Inpatient midwifery staffing levels and postpartum readmissions: a retrospective multicentre longitudinal study

BACKGROUND

Preventing readmission to hospital after giving birth is a key priority, as rates have been rising along with associated costs. There are many contributing factors to readmission, and some are thought to be preventable. Nurse and midwife understaffing has been linked to deficits in care quality. This study explores the relationship between staffing levels and readmission rates in maternity settings.

METHODS

We conducted a retrospective longitudinal study using routinely collected individual patient data in three maternity services in England from 2015 to 2020. Data on admissions, discharges and case-mix were extracted from hospital administration systems. Staffing and workload were calculated in Hours Per Patient day per shift in the first two 12-hour shifts of the index (birth) admission. Postpartum readmissions and staffing exposures for all birthing admissions were entered into a hierarchical multivariable logistic regression model to estimate the odds of readmission when staffing was below the mean level for the maternity service.

RESULTS

64 250 maternal admissions resulted in birth and 2903 mothers were readmitted within 30 days of discharge (4.5%). Absolute levels of staffing ranged between 2.3 and 4.1 individuals per midwife in the three services. Below average midwifery staffing was associated with higher rates of postpartum readmissions within 7 days of discharge (adjusted OR (aOR) 1.108, 95% CI 1.003 to 1.223). The effect was smaller and not statistically significant for readmissions within 30 days of discharge (aOR 1.080, 95% CI 0.994 to 1.174). Below average maternity assistant staffing was associated with lower rates of postpartum readmissions (7 days, aOR 0.957, 95% CI 0.867 to 1.057; 30 days aOR 0.965, 95% CI 0.887 to 1.049, both not statistically significant).

CONCLUSION

We found evidence that lower than expected midwifery staffing levels is associated with more postpartum readmissions. The nature of the relationship requires further investigation including examining potential mediating factors and reasons for readmission in maternity populations.

The association between midwifery staffing and reported harmful incidents: a cross-sectional analysis of routinely collected data

BACKGROUND

Independent inquiries have identified that appropriate staffing in maternity units is key to enabling quality care and minimising harm, but optimal staffing levels can be difficult to achieve when there is a shortage of midwives. The services provided and how they are staffed (total staffing, skill-mix and deployment) have been changing, and the effects of workforce changes on care quality and outcomes have not been assessed. This study aims to explore the association between daily midwifery staffing levels and the rate of reported harmful incidents affecting mothers and babies.

METHODS

We conducted a cross-sectional analysis of daily reports of clinical incidents in maternity inpatient areas matched with inpatient staffing levels for three maternity services in England, using data from April 2015 to February 2020. Incidents resulting in harm to mothers or babies was the primary outcome measure. Staffing levels were calculated from daily staffing rosters, quantified in Hours Per Patient Day (HPPD) for midwives and maternity assistants. Understaffing was defined as staffing below the mean for the service. A negative binomial hierarchical model was used to assess the relationship between exposure to low staffing and reported incidents involving harm.

RESULTS

The sample covered 106,904 maternal admissions over 46 months. The rate of harmful incidents in each of the three services ranged from 2.1 to 3.0 per 100 admissions across the study period. Understaffing by registered midwives was associated with an 11% increase in harmful incidents (adjusted IRR 1.110, 95% CI 1.002,1.229). Understaffing by maternity assistants was not associated with an increase in harmful incidents (adjusted IRR 0.919, 95% 0.813,1.039). Analysis of specific types of incidents showed no statistically significant associations, but most of the point estimates were in the direction of increased incidents when services were understaffed.

CONCLUSION

When there is understaffing by registered midwives, more harmful incidents are reported but understaffing by maternity assistants is not associated with higher risk of harms. Adequate registered midwife staffing levels are crucial for maintaining safety. Changes in the profile of maternity service workforces need to be carefully scrutinised to prevent mothers and babies being put at risk of avoidable harm.

The important factors nurses consider when choosing shift patterns: A cross-sectional study

AIM

To gain a deeper understanding of what is important to nurses when thinking about shift patterns and the organisation of working time.

DESIGN

A cross-sectional survey of nursing staff working across the UK and Ireland collected quantitative and qualitative responses.

METHODS

We recruited from two National Health Service Trusts and through an open call via trade union membership, online/print nursing profession magazines and social media. Worked versus preferred shift length/pattern, satisfaction and choice over shift patterns and nurses' views on aspects related to work and life (when working short, long, rotating shifts) were analysed with comparisons of proportions of agreement and crosstabulation. Qualitative responses on important factors related to shift preferences were analysed with inductive thematic analysis.

RESULTS

Eight hundred and seventy-three survey responses were collected. When nurses worked long shifts and rotating shifts, lower proportions reported being satisfied with their shifts and working their preferred shift length and pattern. Limited advantages were realised when comparing different shift types; however, respondents more frequently associated 'low travel costs' and 'better ability to do paid overtime' with long shifts and 'healthy diet/exercise' with short shifts; aspects related to rotating shifts often had the lowest proportions of agreement. In the qualitative analysis, three themes were developed: 'When I want to work', 'Impacts to my life outside work' and 'Improving my work environment'. Reasons for nurses' shift preferences were frequently related to nurses' priorities outside of work, highlighting the importance of organising schedules that support a good work-life balance.

RELEVANCE TO CLINICAL PRACTICE

General scheduling practices like adhering to existing shift work guidelines, using consistent and predictable shift patterns and facilitating flexibility over working time were identified by nurses as enablers for their preferences and priorities. These practices warrant meaningful consideration when establishing safe and efficient nurse rosters.

PATIENT OR PUBLIC CONTRIBUTION

This survey was developed and tested with a diverse group of stakeholders, including nursing staff, patients, union leads and ward managers.

REPORTING METHOD

The Strengthening the Reporting of Observational Studies (STROBE) checklist for cross-sectional studies was used to guide reporting.

Safer and more efficient vital signs monitoring protocols to identify the deteriorating patients in the general hospital ward: an observational study

Background

The frequency at which patients should have their vital signs (e.g. blood pressure, pulse, oxygen saturation) measured on hospital wards is currently unknown. Current National Health Service monitoring protocols are based on expert opinion but supported by little empirical evidence. The challenge is finding the balance between insufficient monitoring (risking missing early signs of deterioration and delays in treatment) and over-observation of stable patients (wasting resources needed in other aspects of care).

Objective

Provide an evidence-based approach to creating monitoring protocols based on a patient's risk of deterioration and link these to nursing workload and economic impact.

Design

Our study consisted of two parts: (1) an observational study of nursing staff to ascertain the time to perform vital sign observations; and (2) a retrospective study of historic data on patient admissions exploring the relationships between National Early Warning Score and risk of outcome over time. These were underpinned by opinions and experiences from stakeholders.

Setting and participants

Observational study: observed nursing staff on 16 randomly selected adult general wards at four acute National Health Service hospitals. Retrospective study: extracted, linked and analysed routinely collected data from two large National Health Service acute trusts; data from over 400,000 patient admissions and 9,000,000 vital sign observations.

Results

Observational study found a variety of practices, with two hospitals having registered nurses take the majority of vital sign observations and two favouring healthcare assistants or student nurses. However, whoever took the observations spent roughly the same length of time. The average was 5:01 minutes per observation over a 'round', including time to locate and prepare the equipment and travel to the patient area. Retrospective study created survival models predicting the risk of outcomes over time since the patient was last observed. For low-risk patients, there was little difference in risk between 4 hours and 24 hours post observation.

Conclusions

We explored several different scenarios with our stakeholders (clinicians and patients), based on how 'risk' could be managed in different ways. Vital sign observations are often done more frequently than necessary from a bald assessment of the patient's risk, and we show that a maximum threshold of risk could theoretically be achieved with less resource. Existing resources could therefore be redeployed within a changed protocol to achieve better outcomes for some patients without compromising the safety of the rest. Our work supports the approach of the current monitoring protocol, whereby patients' National Early Warning Score 2 guides observation frequency. Existing practice is to observe higher-risk patients more frequently and our findings have shown that this is objectively justified. It is worth noting that important nurse-patient interactions take place during vital sign monitoring and should not be eliminated under new monitoring processes. Our study contributes to the existing evidence on how vital sign observations should be scheduled. However, ultimately, it is for the relevant professionals to decide how our work should be used.

Study registration

This study is registered as ISRCTN10863045.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/05/03) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 6. See the NIHR Funding and Awards website for further award information.

Evidence on the use of Birthrate Plus® to guide safe staffing in maternity services - A systematic scoping review

BACKGROUND

Birthrate Plus® is a widely used tool that informs decisions about the number of midwifery staff needed to provide safe and high quality care in maternity services. Evidence about the effectiveness, validity, reliability, and feasibility of tools such as this is needed.

OBJECTIVE

To identify, describe and analyse the available evidence supporting the use of Birthrate Plus.

METHODS

We searched PubMed, Medline, CINAHL, Google Scholar, Scopus, Academic Search, British Library Ethos, Directory of Open Access Journals and Science Direct. Studies were eligible if they reported empirical data relevant to the validity, reliability, or useability of Birthrate Plus or if they measured the impact on staffing levels, outcomes, costs or provided a comparison with other methods.

RESULTS

23 sources of evidence were identified and reviewed. We found no prospective intervention studies on the use of Birthrate Plus to demonstrate outcomes for mothers, babies or staff wellbeing. Nor did we find studies comparing the tool to other methods or addressing resource use. Most of the evidence was descriptive, focussing on the use of the tool or the results of Birthrate Plus assessments. There is some evidence of the reliability of application of categories within the tool, the ability of the tool to detect variation in demand and to highlight staff shortages.

CONCLUSIONS

In terms of traditional hierarchies of evidence, the evidence for Birthrate Plus is weak. There is a need for more independent research or simulation using real world data to understand how the tool performs in the current context of midwifery practice.

The association between nurse staffing and quality of care in emergency departments: A systematic review

BACKGROUND

The relationship between nurse staffing, skill-mix and quality of care has been well-established in medical and surgical settings, however, there is relatively limited evidence of this relationship in emergency departments. Those that have been published identified that lower nurse staffing levels in emergency departments are generally associated with worse outcomes with the conclusion that the evidence in emergency settings was, at best, weak.

METHODS

We searched thirteen electronic databases for potentially eligible papers published in English up to December 2023. Studies were included if they reported on patient outcomes associated with nurse staffing within emergency departments. Observational, cross-sectional, prospective, retrospective, interrupted time-series designs, difference-in-difference, randomised control trials or quasi-experimental studies and controlled before and after studies study designs were considered for inclusion. Team members independently screened titles and abstracts. Data was synthesised using a narrative approach.

RESULTS

We identified 16 papers for inclusion; the majority of the studies (n = 10/16) were observational. The evidence reviewed identified that poorer staffing levels within emergency departments are associated with increased patient wait times, a higher proportion of patients who leave without being seen and an increased length of stay. Lower levels of nurse staffing are also associated with an increase in time to medications and therapeutic interventions, and increased risk of cardiac arrest within the emergency department.

CONCLUSION

Overall, there remains limited high-quality empirical evidence addressing the association between emergency department nurse staffing and patient outcomes. However, it is evident that lower levels of nurse staffing are associated with adverse events that can result in delays to the provision of care and serious outcomes for patients. There is a need for longitudinal studies coupled with research that considers the relationship with skill-mix, other staffing grades and patient outcomes as well as a wider range of geographical settings.

TWEETABLE ABSTRACT

Lower levels of nurse staffing in emergency departments are associated with delays in patients receiving treatments and poor quality care including an increase in leaving without being seen, delay in accessing treatments and medications and cardiac arrest.

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

BACKGROUND

Extensive research shows associations between increased nurse staffing levels, skill mix and patient outcomes. However, showing that improved staffing levels are linked to improved outcomes is not sufficient to provide a case for increasing them. This review of economic studies in acute hospitals aims to identify costs and consequences associated with different nurse staffing configurations in hospitals.

METHODS

We included economic studies exploring the effect of variation in nurse staffing. We searched PubMed, CINAHL, Embase Econlit, Cochrane library, DARE, NHS EED and the INAHTA website. Risk of bias was assessed using a framework based on the NICE guidance for public health reviews and Henrikson's framework for economic evaluations. Inclusion, data extraction and critical appraisal were undertaken by pairs of reviewers with disagreements resolved by the entire review team. Results were synthesised using a hierarchical matrix to summarise findings of economic evaluations.

RESULTS

We found 23 observational studies conducted in the United States of America (16), Australia, Belgium, China, South Korea, and the United Kingdom (3). Fourteen had high risk of bias and nine moderate. Most studies addressed levels of staffing by RNs and/or licensed practical nurses. Six studies found that increased nurse staffing levels were associated with improved outcomes and reduced or unchanged net costs, but most showed increased costs and outcomes. Studies undertaken outside the USA showed that increased nurse staffing was likely to be cost-effective at a per capita gross domestic product (GDP) threshold or lower. Four studies found that increased skill mix was associated with improved outcomes but increased staff costs. Three studies considering net costs found increased registered nurse skill mix associated with net savings and similar or improved outcomes.

CONCLUSION

Although more evidence on cost-effectiveness is still needed, increases in absolute or relative numbers of registered nurses in general medical and surgical wards have the potential to be highly cost-effective. The preponderance of the evidence suggests that increasing the proportion of registered nurses is associated with improved outcomes and, potentially, reduced net cost. Conversely, policies that lead to a reduction in the proportion of registered nurses in nursing teams could give worse outcomes at increased costs and there is no evidence that such approaches are cost-effective. In an era of registered nurse scarcity, these results favour investment in registered nurse supply as opposed to using lesser qualified staff as substitutes, especially where baseline nurse staffing and skill mix are low.

REGISTRATION

PROSPERO (CRD42021281202).

TWEETABLE ABSTRACT

Increasing registered nurse staffing and skill mix can be a net cost-saving solution to nurse shortages. Contrary to the strong policy push towards a dilution of nursing skill mix, investment in supply of RNs should become the priority.

Clinical efficacy of IgM-enriched immunoglobulin as adjunctive therapy in neonatal and pediatric sepsis: a systematic review and meta-analysis

Background

Sepsis is a major cause of mortality and morbidity globally, with around one-quarter of all sepsis-related deaths occurring in children under the age of 5. We conducted a meta-analysis and systematic review of the literature to evaluate the clinical effectiveness of an IgM-enriched immunoglobulin preparation in pediatrics patients and neonates with sepsis.

Methods

Systematic searches of PubMed, the Cochrane Library and Embase databases were performed in November 2022, with no date limitations, to identify studies in which IgM-enriched immunoglobulin was used as adjunctive therapy in neonatal and pediatric patients with sepsis.

Results

In total, 15 studies fulfilled the eligibility criteria, 13 neonatal studies and 2 pediatric studies. Pooled estimates from all studies indicated that mortality rates were significantly lower in patients who received treatment with the IgM-enriched immunoglobulin compared with controls (OR 0.41; 95% CI 0.32-0.55). Further analyses in neonatal studies, alone, showed a significant benefit with longer treatment durations (>3 days) vs. the recommended treatment duration (3 days) (OR 0.32; 95% CI 0.22-0.47) vs. (OR 0.61; 95% CI 0.41-0.92). Treatment with IgM-enriched immunoglobulin was associated with a lower mortality risk compared with controls in prospective studies vs. retrospective analyses (OR 0.37; 95% CI 0.27-0.51) vs. (OR 0.73; 95% CI 0.41-1.30).

Conclusions

This systematic review suggests that adjunctive treatment with IgM-enriched immunoglobulin may reduce the risk of mortality in neonatal and pediatric populations. However, large randomized controlled trials are required to further substantiate and evaluate these findings.

Shift work characteristics and burnout among nurses: cross-sectional survey

BACKGROUND

Nurses working long shifts (≥12 h) experience higher levels of burnout. Yet other shift characteristics, including fixed versus rotating night work, weekly hours and breaks have not been considered. Choice over shift length may moderate the relationship; however, this has not been tested.

AIMS

To examine the association between shift work characteristics and burnout and exhaustion, and whether choice over shift length influences burnout and exhaustion.

METHODS

Cross-sectional online survey of nursing staff working in the UK and Ireland. We recruited two large National Health Service Trusts, through trade union membership, online/print nursing magazines and social media. We assessed associations using both univariable and multivariable generalized linear models.

RESULTS

We had 873 valid responses. Reports of inadequate staffing levels (odds ratio [OR] = 2.84; 95% confidence interval [CI] 2.08-3.90) and less choice over shift length (OR = 0.20; 95% CI 0.06-0.54) were associated with higher burnout in multivariable models. Similar associations were found for exhaustion, where rarely or never taking breaks was also a predictor (OR = 1.61; 95% CI 1.05-2.52). Nurses who worked long shifts had less choice than those working shifts of 8 h or less (66% of 12-h shift nurses versus 44% 8-h shift nurses reporting having no choice), but choice did not moderate the relationship between shift length and burnout and exhaustion.

CONCLUSIONS

The relationship between long shifts and increased burnout reported previously might have arisen from a lack of choice for those staff working long shifts. Whether limited choice for staff is intrinsically linked to long shifts is unclear.

Staffing levels and hospital mortality in England: a national panel study using routinely collected data

OBJECTIVES

Examine the association between multiple clinical staff levels and case-mix adjusted patient mortality in English hospitals. Most studies investigating the association between hospital staffing levels and mortality have focused on single professional groups, in particular nursing. However, single staff group studies might overestimate effects or neglect important contributions to patient safety from other staff groups.

DESIGN

Retrospective observational study of routinely available data.

SETTING AND PARTICIPANTS

138 National Health Service hospital trusts that provided general acute adult services in England between 2015 and 2019.

OUTCOME MEASURE

Standardised mortality rates were derived from the Summary Hospital level Mortality Indicator data set, with observed deaths as outcome in our models and expected deaths as offset. Staffing levels were calculated as the ratio of occupied beds per staff group. We developed negative binomial random-effects models with trust as random effects.

RESULTS

Hospitals with lower levels of medical and allied healthcare professional (AHP) staff (e.g, occupational therapy, physiotherapy, radiography, speech and language therapy) had significantly higher mortality rates (rate ratio: 1.04, 95% CI 1.02 to 1.06, and 1.04, 95% CI 1.02 to 1.06, respectively), while those with lower support staff had lower mortality rates (0.85, 95% CI 0.79 to 0.91 for nurse support, and 1.00, 95% CI 0.99 to 1.00 for AHP support). Estimates of the association between staffing levels and mortality were stronger between-hospitals than within-hospitals, which were not statistically significant in a within-between random effects model.

CONCLUSIONS

In additional to medicine and nursing, AHP staffing levels may influence hospital mortality rates. Considering multiple staff groups simultaneously when examining the association between hospital mortality and clinical staffing levels is crucial.

TRIAL REGISTRATION NUMBER

NCT04374812.

The association between multi-disciplinary staffing levels and mortality in acute hospitals: a systematic review

OBJECTIVES

Health systems worldwide are faced with the challenge of adequately staffing their hospital services. Much of the current research and subsequent policy has been focusing on nurse staffing and minimum ratios to ensure quality and safety of patient care. Nonetheless, nurses are not the only profession who interact with patients, and, therefore, not the only professional group who has the potential to influence the outcomes of patients while in hospital. We aimed to synthesise the evidence on the relationship between multi-disciplinary staffing levels in hospital including nursing, medical and allied health professionals and the risk of death.

METHODS

Systematic review. We searched Embase, Medline, CINAHL, and the Cochrane Library for quantitative or mixed methods studies with a quantitative component exploring the association between multi-disciplinary hospital staffing levels and mortality.

RESULTS

We included 12 studies. Hospitals with more physicians and registered nurses had lower mortality rates. Higher levels of nursing assistants were associated with higher patient mortality. Only two studies included other health professionals, providing scant evidence about their effect.

CONCLUSIONS

Pathways for allied health professionals such as physiotherapists, occupational therapists, dietitians, pharmacists, to impact safety and other patient outcomes are plausible and should be explored in future studies.

Unhealthy Food and Beverage Consumption in Children and Risk of Overweight and Obesity: A Systematic Review and Meta-Analysis

This WHO-commissioned review contributed to the update of complementary feeding recommendations, synthesizing evidence on effects of unhealthy food and beverage consumption in children on overweight and obesity. We searched PubMed (Medline), Cochrane CENTRAL, and Embase for articles, irrespective of language or geography. Inclusion criteria were: 1) randomized controlled trials (RCTs), non-RCTs, cohort studies, and pre/post studies with control; 2) participants aged ≤10.9 y at exposure; 3) studies reporting greater consumption of unhealthy foods/beverages compared with no or low consumption; 4) studies assessing anthropometric and/or body composition; and 5) publication date ≥1971. Unhealthy foods and beverages were defined using nutrient- and food-based approaches. Risk of bias was assessed using the ROBINS-I (risk of bias in nonrandomized studies of interventions version I) and RoB2 [Cochrane RoB (version 2)] tools for nonrandomized and randomized studies, respectively. Narrative synthesis was complemented by meta-analyses where appropriate. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation. Of 26,542 identified citations, 60 studies from 71 articles were included. Most studies were observational (59/60), and no included studies were from low-income countries. The evidence base was low quality, as assessed by ROBINS-I and RoB2 tools. Evidence synthesis was limited by the different interventions and comparators across studies. Evidence indicated that consumption of sugar-sweetened beverages (SSBs) and unhealthy foods in childhood may increase BMI/BMI z-score, percentage body fat, or odds of overweight/obesity (low certainty of evidence). Artificially sweetened beverages and 100% fruit juice consumption make little/no difference to BMI, percentage body fat, or overweight/obesity outcomes (low certainty of evidence). Meta-analyses of a subset of studies indicated a positive association between SSB intake and percentage body fat, but no association with change in BMI and BMI z-score. High-quality epidemiological studies that are designed to assess the effects of unhealthy food consumption during childhood on risk of overweight/obesity are needed to contribute to a more robust evidence base upon which to design policy recommendations. This protocol was registered at https://www.crd.york.ac.uk/PROSPERO as CRD42020218109.

A global overview of healthcare workers' turnover intention amid COVID-19 pandemic: a systematic review with future directions

BACKGROUND

Globally, the health workforce has long suffered from labour shortages. This has been exacerbated by the workload increase caused by the COVID-19 pandemic. Major collapses in healthcare systems across the world during the peak of the pandemic led to calls for strategies to alleviate the increasing job attrition problem within the healthcare sector. This turnover may worsen given the overwhelming pressures experienced by the health workforce during the pandemic, and proactive measures should be taken to retain healthcare workers. This review aims to examine the factors affecting turnover intention among healthcare workers during the COVID-19 pandemic.

METHODS

A mixed studies systematic review was conducted. The PubMed, Embase, Scopus, CINAHL, Web of Science and PsycINFO databases were searched from January 2020 to March 2022. The Joanna Briggs Institute's Critical Appraisal Tools and the Mixed Methods Appraisal Tool version 2018 were applied by two independent researchers to critically appraise the methodological quality. Findings were synthesised using a convergent integrated approach and categorised thematically.

RESULTS

Forty-three studies, including 39 quantitative, two qualitative and two mixed methods studies were included in this review. Eighteen were conducted in the Middle East, ten in the Americas, nine in the Asia-Pacific region and six in Europe. Nurses (n = 35) were included in the majority of the studies, while physicians (n = 13), allied health workers (n = 11) and healthcare administrative or management staff (n = 7) were included in a smaller proportion. Five themes emerged from the data synthesis: (1) fear of COVID-19 exposure, (2) psychological responses to stress, (3) socio-demographic characteristics, (4) adverse working conditions, and (5) organisational support.

CONCLUSIONS

A wide range of factors influence healthcare workers' turnover intention in times of pandemic. Future research should be more focused on specific factors, such as working conditions or burnout, and specific vulnerable groups, including migrant healthcare workers and healthcare profession minorities, to aid policymakers in adopting strategies to support and incentivise them to retain them in their healthcare jobs.

Exploring the relationship between women’s experience of postnatal care and reported staffing measures: An observational study

Background

Women have reported dissatisfaction with care received on postnatal wards and this area has been highlighted for improvement. Studies have shown an association between midwifery staffing levels and postnatal care experiences, but so far, the influence of registered and support staff deployed in postnatal wards has not been studied. This work is timely as the number of support workers has increased in the workforce and there has been little research on skill mix to date.

Methods

Cross sectional secondary analysis including 13,264 women from 123 postnatal wards within 93 hospital Trusts. Staffing was measured in each organisation as Full Time Equivalent staff employed per 100 births, and on postnatal wards, using Hours Per Patient Day. Women’s experiences were assessed using four items from the 2019 national maternity survey. Multilevel logistic regression models were used to examine relationships and adjust for maternal age, parity, ethnicity, type of birth, and medical staff.

Results

Trusts with higher levels of midwifery staffing had higher rates of women reporting positive experiences of postnatal care. However, looking at staffing on postnatal wards, there was no evidence of an association between registered nurses and midwives hours per patient day and patient experience. Wards with higher levels of support worker staffing were associated with higher rates of women reporting they had help when they needed it and were treated with kindness and understanding.

Conclusion

The relationship between reported registered staffing levels on postnatal wards and women’s experience is uncertain. Further work should be carried out to examine why relationships observed using whole Trust staffing were not replicated closer to the patient, with reported postnatal ward staffing. It is possible that recorded staffing levels on postnatal wards do not actually reflect staff deployment if midwives are floated to cover delivery units. This study highlights the potential contribution of support workers in providing quality care on postnatal wards.

Evaluation of the Prevalence of Punctate White Matter Lesions in a Healthy Volunteer Neonatal Population

Hypoxic-ischemic injury is the most common cause of neonatal encephalopathy. T1-weighted punctate white matter lesions have been described in hypoxic-ischemic injury. We have reviewed a healthy volunteer neonatal population to assess the prevalence of punctate white matter lesions in neonates with no clinical signs of hypoxic-ischemic injury. Fifty-two subjects were scanned on a neonatal-specific 3T MR imaging scanner. Twelve patients were excluded due to the lack of T1-weighted imaging, leaving a total of 40 patients (35 term, 5 preterm) assessed in the study. One had a solitary T1-punctate white matter lesion. We concluded that solitary punctate white matter lesions have a low prevalence in healthy neonates.

A workplace organisational intervention to improve hospital nurses' and physicians' mental health: study protocol for the Magnet4Europe wait list cluster randomised controlled trial

INTRODUCTION

The increasing burden of mental distress reported by healthcare professionals is a matter of serious concern and there is a growing recognition of the role of the workplace in creating this problem. Magnet hospitals, a model shown to attract and retain staff in US research, creates positive work environments that aim to support the well-being of healthcare professionals.

METHODS AND ANALYSIS

Magnet4Europe is a cluster randomised controlled trial, with wait list controls, designed to evaluate the effects of organisational redesign, based on the Magnet model, on nurses' and physicians' well-being in general acute care hospitals, using a multicomponent implementation strategy. The study will be conducted in more than 60 general acute care hospitals in Belgium, England, Germany, Ireland, Norway and Sweden. The primary outcome is burnout among nurses and physicians, assessed in longitudinal surveys of nurses and physicians at participating hospitals. Additional data will be collected from them on perceived work environments, patient safety and patient quality of care and will be triangulated with data from medical records, including case mix-adjusted in-hospital mortality. The process of implementation will be evaluated using qualitative data from focus group and key informant interviews.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee Research UZ/KU Leuven, Belgium; additionally, ethics approval is obtained in all other participating countries either through a central or decentral authority. Findings will be disseminated at conferences, through peer-reviewed manuscripts and via social media.

TRIAL REGISTRATION NUMBER

ISRCTN10196901.

Because they're worth it? A discussion paper on the value of 12-h shifts for hospital nursing

The organisation of the 24-h day for hospital nurses in two 12-h shifts has been introduced with value propositions of reduced staffing costs, better quality of care, more efficient work organisation, and increased nurse recruitment and retention. While existing reviews consider the impact of 12-h shifts on nurses' wellbeing and performance, this discussion paper aims to specifically shed light on whether the current evidence supports the value propositions around 12-h shifts. We found little evidence of the value propositions being realised. Staffing costs are not reduced with 12-h shifts, and outcomes related to productivity and efficiency, including sickness absence and missed nursing care are negatively affected. Nurses working 12-h shifts do not perform more safely than their counterparts working shorter shifts, with evidence pointing to a likely negative effect on safe care due to increased fatigue and sleepiness. In addition, nurses working 12-h shifts may have access to fewer educational opportunities than nurses working shorter shifts. Despite some nurses preferring 12-h shifts, the literature does not indicate that this shift pattern leads to increased recruitment, with studies reporting that nurses working long shifts are more likely to express intention to leave their job. In conclusion, there is little if any support for the value propositions that were advanced when 12-h shifts were introduced. While 12-h shifts might be here to stay, it is important that the limitations, including reduced productivity and efficiency, are recognised and accepted by those in charge of implementing schedules for hospital nurses.

The organisation of nurse staffing in intensive care units: a qualitative study

AIMS

To examine the organisation of the nursing workforce in intensive care units and identify factors that influence how the workforce operates.

BACKGROUND

Pre-pandemic UK survey data show that up to 60% of intensive care units did not meet locally agreed staffing numbers and 40% of ICUs were closing beds at least once a week because of workforce shortages, specifically nursing. Nurse staffing in intensive care is based on the assumption that sicker patients need more nursing resource than those recovering from critical illness. These standards are based on historical working, and expert professional consensus, deemed the weakest form of evidence.

METHODS

Focus groups with intensive care health care professionals (n= 52 participants) and individual interviews with critical care network leads and policy leads (n= 14 participants) in England between December 2019 and July 2020. Data were analysed using framework analysis.

FINDINGS

Three themes were identified: the constraining or enabling nature of intensive care and hospital structures; whole team processes to mitigate nurse staffing shortfalls; and the impact of nurse staffing on patient, staff and intensive care flow outcomes. Staff made decisions about staffing throughout a shift and were influenced by a combination of factors illuminated in the three themes.

CONCLUSIONS

Whilst nurse: patient ratios were clearly used to set the nursing establishment, it was clear that rostering and allocation/re-allocation during a shift took into account many other factors, such as patient and family nursing needs, staff wellbeing, intensive care layout and the experience, and availability, of other members of the multi-professional team. This has important implications for future planning for intensive care nurse staffing and highlights important factors to be accounted for in future research studies.

IMPLICATIONS FOR NURSING MANAGEMENT

In order to safeguard patient and staff safety, factors such as the ICU layout need to be considered in staffing decisions and the local business case for nurse staffing needs to reflect these factors. Patient safety in intensive care may not be best served by a blanket 'ratio' approach to nurse staffing, intended to apply uniformly across health services.

'I'll put up with things for a long time before I need to call anybody': Face work, the Total Institution and the perpetuation of care inequalities

Failures in fundamental care (e.g. nutrition or pain-relief) for hospitalised patients can have serious consequences, including avoidable deaths. Policy rhetoric of 'shared decision-making' fails to consider how structural constraints and power dynamics limit patient agency in nursing staff-patient interactions. Goffman's concepts of face work, the presentation of self and the Total Institution shaped our analysis of interview and focus group data from hospital patients. Patients avoided threatening 'good' patient and staff face by only requesting missed care when staff face was convincing as 'caring' and 'available' ('engaged'). Patients did not request care from 'distracted' staff ('caring' but not 'available'), whilst patient requests were ignored in Total Institution-like 'dismissive' interactions. This meant patients experienced missed care with both 'distracted' and 'dismissive' staff. Patients with higher support needs were less able to carry out their own missed care to protect staff face, so experienced more serious care omissions. These findings show that many elements of the Total Institution survive in modern healthcare settings despite attempts to support individualised care. Unless nursing staff can maintain face as 'engaged' (despite organisational constraints that can reduce their capacity to do so) patient participation in care decisions will remain at the level of rhetoric.

The future of the drug phenomenon and drug monitoring in Europe until 2030

 

We are living in an era of fast and fundamental changes with an uneven impact on geographies and generations. The pace of the social transformations and technology innovations is accelerating and outpacing policies and responses in place. Also, the European drug situation and drug markets are becoming more complex and dynamic, with important implications for the EU drug monitoring system and research. Therefore the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) conducted the first ‘futures exercise' to inform the agency's strategic reflection on how to improve the response of the EU monitoring system in the context of rapid changes in the information environment and new information needs. The EMCDDA piloted the usefulness of the foresight approach for transforming the agency and its monitoring activities into a more sensitive and agile system, which could, in turn, help increase Europe's preparedness for future challenges in health and security areas. The ‘futures exercise' applied the horizon-scanning method to study events, issues, and trends affecting the drug area and went far beyond the drugs or the addiction field and the European region. It analysed global drivers of change that may have in the future implications for the drugs situation, drug monitoring and related responses. The methods applied ranged from literature review, thematic analysis, workshops and expert panels. It had a robust participatory component to enable stakeholders representing different disciplines and countries to contribute to and benefit from the process. Out of 14 Megatrends, five were selected as most significant for the drugs field, and the future EMCDDA work: technological change, climate change and environmental degradation, diversified inequalities, shifts in health challenges and population. Moreover, four categories of emerging changes in the drugs field were identified: shifts in drug policy, the discourse of addictions, drug markets and drug services.

Key messages

Foresight is a valuable tool for analysis going beyond specific areas of expertise and recognising that a single-issue focus is often insufficient in dealing with emerging threats and opportunities. A participatory approach contributes to building a shared vision of the major drivers of change impacting the drugs field, information needs and future developments in the EU drug monitoring system.

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

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION AND REVIEW METHODS

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

RESULTS

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

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

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

Consensus Development Project (CDP): An overview of staffing for safe and effective nursing care

We present an overview of the research evidence on nurse staffing levels in acute hospitals, and how it has been applied to policy and practice, focussing primarily on the UK. Drawing on research reviews and examples of specific studies, we outline the current state of knowledge. Much of the evidence comes from cross-sectional studies. More recently, longitudinal studies allow a causal link between staffing and outcomes to be inferred. Lack of specificity on staffing levels has hindered application of research findings to practice; research rarely specifies how many nurses are needed for safe and effective care. The most significant impediment to achieving safe staffing has been an underestimation of the number of RNs needed and overestimation of the potential for substitution, resulting in low baseline staffing and a national shortage of RNs. Repeatedly, new staffing solutions are sought rather than tackle the problem of too few RNs head-on.

Outcomes sensitive to critical care nurse staffing levels: A systematic review

OBJECTIVE

To determine associations between variations in registered nurse staffing levels in adult critical care units and outcomes such as patient, nurse, organisational and family outcomes.

METHODS

We published and adhered to a protocol, stored in an open access repository and searched for quantitative studies written in the English language and held in CINAHL Plus, MEDLINE, PsycINFO, SCOPUS and NDLTD databases up to July 2020. Three authors independently extracted data and critically appraised papers meeting the inclusion criteria. Results are summarised in tables and discussed in terms of strength of internal validity. A detailed review of the two most commonly measured outcomes, patient mortality and nosocomial infection, is also presented.

RESULTS

Our search returned 7960 titles after duplicates were removed; 55 studies met the inclusion criteria. Studies with strong internal validity report significant associations between lower levels of critical care nurse staffing and increased odds of both patient mortality (1.24-3.50 times greater) and nosocomial infection (3.28-3.60 times greater), increased hospital costs, lower nurse-perceived quality of care and lower family satisfaction. Meta-analysis was not feasible because of the wide variation in how both staffing and outcomes were measured.

CONCLUSIONS

A large number of studies including several with high internal validity provide evidence that higher levels of critical care nurse staffing are beneficial to patients, staff and health services. However, inconsistent approaches to measurement and aggregation of staffing levels reported makes it hard to translate findings into recommendation for safe staffing in critical care.

Ward staffing guided by a patient classification system: A multi-criteria analysis of "fit" in three acute hospitals

AIMS

To assess how well the Safer Nursing Care Tool (SNCT) predicts staffing requirements on hospital wards, and to use professional judgement to generate hypotheses about factors associated with a "poor fit".

BACKGROUND

The SNCT is widely used in the UK, but there is scant evidence about factors that influence the quality of staffing decisions based upon such patient classification systems.

METHODS

Secondary analysis of data from 69 wards in three acute hospitals to assess the precision of the estimated staffing requirement, variation of estimates, correspondence with professional judgement and achieved staffing levels. Nursing workforce leads suggested factors associated with poor fit, based on the wards that rated worst.

RESULTS

39% of wards were frequently understaffed, while frequent overstaffing was less common (12%). 24% of wards needed a sample of over 182 days to estimate the establishment precisely. Potential reasons identified for poor fit included high turnover, older patients, high levels of 1-to-1 specialing, cancer care, small ward size and high within-day variation in demand.

CONCLUSIONS

Using a staffing tool without applying professional judgement or triangulating against other methods can lead to inaccurate estimates of staffing requirements and unsafe staffing levels.

IMPLICATIONS FOR NURSING MANAGEMENT

Despite the availability of software to calculate staffing requirements, application of professional judgement remains essential.

Estimating the economic cost of nurse sensitive adverse events amongst patients in medical and surgical settings

AIMS

To identify the costs associated with nurse sensitive adverse events and the impact of these events on patients' length of stay.

DESIGN

Retrospective cohort study using administrative hospital data.

METHODS

Data were sourced from patient discharge information (N = 5544) from six acute wards within three hospitals (July 2016-October 2017). A retrospective patient record review was undertaken by extracting data from the hospitals' administrative systems on inpatient discharges, length of stay and diagnoses; eleven adverse events sensitive to nurse staffing were identified within the administrative system. A negative binomial regression is employed to assess the impact of nurse sensitive adverse events on length of stay.

RESULTS

Sixteen per cent of the sample (n = 897) had at least one nurse sensitive adverse event during their episode of care. The model revealed when age, gender, admission type and complexity are controlled for, each additional nurse sensitive adverse event experienced by a patient was associated with an increase in the length of stay beyond the national average by 0.48 days (p = .001). Applying this to the daily average cost of inpatient stay per patient (€1456), we estimate the average cost associated with each nurse sensitive adverse event to be €694. Extrapolating this nationally, the economic cost of nurse sensitive adverse events to the health service in Ireland is estimated to be €91.3 million annually.

CONCLUSION

These potentially avoidable events are associated with a significant economic burden to health systems. The estimates provided here can be used to inform and prepare the way for future economic evaluations of nurse staffing initiatives that aim to improve care and safety.

IMPACT

As many of these nurse sensitive adverse events are avoidable, in addition to patient benefits, there is a potential substantial financial return on investment from strategies such as improved nurse staffing that can reduce their occurrence.

Association between Quality of Interactions Schedule ratings and care experiences of people with a dementia in general hospital settings: a validation study

INTRODUCTION

Establishing methods to evaluate interactions between hospital staff and patients with a dementia is vital to inform care delivery. This study aimed to assess the validity of Quality of Interactions Schedule (QuIS) ratings in relation to the care experiences of people with a dementia in a general hospital setting.

METHODS

Four hundred and ninety face-to-face interactions between staff and patients with a dementia (n = 107) on six medicine for older people wards in a UK National Health Service hospital were observed and rated using QuIS and the Psychological Well-Being in Cognitively Impaired Persons (PWB-CIP) tool. We also invited patient ratings for longer interactions (n = 217). Analyses explored associations between QuIS ratings, PWB-CIP ratings and patient ratings.

RESULTS

When QuIS was rated negative, the mean researcher-rated patient psychological well-being was lower (PWB = 7.9 out of maximum score of 10) than when QuIS was non-negative (PWB = 8.8, p = 0.036). Negative QuIS ratings were associated with negative ratings on seven out of ten individual PWB-CIP items. When QuIS was rated negative, the associated patient rating was 4% less likely to be 'happy'. The patient was also 4% more likely to rate the interaction as 'kind'. Patients struggled to participate in care ratings.

CONCLUSIONS

Some patients found responding to researcher questions difficult or not relevant, reflecting the need for development of more suitable methods in this field. Our findings of an association between lower quality QuIS-rated interactions and lower psychological well-being lend support to the use of QuIS with patient populations that include people with a dementia.

The association between nurse staffing and inpatient mortality: A shift-level retrospective longitudinal study

BACKGROUND

Worldwide, hospitals face pressure to reduce costs. Some respond by working with a reduced number of nurses or less qualified nursing staff.

OBJECTIVE

This study aims at examining the relationship between mortality and patient exposure to shifts with low or high nurse staffing.

METHODS

This longitudinal study used routine shift-, unit-, and patient-level data for three years (2015-2017) from one Swiss university hospital. Data from 55 units, 79,893 adult inpatients and 3646 nurses (2670 registered nurses, 438 licensed practical nurses, and 538 unlicensed and administrative personnel) were analyzed. After developing a staffing model to identify high- and low-staffed shifts, we fitted logistic regression models to explore associations between nurse staffing and mortality.

RESULTS

Exposure to shifts with high levels of registered nurses had lower odds of mortality by 8.7% [odds ratio 0.91 95% CI 0.89-0.93]. Conversely, low staffing was associated with higher odds of mortality by 10% [odds ratio 1.10 95% CI 1.07-1.13]. The associations between mortality and staffing by other groups was less clear. For example, both high and low staffing of unlicensed and administrative personnel were associated with higher mortality, respectively 1.03 [95% CI 1.01-1.04] and 1.04 [95% CI 1.03-1.06].

DISCUSSION AND IMPLICATIONS

This patient-level longitudinal study suggests a relationship between registered nurses staffing levels and mortality. Higher levels of registered nurses positively impact patient outcome (i.e. lower odds of mortality) and lower levels negatively (i.e. higher odds of mortality). Contributions of the three other groups to patient safety is unclear from these results. Therefore, substitution of either group for registered nurses is not recommended.

How long do nursing staff take to measure and record patients' vital signs observations in hospital? A time-and-motion study

Introduction

Monitoring vital signs in hospital is an important part of safe patient care. However, there are no robust estimates of the workload it generates for nursing staff. This makes it difficult to plan adequate staffing to ensure current monitoring protocols can be delivered.

Objective

To estimate the time taken to measure and record one set of patient's vital signs; and to identify factors associated with the time required to measure and record one set of patient's vital signs.

Methods

We undertook a time-and-motion study of 16 acute medical or surgical wards across four hospitals in England. Two trained observers followed a standard operating procedure to record the time taken to measure and record vital signs. We used mixed-effects models to estimate the mean time using whole vital signs rounds, which included equipment preparation, time spent taking vital signs at the bedside, vital signs documentation, and equipment storing. We tested whether our estimates were influenced by nurse, ward and hospital factors.

Results

After excluding non-vital signs related interruptions, dividing the length of a vital signs round by the number of vital signs assessments in that round yielded an estimated time per vital signs set of 5 min and 1 second (95% Confidence Interval (CI) = 4:39–5:24). If interruptions within the round were included, the estimated time was 6:26 (95% CI = 6:01–6:50). If only time taking each patient's vital signs at the bedside was considered, after excluding non-vital signs related interruptions, the estimated time was 3:45 (95% CI = 3:32–3:58). We found no substantial differences by hospital, ward or nurse characteristics, despite different systems for recording vital signs being used across the hospitals.

Discussion

The time taken to observe and record a patient's vital signs is considerable, so changes to recommended assessment frequency could have major workload implications. Variation in estimates derived from previous studies may, in part, arise from a lack of clarity about what was included in the reported times. We found no evidence that nurses save time when using electronic vital signs recording, or that the grade of staff measuring the vital signs influenced the time taken.

Conclusions

Measuring and recording vital signs is time consuming and the impact of interruptions and preparation away from the bedside is considerable. When considering the nursing workload around vital signs assessment, no assumption of relative efficiency should be made if different technologies or staff groups are deployed.

The association between ward staffing levels, mortality and hospital readmission in older hospitalised adults, according to presence of cognitive impairment: a retrospective cohort study

BACKGROUND

Lower nurse staffing levels are associated with increased hospital mortality. Older patients with cognitive impairments (CI) have higher mortality rates than similar patients without CI and may be additionally vulnerable to low staffing.

OBJECTIVES

To explore associations between registered nurse (RN) and nursing assistant (NA) staffing levels, mortality and readmission in older patients admitted to general medical/surgical wards.

RESEARCH DESIGN

Retrospective cohort.

PARTICIPANTS

All unscheduled admissions to an English hospital of people aged ≥75 with cognitive screening over 14 months.

MEASURES

The exposure was defined as deviation in staffing hours from the ward daily mean, averaged across the patient stay. Outcomes were mortality in hospital/within 30 days of discharge and 30-day re-admission. Analyses were stratified by CI.

RESULTS

12,544 admissions were included. Patients with CI (33.2%) were exposed to similar levels of staffing as those without. An additional 0.5 RN hours per day was associated with 10% reduction in the odds of death overall (odds ratio 0.90 [95% CI 0.84-0.97]): 15% in patients with CI (OR 0.85 [0.74-0.98]) and 7% in patients without (OR 0.93 [0.85-1.02]). An additional 0.5 NA hours per day was associated with a 15% increase in mortality in patients with no impairment. Readmissions decreased by 6% for an additional 0.5 RN hours in patients with CI.

CONCLUSIONS

Although exposure to low staffing was similar, the impact on mortality and readmission for patients with CI was greater. Increased mortality with higher NA staffing in patients without CI needs exploration.

Beyond ratios - flexible and resilient nurse staffing options to deliver cost-effective hospital care and address staff shortages: A simulation and economic modelling study

BACKGROUND

In the face of pressure to contain costs and make best use of scarce nurses, flexible staff deployment (floating staff between units and temporary hires) guided by a patient classification system may appear an efficient approach to meeting variable demand for care in hospitals.

OBJECTIVES

We modelled the cost-effectiveness of different approaches to planning baseline numbers of nurses to roster on general medical/surgical units while using flexible staff to respond to fluctuating demand.

DESIGN AND SETTING

We developed an agent-based simulation, where hospital inpatient units move between being understaffed, adequately staffed or overstaffed as staff supply and demand (as measured by the Safer Nursing Care Tool patient classification system) varies. Staffing shortfalls are addressed by floating staff from overstaffed units or hiring temporary staff. We compared a standard staffing plan (baseline rosters set to match average demand) with a higher baseline 'resilient' plan set to match higher than average demand, and a low baseline 'flexible' plan. We varied assumptions about temporary staff availability and estimated the effect of unresolved low staffing on length of stay and death, calculating cost per life saved.

RESULTS

Staffing plans with higher baseline rosters led to higher costs but improved outcomes. Cost savings from lower baseline staff mainly arose because shifts were left understaffed and much of the staff cost saving was offset by costs from longer patient stays. With limited temporary staff available, changing from low baseline flexible plan to the standard plan cost £13,117 per life saved and changing from the standard plan to the higher baseline 'resilient' plan cost £8,653 per life saved. Although adverse outcomes from low baseline staffing reduced when more temporary staff were available, higher baselines were even more cost-effective because the saving on staff costs also reduced. With unlimited temporary staff, changing from low baseline plan to the standard cost £4,520 per life saved and changing from the standard plan to the higher baseline cost £3,693 per life saved.

CONCLUSION

Shift-by-shift measurement of patient demand can guide flexible staff deployment, but the baseline number of staff rostered must be sufficient. Higher baseline rosters are more resilient in the face of variation and appear cost-effective. Staffing plans that minimise the number of nurses rostered in advance are likely to harm patients because temporary staff may not be available at short notice. Such plans, which rely heavily on flexible deployments, do not represent an efficient or effective use of nurses.

STUDY REGISTRATION

ISRCTN 12307968 Tweetable abstract: Economic simulation model of hospital units shows low baseline staff levels with high use of flexible staff are not cost-effective and don't solve nursing shortages.

Observational study of the relationship between nurse staffing levels and compliance with mandatory nutritional assessments in hospital

BACKGROUND

In the UK, it is recommended that hospital patients have their nutritional status assessed within 24 h of admission using the Malnutrition Universal Screening Tool (MUST). The present study aimed to examine the association between nurse staffing levels and missed nutritional status assessments.

METHODS

A single-centre, retrospective, observational study was employed using routinely collected MUST assessments from 32 general adult hospital wards over 2 years, matched to ward nurse staffing levels. We used mixed-effects logistic regression to control for ward characteristics and patient factors.

RESULTS

Of 43 451 instances where staffing levels could be linked to a patient for whom an assessment was due, 21.4% had no MUST score recorded within 24 h of admission. Missed assessments varied between wards (8-100%). There was no overall association between registered nurse staffing levels and missed assessments; although higher admissions per registered nurse were associated with more missed assessments [odds ratio (OR) = 1.09, P = 0.005]. Higher healthcare assistant staffing was associated with lower rates of missed assessments (OR = 0.80, P < 0.001). There was a significant interaction between registered nurses and healthcare assistants staffing levels (OR = 0.97, P = 0.011).

CONCLUSIONS

Despite a written hospital policy requiring a nutritional assessment within 24 h of admission, missed assessments were common. The observed results show that compliance with the policy for routine MUST assessments within 24 h of hospital admission is sensitive to staffing levels and workload. This has implications for planning nurse staffing.

Healthcare Workers Bioresource: Study outline and baseline characteristics of a prospective healthcare worker cohort to study immune protection and pathogenesis in COVID-19

Background: Most biomedical research has focused on sampling COVID-19 patients presenting to hospital with advanced disease, with less focus on the asymptomatic or paucisymptomatic. We established a bioresource with serial sampling of health care workers (HCWs) designed to obtain samples before and during mainly mild disease, with follow-up sampling to evaluate the quality and duration of immune memory. Methods: We conducted a prospective study on HCWs from three hospital sites in London, initially at a single centre (recruited just prior to first peak community transmission in London), but then extended to multiple sites 3 weeks later (recruitment still ongoing, target n=1,000). Asymptomatic participants attending work complete a health questionnaire, and provide a nasal swab (for SARS-CoV-2 RNA by RT-PCR tests) and blood samples (mononuclear cells, serum, plasma, RNA and DNA are biobanked) at 16 weekly study visits, and at 6 and 12 months. Results: Preliminary baseline results for the first 731 HCWs (400 single-centre, 331 multicentre extension) are presented. Mean age was 38±11 years; 67% are female, 31% nurses, 20% doctors, and 19% work in intensive care units. COVID-19-associated risk factors were: 37% black, Asian or minority ethnicities; 18% smokers; 13% obesity; 11% asthma; 7% hypertension and 2% diabetes mellitus. At baseline, 41% reported symptoms in the preceding 2 weeks. Preliminary test results from the initial cohort (n=400) are available: PCR at baseline for SARS-CoV-2 was positive in 28 of 396 (7.1%, 95% CI 4.9-10.0%) and 15 of 385 (3.9%, 2.4-6.3%) had circulating IgG antibodies. Conclusions: This COVID-19 bioresource established just before the peak of infections in the UK will provide longitudinal assessments of incident infection and immune responses in HCWs through the natural time course of disease and convalescence. The samples and data from this bioresource are available to academic collaborators by application  https://covid-consortium.com/application-for-samples/.

Healthcare Workers Bioresource: Study outline and baseline characteristics of a prospective healthcare worker cohort to study immune protection and pathogenesis in COVID-19

Background: Most biomedical research has focused on sampling COVID-19 patients presenting to hospital with advanced disease, with less focus on the asymptomatic or paucisymptomatic. We established a bioresource with serial sampling of health care workers (HCWs) designed to obtain samples before and during mainly mild disease, with follow-up sampling to evaluate the quality and duration of immune memory.

Methods: We conducted a prospective study on HCWs from three hospital sites in London, initially at a single centre (recruited just prior to first peak community transmission in London), but then extended to multiple sites 3 weeks later (recruitment still ongoing, target n=1,000). Asymptomatic participants attending work complete a health questionnaire, and provide a nasal swab (for SARS-CoV-2 RNA by RT-PCR tests) and blood samples (mononuclear cells, serum, plasma, RNA and DNA are biobanked) at 16 weekly study visits, and at 6 and 12 months.

Results: Preliminary baseline results for the first 731 HCWs (400 single-centre, 331 multicentre extension) are presented. Mean age was 38±11 years; 67% are female, 31% nurses, 20% doctors, and 19% work in intensive care units. COVID-19-associated risk factors were: 37% black, Asian or minority ethnicities; 18% smokers; 13% obesity; 11% asthma; 7% hypertension and 2% diabetes mellitus. At baseline, 41% reported symptoms in the preceding 2 weeks. Preliminary test results from the initial cohort (n=400) are available: PCR at baseline for SARS-CoV-2 was positive in 28 of 396 (7.1%, 95% CI 4.9-10.0%) and 15 of 385 (3.9%, 2.4-6.3%) had circulating IgG antibodies.

Conclusions: This COVID-19 bioresource established just before the peak of infections in the UK will provide longitudinal assessments of incident infection and immune responses in HCWs through the natural time course of disease and convalescence. The samples and data from this bioresource are available to academic collaborators by application  https://covid-consortium.com/application-for-samples/.

Impact of volunteers in the emergency department

BACKGROUND

Fundamental aspects of patient experience have been reported as substandard in emergency departments. Hospital volunteers can improve the patient experience in inpatient settings. However, evidence is limited on their impact in emergency departments.

AIMS

To determine whether emergency department volunteers could enhance patient experience through assisting with the psychological aspect of patient care and patients' nutritional needs.

METHODS

Patients attending an emergency department responded to a questionnaire as part of a cross-sectional study. Comparisons were made between when the volunteer scheme was running and when there were no volunteers. Outcomes included patient experience of emotional support from staff and access to food and drink.

RESULTS

Patients present when the volunteer scheme was running reported obtaining food and drink more often (96/124 vs 20/39, % rate difference 26, 95% CI 10-42, P=0.002) and that a member of staff offered them something to eat and drink more frequently (96/146 vs 19/52, % rate difference 29, 95% CI 14-45, P<0.001). There was no difference between patient responses when the volunteer scheme was running and not for emotional support from staff (49/68 vs 14/21, % rate difference 5, 95% CI -17-28, P=0.63).

CONCLUSIONS

Hospital volunteers made a substantial contribution to providing food and drink to patients in the emergency department. Emotional support from volunteers was limited.

Night work for hospital nurses and sickness absence: a retrospective study using electronic rostering systems

There is conflicting evidence on the effect of night work on sickness absence. Most previous studies used self-reporting to identify shift patterns and measure levels of sickness absence. In contrast, this study used objective data from electronic rosters to explore the association of nurses' patterns of night work and sickness absence. This was a retrospective longitudinal study of nurse roster data from 32 general medical and surgical wards in a large acute hospital in England. We used data from 3 years and included both registered nurses and unregistered nursing assistants. We used generalized linear-mixed models to explore the association between night work and the subsequent occurrence of sickness absence. Of 601,282 shifts worked by 1944 nursing staff, 38,051 shifts were lost due to sickness absence. After controlling for potential confounders including proportion of long (≥12 h) shifts worked, proportion of overtime shifts, proportion of shifts worked in the past 7 days, and staff grade, we found that staff working more than 75% of their shifts in the past 7 days as night shifts were more likely to experience sickness absence (aOR = 1.12; 95% CI: 1.03-1.21), compared to staff working on day only schedules. Sub-group analysis found that an association between a high proportion of night shifts worked and long-term sickness (aOR = 1.31; 95% CI: 1.15-1.50), but not short-term sickness. Working high proportions of night shifts, likely representing permanent night work schedules, is associated with a higher risk of long-term sickness absence for nurses working in inpatient adult wards in acute hospitals. The higher sickness absence rates associated with permanent night shifts could result in additional costs or loss of productivity for hospitals. This study challenges the assumption that permanent night schedules maximize circadian adjustment and, therefore, reduce health problems.

Development and validation of a methodology to measure the time taken by hospital nurses to make vital signs observations

BACKGROUND

Several time and motion studies have sought to quantify the nursing work involved in observing patients' vital signs. However, none of these studies offered a validated methodology that can be replicated. This is reflected in the high variation between these studies in the mean times for measuring and recording observations.

AIM

To describe the development and inter-rater reliability of a methodology for observing the nursing time and workload involved in measuring and recording patients' vital signs.

DISCUSSION

The authors developed a methodology that used the quality of interactions (QI) tool ( Bridges et al 2018 ) to measure and record the start and finish times of the rounds of nurses observing vital signs and individual observations clustered in rounds. Two raters concurrently documented their observations of nurses undertaking patient observations in a simulated setting. The tool and associated documentation were found to be easy to use, and there was a high level of agreement in measurements by different observers.

CONCLUSION

The authors' methodology can be used to reliably measure the time involved in taking vital signs.

IMPLICATIONS FOR PRACTICE

Using the QI tool may increase precision when timing and classifying nursing activities concerning observing vital signs. The authors anticipate that it could be adapted effectively to measure several other nursing activities and so support researchers interested in capturing different aspects of nurses' work.

The association between 12-hour shifts and nurses-in-charge's perceptions of missed care and staffing adequacy: a retrospective cross-sectional observational study

BACKGROUND

Due to worldwide nursing shortages and difficulty retaining staff, long shifts for nursing staff (both registered nurses and nursing assistants) working in hospitals have been adopted widely. Because long shifts reduce the daily number of shifts from three to two, many assume that long shifts improve productivity by removing one handover and staff overlap. However, it is unclear whether staffing levels are more likely to be perceived as adequate when more long shifts are used.

OBJECTIVES

To investigate the association between the proportion of long (≥12-hour) shifts worked on a ward and nurses-in-charge's perceptions that the staffing level was sufficient to meet patient need.

METHODS

A retrospective cross-sectional study using routinely collected data (patient administrative data and rosters) linked to nurses-in-charge's reports from 81 wards within four English hospitals across 1 year (2017). Hierarchical logistic regression models were used to determine associations between the proportion of long shifts and nurses-in-charge's reports of having enough staff for quality or leaving necessary nursing care undone, after controlling for the staffing level relative to demand (shortfall). We tested for interactions between staffing shortfall and the proportion of long shifts.

RESULTS

The sample comprised 19648 ward days. On average across wards, 72% of shifts were long. With mixed short and long shifts, the odds of nurses-in-charge reporting that there were enough staff for quality were 14-17% lower than when all shifts were long. For example, the odds of reporting enough staff for quality with between 60-80% long shifts was 15% lower (95% confidence interval 2% to 27%) than with all long shifts. Associations with nursing care left undone were consistent with this pattern. Although including interactions between staffing shortfalls and the proportion of long shifts did not improve model fit, the effect of long shifts did appear to differ according to shortfall, with lower proportions of long shifts associated with benefits when staffing levels were high relative to current norms.

CONCLUSIONS

Rather than a clear distinction between wards using short and long shifts, we found that a mixed pattern operated on most days and wards, with no wards using all short shifts. We found that when wards use exclusively long shifts rather than a mixture, nurses-in-charge are more likely to judge that they have enough staff. However, the adverse effects of mixed shifts on perceptions of staffing adequacy may be reduced or eliminated by higher staffing levels. ISRCTN 12307968. Tweetable abstract 12-hour shifts in nursing: a mix of short and long shifts may be worse than all long shifts.

Burnout in nursing: a theoretical review

BACKGROUND

Workforce studies often identify burnout as a nursing 'outcome'. Yet, burnout itself-what constitutes it, what factors contribute to its development, and what the wider consequences are for individuals, organisations, or their patients-is rarely made explicit. We aimed to provide a comprehensive summary of research that examines theorised relationships between burnout and other variables, in order to determine what is known (and not known) about the causes and consequences of burnout in nursing, and how this relates to theories of burnout.

METHODS

We searched MEDLINE, CINAHL, and PsycINFO. We included quantitative primary empirical studies (published in English) which examined associations between burnout and work-related factors in the nursing workforce.

RESULTS

Ninety-one papers were identified. The majority (n = 87) were cross-sectional studies; 39 studies used all three subscales of the Maslach Burnout Inventory (MBI) Scale to measure burnout. As hypothesised by Maslach, we identified high workload, value incongruence, low control over the job, low decision latitude, poor social climate/social support, and low rewards as predictors of burnout. Maslach suggested that turnover, sickness absence, and general health were effects of burnout; however, we identified relationships only with general health and sickness absence. Other factors that were classified as predictors of burnout in the nursing literature were low/inadequate nurse staffing levels, ≥ 12-h shifts, low schedule flexibility, time pressure, high job and psychological demands, low task variety, role conflict, low autonomy, negative nurse-physician relationship, poor supervisor/leader support, poor leadership, negative team relationship, and job insecurity. Among the outcomes of burnout, we found reduced job performance, poor quality of care, poor patient safety, adverse events, patient negative experience, medication errors, infections, patient falls, and intention to leave.

CONCLUSIONS

The patterns identified by these studies consistently show that adverse job characteristics-high workload, low staffing levels, long shifts, and low control-are associated with burnout in nursing. The potential consequences for staff and patients are severe. The literature on burnout in nursing partly supports Maslach's theory, but some areas are insufficiently tested, in particular, the association between burnout and turnover, and relationships were found for some MBI dimensions only.

The association between 12-hour shifts and nurses-in-charge's perceptions of missed care and staffing adequacy: a retrospective cross-sectional observational study

BACKGROUND

Due to worldwide nursing shortages and difficulty retaining staff, long shifts for nursing staff (both registered nurses and nursing assistants) working in hospitals have been adopted widely. Because long shifts reduce the daily number of shifts from three to two, many assume that long shifts improve productivity by removing one handover and staff overlap. However, it is unclear whether staffing levels are more likely to be perceived as adequate when more long shifts are used.

OBJECTIVES

To investigate the association between the proportion of long (≥12-hour) shifts worked on a ward and nurses-in-charge's perceptions that the staffing level was sufficient to meet patient need.

METHODS

A retrospective cross-sectional study using routinely collected data (patient administrative data and rosters) linked to nurses-in-charge's reports from 81 wards within four English hospitals across 1 year (2017). Hierarchical logistic regression models were used to determine associations between the proportion of long shifts and nurses-in-charge's reports of having enough staff for quality or leaving necessary nursing care undone, after controlling for the staffing level relative to demand (shortfall). We tested for interactions between staffing shortfall and the proportion of long shifts.

RESULTS

The sample comprised 19648 ward days. On average across wards, 72% of shifts were long. With mixed short and long shifts, the odds of nurses-in-charge reporting that there were enough staff for quality were 14-17% lower than when all shifts were long. For example, the odds of reporting enough staff for quality with between 60-80% long shifts was 15% lower (95% confidence interval 2% to 27%) than with all long shifts. Associations with nursing care left undone were consistent with this pattern. Although including interactions between staffing shortfalls and the proportion of long shifts did not improve model fit, the effect of long shifts did appear to differ according to shortfall, with lower proportions of long shifts associated with benefits when staffing levels were high relative to current norms.

CONCLUSIONS

Rather than a clear distinction between wards using short and long shifts, we found that a mixed pattern operated on most days and wards, with no wards using all short shifts. We found that when wards use exclusively long shifts rather than a mixture, nurses-in-charge are more likely to judge that they have enough staff. However, the adverse effects of mixed shifts on perceptions of staffing adequacy may be reduced or eliminated by higher staffing levels. ISRCTN 12307968. Tweetable abstract 12-hour shifts in nursing: a mix of short and long shifts may be worse than all long shifts.

Performance of the Safer Nursing Care Tool to measure nurse staffing requirements in acute hospitals: a multicentre observational study

OBJECTIVES

The best way to determine nurse staffing requirements on hospital wards is unclear. This study explores the precision of estimates of nurse staffing requirements made using the Safer Nursing Care Tool (SNCT) patient classification system for different sample sizes and investigates whether recommended staff levels correspond with professional judgements of adequate staffing.

DESIGN

Observational study linking datasets of staffing requirements (estimated using a tool) to professional judgements of adequate staffing. Multilevel logistic regression modelling.

SETTING

81 medical/surgical units in four acute care hospitals.

PARTICIPANTS

22 364 unit days where staffing levels and SNCT ratings were linked to nurse reports of "enough staff for quality".

PRIMARY OUTCOME MEASURES

SNCT-estimated staffing requirements and nurses' assessments of staffing adequacy.

RESULTS

The recommended minimum sample of 20 days allowed the required number to employ (the establishment) to be estimated with a mean precision (defined as half the width of the CI as a percentage of the mean) of 4.1%. For most units, much larger samples were required to estimate establishments within ±1 whole time equivalent staff member. When staffing was lower than that required according to the SNCT, for each hour per patient day of registered nurse staffing below the required staffing level, the odds of nurses reporting that there were enough staff to provide quality care were reduced by 11%. Correspondingly, the odds of nurses reporting that necessary nursing care was left undone were increased by 14%. No threshold indicating an optimal staffing level was observed. Surgical specialty, patient turnover and more single rooms were associated with lower odds of staffing adequacy.

CONCLUSIONS

The SNCT can provide reliable estimates of the number of nurses to employ on a unit, but larger samples than the recommended minimum are usually required. The SNCT provides a measure of nursing workload that correlates with professional judgements, but the recommended staffing levels may not be optimal. Some important sources of systematic variations in staffing requirements for some units are not accounted for. SNCT measurements are a potentially useful adjunct to professional judgement but cannot replace it.

TRIAL REGISTRATION NUMBER

ISRCTN12307968.

Longitudinal Study of the Variation in Patient Turnover and Patient-to-Nurse Ratio: Descriptive Analysis of a Swiss University Hospital

Background

Variations in patient demand increase the challenge of balancing high-quality nursing skill mixes against budgetary constraints. Developing staffing guidelines that allow high-quality care at minimal cost requires first exploring the dynamic changes in nursing workload over the course of a day.

Objective

Accordingly, this longitudinal study analyzed nursing care supply and demand in 30-minute increments over a period of 3 years. We assessed 5 care factors: patient count (care demand), nurse count (care supply), the patient-to-nurse ratio for each nurse group, extreme supply-demand mismatches, and patient turnover (ie, number of admissions, discharges, and transfers).

Methods

Our retrospective analysis of data from the Inselspital University Hospital Bern, Switzerland included all inpatients and nurses working in their units from January 1, 2015 to December 31, 2017. Two data sources were used. The nurse staffing system (tacs) provided information about nurses and all the care they provided to patients, their working time, and admission, discharge, and transfer dates and times. The medical discharge data included patient demographics, further admission and discharge details, and diagnoses. Based on several identifiers, these two data sources were linked.

Results

Our final dataset included more than 58 million data points for 128,484 patients and 4633 nurses across 70 units. Compared with patient turnover, fluctuations in the number of nurses were less pronounced. The differences mainly coincided with shifts (night, morning, evening). While the percentage of shifts with extreme staffing fluctuations ranged from fewer than 3% (mornings) to 30% (evenings and nights), the percentage within “normal” ranges ranged from fewer than 50% to more than 80%. Patient turnover occurred throughout the measurement period but was lowest at night.

Conclusions

Based on measurements of patient-to-nurse ratio and patient turnover at 30-minute intervals, our findings indicate that the patient count, which varies considerably throughout the day, is the key driver of changes in the patient-to-nurse ratio. This demand-side variability challenges the supply-side mandate to provide safe and reliable care. Detecting and describing patterns in variability such as these are key to appropriate staffing planning. This descriptive analysis was a first step towards identifying time-related variables to be considered for a predictive nurse staffing model.