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Tate K, Penconek T, Booth A, Harvey G, Flynn R, Lalleman P, Wolbers I, Hoben M, Estabrooks CA, Cummings GG. Contextually appropriate nurse staffing models: a realist review protocol. BMJ Open 2024; 14:e082883. [PMID: 38719308 PMCID: PMC11086385 DOI: 10.1136/bmjopen-2023-082883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 04/08/2024] [Indexed: 05/12/2024] Open
Abstract
INTRODUCTION Decisions about nurse staffing models are a concern for health systems globally due to workforce retention and well-being challenges. Nurse staffing models range from all Registered Nurse workforce to a mix of differentially educated nurses and aides (regulated and unregulated), such as Licensed Practical or Vocational Nurses and Health Care Aides. Systematic reviews have examined relationships between specific nurse staffing models and client, staff and health system outcomes (eg, mortality, adverse events, retention, healthcare costs), with inconclusive or contradictory results. No evidence has been synthesised and consolidated on how, why and under what contexts certain staffing models produce different outcomes. We aim to describe how we will (1) conduct a realist review to determine how nurse staffing models produce different client, staff and health system outcomes, in which contexts and through what mechanisms and (2) coproduce recommendations with decision-makers to guide future research and implementation of nurse staffing models. METHODS AND ANALYSIS Using an integrated knowledge translation approach with researchers and decision-makers as partners, we are conducting a three-phase realist review. In this protocol, we report on the final two phases of this realist review. We will use Citation tracking, tracing Lead authors, identifying Unpublished materials, Google Scholar searching, Theory tracking, ancestry searching for Early examples, and follow-up of Related projects (CLUSTER) searching, specifically designed for realist searches as the review progresses. We will search empirical evidence to test identified programme theories and engage stakeholders to contextualise findings, finalise programme theories document our search processes as per established realist review methods. ETHICS AND DISSEMINATION Ethical approval for this study was provided by the Health Research Ethics Board of the University of Alberta (Study ID Pro00100425). We will disseminate the findings through peer-reviewed publications, national and international conference presentations, regional briefing sessions, webinars and lay summary.
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Affiliation(s)
- Kaitlyn Tate
- College of Health Sciences, Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Tatiana Penconek
- College of Health Sciences, Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew Booth
- School of Medicine and Population Health, University of Sheffield, Sheffield, South Yorkshire, UK
| | - Gillian Harvey
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Rachel Flynn
- School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | | | - Inge Wolbers
- University of Applied Sciences Utrecht, Utrecht, Netherlands
| | - Matthias Hoben
- School of Health Policy and Management, York University, Toronto, Ontario, Canada
| | - Carole A Estabrooks
- College of Health Sciences, Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Greta G Cummings
- College of Health Sciences, Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
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O'Guinn ML, Vojvodic V, Ourshalimian S, Garcia I, Chaudhari PP, Spurrier R. Seasonality and temporal variation of pediatric trauma in Southern California. Injury 2024; 55:111266. [PMID: 38141391 DOI: 10.1016/j.injury.2023.111266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 12/01/2023] [Accepted: 12/02/2023] [Indexed: 12/25/2023]
Abstract
INTRODUCTION Seasonality of pediatric trauma has been previously described, although the association of season with hour of presentation is less understood. Both factors have potential implications for resource allocation and team preparedness. METHODS A multicenter retrospective study was conducted to analyze the records of injured children <18 years-old who presented to one of the 15 trauma centers within Los Angeles County. Data from the County Trauma and Emergency Medicine Information System Registry was abstracted from 1/1/10 to 12/31/21. Patient demographics, mechanism of injury (MOI) and time of presentation by season were analyzed using Kruskal Wallis tests and chi-square tests. RESULTS A total of 30,444 pediatric trauma presentations were included. Both the time of presentation and the MOI differed significantly by season with p < 0.001. Autumn had a higher incidence of pedestrian injuries during hours of 08:00 and 15:0020:00, and sports injuries from 16:00 to 21:00. In the Summer there were more burns between 17:00 and 23:00 and falls from greater than 10 ft after 13:00. The mode of transport used was also different across seasons (p = 0.03), with the use of both air and ground EMS greatest during summer and least during winter. The hours of greatest utilization remained relatively constant for all seasons for air transport (18:00-19:00 h) and ground transport (19:00-20:00 h). CONCLUSION These data demonstrate the significant seasonal and temporal variation within pediatric trauma. These findings could be used to inform improvements in emergency response, and resource allocation in particular.
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Affiliation(s)
- MaKayla L O'Guinn
- Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027, United States
| | - Vanya Vojvodic
- Keck School of Medicine of University of Southern California, 1975 Zonal Ave, Los Angeles, CA 90033, United States
| | - Shadassa Ourshalimian
- Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027, United States
| | - Iris Garcia
- Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027, United States
| | - Pradip P Chaudhari
- Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027, United States; Keck School of Medicine of University of Southern California, 1975 Zonal Ave, Los Angeles, CA 90033, United States
| | - Ryan Spurrier
- Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027, United States; Keck School of Medicine of University of Southern California, 1975 Zonal Ave, Los Angeles, CA 90033, United States; University of Southern California, 3470 Trousdale Parkway, Los Angeles, CA 90089, United States.
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Williams M, Coppin JD, Bender M. Predictors of Clinical Nurse Leader implementation success across a national sample of settings: A Bayesian multilevel modeling analysis. J Nurs Scholarsh 2023; 55:1238-1247. [PMID: 37603445 DOI: 10.1111/jnu.12926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 06/24/2023] [Accepted: 07/11/2023] [Indexed: 08/23/2023]
Abstract
INTRODUCTION The Clinical Nurse Leader (CNL) care model is a different way of organizing frontline nursing care delivery in contrast to the traditional "staff nurse" model and is increasingly being adopted by health systems across the United States and abroad. However, variability in implementation and outcomes has been noted across health settings. AIM A recently validated CNL Practice Model provides an explanatory pathway for CNL model integration into practice. The purpose of this study was to identify and compare patterns of empirical correspondence to the CNL Practice Model and predict their influence on implementation success. METHODS We conducted a secondary analysis of a 2015 national-level study with clinicians and administrators involved with CNL initiatives in their health system. A psychometrically validated CNL Practice Survey was used to collect data measuring the presence (0%-100%) of the five domains of the CNL Practice Model (organizational readiness, CNL structuring, CNL practices, outcomes, and value) and one measure of CNL implementation success. We modeled the complex hierarchical structure of the data using a Bayesian multilevel regression mixed modeling approach. A zero-one-inflated beta distribution, a mixture of Bernoulli distributions for the minimum and maximum responses and a beta distribution for the responses between the minimum and maximum, was used to fit success ratings in the model. RESULTS A total of 920 participants responded, 540 (59%) provided success scores. The model captured ratings skewed toward upper bound, while also adequately modeling data between the minimum and maximum values. The Bayesian model converged and gave estimates for all hierarchical parameters, which would likely have failed to converge in a pure maximum likelihood framework. The variability around success score across CNL Practice Model element ratings was greatest at the component level, 0.29 (0.18-0.48), compared to either the domain level, 0.16 (0.01-0.54), or the item level, 0.09 (0.01-0.17). The components most predictive of implementation success were (a) consensus CNL model can close gaps, (b) organization level implementation strategy, and (c) alignment of empirical CNL microsystem level structuring to the model's conceptualization. CONCLUSIONS Findings provide further empirical evidence to support the explanatory pathway proposed by the CNL Practice Model and identified specific organizational readiness and CNL workflow structures that are critical antecedents predictive of CNL practice manifestation and production of expected outcomes. Findings indicate actionable implementation evidence that can be successfully adopted across real-world healthcare settings to achieve safer and higher quality patient care. CLINICAL RELEVANCE CNL integrated care delivery is a frontline nursing care model that is being increasingly adopted by health systems across the United States and abroad. However, variability in CNL implementation and outcomes has been noted across health settings, limiting its evidence base. Findings of this study contribute a better understanding about the variability of CNL practice and outcomes found in the literature and contribute empirical and conceptual clarity about the relationships between modes of CNL implementation and successful adoption in healthcare settings.
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Affiliation(s)
| | | | - Miriam Bender
- Sue & Bill Gross School of Nursing, University of California Irvine, Irvine, California, USA
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Ruhmel S, Ndirangu-Mugo E, Mwizerwa J, Sarki A, Pallangyo E. Capacity building among nursing and midwifery professional associations in East Africa. Glob Health Action 2022; 15:2118173. [PMID: 36278934 PMCID: PMC9602823 DOI: 10.1080/16549716.2022.2118173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Despite improvements in educational opportunities, policy changes, and pay raises in the nursing and midwifery professions in East Africa, poor working conditions, few professional development opportunities, and a general lack of respect for these professions predominate. These issues contribute to a low quality of care among a population with a high burden of communicable diseases. Health professional associations may help to address these challenges by providing a voice for nurses and midwives. Objective This study evaluated the impact of a 5-year programme focused on strengthening nurses’ and midwives’ professional associations in East Africa. Methods This study used a mixed methods design. Quantitative, cross-sectional descriptive data were captured via surveys (n = 1,266) distributed to association members. In-depth interviews (n = 65) were used to obtain qualitative data and complement the survey responses. Quantitative and qualitative data collection occurred concurrently. The results were compared to assess the impact of the programme across Uganda, Kenya, and Tanzania. Results The programme successfully built capacity in four of five organisational capacity areas: resource mobilisation, financial management, strategy, and monitoring and evaluation. Marketing and communications, the fifth targeted area, did not show improvement. Capacity in both research and service delivery was also improved, despite the programme not providing training in these areas. In addition, collaboration among associations and their members was improved. Conclusion These results support existing evidence on the impact of capacity building among professional nursing associations and coincide with the World Health Organization’s objectives for nursing. Future capacity building programmes should consider replicating the successful activities from this programme and investigate ways to reach more rural branches and provide tailored content. This study contributes to a small but growing body of knowledge that supports capacity building among the African health workforce.
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Affiliation(s)
- Stephen Ruhmel
- Janssen Research & Development, LLC, Johnson & Johnson, Titusville, NJ, USA,CONTACT Stephen Ruhmel Janssen Research & Development, LLC, Johnson & Johnson, 1125 Trenton-Harbourton Rd, Titusville, NJ08560, USA
| | | | - Joseph Mwizerwa
- Aga Khan University School of Nursing and Midwifery, Kampala, Uganda
| | - Ahmed Sarki
- Aga Khan University School of Nursing and Midwifery, Kampala, Uganda
| | - Eunice Pallangyo
- Aga Khan University School of Nursing and Midwifery, Dar es Salaam, Tanzania
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Jackson J. "I love the job…" Thriving in nursing: A qualitative interview study with framework analysis. Int Emerg Nurs 2022; 62:101172. [PMID: 35483210 DOI: 10.1016/j.ienj.2022.101172] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 03/04/2022] [Accepted: 03/23/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Burnout is a well-known issue among nurses in critical care settings, including emergency nurses. There are decades of research indicating that emergency nurses experience burnout in their work. However, many nurses have long careers in emergency settings, which suggests that burnout is not the only outcome for nurses. Thriving may also be part of nurses' experiences. The Model of Thriving at Work includes external factors (autonomy, climate of trust and respect, and information sharing) and internal factors (knowledge, personal outlook, and relationships). Thriving is characterized by the concepts of vitality and ongoing learning. Previous researchers suggest that thriving fits with some nurses' experiences, based on validated questionnaires. However, thriving has not been investigated among nurses using interview approaches. AIMS This article explores nurses' experiences of thriving and assesses the fit of Spreitzer et al.'s Model of Thriving at Work with nurses' experiences. STUDY DESIGN Qualitative interview study, using framework analysis. METHODS Eleven nurses, from a single site, completed semi-structured interviews. These interviews explored nurses' workplace experiences, both positive and negative. RESULTS Participants reported experiences that fit with the Model of Thriving at Work, consisting of vitality, ongoing learning, and external and internal factors. Nurses hesitated to describe themselves in positive ways, referring instead to being 'not burnt out'. Nurses could, however, readily identify qualities of thriving in others, and viewed those nurses as aspirational. In addition to the Model, participants highlighted their emotional burden, workload, and ethical issues as important contributors to thriving. The Model could potentially be expanded to include these factors. CONCLUSIONS Thriving at work could be part of a range of emergency nurses' workplace outcomes. External and internal factors contribute to thriving. Healthcare leaders could support thriving among emergency nurses by fostering a positive work environment.
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Affiliation(s)
- Jennifer Jackson
- Faculty of Nursing, University of Calgary, Professional Faculties Building, 2500 University Drive NW, Calgary, AB T2N 1N4, Canada. https://twitter.com/@JJackson_RN
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Ferrario MM, Veronesi G, Borchini R, Cavicchiolo M, Dashi O, Dalla Gasperina D, Martinelli G, Gianfagna F. Time Trends of Percutaneous Injuries in Hospital Nurses: Evidence of the Interference between Effects of Adoption of Safety Devices and Organizational Factors. Int J Environ Res Public Health 2021; 18:ijerph18084371. [PMID: 33924104 PMCID: PMC8074301 DOI: 10.3390/ijerph18084371] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/09/2021] [Accepted: 04/16/2021] [Indexed: 01/14/2023]
Abstract
Few studies have focused on the combined effects of devices and work organization on needlestick injuries trends. The aim of the study was to estimate trends of percutaneous injury rates (IR) in nurses (N) and nurse assistants (NA) over a 10 year period, in which passive safety devices were progressively adopted. Percutaneous and mucocutaneous injuries registered in a University Hospital in Northern Italy in Ns and NAs in 2007–2016 were analyzed. Organizational data were also available on shift schedules, turnover, downsizing and age- and skill-mix. We estimated IRs per 100 full-time equivalent workers from Poisson models and their average annual percent changes (APC) from joinpoint regression model. In the entire period, monotonic decreases in percutaneous IRs occurred among day-shift Ns (APC = −20.9%; 95% CI: −29.8%, −12%) and NAs (APC = −15.4%; −32.9%, 2.2%). Joinpoint modeling revealed a turning point in 2012 for night-shift Ns, with a steady decline in 2007–2012 (APC = −19.4%; −27.9%, −10.9%), and an increase thereafter (APC = +13.5%; 1.5%, 25.5%). In comparison to 2008 and 2012, in 2016 night-shift Ns were 5.9 and 2.5 times more likely to be younger and less qualified or experienced than day-shift Ns. The observed declines in percutaneous injury rates occurred in a time period when safety devices were progressively implemented. The causal nature of multiple exposures and organizational procedures in affecting injury time trends should be further addressed by quasi-experimental studies.
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Affiliation(s)
- Marco M. Ferrario
- Department of Medicine and Surgery, School of Medicine, University of Insubria, 21100 Varese, Italy; (G.V.); (D.D.G.); (F.G.)
- Occupational, Preventive and Toxicology Unit, ASST Sette Laghi, 21100 Varese, Italy
- Correspondence:
| | - Giovanni Veronesi
- Department of Medicine and Surgery, School of Medicine, University of Insubria, 21100 Varese, Italy; (G.V.); (D.D.G.); (F.G.)
| | - Rossana Borchini
- Occupational and Preventive Medicine Unit, ASST Lariana, 22100 Como, Italy;
| | - Marco Cavicchiolo
- School of Specialization in Occupational Medicine, University of Insubria, 21100 Varese, Italy; (M.C.); (O.D.)
| | - Oriana Dashi
- School of Specialization in Occupational Medicine, University of Insubria, 21100 Varese, Italy; (M.C.); (O.D.)
| | - Daniela Dalla Gasperina
- Department of Medicine and Surgery, School of Medicine, University of Insubria, 21100 Varese, Italy; (G.V.); (D.D.G.); (F.G.)
| | | | - Francesco Gianfagna
- Department of Medicine and Surgery, School of Medicine, University of Insubria, 21100 Varese, Italy; (G.V.); (D.D.G.); (F.G.)
- Mediterranea Cardiocentro, 80122 Napoli, Italy
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Kushemererwa D, Davis J, Moyo N, Gilbert S, Gray R. The Association between Nursing Skill Mix and Mortality for Adult Medical and Surgical Patients: Protocol for a Systematic Review. Int J Environ Res Public Health 2020; 17:ijerph17228604. [PMID: 33228155 PMCID: PMC7699481 DOI: 10.3390/ijerph17228604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/14/2020] [Accepted: 11/16/2020] [Indexed: 12/20/2022]
Abstract
Skill mix refers to the number and educational experience of nurses working in clinical settings. Authors have used several measures to determine the skill mix, which includes nurse-to-patient ratio and the proportion of baccalaureate-prepared nurses. Observational studies have tested the association between nursing skill mix and patient outcomes (mortality). To date, this body of research has not been subject to systematic review or meta-analysis. The aim of this study is to systematically review and meta-analyse observational and experimental research that tests the association between nursing skill mix and patient mortality in medical and surgical settings. We will search four key electronic databases—MEDLINE [OVID], EMBASE [OVID], CINAHL [EBSCOhost], and ProQuest Central (five databases)—from inception. Title, abstract, and full-text screening will be undertaken independently by at least two researchers using COVIDENCE review management software. We will include studies where the authors report an association between nursing skill mix and outcomes in adult medical and surgical inpatients. Extracted data from included studies will consist measures of nursing skill mix and inpatient mortality outcomes. A meta-analysis will be undertaken if there are at least two studies with similar designs, exposures, and outcomes. The findings will inform future research and workforce planning in health systems internationally.
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van Schalkwyk MC, Bourek A, Kringos DS, Siciliani L, Barry MM, De Maeseneer J, McKee M. The best person (or machine) for the job: Rethinking task shifting in healthcare. Health Policy 2020; 124:1379-1386. [PMID: 32900551 DOI: 10.1016/j.healthpol.2020.08.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 05/27/2020] [Accepted: 08/23/2020] [Indexed: 12/27/2022]
Abstract
Globally, health systems are faced with the difficult challenge of how to get the best results with the often limited number of health workers available to them. Exacerbating this challenge is the task of meeting ever-changing needs of service users and managing unprecedented technological advances. The process of matching skills to changing needs and opportunities is termed task shifting. It involves questioning health service goals, what health workers do, asking if it can be done in a better way, and implementing change. Task shifting in healthcare is often conceptualised as a process of transferring responsibility for 'simple' tasks from high-skilled but scarce health workers to those with less expertise and lower pay, and predominantly viewed as a means to reduce costs and promote efficiency. Here we present a position paper based on the work and expertise of the European Commission Expert Panel on Effective ways of Investing in Health. It contends that this is over simplistic, and aims to provide a new task shifting framework, informed by relevant evidence, and a series of recommendations. While far from comprehensive, there is a growing body of evidence that certain tasks traditionally undertaken by one type of health worker can be undertaken by others (or machines), in some cases to a higher standard, thus challenging the persistence of rigid professional boundaries. Task shifting has the potential to contribute to health systems strengthening when accompanied by adequate planning, resources, education, training and transparency.
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Affiliation(s)
- May Ci van Schalkwyk
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, United Kingdom
| | - Aleš Bourek
- Masaryk University Center for Healthcare Quality, Czech Republic
| | - Dionne Sofia Kringos
- Amsterdam UMC, University of Amsterdam, Department of Public Health and Occupational Health, Amsterdam Public Health Research Institute, Meibergdreef 9, Amsterdam, The Netherlands
| | - Luigi Siciliani
- Department of Economics and Related Studies, University of York, York, United Kingdom
| | - Margaret M Barry
- Head of World Health Organization Collaborating Centre for Health Promotion Research, School of Health Sciences, National University of Ireland, Galway, Ireland
| | - Jan De Maeseneer
- Department of Public Health and Primary Health Care, Ghent University, Belgium
| | - Martin McKee
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, United Kingdom.
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Ayorinde AA, Williams I, Mannion R, Song F, Skrybant M, Lilford RJ, Chen YF. Publication and related bias in quantitative health services and delivery research: a multimethod study. Health Serv Deliv Res 2020. [DOI: 10.3310/hsdr08330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Bias in the publication and reporting of research findings (referred to as publication and related bias here) poses a major threat in evidence synthesis and evidence-based decision-making. Although this bias has been well documented in clinical research, little is known about its occurrence and magnitude in health services and delivery research.
Objectives
To obtain empirical evidence on publication and related bias in quantitative health services and delivery research; to examine current practice in detecting/mitigating this bias in health services and delivery research systematic reviews; and to explore stakeholders’ perception and experiences concerning such bias.
Methods
The project included five distinct but interrelated work packages. Work package 1 was a systematic review of empirical and methodological studies. Work package 2 involved a survey (meta-epidemiological study) of randomly selected systematic reviews of health services and delivery research topics (n = 200) to evaluate current practice in the assessment of publication and outcome reporting bias during evidence synthesis. Work package 3 included four case studies to explore the applicability of statistical methods for detecting such bias in health services and delivery research. In work package 4 we followed up four cohorts of health services and delivery research studies (total n = 300) to ascertain their publication status, and examined whether publication status was associated with statistical significance or perceived ‘positivity’ of study findings. Work package 5 involved key informant interviews with diverse health services and delivery research stakeholders (n = 24), and a focus group discussion with patient and service user representatives (n = 8).
Results
We identified only four studies that set out to investigate publication and related bias in health services and delivery research in work package 1. Three of these studies focused on health informatics research and one concerned health economics. All four studies reported evidence of the existence of this bias, but had methodological weaknesses. We also identified three health services and delivery research systematic reviews in which findings were compared between published and grey/unpublished literature. These reviews found that the quality and volume of evidence and effect estimates sometimes differed significantly between published and unpublished literature. Work package 2 showed low prevalence of considering/assessing publication (43%) and outcome reporting (17%) bias in health services and delivery research systematic reviews. The prevalence was lower among reviews of associations than among reviews of interventions. The case studies in work package 3 highlighted limitations in current methods for detecting these biases due to heterogeneity and potential confounders. Follow-up of health services and delivery research cohorts in work package 4 showed positive association between publication status and having statistically significant or positive findings. Diverse views concerning publication and related bias and insights into how features of health services and delivery research might influence its occurrence were uncovered through the interviews with health services and delivery research stakeholders and focus group discussion conducted in work package 5.
Conclusions
This study provided prima facie evidence on publication and related bias in quantitative health services and delivery research. This bias does appear to exist, but its prevalence and impact may vary depending on study characteristics, such as study design, and motivation for conducting the evaluation. Emphasis on methodological novelty and focus beyond summative assessments may mitigate/lessen the risk of such bias in health services and delivery research. Methodological and epistemological diversity in health services and delivery research and changing landscape in research publication need to be considered when interpreting the evidence. Collection of further empirical evidence and exploration of optimal health services and delivery research practice are required.
Study registration
This study is registered as PROSPERO CRD42016052333 and CRD42016052366.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 33. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Abimbola A Ayorinde
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Iestyn Williams
- Health Services Management Centre, School of Social Policy, University of Birmingham, Birmingham, UK
| | - Russell Mannion
- Health Services Management Centre, School of Social Policy, University of Birmingham, Birmingham, UK
| | - Fujian Song
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Magdalena Skrybant
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Richard J Lilford
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Yen-Fu Chen
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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Cochrane Effective Practice and Organisation of Care Group, Michelle Butler, Timothy J Schultz, Jonathan Drennan. Substitution of nurses for physicians in the hospital setting for patient, process of care, and economic outcomes. Cochrane Database Syst Rev 2020; 2020:CD013616. [ DOI: 10.1002/14651858.CD013616] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: The main objective of the review is to examine the impact of substituting nurses for doctors in the hospital setting (hospital inpatient units and outpatient clinics) on patient outcomes, process of care outcomes, and economic outcomes. The secondary objectives of this review are to assess whether the effects of nurse‐doctor substitution differ according to healthcare setting (low‐ and middle‐income countries versus high‐income countries), patient disease, patient type (inpatients versus outpatients), and mode of nursing practice (unsupervised versus delegated/under medical supervision).
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Griffiths P, Saville C, Ball JE, Chable R, Dimech A, Jones J, Jeffrey Y, Pattison N, Saucedo AR, Sinden N, Monks T. The Safer Nursing Care Tool as a guide to nurse staffing requirements on hospital wards: observational and modelling study. Health Serv Deliv Res 2020. [DOI: 10.3310/hsdr08160] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BackgroundThe Safer Nursing Care Tool is a system designed to guide decisions about nurse staffing requirements on hospital wards, in particular the number of nurses to employ (establishment). The Safer Nursing Care Tool is widely used in English hospitals but there is a lack of evidence about how effective and cost-effective nurse staffing tools are at providing the staffing levels needed for safe and quality patient care.ObjectivesTo determine whether or not the Safer Nursing Care Tool corresponds to professional judgement, to assess a range of options for using the Safer Nursing Care Tool and to model the costs and consequences of various ward staffing policies based on Safer Nursing Care Tool acuity/dependency measure.DesignThis was an observational study on medical/surgical wards in four NHS hospital trusts using regression, computer simulations and economic modelling. We compared the effects and costs of a ‘high’ establishment (set to meet demand on 90% of days), the ‘standard’ (mean-based) establishment and a ‘flexible (low)’ establishment (80% of the mean) providing a core staff group that would be sufficient on days of low demand, with flexible staff re-deployed/hired to meet fluctuations in demand.SettingMedical/surgical wards in four NHS hospital trusts.Main outcome measuresThe main outcome measures were professional judgement of staffing adequacy and reports of omissions in care, shifts staffed more than 15% below the measured requirement, cost per patient-day and cost per life saved.Data sourcesThe data sources were hospital administrative systems, staff reports and national reference costs.ResultsIn total, 81 wards participated (85% response rate), with data linking Safer Nursing Care Tool ratings and staffing levels for 26,362 wards × days (96% response rate). According to Safer Nursing Care Tool measures, 26% of all ward-days were understaffed by ≥ 15%. Nurses reported that they had enough staff to provide quality care on 78% of shifts. When using the Safer Nursing Care Tool to set establishments, on average 60 days of observation would be needed for a 95% confidence interval spanning 1 whole-time equivalent either side of the mean. Staffing levels below the daily requirement estimated using the Safer Nursing Care Tool were associated with lower odds of nurses reporting ‘enough staff for quality’ and more reports of missed nursing care. However, the relationship was effectively linear, with staffing above the recommended level associated with further improvements. In simulation experiments, ‘flexible (low)’ establishments led to high rates of understaffing and adverse outcomes, even when temporary staff were readily available. Cost savings were small when high temporary staff availability was assumed. ‘High’ establishments were associated with substantial reductions in understaffing and improved outcomes but higher costs, although, under most assumptions, the cost per life saved was considerably less than £30,000.LimitationsThis was an observational study. Outcomes of staffing establishments are simulated.ConclusionsUnderstanding the effect on wards of variability of workload is important when planning staffing levels. The Safer Nursing Care Tool correlates with professional judgement but does not identify optimal staffing levels. Employing more permanent staff than recommended by the Safer Nursing Care Tool guidelines, meeting demand most days, could be cost-effective. Apparent cost savings from ‘flexible (low)’ establishments are achieved largely by below-adequate staffing. Cost savings are eroded under the conditions of high temporary staff availability that are required to make such policies function.Future workResearch is needed to identify cut-off points for required staffing. Prospective studies measuring patient outcomes and comparing the results of different systems are feasible.Trial registrationCurrent Controlled Trials ISRCTN12307968.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 8, No. 16. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Peter Griffiths
- School of Health Sciences, University of Southampton, Southampton, UK
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, University of Southampton, Southampton, UK
| | - Christina Saville
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Jane E Ball
- School of Health Sciences, University of Southampton, Southampton, UK
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, University of Southampton, Southampton, UK
| | - Rosemary Chable
- Training, Development & Workforce, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Andrew Dimech
- Clinical Services, The Royal Marsden NHS Foundation Trust, London, UK
| | - Jeremy Jones
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Yvonne Jeffrey
- Nursing & Patient Services, Poole Hospital NHS Foundation Trust, Poole, UK
| | - Natalie Pattison
- Clinical Services, The Royal Marsden NHS Foundation Trust, London, UK
- School of Health and Social Work, University of Hertfordshire, Hatfield, UK
| | | | - Nicola Sinden
- Nursing Directorate, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Thomas Monks
- School of Health Sciences, University of Southampton, Southampton, UK
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, University of Southampton, Southampton, UK
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Griffiths P, Saville C, Ball J, Jones J, Pattison N, Monks T. Nursing workload, nurse staffing methodologies and tools: A systematic scoping review and discussion. Int J Nurs Stud 2019; 103:103487. [PMID: 31884330 PMCID: PMC7086229 DOI: 10.1016/j.ijnurstu.2019.103487] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 09/10/2019] [Accepted: 11/18/2019] [Indexed: 02/03/2023]
Abstract
Background The importance of nurse staffing levels in acute hospital wards is widely recognised but evidence for tools to determine staffing requirements although extensive, has been reported to be weak. Building on a review of reviews undertaken in 2014, we set out to give an overview of the major approaches to assessing nurse staffing requirements and identify recent evidence in order to address unanswered questions including the accuracy and effectiveness of tools. Methods We undertook a systematic scoping review. Searches of Medline, the Cochrane Library and CINAHL were used to identify recent primary research, which was reviewed in the context of conclusions from existing reviews. Results The published literature is extensive and describes a variety of uses for tools including establishment setting, daily deployment and retrospective review. There are a variety of approaches including professional judgement, simple volume-based methods (such as patient-to-nurse ratios), patient prototype/classification and timed-task approaches. Tools generally attempt to match staffing to a mean average demand or time requirement despite evidence of skewed demand distributions. The largest group of recent studies reported the evaluation of (mainly new) tools and systems, but provides little evidence of impacts on patient care and none on costs. Benefits of staffing levels set using the tools appear to be linked to increased staffing with no evidence of tools providing a more efficient or effective use of a given staff resource. Although there is evidence that staffing assessments made using tools may correlate with other assessments, different systems lead to dramatically different estimates of staffing requirements. While it is evident that there are many sources of variation in demand, the extent to which systems can deliver staffing levels to meet such demand is unclear. The assumption that staffing to meet average need is the optimal response to varying demand is untested and may be incorrect. Conclusions Despite the importance of the question and the large volume of publication evidence about nurse staffing methods remains highly limited. There is no evidence to support the choice of any particular tool. Future research should focus on learning more about the use of existing tools rather than simply developing new ones. Priority research questions include how best to use tools to identify the required staffing level to meet varying patient need and the costs and consequences of using tools. Tweetable abstract Decades of research on tools to determine nurse staffing requirements is largely uninformative. Little is known about the costs or consequences of widely used tools.
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Affiliation(s)
- Peter Griffiths
- University of Southampton, Health Sciences, United Kingdom; National Institute for Health Research Applied Research Collaboration (Wessex), United Kingdom; Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Sweden.
| | - Christina Saville
- University of Southampton, Health Sciences, United Kingdom; National Institute for Health Research Applied Research Collaboration (Wessex), United Kingdom
| | - Jane Ball
- University of Southampton, Health Sciences, United Kingdom; Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Sweden
| | - Jeremy Jones
- University of Southampton, Health Sciences, United Kingdom
| | - Natalie Pattison
- University of Hertfordshire, School of Health and Social Work, United Kingdom; East & North Hertfordshire NHS Trust, United Kingdom
| | - Thomas Monks
- University of Exeter, College of Medicine and Health, United Kingdom; National Institute for Health Research Applied Research Collaboration (Wessex), United Kingdom
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Thériault M, Dubois C, Borgès da Silva R, Prud’homme A. Nurse staffing models in acute care: A descriptive study. Nurs Open 2019; 6:1218-1229. [PMID: 31367448 PMCID: PMC6650648 DOI: 10.1002/nop2.321] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 05/01/2019] [Accepted: 05/21/2019] [Indexed: 11/09/2022] Open
Abstract
AIMS To identify nurse staffing groups in acute care facilities. DESIGN This retrospective descriptive study used a configurational approach. METHODS Data from a two-month target period from January-March 2016 were collected for 40 facilities in four different hospitals in one of the largest regions of Quebec. Multiple factorial analysis and hierarchical ascendant classification were used to generate a limited number of nurse staffing groups. RESULTS/FINDINGS Four distinct nurse staffing groups emerged from this study. The least resourced model relied mainly on less qualified personnel and agency staff. The moderately resourced basic model was assessed as average across all staffing dimensions, but employed less overtime, relying mostly on auxiliary nurses. The moderately resourced professional group, also moderate in most variables, involved more overtime and fewer less qualified personnel. The most resourced group maximized highly qualified personnel and minimized instability in the nursing team. CONCLUSION This study covered multiple staffing groups with widely varying characteristics. Most groups entailed risks for quality of care at one or more levels. Few care units approached the theoretical staffing ideal.
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Affiliation(s)
- Marianne Thériault
- Faculty of NursingUniversity of MontrealMontrealQuebecCanada
- Public Health Research InstituteUniversity of MontrealMontrealQuebecCanada
| | - Carl‐Ardy Dubois
- Public Health Research InstituteUniversity of MontrealMontrealQuebecCanada
- Department of Management, Evaluation and Health PolicyUniversity of MontrealMontrealQuebecCanada
| | - Roxane Borgès da Silva
- Public Health Research InstituteUniversity of MontrealMontrealQuebecCanada
- Department of Management, Evaluation and Health PolicyUniversity of MontrealMontrealQuebecCanada
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Gathara D, Serem G, Murphy GAV, Obengo A, Tallam E, Jackson D, Brownie S, English M. Missed nursing care in newborn units: a cross-sectional direct observational study. BMJ Qual Saf 2019; 29:19-30. [PMID: 31171710 PMCID: PMC6923939 DOI: 10.1136/bmjqs-2019-009363] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 05/16/2019] [Accepted: 05/18/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Improved hospital care is needed to reduce newborn mortality in low/middle-income countries (LMIC). Nurses are essential to the delivery of safe and effective care, but nurse shortages and high patient workloads may result in missed care. We aimed to examine nursing care delivered to sick newborns and identify missed care using direct observational methods. METHODS A cross-sectional study using direct-observational methods for 216 newborns admitted in six health facilities in Nairobi, Kenya, was used to determine which tasks were completed. We report the frequency of tasks done and develop a nursing care index (NCI), an unweighted summary score of nursing tasks done for each baby, to explore how task completion is related to organisational and newborn characteristics. RESULTS Nursing tasks most commonly completed were handing over between shifts (97%), checking and where necessary changing diapers (96%). Tasks with lowest completion rates included nursing review of newborns (38%) and assessment of babies on phototherapy (15%). Overall the mean NCI was 60% (95% CI 58% to 62%), at least 80% of tasks were completed for only 14% of babies. Private sector facilities had a median ratio of babies to nurses of 3, with a maximum of 7 babies per nurse. In the public sector, the median ratio was 19 babies and a maximum exceeding 25 babies per nurse. In exploratory multivariable analyses, ratios of ≥12 babies per nurse were associated with a 24-point reduction in the mean NCI compared with ratios of ≤3 babies per nurse. CONCLUSION A significant proportion of nursing care is missed with potentially serious effects on patient safety and outcomes in this LMIC setting. Given that nurses caring for fewer babies on average performed more of the expected tasks, addressing nursing is key to ensuring delivery of essential aspects of care as part of improving quality and safety.
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Affiliation(s)
- David Gathara
- Public Health Research, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya .,Nursing and Midwifery, Aga Khan University School of Nursing and Midwifery East Africa, Nairobi, Kenya
| | - George Serem
- Public Health Research, KEMRI/Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Alfred Obengo
- National Nurses Association of Kenya, Nairobi, Kenya
| | - Edna Tallam
- Registration and Licensing, Nursing Council of Kenya, Nairobi, Kenya
| | - Debra Jackson
- Nursing and Midwifery, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Sharon Brownie
- Nursing and Midwifery, Aga Khan University School of Nursing and Midwifery East Africa, Nairobi, Kenya.,School of Medicine, Griffith University Faculty of Health, Gold Coast, Queensland, Australia
| | - Mike English
- Public Health Research, KEMRI/Wellcome Trust Research Programme, Nairobi, Kenya.,Department of Paediatrics, University of Oxford, Oxford, UK
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Martin G, Clarke J, Liew F, Arora S, King D, Aylin P, Darzi A. Evaluating the impact of organisational digital maturity on clinical outcomes in secondary care in England. NPJ Digit Med 2019; 2:41. [PMID: 31304387 PMCID: PMC6550220 DOI: 10.1038/s41746-019-0118-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 04/18/2019] [Indexed: 12/24/2022] Open
Abstract
All healthcare systems are increasingly reliant on health information technology to support the delivery of high-quality, efficient and safe care. Data on its effectiveness are however limited. We therefore sought to examine the impact of organisational digital maturity on clinical outcomes in secondary care within the English National Health Service. We conducted a retrospective analysis of routinely collected administrative data for 13,105,996 admissions across 136 hospitals in England from 2015 to 2016. Data from the 2016 NHS Clinical Digital Maturity Index were used to characterise organisational digital maturity. A multivariable regression model including 12 institutional covariates was utilised to examine the relationship between one measure of organisational digital maturity and five key clinical outcome measures. There was no significant relationship between organisational digital maturity and risk-adjusted 30-day mortality, 28-day readmission rates or complications of care. In multivariable analysis risk-adjusted long length of stay and harm-free care were significantly related to aspects of organisational digital maturity; digitally mature hospitals may not only deliver more harm-free care episodes but also may have a significantly increased risk of patients experiencing a long length of stay. Organisational digital maturity is to some extent related to selected clinical outcomes in secondary care in England. Digital maturity is, however, also strongly linked to other institutional factors that likely play a greater role in influencing clinical outcomes. There is a need to better understand how health IT impacts care delivery and supports other drivers of hospital quality.
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Affiliation(s)
- Guy Martin
- 1Department of Surgery & Cancer, Imperial College London, London, UK
| | - Jonathan Clarke
- 1Department of Surgery & Cancer, Imperial College London, London, UK
| | - Felicity Liew
- 2School of Public Health, Imperial College London, London, UK
| | - Sonal Arora
- 1Department of Surgery & Cancer, Imperial College London, London, UK
| | - Dominic King
- 1Department of Surgery & Cancer, Imperial College London, London, UK.,3DeepMind, London, UK
| | - Paul Aylin
- 2School of Public Health, Imperial College London, London, UK
| | - Ara Darzi
- 1Department of Surgery & Cancer, Imperial College London, London, UK
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Butler M, Schultz TJ, Halligan P, Sheridan A, Kinsman L, Rotter T, Beaumier J, Kelly RG, Drennan J. Hospital nurse-staffing models and patient- and staff-related outcomes. Cochrane Database Syst Rev 2019; 4:CD007019. [PMID: 31012954 PMCID: PMC6478038 DOI: 10.1002/14651858.cd007019.pub3] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
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.
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Affiliation(s)
- Michelle Butler
- Dublin City UniversityFaculty of Science and HealthCollins Avenue, GlasnevinDublinIrelandDublin 9
| | - Timothy J Schultz
- University of AdelaideDiscipline of NursingAdelaideSouth AustraliaAustralia
| | - Phil Halligan
- University College DublinSchool of Nursing, Midwifery and Health SystemsDublinIreland
| | - Ann Sheridan
- University College DublinSchool of Nursing, Midwifery and Health SystemsDublinIreland
| | - Leigh Kinsman
- The University of Newcastle and Mid North Coast Local Health DistrictSchool of Nursing and MidwiferyPort MacquarieNew South WalesAustralia2444
| | - Thomas Rotter
- School of Nursing, Queen's UniversityHealthcare Quality Programs82‐84 Barrie StretKingston, OntarioOntarioCanadaK7L 3N6
| | - Jonathan Beaumier
- University of British ColumbiaSchool of Population and Public Health2206 East MallVancouverBCCanadaV6T 1Z3
| | - Robyn Gail Kelly
- University of TasmaniaSchool of Health SciencesLocked Bag 1322NewnhamTasmaniaAustralia7250
| | - Jonathan Drennan
- Brookfield Health Sciences Complex, University College CorkSchool of Nursing and Midwifery, College of Medicine and HealthCollege RoadCorkIrelandT12 AK54
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Abstract
BACKGROUND Pressure ulcers, which are a localised injury to the skin, or underlying tissue, or both, occur when people are unable to reposition themselves to relieve pressure on bony prominences. Pressure ulcers are often difficult to heal, painful, expensive to manage and have a negative impact on quality of life. While individual patient safety and quality care stem largely from direct healthcare practitioner-patient interactions, each practitioner-patient wound-care contact may be constrained or enhanced by healthcare organisation of services. Research is needed to demonstrate clearly the effect of different provider-orientated approaches to pressure ulcer prevention and treatment. OBJECTIVES To assess the effects of different provider-orientated interventions targeted at the organisation of health services, on the prevention and treatment of pressure ulcers. SEARCH METHODS In April 2018 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched three clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA Randomised controlled trials (RCTs), cluster-RCTs, non-RCTs, controlled before-and-after studies and interrupted time series, which enrolled people at risk of, or people with existing pressure ulcers, were eligible for inclusion in the review. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, risk of bias assessment, data extraction and GRADE assessment of the certainty of evidence. MAIN RESULTS The search yielded a total of 3172 citations and, following screening and application of the inclusion and exclusion criteria, we deemed four studies eligible for inclusion. These studies reported the primary outcome of pressure ulcer incidence or pressure ulcer healing, or both.One controlled before-and-after study explored the impact of transmural care (a care model that provided activities to support patients and their family/partners and activities to promote continuity of care), among 62 participants with spinal cord injury. It is unclear whether transmural care leads to a difference in pressure ulcer incidence compared with usual care (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.53 to 1.64; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision).One RCT explored the impact of hospital-in-the-home care, among 100 older adults. It is unclear whether hospital-in-the-home care leads to a difference in pressure ulcer incidence risk compared with hospital admission (RR 0.32, 95% CI 0.03 to 2.98; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision).A third study (cluster-randomised stepped-wedge trial), explored the impact of being cared for by enhanced multidisciplinary teams (EMDT), among 161 long-term-care residents. The analyses of the primary outcome used measurements of 201 pressure ulcers from 119 residents. It is unclear if EMDT reduces the pressure ulcer incidence rate compared with usual care (hazard ratio (HR) 1.12, 95% CI 0.74 to 1.68; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). It is unclear whether there is a difference in the number of wounds healed (RR 1.69, 95% CI 1.00 to 2.87; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). It is unclear whether there is a difference in the reduction in surface area, with and without EMDT, (healing rate 1.006; 95% CI 0.99 to 1.03; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). It is unclear if EMDT leads to a difference in time to complete healing (HR 1.48, 95% CI 0.79 to 2.78, very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision).The final study (quasi-experimental cluster trial), explored the impact of multidisciplinary wound care among 176 nursing home residents. It is unclear whether there is a difference in the number of pressure ulcers healed between multidisciplinary care, or usual care (RR 1.18, 95% CI 0.98 to 1.42; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). It is unclear if this type of care leads to a difference in time to complete healing compared with usual care (HR 1.73, 95% CI 1.20 to 2.50; very low-certainty evidence; downgraded twice for very serious study limitations and twice for very serious imprecision).In all studies the certainty of the evidence is very low due to high risk of bias and imprecision. We downgraded the evidence due to study limitations, which included selection and attrition bias, and sample size. Secondary outcomes, such as adverse events were not reported in all studies. Where they were reported it was unclear if there was a difference as the certainty of evidence was very low. AUTHORS' CONCLUSIONS Evidence for the impact of organisation of health services for preventing and treating pressure ulcers remains unclear. Overall, GRADE assessments of the evidence resulted in judgements of very low-certainty evidence. The studies were at high risk of bias, and outcome measures were imprecise due to wide confidence intervals and small sample sizes, meaning that additional research is required to confirm these results. The secondary outcomes reported varied across the studies and some were not reported. We judged the evidence from those that were reported (including adverse events), to be of very low certainty.
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Affiliation(s)
- Pauline Joyce
- Royal College of Surgeons in IrelandSchool of Medicine121 St. Stephens GreenDublinIreland2
| | - Zena EH Moore
- Royal College of Surgeons in IrelandSchool of Nursing & Midwifery123 St. Stephen's GreenDublinIrelandD2
| | - Janice Christie
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & HealthOxford RoadManchesterLancashireUKM13 9PL
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Burton CR, Rycroft-Malone J, Williams L, Davies S, McBride A, Hall B, Rowlands AM, Jones A, Fisher D, Jones M, Caulfield M. NHS managers’ use of nursing workforce planning and deployment technologies: a realist synthesis. Health Serv Deliv Res 2018. [DOI: 10.3310/hsdr06360] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundPolicy and reviews of health-care safety and quality emphasise the role of NHS managers in ensuring safe, good-quality patient care through effective staffing. Guidance requires that NHS managers combine professional judgement with evidence-based workforce planning and deployment tools and technologies (WPTs). Evidence has focused on the effectiveness of WPTs, but little is known about supporting their implementation, or the impact of using WPTs across settings.ObjectivesThe review answered the following question: ‘NHS managers’ use of workforce planning and deployment technologies and their impacts on nursing staffing and patient care: what works, for whom, how and in what circumstances?’.DesignA realist synthesis was conducted. A programme theory was formulated and expressed as hypotheses in the form of context, mechanisms and outcomes; this considered how, through using WPTs, particular conditions produced responses to generate outcomes. There were four phases: (1) development of a theoretical territory to understand nurse workforce planning and deployment complexity, resulting in an initial programme theory; (2) retrieval, review and synthesis of evidence, guided by the programme theory; (3) testing and refinement of the programme theory for practical application; and (4) actionable recommendations to support NHS managers in the implementation of WPTs for safe staffing.ParticipantsNHS managers, patient and public representatives and policy experts informed the programme theory in phase 1, which was validated in interviews with 10 NHS managers. In phase 3, 11 NHS managers were interviewed to refine the programme theory.ResultsWorkforce planning and deployment tools and technologies can be characterised functionally by their ability to summarise and aggregate staffing information, communicate about staffing, allocate staff and facilitate compliance with standards and quality assurance. NHS managers need to combine local knowledge and professional judgement with data from WPTs for effective staffing decisions. WPTs are used in a complex workforce system in which proximal factors (e.g. the workforce satisfaction with staffing) can influence distal factors (e.g. organisational reputation and potential staff recruitment). The system comprises multiple organisational strategies (e.g. professional and financial), which may (or may not) align around effective staffing. The positive impact of WPTs can include ensuring that staff are allocated effectively, promoting the patient safety agenda within an organisation, learning through comparison about ‘what works’ in effective staffing and having greater influence in staffing work. WPTs appear to have a positive impact when they visibly integrate data on needs and resources and when there is technical and leadership support. A collaborative process appears to be best for developing and implementing WPTs, so that they are fit for purpose.LimitationsThe evidence, predominantly from acute care, often lacked detail on how managers applied professional judgement to WPTs for staffing decisions. The evidence lacked specificity about how managers develop skills on communicating staffing decisions to patients and the public.Conclusions and recommendationsThe synthesis produced initial explanations of the use and impact of WPTs for decision-making and what works to support NHS managers to use these effectively. It is suggested that future research should further evaluate the programme theory.Study registrationThis study is registered as PROSPERO CRD42016038132.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Christopher R Burton
- School of Healthcare Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Jo Rycroft-Malone
- School of Healthcare Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Lynne Williams
- School of Healthcare Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Siân Davies
- School of Healthcare Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Anne McBride
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Beth Hall
- School of Healthcare Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | | | - Adrian Jones
- Betsi Cadwaladr University Health Board, Bangor, UK
| | - Denise Fisher
- School of Healthcare Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Margaret Jones
- School of Healthcare Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Maria Caulfield
- School of Healthcare Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
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19
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Peršolja M. The effect of nurse staffing patterns on patient satisfaction and needs: a cross-sectional study. J Nurs Manag 2018; 26:858-865. [DOI: 10.1111/jonm.12616] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Melita Peršolja
- Nova Gorica Unit of Faculty of Health Sciences; University of Primorska; Nova Gorica Slovenia
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Ferrua R, Nelson JW, Gatta C, Croso A, Gilot CB, Dal Molin A. The Impact of the Primary Nursing Model on Cultural Improvement: A Mixed-Method Study. Creat Nurs 2016; 22:259-67. [PMID: 29195540 DOI: 10.1891/1078-4535.22.4.259] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Evaluating the implementation of care models such as Primary Nursing requires assessment of both short-term and long-term outcomes. In a hospital in Piemonte, Italy, a mixedmethod time-series study was conducted to assess if and how the organizational culture of nurses changed in relation to the implementation of a new organizational model of care. Instruments used included the Condition of Work Effectiveness Questionnaire (CWEQ II) and an investigator-developed questionnaire to evaluate perceptions of dimensions consistent with Primary Nursing. Results showed a significant culture change over time related to the implementation of Primary Nursing, mainly in terms of nurses' understanding of their professional role specifications. In addition, the results supported a relationship between being involved in the project implementation and the procedural and cultural approach adopted.
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Park MH, Black N, Ritchie CW, Hendriks AAJ, Smith SC. Is the effectiveness of memory assessment services associated with their structural and process characteristics? Int J Geriatr Psychiatry 2018; 33:75-84. [PMID: 28170105 DOI: 10.1002/gps.4675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 01/11/2017] [Indexed: 11/07/2022]
Abstract
OBJECTIVES The aim of this study was to investigate whether structural and process characteristics of memory assessment services (MASs) are associated with outcomes (changes in patients' health-related quality of life (HRQL), carers' HRQL and carers' burden) over the first 6 months following the first appointment. METHODS Data from 785 patients referred to 69 MASs and 511 of their lay carers, collected at the first appointment and 6 months later. Data on MAS characteristics were collected using a questionnaire at baseline. We used multilevel linear regression models to explore the associations of patients' HRQL and carers' outcomes with structural and process characteristics of MASs. Analyses were conducted on the full sample of patients and carers, and separately on those patients diagnosed with dementia. RESULTS None of the structural (skill mix, workload, volume, provision of clinical assessments and provision of psychosocial support) or process (waiting time, length and number of appointments, anti-dementia drug use and psychosocial interventions use) characteristics included in the analyses were associated with patients' or carers' outcomes at 6 months, apart from the presence of allied health professionals (AHPs), which was associated with a DEMQOL score 2.7 points higher. When only those with a diagnosis of dementia were considered, the association with presence of AHPs was no longer observed. CONCLUSIONS Apart from involving AHPs, alterations to the way MASs are structured or function appear unlikely to improve their effectiveness in improving patients' and carers' HRQL. It is possible that the characteristics of MASs may influence patients' and carers' experience, but this was not studied. Copyright © 2017 John Wiley & Sons, Ltd.
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Affiliation(s)
- Min Hae Park
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Nick Black
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Craig W Ritchie
- Centre for Dementia Prevention, University of Edinburgh, Edinburgh, UK
| | - A A Jolijn Hendriks
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Sarah C Smith
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
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Ciapponi A, Lewin S, Herrera CA, Opiyo N, Pantoja T, Paulsen E, Rada G, Wiysonge CS, Bastías G, Dudley L, Flottorp S, Gagnon M, Garcia Marti S, Glenton C, Okwundu CI, Peñaloza B, Suleman F, Oxman AD. Delivery arrangements for health systems in low-income countries: an overview of systematic reviews. Cochrane Database Syst Rev 2017; 9:CD011083. [PMID: 28901005 PMCID: PMC5621087 DOI: 10.1002/14651858.cd011083.pub2] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Delivery arrangements include changes in who receives care and when, who provides care, the working conditions of those who provide care, coordination of care amongst different providers, where care is provided, the use of information and communication technology to deliver care, and quality and safety systems. How services are delivered can have impacts on the effectiveness, efficiency and equity of health systems. This broad overview of the findings of systematic reviews can help policymakers and other stakeholders identify strategies for addressing problems and improve the delivery of services. OBJECTIVES To provide an overview of the available evidence from up-to-date systematic reviews about the effects of delivery arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on delivery arrangements and informing refinements of the framework for delivery arrangements outlined in the review. METHODS We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of delivery arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use, healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty or employment) and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the findings. Two overview authors independently screened reviews, extracted data, and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence), and assessments of the relevance of findings to low-income countries. MAIN RESULTS We identified 7272 systematic reviews and included 51 of them in this overview. We judged 6 of the 51 reviews to have important methodological limitations and the other 45 to have only minor limitations. We grouped delivery arrangements into eight categories. Some reviews provided more than one comparison and were in more than one category. Across these categories, the following intervention were effective; that is, they have desirable effects on at least one outcome with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects. Who receives care and when: queuing strategies and antenatal care to groups of mothers. Who provides care: lay health workers for caring for people with hypertension, lay health workers to deliver care for mothers and children or infectious diseases, lay health workers to deliver community-based neonatal care packages, midlevel health professionals for abortion care, social support to pregnant women at risk, midwife-led care for childbearing women, non-specialist providers in mental health and neurology, and physician-nurse substitution. Coordination of care: hospital clinical pathways, case management for people living with HIV and AIDS, interactive communication between primary care doctors and specialists, hospital discharge planning, adding a service to an existing service and integrating delivery models, referral from primary to secondary care, physician-led versus nurse-led triage in emergency departments, and team midwifery. Where care is provided: high-volume institutions, home-based care (with or without multidisciplinary team) for people living with HIV and AIDS, home-based management of malaria, home care for children with acute physical conditions, community-based interventions for childhood diarrhoea and pneumonia, out-of-facility HIV and reproductive health services for youth, and decentralised HIV care. Information and communication technology: mobile phone messaging for patients with long-term illnesses, mobile phone messaging reminders for attendance at healthcare appointments, mobile phone messaging to promote adherence to antiretroviral therapy, women carrying their own case notes in pregnancy, interventions to improve childhood vaccination. Quality and safety systems: decision support with clinical information systems for people living with HIV/AIDS. Complex interventions (cutting across delivery categories and other health system arrangements): emergency obstetric referral interventions. AUTHORS' CONCLUSIONS A wide range of strategies have been evaluated for improving delivery arrangements in low-income countries, using sound systematic review methods in both Cochrane and non-Cochrane reviews. These reviews have assessed a range of outcomes. Most of the available evidence focuses on who provides care, where care is provided and coordination of care. For all the main categories of delivery arrangements, we identified gaps in primary research related to uncertainty about the applicability of the evidence to low-income countries, low- or very low-certainty evidence or a lack of studies.
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Affiliation(s)
- Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy (IECS‐CONICET)Argentine Cochrane CentreDr. Emilio Ravignani 2024Buenos AiresCapital FederalArgentinaC1414CPV
| | - Simon Lewin
- Norwegian Institute of Public HealthPO Box 4404OsloNorway0403
- South African Medical Research CouncilHealth Systems Research UnitPO Box 19070TygerbergSouth Africa7505
| | - Cristian A Herrera
- Pontificia Universidad Católica de ChileDepartment of Public Health, School of MedicineMarcoleta 434SantiagoChile
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
| | - Newton Opiyo
- CochraneCochrane Editorial UnitSt Albans House, 57‐59 HaymarketLondonUKSW1Y 4QX
| | - Tomas Pantoja
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | | | - Gabriel Rada
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
- Pontificia Universidad Católica de ChileDepartment of Internal Medicine and Evidence‐Based Healthcare Program, Faculty of MedicineLira 44, Decanato Primer pisoSantiagoChile
| | - Charles S Wiysonge
- South African Medical Research CouncilCochrane South AfricaFrancie van Zijl Drive, Parow ValleyCape TownWestern CapeSouth Africa7505
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesCape TownSouth Africa
| | - Gabriel Bastías
- Pontificia Universidad Católica de ChileDepartment of Public Health, School of MedicineMarcoleta 434SantiagoChile
| | - Lilian Dudley
- Stellenbosch UniversityDivision of Community Health, Faculty of Medicine and Health SciencesFransie Van Zyl DriveTygerbergCape TownSouth Africa7505
| | - Signe Flottorp
- Norwegian Institute of Public HealthDepartment for Evidence SynthesisPO Box 4404 NydalenOsloNorway0403
| | - Marie‐Pierre Gagnon
- CHU de Québec ‐ Université Laval Research CentrePopulation Health and Optimal Health Practices Research Unit10 Rue de l'Espinay, D6‐727Québec CityQCCanadaG1L 3L5
| | - Sebastian Garcia Marti
- Institute for Clinical Effectiveness and Health PolicyBuenos AiresCapital FederalArgentinaC1056ABH
| | - Claire Glenton
- Norwegian Institute of Public HealthGlobal Health UnitPO Box 7004 St Olavs plassOsloNorwayN‐0130
| | - Charles I Okwundu
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesCape TownSouth Africa
| | - Blanca Peñaloza
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | - Fatima Suleman
- University of KwaZulu‐NatalDiscipline of Pharmaceutical Sciences, School of Health SciencesPrivate Bag X54001DurbanKZNSouth Africa4000
| | - Andrew D Oxman
- Norwegian Institute of Public HealthPO Box 4404OsloNorway0403
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Tabatabaee SS, Vafaee-Najar A, Amiresmaili MR, Nekoie-Moghadam M. Nurse Staffing Norm in Iran Hospitals: What Features Should be Included for Success? Int J Prev Med 2017; 8:13. [PMID: 28348723 PMCID: PMC5353769 DOI: 10.4103/2008-7802.201657] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 12/03/2016] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Designing and implementing a model for estimation and distribution of required nurse is one of strategies to prevent unequal distribution of nurses within and between hospitals. The purpose of this research was to determine required features for hospital nursing staff estimation model. METHODS We conducted a qualitative study using a Colaizzi analysis approach. We used semi-structure and in-depth interviews by purposive, quota, and snowball sampling of 32 participants (10 informed experts in area of policy making in human resources in Ministry of Health, 10 decisions making in employment and distribution of human resources in treatment and administrative chancellors of medical universities, and 12 process owners in hospitals). The data were analyzed using ATLAS.ti software version 6.0.15. RESULTS The ten following sub-themes emerged from data analysis: Skill mix and task shifting, work measurement, legal support, stakeholder involvement in designing a model, considering the ward activity, considering type and extent of care patients required, model development by experts predominate in nursing process, considering the nurses availability, considering the capabilities and professional merits of nurses, fitness with social, cultural, and belief of people. The main themes were occupation analysis, planning and policy making, real workload, acceptability, nurses' efficiency, and being a native. CONCLUSIONS Given that standardization of nursing staff estimation is announced as one of the challenges in reaching Iran's 20-year vision plan. Hence, design and implementation of a nursing staff estimation model in regard to identified features could be part of priorities in Ministry of Health in Iran.
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Affiliation(s)
- Seyed Saeed Tabatabaee
- Department of Health Management, Policy and Economics, Health Services Management Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Ali Vafaee-Najar
- Department of Health Management, Health Sciences Research Center, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Reza Amiresmaili
- Medical Informatics Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Mahmood Nekoie-Moghadam
- Department of Health Services Management, Environmental Health Engineering Research Center, Kerman University of Medical Sciences, Kerman, Iran
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Dahlke S, Hall WA, Baumbusch J. Constructing definitions of safety risks while nurses care for hospitalised older people: Secondary analysis of qualitative data. Int J Older People Nurs 2017; 12. [DOI: 10.1111/opn.12148] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 01/11/2017] [Indexed: 01/14/2023]
Affiliation(s)
- Sherry Dahlke
- Faculty of Nursing; University of Alberta; Edmonton AB Canada
| | - Wendy A. Hall
- School of Nursing; University of British Columbia; Vancouver BC Canada
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Staggs VS, Olds DM, Cramer E, Shorr RI. Nursing Skill Mix, Nurse Staffing Level, and Physical Restraint Use in US Hospitals: a Longitudinal Study. J Gen Intern Med 2017; 32:35-41. [PMID: 27553206 PMCID: PMC5215153 DOI: 10.1007/s11606-016-3830-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 06/21/2016] [Accepted: 07/20/2016] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Vincent S. Staggs
- Health Services and Outcomes Research, Children’s Mercy Hospitals and Clinics, 2401 Gillham Rd, Kansas City, 64108 MO USA
- School of Medicine, University of Missouri-Kansas City, 2411 Holmes St, Kansas City, MO 64108 USA
| | - Danielle M. Olds
- School of Nursing, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS 66160 USA
| | - Emily Cramer
- School of Nursing, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS 66160 USA
| | - Ronald I. Shorr
- Geriatric Research, Education and Clinical Center (GRECC), Malcom Randall Veterans Administration Medical Center, Gainesville, FL USA
- Department of Epidemiology, University of Florida, 2004 Mowry Road, PO Box 100231, Gainesville, FL 32610 USA
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Aiken LH, Sloane D, Griffiths P, Rafferty AM, Bruyneel L, McHugh M, Maier CB, Moreno-Casbas T, Ball JE, Ausserhofer D, Sermeus W. Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care. BMJ Qual Saf 2016. [PMID: 28626086 PMCID: PMC5477662 DOI: 10.1136/bmjqs-2016-005567] [Citation(s) in RCA: 373] [Impact Index Per Article: 46.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVES To determine the association of hospital nursing skill mix with patient mortality, patient ratings of their care and indicators of quality of care. DESIGN Cross-sectional patient discharge data, hospital characteristics and nurse and patient survey data were merged and analysed using generalised estimating equations (GEE) and logistic regression models. SETTING Adult acute care hospitals in Belgium, England, Finland, Ireland, Spain and Switzerland. PARTICIPANTS Survey data were collected from 13 077 nurses in 243 hospitals, and 18 828 patients in 182 of the same hospitals in the six countries. Discharge data were obtained for 275 519 surgical patients in 188 of these hospitals. MAIN OUTCOME MEASURES Patient mortality, patient ratings of care, care quality, patient safety, adverse events and nurse burnout and job dissatisfaction. RESULTS Richer nurse skill mix (eg, every 10-point increase in the percentage of professional nurses among all nursing personnel) was associated with lower odds of mortality (OR=0.89), lower odds of low hospital ratings from patients (OR=0.90) and lower odds of reports of poor quality (OR=0.89), poor safety grades (OR=0.85) and other poor outcomes (0.80<OR<0.93), after adjusting for patient and hospital factors. Each 10 percentage point reduction in the proportion of professional nurses is associated with an 11% increase in the odds of death. In our hospital sample, there were an average of six caregivers for every 25 patients, four of whom were professional nurses. Substituting one nurse assistant for a professional nurse for every 25 patients is associated with a 21% increase in the odds of dying. CONCLUSIONS A bedside care workforce with a greater proportion of professional nurses is associated with better outcomes for patients and nurses. Reducing nursing skill mix by adding nursing associates and other categories of assistive nursing personnel without professional nurse qualifications may contribute to preventable deaths, erode quality and safety of hospital care and contribute to hospital nurse shortages.
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Affiliation(s)
- Linda H Aiken
- University of Pennsylvania School of Nursing, Center for Health Outcomes and Policy Research, Philadelphia, Pennsylvania, USA
| | - Douglas Sloane
- University of Pennsylvania School of Nursing, Center for Health Outcomes and Policy Research, Philadelphia, Pennsylvania, USA
| | - Peter Griffiths
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Anne Marie Rafferty
- King's College London, Florence Nightingale School of Nursing and Midwifery, London, UK
| | - Luk Bruyneel
- University of Leuven, Leuven Institute for Healthcare Policy, Leuven, Belgium
| | - Matthew McHugh
- University of Pennsylvania School of Nursing, Center for Health Outcomes and Policy Research, Philadelphia, Pennsylvania, USA
| | - Claudia B Maier
- Department of Healthcare Management, Technische Universitat Berlin, Berlin, Germany
| | - Teresa Moreno-Casbas
- Investén-Isciii. Instituto de Salud Carlos III, Ministerio de Ciencia e Innovación, Madrid, Spain
| | - Jane E Ball
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Dietmar Ausserhofer
- Universitat Basel Department Public Health, Institute of Nursing Science, Basel, BS, Switzerland
| | - Walter Sermeus
- University of Leuven, Leuven Institute for Healthcare Policy, Leuven, Belgium
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Porcel-Gálvez AM, Hörner Schlindwein-Meirelles B, Gil-García E, Morales-Asencio JM, Guerra-Martín MD. [Opinions and nurse' satisfaction with INICIARE 2.0 scale: A qualitative study in a hospital setting]. Enferm Clin 2016; 26:374-380. [PMID: 27780681 DOI: 10.1016/j.enfcli.2016.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Revised: 07/07/2016] [Accepted: 09/22/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To know the opinions and satisfaction of nurses with the use of INICIARE, an instrument developed for assessment of nursing care needs in hospitalized patients. INICIARE is based on Virginia Henderson's conceptual model, and built up with indicators of Nursing Outcomes Classification (NOC) taxonomy. METHOD Exploratory qualitative study, using focus group technique for data collection. The sessions were recorded until saturation of information. A content analysis of syntactic, semantic and pragmatic levels of transcripts was performed. Participants' informed consent was obtained. RESULTS Three focus groups were developed; 24 nurses from two Public Hospitals in Andalusia (Southern Spain) participated; and four thematic categories were created to measure satisfaction with the instrument. INICIARE helped the nursing process. Its closed format, and items in NOC taxonomy streamline evaluation, facilitates its inclusion in Electronic Information Systems, and strengthens effective communication at all levels. CONCLUSIONS Nurses are satisfied with the use of INICIARE scale as a tool to enhance quality of care. It also has potential to be used as a tool for decision making in management of nursing care.
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Affiliation(s)
- Ana María Porcel-Gálvez
- Departamento de Enfermería, Facultad de Enfermería, Fisioterapia y Podología, Universidad de Sevilla, Sevilla, España.
| | | | - Eugenia Gil-García
- Departamento de Enfermería, Facultad de Enfermería, Fisioterapia y Podología, Universidad de Sevilla, Sevilla, España
| | | | - María Dolores Guerra-Martín
- Departamento de Enfermería, Facultad de Enfermería, Fisioterapia y Podología, Universidad de Sevilla, Sevilla, España
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Abstract
OBJECTIVE To provide an overview of effective interventions aimed at reducing rates of adverse events in hospitals. DESIGN Systematic review of systematic reviews. DATA SOURCES PubMed, CINAHL, PsycINFO, the Cochrane Library and EMBASE were searched for systematic reviews published until October 2015. STUDY SELECTION English-language systematic reviews of interventions aimed at reducing adverse events in hospitals, including studies with an experimental design and reporting adverse event rates, were included. Two reviewers independently assessed each study's quality and extracted data on the study population, study design, intervention characteristics and adverse patient outcomes. RESULTS Sixty systematic reviews with moderate to high quality were included. Statistically significant pooled effect sizes were found for 14 types of interventions, including: (1) multicomponent interventions to prevent delirium; (2) rapid response teams to reduce cardiopulmonary arrest and mortality rates; (3) pharmacist interventions to reduce adverse drug events; (4) exercises and multicomponent interventions to prevent falls; and (5) care bundle interventions, checklists and reminders to reduce infections. Most (82%) of the significant effect sizes were based on 5 or fewer primary studies with an experimental study design. CONCLUSIONS The evidence for patient-safety interventions implemented in hospitals worldwide is weak. The findings address the need to invest in high-quality research standards in order to identify interventions that have a real impact on patient safety. Interventions to prevent delirium, cardiopulmonary arrest and mortality, adverse drug events, infections and falls are most effective and should therefore be prioritised by clinicians.
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Affiliation(s)
- Marieke Zegers
- Radboud university medical center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Gijs Hesselink
- Radboud university medical center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Wytske Geense
- Radboud university medical center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Charles Vincent
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Hub Wollersheim
- Radboud university medical center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
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Affiliation(s)
- Lisa Whitehead
- School of Nursing and Midwifery; Edith Cowan University; Western Australia Australia
| | - Helen Myers
- School of Nursing and Midwifery; Edith Cowan University; Western Australia Australia
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Abstract
The primary nursing care model optimizes relationship-based care. Despite using a primary nursing model on a pediatric hematology/oncology inpatient unit, it was hypothesized patients and nurses were dissatisfied with the structure of primary care teams and inconsistency of primary assignments. The purpose of this study was to evaluate patient/family and nurse perceptions of our current care model through assessing gaps in its operationalization and satisfaction. This study used a descriptive cross-sectional design featuring patient/family and nurse surveys. Of the 59 patient/family respondents, 93.2% prefer to have a primary nurse care for them and 85% are satisfied with how often they are assigned a primary care team member. Similarly, 63% of the 57 nurse respondents are satisfied with the current implementation of our primary nursing model and 61% state the model reflects good continuity of care. Yet 80.7% of nurses believe safety would improve for a patient whose nurse works shifts consecutively even if not a primary nurse. Overall, patients, families, and nurses value care continuity and meaningful nurse-patient relationships, which is fundamental to primary nursing.
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Hutchinson M, Higson M, Cleary M, Jackson D. Nursing expertise: a course of ambiguity and evolution in a concept. Nurs Inq 2016; 23:290-304. [DOI: 10.1111/nin.12142] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Marie Hutchinson
- Faculty of Health & Life Sciences; Oxford Brookes University; Oxford UK
- School of Health and Human Sciences; Southern Cross University; Lismore NSW Australia
| | - Mary Higson
- Independent Researcher; Sydney NSW Australia
| | - Michelle Cleary
- Mental Health Nursing; School of Health Sciences; University of Tasmania; Sydney NSW Australia
| | - Debra Jackson
- Faculty of Health & Life Sciences; Oxford Brookes University; Oxford UK
- Oxford Institute of Nursing & Allied Health Research (OxINAHR); Oxford UK
- Oxford University Hospitals NHS Foundation Trust; Oxford UK
- University of New England; Armidale NSW Australia
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Twigg DE, Pugh JD, Gelder L, Myers H. Foundations of a nursing-sensitive outcome indicator suite for monitoring public patient safety in Western Australia. Collegian 2016; 23:167-81. [DOI: 10.1016/j.colegn.2015.03.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Jammali-blasi A, Mcinnes E, Middleton S. A survey of acute care clinicians' views on factors influencing hand hygiene practice and actions to improve hand hygiene compliance. Infect Dis Health 2016; 21:16-25. [DOI: 10.1016/j.idh.2016.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Joyce P, Moore ZEH, Christie J, Dumville JC. Organisation of health services for preventing and treating pressure ulcers. Cochrane Database of Systematic Reviews 2016. [DOI: 10.1002/14651858.cd012132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Pauline Joyce
- Royal College of Surgeons in Ireland; School of Medicine; 121 St. Stephens Green Dublin Ireland 2
| | - Zena EH Moore
- Royal College of Surgeons in Ireland; School of Nursing & Midwifery; 123 St. Stephen's Green Dublin Ireland D2
| | - Janice Christie
- University of Manchester; School of Nursing, Midwifery and Social Work; Oxford Road Manchester Lancashire UK M13 9PL
| | - Jo C Dumville
- University of Manchester; School of Nursing, Midwifery and Social Work; Oxford Road Manchester Lancashire UK M13 9PL
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Pitkäaho T, Partanen P, Miettinen MH, Vehviläinen-Julkunen K. The relationship between nurse staffing and length of stay in acute-care: a one-year time-series data. J Nurs Manag 2016; 24:571-9. [PMID: 26833964 DOI: 10.1111/jonm.12359] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2015] [Indexed: 11/28/2022]
Abstract
AIM To examine the relationship between nurse staffing and patient length of stay in an acute-care hospital over a 1-year period. BACKGROUND Although there has been prior research on the relationship between nurse staffing and length of stay in acute-care hospitals, there is a need for more information on how nurse staffing is related to length of stay longitudinally. METHODS Retrospective time-series registry data from 20 acute-care inpatient units of a Finnish university hospital as a monthly time series in 2008 were analysed by linear mixed models. RESULTS The ratio of registered nurses to all nurses was 72.4%. Nurses worked mainly (96%) full time, and 63% had permanent employment contracts. Statistically significant variation was found in time series of five variables. Statistically significant relationships were found between length of stay and patient acuity, diagnosis-related group-volume, census and nursing hours per patient day at the unit level. Nursing hours per patient day had the strongest correlation with length of stay. CONCLUSION AND IMPLICATIONS FOR NURSING MANAGEMENT A rational response to the variations in patient care needs and intensity in the complex care environment is flexible nurse staffing. Increasing nursing hours per patient day to achieve shorter length of stays is not the only solution, well-functioning care processes are also essential.
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Affiliation(s)
- Taina Pitkäaho
- Department of Nursing Science, University of Eastern Finland, Kuopio, Finland
| | - Pirjo Partanen
- Department of Nursing Science, University of Eastern Finland, Kuopio, Finland
| | | | - Katri Vehviläinen-Julkunen
- Department of Nursing Science, University of Eastern Finland, Kuopio, Finland.,Kuopio University Hospital, Kuopio, Finland
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Gallagher R, Gallagher P, Roche M, Fry M, Chenoweth L, Stein-Parbury J. Nurses' perspectives of the impact of the older person on nursing resources in the emergency department and their profile: A mixed methods study. Int Emerg Nurs 2015; 23:312-6. [DOI: 10.1016/j.ienj.2015.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 03/18/2015] [Accepted: 03/25/2015] [Indexed: 11/28/2022]
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Tazbir J, Wicklein M. Hands when you want them, staffing when you need it. Crit Care Nurse 2015; 34:89-92. [PMID: 25086098 DOI: 10.4037/ccn2014902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Janice Tazbir
- Janice Tazbir is a professor of nursing at Purdue University Calumet, Hammond, Indiana, and a staff nurse in the surgical intensive care unit at the University of Chicago Medicine, Chicago, Illinois.
| | - Mark Wicklein
- Janice Tazbir is a professor of nursing at Purdue University Calumet, Hammond, Indiana, and a staff nurse in the surgical intensive care unit at the University of Chicago Medicine, Chicago, Illinois
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Miani C, Ball S, Pitchforth E, Exley J, King S, Roland M, Fuld J, Nolte E. Organisational interventions to reduce length of stay in hospital: a rapid evidence assessment. Health Services and Delivery Research 2014. [DOI: 10.3310/hsdr02520] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundAvailable evidence on effective interventions to reduce length of stay in hospital is wide-ranging and complex, with underlying factors including those acting at the health system, organisational and patient levels, and the interface between these. There is a need to better understand the diverse literature on reducing the length of hospital stay.ObjectivesThis study sought to (i) describe the nature of interventions that have been used to reduce length of stay in acute care hospitals; (ii) identify the factors that are known to influence length of stay; and (iii) assess the impact of interventions on patient outcomes, service outcomes and costs.Data sourcesWe searched MEDLINE (Ovid), EMBASE, the Health Management Information Consortium and System for Information on Grey Literature in Europe for the period January 1995 to January 2013 with no limitation of publication type.MethodsWe conducted a rapid evidence synthesis of the peer-reviewed literature on organisational interventions set in or initiated from acute hospitals. We considered evidence published between 2003 and 2013. Data were analysed drawing on the principles of narrative synthesis. We also carried out interviews with eight NHS managers and clinical leads in four sites in England.ResultsA total of 53 studies met our inclusion criteria, including 19 systematic reviews and 34 primary studies. Although the overall evidence base was varied and frequently lacked a robust study design, we identified a range of interventions that showed potential to reduce length of stay. These were multidisciplinary team working, for example some forms of organised stroke care; improved discharge planning; early supported discharge programmes; and care pathways. Nursing-led inpatient units were associated with improved outcomes but, if anything, increased length of stay. Factors influencing the impact of interventions on length of stay included contextual factors and the population targeted. The evidence was mixed with regard to the extent to which interventions seeking to reduce length of stay were associated with cost savings.LimitationsWe only considered assessments of interventions which provided a quantitative estimate of the impact of the given organisational intervention on length of hospital stay. There was a general lack of robust evidence and poor reporting, weakening the conclusions that can be drawn from the review.ConclusionsThe design and implementation of an intervention seeking to reduce (directly or indirectly) the length of stay in hospital should be informed by local context and needs. This involves understanding how the intervention is seeking to change processes and behaviours that are anticipated, based on the available evidence, to achieve desired outcomes (‘theory of change’). It will also involve assessing the organisational structures and processes that will need to be put in place to ensure that staff who are expected to deliver the intervention are appropriately prepared and supported. With regard to future research, greater attention should be given to the theoretical underpinning of the design, implementation and evaluation of interventions or programmes. There is a need for further research using appropriate methodology to assess the effectiveness of different types of interventions in different settings. Different evaluation approaches may be useful, and closer relationships between researchers and NHS organisations would enable more formative evaluation. Full economic costing should be undertaken where possible, including considering the cost implications for the wider local health economy.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
| | | | | | | | | | - Martin Roland
- Cambridge Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | | | - Ellen Nolte
- European Observatory on Health Systems and Policies, London School of Economics and Political Science and the London School of Hygiene & Tropical Medicine, London, UK
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Abstract
Patient safety in hospital is dependent on a multitude of factors. Recent reports into the failings of healthcare organisations in the UK have highlighted low staffing levels as a significant factor. There is research into the impact of nurse-to-patient ratios on patient safety, but our literature search found little published data that would allow healthcare providers to define a minimum number of physician staff and skills mix that would assure safety in the largest hospital specialty: unscheduled (acute) medicine. Future work should focus on the evaluation of existing data on hospital mortality rates and physician staffing levels as well as on empirical time and motion studies to ascertain the resources required to undertake safe medical care at times of peak demand.
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Affiliation(s)
- Jodie Sabin
- Department of Medicine, Ysbyty Gwynedd, Bangor, UK
| | | | - Louella Vaughan
- Department of Medicine, Northwest London Collaboration for Leadership in Applied Health Research and Care, London, UK
| | - Rhid Dowdle
- Department of Medicine, Royal Glamorgan Hospital, Llantrisant, UK
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Das JK, Kumar R, Salam RA, Lassi ZS, Bhutta ZA. Evidence from facility level inputs to improve quality of care for maternal and newborn health: interventions and findings. Reprod Health 2014; 11 Suppl 2:S4. [PMID: 25208539 PMCID: PMC4160922 DOI: 10.1186/1742-4755-11-s2-s4] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Most of the maternal and newborn deaths occur at birth or within 24 hours of birth. Therefore, essential lifesaving interventions need to be delivered at basic or comprehensive emergency obstetric care facilities. Facilities provide complex interventions including advice on referrals, post discharge care, long-term management of chronic conditions along with staff training, managerial and administrative support to other facilities. This paper reviews the effectiveness of facility level inputs for improving maternal and newborn health outcomes. We considered all available systematic reviews published before May 2013 on the pre-defined facility level interventions and included 32 systematic reviews. Findings suggest that additional social support during pregnancy and labour significantly decreased the risk of antenatal hospital admission, intrapartum analgesia, dissatisfaction, labour duration, cesarean delivery and instrumental vaginal birth. However, it did not have any impact on pregnancy outcomes. Continued midwifery care from early pregnancy to postpartum period was associated with reduced medical procedures during labour and shorter length of stay. Facility based stress training and management interventions to maintain well performing and motivated workforce, significantly reduced job stress and improved job satisfaction while the interventions tailored to address identified barriers to change improved the desired practice. We found limited and inconclusive evidence for the impacts of physical environment, exit interviews and organizational culture modifications. At the facility level, specialized midwifery teams and social support during pregnancy and labour have demonstrated conclusive benefits in improving maternal newborn health outcomes. However, the generalizability of these findings is limited to high income countries. Future programs in resource limited settings should utilize these findings to implement relevant interventions tailored to their needs.
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Affiliation(s)
- Jai K Das
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Rohail Kumar
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Rehana A Salam
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Zohra S Lassi
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Zulfiqar A Bhutta
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
- Program for Global Pediatric Research, Hospital For Sick Children, Toronto
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Bray BD, Ayis S, Campbell J, Cloud GC, James M, Hoffman A, Tyrrell PJ, Wolfe CD, Rudd AG. Associations between stroke mortality and weekend working by stroke specialist physicians and registered nurses: prospective multicentre cohort study. PLoS Med 2014; 11:e1001705. [PMID: 25137386 DOI: 10.1371/journal.pmed.1001705] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 07/10/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Observational studies have reported higher mortality for patients admitted on weekends. It is not known whether this "weekend effect" is modified by clinical staffing levels on weekends. We aimed to test the hypotheses that rounds by stroke specialist physicians 7 d per week and the ratio of registered nurses to beds on weekends are associated with mortality after stroke. METHODS AND FINDINGS We conducted a prospective cohort study of 103 stroke units (SUs) in England. Data of 56,666 patients with stroke admitted between 1 June 2011 and 1 December 2012 were extracted from a national register of stroke care in England. SU characteristics and staffing levels were derived from cross-sectional survey. Cox proportional hazards models were used to estimate hazard ratios (HRs) of 30-d post-admission mortality, adjusting for case mix, organisational, staffing, and care quality variables. After adjusting for confounders, there was no significant difference in mortality risk for patients admitted to a stroke service with stroke specialist physician rounds fewer than 7 d per week (adjusted HR [aHR] 1.04, 95% CI 0.91-1.18) compared to patients admitted to a service with rounds 7 d per week. There was a dose-response relationship between weekend nurse/bed ratios and mortality risk, with the highest risk of death observed in stroke services with the lowest nurse/bed ratios. In multivariable analysis, patients admitted on a weekend to a SU with 1.5 nurses/ten beds had an estimated adjusted 30-d mortality risk of 15.2% (aHR 1.18, 95% CI 1.07-1.29) compared to 11.2% for patients admitted to a unit with 3.0 nurses/ten beds (aHR 0.85, 95% CI 0.77-0.93), equivalent to one excess death per 25 admissions. The main limitation is the risk of confounding from unmeasured characteristics of stroke services. CONCLUSIONS Mortality outcomes after stroke are associated with the intensity of weekend staffing by registered nurses but not 7-d/wk ward rounds by stroke specialist physicians. The findings have implications for quality improvement and resource allocation in stroke care. Please see later in the article for the Editors' Summary.
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Nair M, Yoshida S, Lambrechts T, Boschi-Pinto C, Bose K, Mason EM, Mathai M. Facilitators and barriers to quality of care in maternal, newborn and child health: a global situational analysis through metareview. BMJ Open 2014; 4:e004749. [PMID: 24852300 PMCID: PMC4039842 DOI: 10.1136/bmjopen-2013-004749] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 04/10/2014] [Accepted: 05/02/2014] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE Conduct a global situational analysis to identify the current facilitators and barriers to improving quality of care (QoC) for pregnant women, newborns and children. STUDY DESIGN Metareview of published and unpublished systematic reviews and meta-analyses conducted between January 2000 and March 2013 in any language. Assessment of Multiple Systematic Reviews (AMSTAR) is used to assess the methodological quality of systematic reviews. SETTINGS Health systems of all countries. Study outcome: QoC measured using surrogate indicators--effective, efficient, accessible, acceptable/patient centred, equitable and safe. ANALYSIS Conducted in two phases (1) qualitative synthesis of extracted data to identify and group the facilitators and barriers to improving QoC, for each of the three population groups, into the six domains of WHO's framework and explore new domains and (2) an analysis grid to map the common facilitators and barriers. RESULTS We included 98 systematic reviews with 110 interventions to improve QoC from countries globally. The facilitators and barriers identified fitted the six domains of WHO's framework--information, patient-population engagement, leadership, regulations and standards, organisational capacity and models of care. Two new domains, 'communication' and 'satisfaction', were generated. Facilitators included active and regular interpersonal communication between users and providers; respect, confidentiality, comfort and support during care provision; engaging users in decision-making; continuity of care and effective audit and feedback mechanisms. Key barriers identified were language barriers in information and communication; power difference between users and providers; health systems not accounting for user satisfaction; variable standards of implementation of standard guidelines; shortage of resources in health facilities and lack of studies assessing the role of leadership in improving QoC. These were common across the three population groups. CONCLUSIONS The barriers to good-quality healthcare are common for pregnant women, newborns and children; thus, interventions targeted to address them will have uniform beneficial effects. Adopting the identified facilitators would help countries strengthen their health systems and ensure high-quality care for all.
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Affiliation(s)
- Manisha Nair
- National Perinatal Epidemiology Unit (NPEU), Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
| | - Sachiyo Yoshida
- Department of Maternal, Newborn, Child & Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Thierry Lambrechts
- Department of Maternal, Newborn, Child & Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Cynthia Boschi-Pinto
- Department of Maternal, Newborn, Child & Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Krishna Bose
- Department of Maternal, Newborn, Child & Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Elizabeth Mary Mason
- Department of Maternal, Newborn, Child & Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Matthews Mathai
- Department of Maternal, Newborn, Child & Adolescent Health, World Health Organization, Geneva, Switzerland
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Dawson AJ, Stasa H, Roche MA, Homer CS, Duffield C. Nursing churn and turnover in Australian hospitals: nurses perceptions and suggestions for supportive strategies. BMC Nurs 2014; 13:11. [PMID: 24708565 DOI: 10.1186/1472-6955-13-11] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 04/03/2014] [Indexed: 11/21/2022] Open
Abstract
Background This study aimed to reveal nurses’ experiences and perceptions of turnover in Australian hospitals and identify strategies to improve retention, performance and job satisfaction. Nursing turnover is a serious issue that can compromise patient safety, increase health care costs and impact on staff morale. A qualitative design was used to analyze responses from 362 nurses collected from a national survey of nurses from medical and surgical nursing units across 3 Australian States/Territories. Method A qualitative design was used to analyze responses from 362 nurses collected from a national survey of nurses from medical and surgical nursing units across 3 Australian States/Territories. Results Key factors affecting nursing turnover were limited career opportunities; poor support; a lack of recognition; and negative staff attitudes. The nursing working environment is characterised by inappropriate skill-mix and inadequate patient-staff ratios; a lack of overseas qualified nurses with appropriate skills; low involvement in decision-making processes; and increased patient demands. These issues impacted upon heavy workloads and stress levels with nurses feeling undervalued and disempowered. Nurses described supportive strategies: improving performance appraisals, responsive preceptorship and flexible employment options. Conclusion Nursing turnover is influenced by the experiences of nurses. Positive steps can be made towards improving workplace conditions and ensuring nurse retention. Improving performance management and work design are strategies that nurse managers could harness to reduce turnover.
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Hamilton P, Willis E, Henderson J, Harvey C, Toffoli L, Abery E, Verrall C. Mapping social processes at work in nursing knowledge development. Nurs Health Sci 2014; 16:395-402. [DOI: 10.1111/nhs.12106] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 09/13/2013] [Accepted: 10/14/2013] [Indexed: 11/27/2022]
Affiliation(s)
- Patti Hamilton
- Department of Nursing; Texas Woman's University; Denton Texas USA
| | - Eileen Willis
- Department of Social Health Science; Department of Nursing and Midwifery; Flinders University; Adelaide South Australia Australia
| | - Julie Henderson
- Department of Social Health Science; Department of Nursing and Midwifery; Flinders University; Adelaide South Australia Australia
| | - Clare Harvey
- Department of Nursing and Midwifery; Eastern Institute of Technology; Hawkes Bay New Zealand
| | - Luisa Toffoli
- Department of Nursing and Midwifery; University of South Australia; Adelaide South Australia Australia
| | - Elizabeth Abery
- Department of Social Health Science; Department of Nursing and Midwifery; Flinders University; Adelaide South Australia Australia
| | - Claire Verrall
- Department of Social Health Science; Department of Nursing and Midwifery; Flinders University; Adelaide South Australia Australia
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Wu Y, Fujita S, Seto K, Ito S, Matsumoto K, Huang CC, Hasegawa T. The impact of nurse working hours on patient safety culture: a cross-national survey including Japan, the United States and Chinese Taiwan using the Hospital Survey on Patient Safety Culture. BMC Health Serv Res 2013; 13:394. [PMID: 24099314 PMCID: PMC3852210 DOI: 10.1186/1472-6963-13-394] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 09/30/2013] [Indexed: 11/11/2022] Open
Abstract
Background A positive patient safety culture (PSC) is one of the most critical components to improve healthcare quality and safety. The Hospital Survey on Patient Safety Culture (HSOPS), developed by the US Agency for Healthcare Research and Quality, has been used to assess PSC in 31 countries. However, little is known about the impact of nurse working hours on PSC. We hypothesized that long nurse working hours would deteriorate PSC, and that the deterioration patterns would vary between countries. Moreover, the common trends observed in Japan, the US and Chinese Taiwan may be useful to improve PSC in other countries. The purpose of this study was to clarify the impact of long nurse working hours on PSC in Japan, the US, and Chinese Taiwan using HSOPS. Methods The HSOPS questionnaire measures 12 sub-dimensions of PSC, with higher scores indicating a more positive PSC. Odds ratios (ORs) were calculated using a generalized linear mixed model to evaluate the impact of working hours on PSC outcome measures (patient safety grade and number of events reported). Tukey’s test and Cohen’s d values were used to verify the relationships between nurse working hours and the 12 sub-dimensions of PSC. Results Nurses working ≥60 h/week in Japan and the US had a significantly lower OR for patient safety grade than those working <40 h/week. In the three countries, nurses working ≥40 h/week had a significantly higher OR for the number of events reported. The mean score on ‘staffing’ was significantly lower in the ≥60-h group than in the <40-h group in all the three countries. The mean score for ‘teamwork within units’ was significantly lower in the ≥60-h group than in the <40-h group in Japan and Chinese Taiwan. Conclusions Patient safety grade deteriorated and the number of events reported increased with long working hours. Among the 12 sub-dimensions of PSC, long working hours had an impact on ‘staffing’ and ‘teamwork within units’ in Japan, the US and Chinese Taiwan.
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Affiliation(s)
- Yinghui Wu
- Division of Health Policy & Health Service Research, Department of Social Medicine, Toho University School of Medicine, 5-21-16 Omori-Nishi, Ota-ku, Tokyo 143-8540, Japan.
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Clark A, Moule P, Topping A, Serpell M. Rescheduling nursing shifts: scoping the challenge and examining the potential of mathematical model based tools. J Nurs Manag 2013; 23:411-20. [PMID: 23923979 DOI: 10.1111/jonm.12158] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2013] [Indexed: 11/30/2022]
Abstract
AIM To review research in the literature on nursing shift scheduling / rescheduling, and to report key issues identified in a consultation exercise with managers in four English National Health Service trusts to inform the development of mathematical tools for rescheduling decision-making. BACKGROUND Shift rescheduling is unrecognised as an everyday time-consuming management task with different imperatives from scheduling. Poor rescheduling decisions can have quality, cost and morale implications. EVALUATION A systematic critical literature review identified rescheduling issues and existing mathematic modelling tools. A consultation exercise with nursing managers examined the complex challenges associated with rescheduling. KEY ISSUES Minimal research exists on rescheduling compared with scheduling. Poor rescheduling can result in greater disruption to planned nursing shifts and may impact negatively on the quality and cost of patient care, and nurse morale and retention. Very little research examines management challenges or mathematical modelling for rescheduling. CONCLUSION Shift rescheduling is a complex and frequent management activity that is more challenging than scheduling. Mathematical modelling may have potential as a tool to support managers to minimise rescheduling disruption. IMPLICATIONS FOR NURSING MANAGEMENT The lack of specific methodological support for rescheduling that takes into account its complexity, increases the likelihood of harm for patients and stress for nursing staff and managers.
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Affiliation(s)
- Alistair Clark
- Department of Engineering Design and Mathematics, University of the West of England, Bristol, UK
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Abstract
AIMS To test the selected propositions of the middle-range theory of nursing intellectual capital. BACKGROUND The nursing intellectual capital theory conceptualizes nursing knowledge's influence on patient and organizational outcomes. The theory proposes nursing human capital, nurses' knowledge, skills and experience, is related to the quality of patient care and nurse recruitment and retention of an inpatient care unit. Two factors in the work environment, nurse staffing and employer support for nurse continuing professional development, are proposed to influence nursing human capital's association with patient and organizational outcomes. DESIGN A cross-sectional survey design. METHODS The study took place in 2008 in six Canadian acute care hospitals. Financial, human resource and risk data were collected from hospital departments and unit managers. Clearly specified empirical indicators quantified the study variables. The propositions of the theory were tested with data from 91 inpatient care units using structural equation modelling. RESULTS The propositions associated with the nursing human capital concept were supported. The propositions associated with the employer support for nurse continuing professional development concept were not. The proposition that nurse staffing's influences on patient outcomes was mediated by the nursing human capital of an inpatient unit, was partially supported. CONCLUSION Some of the theory's propositions were empirically validated. Additional theoretical work is needed to refine the operationalization and measurement of some of the theory's concepts. Further research with larger samples of data from different geographical settings and types of hospitals is required to determine if the theory can withstand empirical scrutiny.
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Affiliation(s)
- Christine L Covell
- Institute of Gender and Health, Canadian Institutes of Health Research, Faculty of Health Sciences, University of Ottawa, Ontario, Canada
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Carabetta M, Lombardo K, Kline NE. Implementing Primary Care in the Perianesthesia Setting Using a Relationship-Based Care Model. J Perianesth Nurs 2013; 28:16-20. [DOI: 10.1016/j.jopan.2012.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Revised: 07/18/2012] [Accepted: 10/08/2012] [Indexed: 11/29/2022]
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Affiliation(s)
- Nancy P Hanrahan
- Nancy P. Hanrahan, PhD, RN, FAAN, University of Pennsylvania School of Nursing, Philadelphia, PA 19104-4217, USA.
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