations.

CONCLUSION

Emergency and difficult situations require more competences than offered by basic nursing education. The continuous presence of care providers with additional education is necessary for each care area to respond adequately to emergency and difficult situations. Nurses with additional academic qualifications need to be available for consultation. There are only a few possibilities of employing lower qualified staff in direct care, with the exception of support with regard to administrative tasks. Cognitive and affective aspects of the competences require particular attention during the education programme.

Relationship between nursing interventions and outcome achievement in acute care settings

The extent to which nursing interventions provided during hospitalization are associated with patients' therapeutic self-care and functional health outcomes was explored with a voluntary sample of 574 patients. Nurses collected data on patient outcomes at admission and discharge using the minimum data set (MDS) and the therapeutic self-care scale (TSCS). Research assistants audited charts for documentation of nursing interventions. The results indicated that nursing interventions aimed at exercise promotion, positioning, and self-care assistance predicted functional status outcome. Higher functional status outcome predicted therapeutic self-care ability at hospital discharge. The results demonstrate that nurses can use MDS and TSCS data on patient outcomes to gain insight into the effectiveness of their interventions.

Analysis of nursing records of cardiac-surgery patients based on the nursing process and focusing on nursing outcomes

This study analyzed what nurses wrote in narrative nursing notes for cardiac-surgery patients. The nursing notes of 46 patients were analyzed based on the nursing process. Eight patterns were extracted according to different combinations of nursing process components, of which an assessment alone was the most frequent nursing phrase (45.8%), followed by assessment or diagnosis-intervention-outcome (25.9%). The content of the nursing notes was also classified into 15 categories, of which nursing outcomes were recorded more frequently in nursing care driven mainly by physician's order such as disease-related symptom management, insomnia care, respiratory care, and pain control, than in independent nursing care such as education and emotional care. A survey on the attitudes of nurses toward the nursing record revealed that they do not document nursing outcomes as much as they think they do. The main reasons for this discrepancy were insufficient time for recording and lack of knowledge about why, how, and what to evaluate. Even though there is room for improvement, nursing notes represent a useful resource for determining nursing contributions to patient outcomes.