Associations between rates of unassisted inpatient falls and levels of registered and non-registered nurse staffing

Relationship Between Unit Characteristics and Fall Incidence: A Cross-Sectional Survey Using Administrative Data in Japan

BACKGROUND

Falls are the most frequent accident experienced by inpatients in hospitals. As falls affect patient outcomes, high fall risk factors should be studied to prevent falls and improve patient safety. However, the relationship between hospital unit characteristics and fall risk has never been assessed.

PURPOSE

This study was designed to identify the unit characteristics significantly related to fall risk.

METHODS

A cross-sectional study was conducted on the medical records of patients hospitalized in a Japanese academic hospital between 2018 and 2019. This study quantified unit activities and utilized Diagnosis Procedure Combination data to examine unit characteristics related to falls based on unit day.

RESULTS

Data on 16,307 patients were included in the analysis, and 355 unit days were certified as fall events. Based on patient condition and medical treatment, the results identified antineoplastic injections, radiation therapy, aseptic treatment room, and functional status of partly assisted transfers, meals, and oral care as unit characteristics associated with increased fall events. Decreased nursing time per patient at night (odds ratio [OR] = 0.75, p = .04) and higher numbers of partially assisted transfer patients were also identified as unit characteristics associated with higher fall incidence rates (OR = 5.56, p = .01).

CONCLUSIONS

The results of this study are expected to assist nurses to predict falls based on unit characteristics; reducing nursing time in the units was found to be a factor associated with higher fall risk. Nurse managers must understand the unit-related fall risk factors, appropriately assign nurse staffing numbers, and demonstrate nursing leadership to prevent falls in their units.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

A mixed method approach using the Q Methodology was employed.

SETTING(S)

Three public and private hospitals in Japan.

PARTICIPANTS

Eighteen nurses participated in the study.

METHODS

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

RESULTS

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

CONCLUSIONS

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

STUDY REGISTRATION

Not registered.

Metro-Nonmetro Differences in Adverse Events in Residential Care Communities: Results From the National Post-Acute and Long-Term Care Study

More than 1 in 5 older Americans live in rural areas (10.6 million of the 46.2 million aged 65 and older). Long-term care for aging rural populations is a growing challenge in the United States. Research on long-term care services in nonmetro areas has focused almost exclusively on nursing home care, despite growth of residential care alternatives. This paper uses unique facility-level data from the 2020 National Post-acute and Long-term Care Study (NPALS) to examine the relationship of residential care community (RCC) features in metro and nonmetro settings with adverse outcomes (emergency department visits, overnight hospital stays, and falls). Nationally, in 2020, about 13.5% of RCC residents made visits to the emergency department, 8.6% had overnight hospital stays, and 21.3% had falls. Controlling for facility characteristics, RCCs in metro areas had higher risks of overnight hospital stays (p < .001) but lower risks of falls (p = .06).

Changes in Hospital Adverse Events and Patient Outcomes Associated With Private Equity Acquisition

Importance

The effects of private equity acquisitions of US hospitals on the clinical quality of inpatient care and patient outcomes remain largely unknown.

Objective

To examine changes in hospital-acquired adverse events and hospitalization outcomes associated with private equity acquisitions of US hospitals.

Design, Setting, and Participants

Data from 100% Medicare Part A claims for 662 095 hospitalizations at 51 private equity-acquired hospitals were compared with data for 4 160 720 hospitalizations at 259 matched control hospitals (not acquired by private equity) for hospital stays between 2009 and 2019. An event study, difference-in-differences design was used to assess hospitalizations from 3 years before to 3 years after private equity acquisition using a linear model that was adjusted for patient and hospital attributes.

Main Outcomes and Measures

Hospital-acquired adverse events (synonymous with hospital-acquired conditions; the individual conditions were defined by the US Centers for Medicare & Medicaid Services as falls, infections, and other adverse events), patient mix, and hospitalization outcomes (including mortality, discharge disposition, length of stay, and readmissions).

Results

Hospital-acquired adverse events (or conditions) were observed within 10 091 hospitalizations. After private equity acquisition, Medicare beneficiaries admitted to private equity hospitals experienced a 25.4% increase in hospital-acquired conditions compared with those treated at control hospitals (4.6 [95% CI, 2.0-7.2] additional hospital-acquired conditions per 10 000 hospitalizations, P = .004). This increase in hospital-acquired conditions was driven by a 27.3% increase in falls (P = .02) and a 37.7% increase in central line-associated bloodstream infections (P = .04) at private equity hospitals, despite placing 16.2% fewer central lines. Surgical site infections doubled from 10.8 to 21.6 per 10 000 hospitalizations at private equity hospitals despite an 8.1% reduction in surgical volume; meanwhile, such infections decreased at control hospitals, though statistical precision of the between-group comparison was limited by the smaller sample size of surgical hospitalizations. Compared with Medicare beneficiaries treated at control hospitals, those treated at private equity hospitals were modestly younger, less likely to be dually eligible for Medicare and Medicaid, and more often transferred to other acute care hospitals after shorter lengths of stay. In-hospital mortality (n = 162 652 in the population or 3.4% on average) decreased slightly at private equity hospitals compared with the control hospitals; there was no differential change in mortality by 30 days after hospital discharge.

Conclusions and Relevance

Private equity acquisition was associated with increased hospital-acquired adverse events, including falls and central line-associated bloodstream infections, along with a larger but less statistically precise increase in surgical site infections. Shifts in patient mix toward younger and fewer dually eligible beneficiaries admitted and increased transfers to other hospitals may explain the small decrease in in-hospital mortality at private equity hospitals relative to the control hospitals, which was no longer evident 30 days after discharge. These findings heighten concerns about the implications of private equity on health care delivery.

Frequency, Characteristics, and Risk Factors for Falls at an Inpatient Cancer Rehabilitation Unit

PURPOSE

Falls in the hospital can lead to adverse events, including injuries. Studies have shown that patients with cancer and those undergoing inpatient rehabilitation (IPR) are at higher risk for falls. Therefore, we measured the frequency, degree of harm, and characteristics of patients who fell in an inpatient cancer rehabilitation unit.

METHODS

A retrospective review was conducted on inpatient cancer rehabilitation patients admitted from January 2012 to February 2016. Fall frequency, degree of harm, fall circumstances, cancer type, patient's fall risk score on the basis of the MD Anderson Cancer Center Adult Inpatient Fall Risk Assessment Tool (MAIFRAT), length of stay, and risk factors were evaluated for patients.

RESULTS

There were 72 out of 1,571 unique individual falls (4.6%), with a falls incidence of 3.76 falls per 1,000 patient-days. Most fallers (86%) suffered no harm. Risk factors for falls included presence of patient-controlled analgesia pump (P = .03), pump such as insulin or wound vacuum-assisted closure (P < .01), nasogastric, gastric, or chest tube (P = .05), and higher MAIFRAT score (P < .01). The fallers were younger (62 v 66; P = .04), had a longer IPR stay (13 v 9; P = .03), and had a lower Charlson comorbidity index (6 v 8; P < .01).

CONCLUSION

The frequency and degree of harm for falls in the IPR unit were less than previous studies, which suggests that mobilization for these patients with cancer is safe. The presence of certain medical devices may contribute to fall risk, and more research is needed to better prevent falls in this higher-risk subgroup.

Analyzing a Multifactorial Fall Prevention Program Using ARIMA Models

BACKGROUND

Preventing inpatient falls is challenging for hospitals to improve and often leads to patient injury.

PURPOSE

To describe multifactorial patient-tailored interventions and to evaluate whether they were associated with a sustained decline in total and injury falls.

METHODS

A multifactorial fall prevention program was instituted over the course of several years. An interrupted time series design was used to assess the effect of each intervention on total and injury fall rates. ARIMA models were built to assess the step and ramp change.

RESULTS

Total fall rates decreased from 4.3 to 3.6 falls per 1000 patient days (16.28% decrease), and injury fall rates decreased from 1.02 to 0.8 falls per 1000 patient days (21.57% decrease). All the interventions contributed to fall reduction, with specific interventions contributing more than others.

CONCLUSIONS

Using multiple interventions that are sustained long enough to demonstrate success reduced the total fall rate and injury fall rate.

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

AIM

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

DESIGN

A multicentre retrospective observational study.

METHODS

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

RESULTS

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

CONCLUSION

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

IMPACT

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

Quality and Safety in Health Care, Part LXXX: The National Database for Nursing Quality Indicators and the Practice Environment Scale of the Nursing Work Index

ABSTRACT

The National Database for Nursing Quality Indicators is an important source of information used to benchmark nursing by unit category in multiple areas related to not only structure and process but also outcome. It also provides some information regarding best practices and the cost to achieve certain results. The Practice Environment Scale of the Nursing Work Index is a frequently used way to measure the professional practice environment of nurses and the relationship of the latter to quality, safety, and other outcomes.

Staffing and patient-related factors affecting inpatient falls in a psychiatric hospital: a 5-year retrospective matched case–control study

Background

The frequency and severity of falls of psychiatric inpatients in Thailand have not been previously reported. Also, the risk factors of falls have been numerous and complicated. This study aimed to investigate the staffing factors and patient-related factors that increase the likelihood of falls among psychiatric inpatients.

Methods

A five-year retrospective matched case–control study was conducted that selected cases of inpatients who fell and which were reported to the hospital risk management system. Subjects were compared to two control patients from the same hospital (1:2) by age (± 5 years), sex, and admission the same year. The total sample consisted of 240 patients. Univariate and multivariate conditional logistic regression was used to analyze the data.

Results

Of the eighty falls, 86.3% resulted in temporary harm and required intervention. The multivariate model showed that three patient-related factors were associated with increased inpatient falls: (1) having an acute psychotic condition (adjusted odds ratio (AOR) = 4.34; 95% CI 1.45, 13.05; p < 0.05), (2) polypharmacy with more than four types of medicines (AOR = 3.06; 95% CI 1.59, 5.88; p < 0.05), and (3) taking atypical psychiatric drugs (AOR = 2.74; 95% CI 1.35, 5.58; p < 0.05). Staffing for 26–50 patients in the wards was more protective for falls than with 25 or fewer patients (AOR = .17; 95% CI 0.04, 0.72; p < 0.05).

Conclusions

The risk factors found may help assess fall risk and manage the number of patients in psychiatric units. Drug dosage and drug interaction of antipsychotic drugs and cardiovascular agents with other medications and drug administration timing before falls are recommended for further investigation. Also, staff ratio per patient and the proportion of staff mix in psychiatric units need further study to establish adequate levels of surveillance to prevent inpatient falls.

Evaluation of Automated Video Monitoring to Decrease the Risk of Unattended Bed Exits in Small Rural Hospitals

OBJECTIVES

This study aimed to evaluate the effectiveness of using 1 to 4 mobile or fixed automated video monitoring systems (AVMSs) to decrease the risk of unattended bed exits (UBEs) as antecedents to unassisted falls among patients at high risk for falls and fall-related injuries in 15 small rural hospitals.

METHODS

We compared UBE rates and fall rates during baseline (5 months in which patient movement was recorded but nurses did not receive alerts) and intervention phases (2 months in which nurses received alerts). We determined lead time (seconds elapsed from the first alert because of patient movement until 3 seconds after an UBE) during baseline and positive predictive value and sensitivity during intervention.

RESULTS

Age and fall risk were negatively associated with the baseline patient rate of UBEs/day. From baseline to intervention: in 9 hospitals primarily using mobile systems, UBEs/day decreased from 0.84 to 0.09 (89%); in 5 hospitals primarily using fixed systems, UBEs/day increased from 0.43 to 3.18 (649%) as patients at low risk for falls were observed safely exiting the bed; and among 13 hospitals with complete data, total falls/1000 admissions decreased from 8.83 to 5.53 (37%), and injurious falls/1000 admissions decreased from 2.52 to 0.55 (78%). The median lead time of the AVMS was 28.5 seconds, positive predictive value was nearly 60%, and sensitivity was 97.4%.

CONCLUSIONS

Use of relatively few AVMSs may allow nurses to adaptively manage UBEs as antecedents to unassisted falls and fall-related injuries in small rural hospitals. Additional research is needed in larger hospitals to better understand the effectiveness of AVMSs.

Risk Factors Preventing Immediate Fall Detection: A Study Using Zero-Inflated Negative Binomial Regression

PURPOSE

Falls are the most common accidents in healthcare facilities, and timely intervention can have a positive effect on the hazards and trauma experienced by patients after a fall. This study determined the factors affecting the time taken to detect a fall.

METHODS

A total of 3,470 cases of falls reported through the Korea Patient Safety Reporting and Learning System were included in the analysis. A zero-inflated negative binomial regression method was used for this retrospective secondary data analysis study.

RESULTS

There were 537 patients whose falls were not detected immediately; the count model was used to predict risk factors that delayed fall detection. Women aged 60-69 years-compared to those below 60 years and an evening nursing shift, compared to a day shift-were identified as significant factors. The fall detection time of about 2,933 patients was zero; therefore, the logit model was applied to predict a patient's possibility of belonging to the group whose fall was detected immediately. Comparisons of tertiary hospitals with general hospitals and hospitals, of the evening shift with the day shift, and of the day shift with the night shift indicated significant influencing factors.

CONCLUSIONS

These findings can assist nurses in recognizing patient and hospital characteristics related to delayed fall detection. Strategies to improve patient safety in healthcare facilities that focus on patient characteristics such as age can be recommended. Furthermore, nurse staffing requires improvement to detect fall incidents immediately.

Do Falls and Other Safety Issues Occur More Often During Handovers When Nurses Are Away From Patients? Findings From a Retrospective Study Design

BACKGROUND

No studies have assessed the differences in the incidences of falls and other patient safety events (PSEs) during handovers performed away from patients compared with when nurses are on the unit.

PURPOSE

The primary aim was to explore the incidence of falls and their severity during handovers compared with during nonhandover times; the secondary aim was to explore the occurrence of other PSEs during handover versus nonhandover times.

METHODS

This was a retrospective study of all PSEs that occurred from 2013 to 2017 in a large Italian academic trust.

RESULTS

There were 1966 falls and 1523 other PSEs. The incidence of falls per 100 hours was 4.9 during handovers and 4.4 during nonhandover times. The incidences of other PSEs were 2.9 and 3.5, respectively. No significant differences in fall outcome severity emerged.

CONCLUSIONS

No differences emerged in the occurrence of falls during handovers performed away from patients and when nurses were on the unit. Other PSEs decreased in occurrence during handovers as compared with other times during the shifts.

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

OBJECTIVE

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

INTRODUCTION

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

INCLUSION CRITERIA

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42018119428.

Using knowledge discovery through data mining to gain intelligence from routinely collected incident reporting in an acute English hospital

PURPOSE

Incident reporting systems are commonly deployed in healthcare but resulting datasets are largely warehoused. This study explores if intelligence from such datasets could be used to improve quality, efficiency, and safety.

DESIGN/METHODOLOGY/APPROACH

Incident reporting data recorded in one NHS acute Trust was mined for insight (n = 133,893 April 2005-July 2016 across 201 fields, 26,912,493 items). An a priori dataset was overlaid consisting of staffing, vital signs, and national safety indicators such as falls. Analysis was primarily nonlinear statistical approaches using Mathematica V11.

FINDINGS

The organization developed a deeper understanding of the use of incident reporting systems both in terms of usability and possible reflection of culture. Signals emerged which focused areas of improvement or risk. An example of this is a deeper understanding of the timing and staffing levels associated with falls. Insight into the nature and grading of reporting was also gained.

PRACTICAL IMPLICATIONS

Healthcare incident reporting data is underused and with a small amount of analysis can provide real insight and application to patient safety.

ORIGINALITY/VALUE

This study shows that insight can be gained by mining incident reporting datasets, particularly when integrated with other routinely collected data.

Association of Use of Contract Nurses With Hospitalized Patient Pressure Injuries and Falls

BACKGROUND

Hospital-acquired pressure injuries (HAPIs) and falls are outcomes sensitive to quality of nursing care. Use of contract (traveler) nurses varies among organizations, but there is little research on the effect of contract nurses on nurse-sensitive outcomes.

OBJECTIVES

To explore the relationship between use of contract nurses and two key nurse-sensitive outcomes, HAPIs and falls.

RESEARCH DESIGN

This was a cross-sectional study of unit-level nursing, patient, and hospital factors versus HAPIs and falls from a national nursing data consortium from 2015 to 2016. We used cluster analysis to identify similar units, and compared outcomes between clusters.

SUBJECTS

605 nursing units in 166 hospitals, 3.2 patients per nurse, and 5.3% contract nurses.

MEASURES

Prevalence and incidence of HAPIs and number of falls, adjusted by patient days.

RESULTS

For both prevalence and incidence of HAPIs, there was a statistically significant difference between the five independent cluster groups (p = .012 and p = .001, respectively). The cluster with the highest percentage of nurse travelers (>7%) had the highest HAPI prevalence (0.84%) and incidence (0.055 per 1,000 patient days) despite higher nurse staffing, compared to HAPI prevalence of 0.32% and incidence of 0.017 per 1,000 patient days in the cluster with the lowest percentage of nurse travelers (<2%). We did not identify a consistent relationship between use of contract nurses and falls.

CONCLUSIONS

Use of contract nurses was associated with higher HAPI prevalence and incidence, independent of staffing levels.

CLINICAL RELEVANCE

Our results suggest that institutions should either minimize the use of contract nurses, or engage in extensive training to confirm that contract nurses have understanding of the institutional practices around HAPIs.

Patient and system factors associated with unassisted and injurious falls in hospitals: an observational study

Background

Unassisted falls are more likely to result in injury than assisted falls. However, little is known about risk factors for falling unassisted. Furthermore, rural hospitals, which care for a high proportion of older adults, are underrepresented in research on hospital falls. This study identified risk factors for unassisted and injurious falls in rural hospitals.

Methods

Seventeen hospitals reported 353 falls over 2 years. We categorized falls by type (assisted vs. unassisted) and outcome (injurious vs. non-injurious). We used multivariate logistic regression to determine factors that predicted fall type and outcome.

Results

With all other factors being equal, the odds of falling unassisted were 2.55 times greater for a patient aged ≥65 than < 65 (95% confidence interval [CI] = 1.30–5.03), 3.70 times greater for a patient with cognitive impairment than without (95% CI = 2.06–6.63), and 6.97 times greater if a gait belt was not identified as an intervention for a patient than if it was identified (95% CI = 3.75–12.94). With all other factors being equal, the odds of an injurious fall were 2.55 times greater for a patient aged ≥65 than < 65 (95% CI = 1.32–4.94), 2.48 times greater if a fall occurred in the bathroom vs. other locations (95% CI = 1.41–4.36), and 3.65 times greater if the fall occurred when hands-on assistance was provided without a gait belt, compared to hands-on assistance with a gait belt (95% CI = 1.34–9.97).

Conclusions

Many factors associated with unassisted or injurious falls in rural hospitals were consistent with research conducted in larger facilities. A novel finding is that identifying a gait belt as an intervention decreased the odds of patients falling unassisted. Additionally, using a gait belt during an assisted fall decreased the odds of injury. We expanded upon other research that found an association between assistance during falls and injury by discovering that the manner in which a fall is assisted is an important consideration for risk mitigation.

Cross-cultural adaptation and psychometric evaluation of the Turkish version of the Self-Efficacy for Preventing Falls-Nurse

AIM

The aim of this study was to test the psychometric properties of the Turkish version of the Self-Efficacy for Preventing Falls-Nurse.

BACKGROUND

Patient falls have negative effects on patients and health care services. Nurses' self-efficacy for preventing falls can affect their performance in interventions to prevent falls.

METHODS

The sample of this methodological study included 326 nurses who work at a university, a training and a public hospital in Turkey. The construct validity of the scale was assessed using the exploratory factor analysis, the confirmatory factor analysis and the known-group technique. The reliability of the scale was assessed through internal consistency approaches and test-retest reliability.

RESULTS

Two factors were extracted through the exploratory factor analysis, and the factors explained 68.69% of total variance. The confirmatory factor analysis showed a significantly good fit for a two-factor structure. Satisfactory evidence was found for test-retest reliability and internal consistency reliability.

CONCLUSION

The Turkish version of the Self-Efficacy for Preventing Falls-Nurse is a reliable and valid scale for assessing nurses' self-efficacy for preventing falls.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers can assess nurses' self-efficacy for preventing falls by using the Turkish version of the Self-Efficacy for Preventing Falls-Nurse. Moreover, they can identify where to focus on improving nurses' self-efficacy by analysing scores of subscales and items.

A quantitative systematic review of the association between nurse skill mix and nursing-sensitive patient outcomes in the acute care setting

AIMS

To examine the association between nurse skill mix (the proportion of total hours provided by Registered Nurses) and patient outcomes in acute care hospitals.

DESIGN

A quantitative systematic review included studies published in English between January 2000 - September 2018.

DATA SOURCES

Cochrane Library, CINAHL Plus with Full Text, MEDLINE, Scopus, Web of Science and Joanna Briggs Institute were searched. Observational and experimental study designs were included. Mix-methods designs were included if the quantitative component met the criteria.

REVIEW METHODS

The Systematic Review guidelines of the Joanna Briggs Institute and its critical appraisal instrument were used. An inverse association was determined when seventy-five percent or more of studies with significant results found this association.

RESULTS

Sixty-three articles were included. Twelve patient outcomes were inversely associated with nursing skill mix (i.e., higher nursing skill mix was significantly associated with improved patient outcomes). These were length of stay; ulcer, gastritis and upper gastrointestinal bleeds; acute myocardial infarction; restraint use; failure-to-rescue; pneumonia; sepsis; urinary tract infection; mortality/30-day mortality; pressure injury; infections and shock/cardiac arrest/heart failure.

CONCLUSION

Nursing skill mix affected 12 patient outcomes. However, further investigation using experimental or longitudinal study designs are required to establish causal relationships. Consensus on the definition of skill mix is required to enable more robust evaluation of the impact of changes in skill mix on patient outcomes.

IMPACT

Skill mix is perhaps more important than the number of nurses in reducing adverse patient outcomes such as mortality and failure to rescue, albeit the optimal staffing profile remains elusive in workforce planning.

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

AIM

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

IMPLICATIONS FOR NURSING MANAGEMENT

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

Determining acute nurse staffing: a hermeneutic review of an evolving science

BACKGROUND

Calculating nurse staffing in the acute hospital has become a key issue but solutions appear distant. Community, mental health and areas such as learning disability nursing have attracted less attention and remain intractable. This review aims to examine current approaches to the issue across many disciplines.

DESIGN

The approach taken is iterative and in the form of a hermeneutic review. 769 pieces of evidence were reviewed from across disciplines such as nursing, medicine, engineering, statistics, population science, computer science and mathematics where hospital nurse staffing was the subject of the study.

RESULTS

A number of themes emerged. The first iteration showed the predominance of unit base approaches (eg, nurse numbers, ratios, activity and workload) and the second was the development of methodologies. Subsequent iterations examined issues such as demand, safety, nurse education, turnover, patient outcomes, patient or staff satisfaction, workload and activity. The majority of studies examined (n=767) demonstrated some association between staffing (units or type/skill) and various factors such as staff or patient satisfaction, working conditions, safety parameters, outcomes complexity of work achieved, work left undone or other factors. Many potential areas such as operational safety research were not utilised.

CONCLUSION

Although the relationship between staffing in acute care and factors such as units, safety or workload is complex, the evidence suggests an interdependent relationship which should only be dismissed with caution. The nature of these relationships should be further examined in order to determine nurse staffing. The body of knowledge appears substantial and complex yet appears to have little impact on policy.

Fall Rates in Urban and Rural Nursing Units: Does Location Matter?

Patient falls remain a leading adverse event in hospitals. In a study of 65 rural hospitals with 222 nursing units and 560 urban hospitals with 4274 nursing units, we found that geographic region, unit type, and nurse staffing, education, experience, and outcomes were associated with fall rates. Implications include specific attention to fall prevention in rehabilitation units, creating better work environments that promote nurse retention, and provide RN-BSN educational opportunities.

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

BACKGROUND

Conclusive evidence on the effect of nurse staffing ratios on nurse-sensitive outcomes (NSOs) has not yet been achieved worldwide.

AIMS

To describe the relationship between nurse staffing and NSOs at a Magnet designated, university hospital a low-income country.

METHODS

A 48-month prospective study assessed the relationship between nurse staffing and six patient outcomes or NSOs in medical-surgical units and critical care units (CCUs). Nurse staffing was measured by nursing hours per patient day (NHPPD) and skill mix, whereas NSOs were total falls and injury falls per 1,000 patient days, percent of surveyed patients with hospital-acquired pressure injuries (HAPI), catheter-associated urinary tract infections, ventilator-associated pneumonia, and central line-associated bloodstream infections (CLABSI) per 1,000 central line days.

RESULTS

The odds for total falls, injury falls, HAPI, and CLABSI in the medical-surgical units were higher with lower NHPPD ratios, OR = 4.67, p = .000; OR = 4.33, p = .001; OR = 3.77, p = .004 and OR = 2.61, p = .006, respectively. For the CCUs, lower rates of NHPPD increased the odds for total falls, OR = 6.25, p = .0007, HAPIs OR = 3.91, p = .001 and CLABSI, OR = 4.78, p = .000. Skill mix was associated with total falls, OR = 2.40, p = .005 and HAPIs OR = 2.07, p = .03 in the medical-surgical units but had no effect in any NSOs in the CCUs.

LINKING EVIDENCE TO ACTION

Higher rates of nurses per patient were effective in improving some NSOs but not others. Skill mix had no effect on any of the six NSOs in the CCUs. As such, the results remain inconclusive as the benefits of the higher nurse to patient ratios in this low-income country warranting further multisite studies in different settings and countries.

Analysis of managerial and healthcare indicators after nursing personnel upsizing

OBJECTIVE

analyze healthcare and managerial indicators after nursing personnel upsizing.

METHOD

a retrospective, descriptive study was conducted using data from computer systems of a university hospital in southern Brazil. Healthcare and managerial indicators related to the first half of 2013 and 2014 were statistically analyzed.

RESULTS

increases of 40.0% in the number of nurses and 16.0% in the number of nursing technicians led to reductions of 12.0% in the number of sickness absences, 21.8% in positive balance for compensatory time off, 92.0% in paid overtime. Reductions of 75.0% in pressure ulcer rates, 10.5% in the number of falls and 50.0% in infections due to indwelling catheter use were also observed.

CONCLUSION

nursing staff upsizing caused a positive impact on managerial and healthcare indicators and helped qualify care and improve work conditions for the nursing team.

Nonlinear Analysis to Detect if Excellent Nursing Work Environments Have Highest Well-Being

PURPOSE

To detect potentially nonlinear associations between nurses' work environment and nurse staffing on the one hand and nurse burnout on the other hand.

DESIGN

A cross-sectional multicountry study for which data collection using a survey of 33,731 registered nurses in 12 European countries took place during 2009 to 2010.

METHODS

A semiparametric latent variable model that describes both linear and potentially nonlinear associations between burnout (Maslach Burnout Inventory: emotional exhaustion, depersonalization, personal accomplishment) and work environment (Practice Environment Scale of the Nursing Work Index: managerial support for nursing, doctor-nurse collegial relations, promotion of care quality) and staffing (patient-to-nurse ratio).

FINDINGS

Similar conclusions are reached from linear and nonlinear models estimating the association between work environment and burnout. For staffing, an increase in the patient-to-nurse ratio is associated with an increase in emotional exhaustion. At about 15 patients per nurse, no further increase in emotional exhaustion is seen.

CONCLUSIONS

Absence of evidence for diminishing returns of improving work environments suggests that continuous improvement and achieving excellence in nurse work environments pays off strongly in terms of lower nurse-reported burnout rates. Nurse staffing policy would benefit from a larger number of studies that identify specific minimum as well as maximum thresholds at which inputs affect nurse and patient outcomes.

CLINICAL RELEVANCE

Nurse burnout is omnipresent and has previously been shown to be related to worse patient outcomes. Additional increments in characteristics of excellent work environments, up to the highest possible standard, correspond to lower nurse burnout.

Association between Nurse Staffing and In-Hospital Bone Fractures: A Retrospective Cohort Study

OBJECTIVE

To determine if sufficient nurse staffing reduced in-hospital fractures in acute care hospitals.

DATA SOURCES/STUDY SETTING

The Japanese Diagnosis Procedure Combination inpatient (DPC) database from July 2010 to March 2014 linked with the Surveys for Medical Institutions.

STUDY DESIGN

We conducted a retrospective cohort study to examine the association of inpatient nurse-to-occupied bed ratio (NBR) with in-hospital fractures. Multivariable logistic regression with generalized estimating equations was performed, adjusting for patient characteristics and hospital characteristics.

DATA COLLECTION/EXTRACTION METHODS

We identified 770,373 patients aged 50 years or older who underwent planned major surgery for some forms of cancer or cardiovascular diseases. We used ICD-10 codes and postoperative procedure codes to identify patients with in-hospital fractures. Hospital characteristics were obtained from the "Survey of Medical Institutions and Hospital Report" and "Annual Report for Functions of Medical Institutions."

PRINCIPAL FINDINGS

Overall, 662 (0.09 percent) in-hospital fractures were identified. Logistic regression analysis showed that the proportion of in-hospital fractures in the group with the highest NBR was significantly lower than that in the group with the lowest NBR (adjusted odd ratios, 0.67; 95 percent confidence interval, 0.44-0.99; p = .048).

CONCLUSIONS

Sufficient nurse staffing may be important to reduce postsurgical in-hospital fractures in acute care hospitals.

Nurse staffing levels and outcomes – mining the UK national data sets for insight

Purpose

Despite the generation of mass data by the nursing workforce, determining the impact of the contribution to patient safety remains challenging. Several cross-sectional studies have indicated a relationship between staffing and safety. The purpose of this paper is to uncover possible associations and explore if a deeper understanding of relationships between staffing and other factors such as safety could be revealed within routinely collected national data sets.

Design/methodology/approach

Two longitudinal routinely collected data sets consisting of 30 years of UK nurse staffing data and seven years of National Health Service (NHS) benchmark data such as survey results, safety and other indicators were used. A correlation matrix was built and a linear correlation operation was applied (Pearson product-moment correlation coefficient).

Findings

A number of associations were revealed within both the UK staffing data set and the NHS benchmarking data set. However, the challenges of using these data sets soon became apparent.

Practical implications

Staff time and effort are required to collect these data. The limitations of these data sets include inconsistent data collection and quality. The mode of data collection and the itemset collected should be reviewed to generate a data set with robust clinical application.

Originality/value

This paper revealed that relationships are likely to be complex and non-linear; however, the main contribution of the paper is the identification of the limitations of routinely collected data. Much time and effort is expended in collecting this data; however, its validity, usefulness and method of routine national data collection appear to require re-examination.

Conducting Nursing Research to Advance and Inform Health Policy

The primary roles of nurse scientists in conducting health policy research are to increase knowledge in the discipline and provide evidence for informing and advancing health policies with the goal of improving the health outcomes of society. Health policy research informs, characterizes, explains, or tests hypotheses by employing a variety of research designs. Health policy research focuses on improving the access to care, the quality and cost of care, and the efficiency with which care is delivered. In this article, we explain how nurses might envision their research in a policy process framework, describe research designs that nurse researchers might use to inform and advance health policies, and provide examples of research conducted by nurse researchers to explicate key concepts in the policy process framework. Health policies are well informed and advanced when nurse researchers have a good understanding of the political process. The policy process framework provides a context for improving the focus and design of research and better explicating the connection between research evidence and policy. Nurses should focus their research on addressing problems of importance that are on the healthcare agenda, work with interdisciplinary teams of researchers, synthesize, and widely disseminate results.

Nursing Skill Mix, Nurse Staffing Level, and Physical Restraint Use in US Hospitals: a Longitudinal Study

BACKGROUND

Although it is plausible that nurse staffing is associated with use of physical restraints in hospitals, this has not been well established. This may be due to limitations in previous cross-sectional analyses lacking adequate control for unmeasured differences in patient-level variables among nursing units.

OBJECTIVE

To conduct a longitudinal study, with units serving as their own control, examining whether nurse staffing relative to a unit's long-term average is associated with restraint use.

DESIGN

We analyzed 17 quarters of longitudinal data using mixed logistic regression, modeling quarterly odds of unit restraint use as a function of quarterly staffing relative to the unit's average staffing across study quarters.

SUBJECTS

3101 medical, surgical, and medical-surgical units in US hospitals participating in the National Database of Nursing Quality Indicators during 2006-2010. Units had to report at least one quarter with restraint use and one quarter without.

MAIN MEASURES

We studied two nurse staffing variables: staffing level (total nursing hours per patient day) and nursing skill mix (proportion of nursing hours provided by RNs). Outcomes were any use of restraint, regardless of reason, and use of restraint for fall prevention.

KEY RESULTS

Nursing skill mix was inversely correlated with restraint use for fall prevention and for any reason. Compared to average quarters, odds of fall prevention restraint and of any restraint were respectively 16 % (95 % CI: 3-29 %) and 18 % (95 % CI: 8-29 %) higher for quarters with very low skill mix.

CONCLUSIONS

In this longitudinal study there was a strong negative correlation between nursing skill mix and physical restraint use. Ensuring that skill mix is consistently adequate should reduce use of restraint.

Mining routinely collected acute data to reveal non-linear relationships between nurse staffing levels and outcomes

OBJECTIVES

Nursing is a safety critical activity but not easily quantified. This makes the building of predictive staffing models a challenge. The aim of this study was to determine if relationships between registered and non-registered nurse staffing levels and clinical outcomes could be discovered through the mining of routinely collected clinical data. The secondary aim was to examine the feasibility and develop the use of 'big data' techniques commonly used in industry for this area of healthcare and examine future uses.

SETTING

The data were obtained from 1 large acute National Health Service hospital trust in England. Routinely collected physiological, signs and symptom data from a clinical database were extracted, imported and mined alongside a bespoke staffing and outcomes database using Mathmatica V.10. The physiological data consisted of 120 million patient entries over 6 years, the bespoke database consisted of 9 years of daily data on staffing levels and safety factors such as falls.

PRIMARY AND SECONDARY OUTCOMES

To discover patterns in these data or non-linear relationships that would contribute to modelling. To examine feasibility of this technique in this field.

RESULTS

After mining, 40 correlations (p<0.00005) emerged between safety factors, physiological data (such as the presence or absence of nausea) and staffing factors. Several inter-related factors demonstrated step changes where registered nurse availability appeared to relate to physiological parameters or outcomes such as falls and the management of symptoms. Data extraction proved challenging as some commercial databases were not built for extraction of the massive data sets they contain.

CONCLUSIONS

The relationship between staffing and outcomes appears to exist. It appears to be non-linear but calculable and a data-driven model appears possible. These findings could be used to build an initial mathematical model for acute staffing which could be further tested.

Prevention of falls in acute hospital settings: a multi-site audit and best practice implementation project

OBJECTIVE

To assess falls prevention practices in Australian hospitals and implement interventions to promote best practice.

DESIGN

A multi-site audit using eight evidence-based audit criteria. Following a baseline audit, barriers to compliance were identified and targeted. Two follow-up audit cycles assessed the sustainability of practice change.

SETTING

Nine acute care hospitals around Australia, including a mix of public and private. One medical ward and one surgical ward from each hospital were involved.

PARTICIPANTS

A clinical leader from each hospital, trained in evidence implementation, conducted the audits and implementation strategies in their setting.

INTERVENTIONS

Multi-component falls prevention interventions were utilized, designed to target specific barriers to compliance identified at each hospital. Common interventions involved staff and patient education.

MAIN OUTCOME MEASURE

Percentage compliance with falls prevention audit criteria and change in compliance between baseline and follow-up audits. Fall rate data were also analysed.

RESULTS

Mean overall compliance at baseline across all hospitals was 50.4% (range 30.8-76.6%). At the first follow-up, this had increased to 74.5% (range 59.4-87.4%), which was sustained at the second follow-up (74.1%, range 48.6-84.4%). There were no statistically significant differences between compliance rates in medical versus surgical wards or in private versus public hospitals. Despite sustained practice improvement, reported fall rates remained unchanged. The focus on staff education possibly led to improved reporting of falls, which may explain the apparent lack of effect on fall rates.

CONCLUSIONS

Clinical audit and feedback is an effective strategy to promote quality improvement in falls prevention practices in acute hospital settings.

Lower Nurse Staffing Levels Are Associated With Occurrences of Inpatient Falls at a Large Pediatric Hospital

No previous research has been published regarding the relationship between nurse staffing levels and inpatient pediatric falls, and previous research in the adult population has yielded conflicting results, probably due in many instances to suboptimal study design. The objective of this study was to examine the relationship between nurse staffing levels and pediatric patient falls in a large children's hospital. A case-control study design was used to compare the nurse staffing level during the shift of patient falls to the staffing level in the same units on shifts when patient falls did not occur. Nurse staffing levels were significantly lower in units when patient falls occurred, particularly during night shift. Targeted nurse staffing interventions in high-risk units could reduce the incidence of inpatient pediatric falls.

Pre-Procedural Patient Education Reduces Fall Risk in an Outpatient Endoscopy Suite

The purpose of this article was to determine whether scripted pre-procedural fall risk patient education and nurses' intention to assist patients after receiving sedation improves receptiveness of nursing assistance during recovery and decreases fall risk in an outpatient endoscopy suite. We prospectively identified high fall risk patients using the following criteria: (1) use of an assistive device, (2) fallen two or more times within the last year, (3) sustained an injury in a fall within a year, (4) age greater than 85 years, or (5) nursing judgment of high fall risk. Using a scripted dialogue, nurses educated high-risk patients of their fall risk and the nurses' intent to assist them to and in the bathroom. Documentation of patient education, script use, and assistance was monitored. Over 24 weeks, 892 endoscopy patients were identified as high fall risk; 790 (88.5%) accepted post-procedural assistance. Documentation of assistance significantly increased from 33% to 100%. Patients receiving education and postprocedural assistance increased from 27.9% to 100% at week 24. No patient falls occurred 12 months following implementation among patients identified as high fall risk. Scripted pre-procedural fall risk education increases patient awareness and receptiveness to assistance and can lead to decreased fall rates.

Longitudinal Association of Registered Nurse National Nursing Specialty Certification and Patient Falls in Acute Care Hospitals

Supplemental Digital Content is available in the text

Background

Researchers have studied inpatient falls in relation to aspects of nurse staffing, focusing primarily on staffing levels and proportion of nursing care hours provided by registered nurses (RNs). Less attention has been paid to other nursing characteristics, such as RN national nursing specialty certification.

Objective

The aim of the study was to examine the relationship over time between changes in RN national nursing specialty certification rates and changes in total patient fall rates at the patient care unit level.

Methods

We used longitudinal data with standardized variable definitions across sites from the National Database of Nursing Quality Indicators. The sample consisted of 7,583 units in 903 hospitals. Relationships over time were examined using multilevel (units nested in hospitals) latent growth curve modeling.

Results

The model indices indicated a good fit of the data to the model. At the unit level, there was a small statistically significant inverse relationship (r = −.08, p = .04) between RN national nursing specialty certification rates and total fall rates; increases in specialty certification rates over time tended to be associated with improvements in total fall rates over time.

Discussion

Our findings may be supportive of promoting national nursing specialty certification as a means of improving patient safety. Future study recommendations are (a) modeling organizational leadership, culture, and climate as mediating variables between national specialty certification rates and patient outcomes and (b) investigating the association of patient safety and specific national nursing specialty certifications which test plans include patient safety, quality improvement, and diffusion of innovation methods in their certifying examinations.

Use of Electronic Health-Related Datasets in Nursing and Health-Related Research

Datasets of gigabyte size are common in medical sciences. There is increasing consensus that significant untapped knowledge lies hidden in these large datasets. This review article aims to discuss Electronic Health-Related Datasets (EHRDs) in terms of types, features, advantages, limitations, and possible use in nursing and health-related research. Major scientific databases, MEDLINE, ScienceDirect, and Scopus, were searched for studies or review articles regarding using EHRDs in research. A total number of 442 articles were located. After application of study inclusion criteria, 113 articles were included in the final review. EHRDs were categorized into Electronic Administrative Health-Related Datasets and Electronic Clinical Health-Related Datasets. Subcategories of each major category were identified. EHRDs are invaluable assets for nursing the health-related research. Advanced research skills such as using analytical softwares, advanced statistical procedures, dealing with missing data and missing variables will maximize the efficient utilization of EHRDs in research.

Assisted and unassisted falls: different events, different outcomes, different implications for quality of hospital care

BACKGROUND

Many hospitals classify inpatient falls as assisted (if a staff member is present to ease the patient's descent or break the fall) or unassisted for quality measurement purposes. Unassisted falls are more likely to result in injury, but there is limited research quantifying this effect or linking the assisted/unassisted classification to processes of care. A study was conducted to link the assisted/unassisted fall classification to both processes and outcomes of care, thereby demonstrating its suitability for use in quality measurement. This was only the second known published study to quantify the increased risk of injury associated with falling unassisted (versus assisted), and the first to estimate the effects of falling unassisted (versus assisted) on the likelihood of specific levels of injury.

METHODS

A cross-sectional analysis of falls from all available 2011 data for 6,539 adult medical, surgical, and medical-surgical units in 1,464 general hospitals participating in the National Database of Nursing Quality Indicators" (NDNQI) was performed.

RESULTS

Participating units reported 166,883 falls (3.44 falls per 1,000 patient-days). Excluding repeat falls, 85.5% of falls were unassisted. Assisted and unassisted falls were associated with different processes and outcomes: Fallers for whom a fall prevention protocol was not in place were more likely to fall unassisted than those for whom one was in place (adjusted odds ratio [aOR], 1.39 [95% confidence interval (CI), 1.32, 1.46]), and unassisted falls were more likely to result in injury (aOR, 1.59 [95% CI, 1.52, 1.67]).

CONCLUSIONS

The assisted/unassisted fall classification is associated with care processes and patient outcomes, making it suitable for quality measurement. Unassisted falls are more likely than assisted falls to result in injury and should be considered a target for future prevention efforts.