Status of the midwifery workforce and childbirth services and the impact of midwife staffing on birth outcomes in China: a multicentre cross-sectional study

OBJECTIVE

To investigate the status of the midwifery workforce and childbirth services in China and to identify the association between midwife staffing and childbirth outcomes.

DESIGN

A descriptive, multicentre cross-sectional survey.

SETTING

Maternity hospitals from the eastern, central and western regions of China.

PARTICIPANTS

Stratified sampling of maternity hospitals between 1 July and 31 December 2021.The sample hospitals received a package of questionnaires, and the head midwives from the participating hospitals were invited to fill in the questionnaires.

RESULTS

A total of 180 hospitals were selected and investigated, staffed with 4159 midwives, 412 obstetric nurses and 1007 obstetricians at the labour and delivery units. The average efficiency index of annual midwifery services was 272 deliveries per midwife. In the sample hospitals, 44.9% of women had a caesarean delivery and 21.4% had an episiotomy. Improved midwife staffing was associated with reduced rates of instrumental vaginal delivery (adjusted β -0.032, 95% CI -0.115 to -0.012, p<0.05) and episiotomy (adjusted β -0.171, 95% CI -0.190 to -0.056, p<0.001).

CONCLUSION

The rates of childbirth interventions including the overall caesarean section in China and the episiotomy rate, especially in the central region, remain relatively high. Improved midwife staffing was associated with reduced rates of instrumental vaginal delivery and episiotomy, indicating that further investments in the midwifery workforce could produce better childbirth outcomes.

The importance of recovery and staffing on midwives' emotional wellbeing: A UK national survey

BACKGROUND

There is currently a gap in the evidence on how working practices, such as the ability to take rest breaks, finish on time or intershift recovery influence outcomes.

AIM

The aim of this study was to explore the association of individual characteristics, work-related factors and working practices on emotional wellbeing outcomes of UK midwives.

METHODS

An online cross-sectional survey collated data between September and October 2020. Outcomes explored were work-related stress, burnout, being pleased with their standard of care, job satisfaction and thoughts about leaving midwifery. Univariate analysis identified the explanatory variables to be investigated using multivariable logistic regression.

FINDINGS

A total of 2347 midwives from the four UK nations completed the survey. No standard approach in monitoring safe staffing or in-shift or intershift recovery was found. There were high levels of work-related stress, burnout and thoughts about leaving midwifery, and low levels of job satisfaction, with just half of midwives reporting they were satisfied with the standard of care they could provide. Multivariable regression revealed that working practices variables, generally related to impeded recovery or compounded by staffing issues, had a significant association with poorer emotional wellbeing outcomes.

CONCLUSION

This research has demonstrated an association between impeded recovery, including a lack of formal methods to monitor this, and poorer emotional wellbeing outcomes, and that staffing levels are highly influential in determining outcomes. There is a need to re-evaluate current approaches to job design and how midwives are expected to work.

TAILR (Nursing-Sensitive Events and Their Association With Individual Nurse Staffing Levels) Project: Protocol for an International Longitudinal Multicenter Study

BACKGROUND

Nursing-sensitive events (NSEs) are common, accounting for up to 77% of adverse events in hospitalized patients (eg, fall-related harm, pressure ulcers, and health care-associated infections). NSEs lead to adverse patient outcomes and impose an economic burden on hospitals due to increased medical costs through a prolonged hospital stay and additional medical procedures. To reduce NSEs and ensure high-quality nursing care, appropriate nurse staffing levels are needed. Although the link between nurse staffing and NSEs has been described in many studies, appropriate nurse staffing levels are lacking. Existing studies describe constant staffing exposure at the unit or hospital level without assessing patient-level exposure to nurse staffing during the hospital stay. Few studies have assessed nurse staffing and patient outcomes using a single-center longitudinal design, with limited generalizability. There is a need for multicenter longitudinal studies with improved potential for generalizing the association between individual nurse staffing levels and NSEs.

OBJECTIVE

This study aimed (1) to determine the prevalence, preventability, type, and severity of NSEs; (2) to describe individual patient-level nurse staffing exposure across hospitals; (3) to assess the effect of nurse staffing on NSEs in patients; and (4) to identify thresholds of safe nurse staffing levels and test them against NSEs in hospitalized patients.

METHODS

This international multicenter study uses a longitudinal and observational research design; it involves 4 countries (Switzerland, Sweden, Germany, and Iran), with participation from 14 hospitals and 61 medical, surgery, and mixed units. The 16-week observation period will collect NSEs using systematic retrospective record reviews. A total of 3680 patient admissions will be reviewed, with 60 randomly selected admissions per unit. To be included, patients must have been hospitalized for at least 48 hours. Nurse staffing data (ie, the number of nurses and their education level) will be collected daily for each shift to assess the association between NSEs and individual nurse staffing levels. Additionally, hospital data (ie, type, teaching status, and ownership) and unit data (ie, service line and number of beds) will be collected.

RESULTS

As of January 2024, the verification process for the plausibility and comprehensibility of patients' and nurse staffing data is underway across all 4 countries. Data analyses are planned to be completed by spring 2024, with the first results expected to be published in late 2024.

CONCLUSIONS

This study will provide comprehensive information on NSEs, including their prevalence, preventability, type, and severity, across countries. Moreover, it seeks to enhance understanding of NSE mechanisms and the potential impact of nurse staffing on these events. We will evaluate within- and between-hospital variability to identify productive strategies to ensure safe nurse staffing levels, thereby reducing NSEs in hospitalized patients. The TAILR (Nursing-Sensitive Events and Their Association With Individual Nurse Staffing Levels) study will focus on the optimization of scarce staffing resources.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56262.

Staffing and Antipsychotic Medication Use in Nursing Homes and Neighborhood Deprivation

Importance

Inappropriate use of antipsychotic medications in nursing homes is a growing public health concern. Residents exposed to higher levels of socioeconomic deprivation in the area around a nursing home may be currently exposed, or have a long history of exposure, to more noise pollution, higher crime rates, and have less opportunities to safely go outside the facility, which may contribute to psychological stress and increased risk of receiving antipsychotic medications inappropriately. However, it is unclear whether neighborhood deprivation is associated with use of inappropriate antipsychotic medications and whether this outcome is different by facility staffing levels.

Objective

To evaluate whether reported inappropriate antipsychotic medication use differs in severely and less severely deprived neighborhoods, and whether these differences are modified by higher levels of total nurse staffing.

Design, Setting, and Participants

This was a cross-sectional analysis of a national sample of nursing homes that linked across 3 national large-scale data sets for the year 2019. Analyses were conducted between April and June 2023.

Exposure

Neighborhood deprivation status (severe vs less severe) and total staffing hours (registered nurse, licensed practical nurse, certified nursing assistant).

Main Outcome and Measures

This study estimated the association between neighborhood deprivation and the percentage of long-stay residents who received an antipsychotic medication inappropriately in the nursing home at least once in the past week and how this varied by nursing home staffing through generalized estimating equations. Analyses were conducted on the facility level and adjusted for state fixed effects.

Results

This study included 10 966 nursing homes (1867 [17.0%] in severely deprived neighborhoods and 9099 [83.0%] in less deprived neighborhoods). Unadjusted inappropriate antipsychotic medication use was greater in nursing homes located in severely deprived neighborhoods (mean [SD], 15.9% [10.7%] of residents) than in those in less deprived neighborhoods (mean [SD], 14.2% [8.8%] of residents). In adjusted models, inappropriate antipsychotic medication use was higher in severely deprived neighborhoods vs less deprived neighborhoods (19.2% vs 17.1%; adjusted mean difference, 2.0 [95% CI, 0.35 to 3.71] percentage points) in nursing homes that fell below critical levels of staffing (less than 3 hours of nurse staffing per resident-day).

Conclusions and Relevance

These findings suggest that levels of staffing modify disparities seen in inappropriate antipsychotic medication use among nursing homes located in severely deprived neighborhoods compared with nursing homes in less deprived neighborhoods. These findings may have important implications for improving staffing in more severely deprived neighborhoods.

Comparison of Sleep and Attention Metrics Among Nurses Working Shifts on a Forward- vs Backward-Rotating Schedule

IMPORTANCE

The association of fast backward-rotating shift work (ie, anticlockwise sequence of afternoon, morning, and night shifts) with subjective and objective measures of sleep-wake quality, daytime attention, and tiredness of health care workers has not yet been established.

OBJECTIVE

To investigate the association of shift rotation direction with tiredness, sleepiness, and sustained attention among nurses working forward- and backward-rotating shifts.

DESIGN, SETTING, AND PARTICIPANTS

Data of this cohort study were collected from nurses working at 5 midsized Italian hospitals. The nurses had either a forward-rotating schedule (ie, morning to afternoon to night) and or a backward-rotating schedule (ie, afternoon to morning to night). The data were collected from July 2017 to February 2020. Data analysis was performed from May to October 2020.

EXPOSURES

Participants were working either forward- or backward-rotating schedules, in which the sequence of 3 shifts (morning, afternoon, and night) changed in a clockwise or anticlockwise direction.

MAIN OUTCOMES AND MEASURES

Sleep data were collected using the Karolinska Sleepiness Scale and Pittsburgh Sleep Quality Index. Sustained attention was measured using the Psychomotor Vigilance Task. Tiredness was evaluated using the Tiredness Symptom Scale.

RESULTS

A total of 144 nurses (mean [SE] age, 41.3 [0.8] years; 92 women [63.9%]) participated in the study; 80 nurses had forward-rotating schedules, and 64 had backward-rotating schedules. Nurses with irregular sleep-wake patterns due to night shift work had poor sleep quality (46 [57.5%] in forward-rotating schedule group; 37 [57.8%] in backward-rotating schedule group). Nurses working backward-rotating shifts exhibited significantly greater sleepiness (F1,139 = 41.23; P < .001) and cognitive slowing (ie, longer median reaction times; F1,139 = 42.12; P < .001) than those working forward rotations. Importantly, these differences were not affected by age, years of employment, and quality of sleep. Of nurses working on a backward-rotating schedule, 60 (93.8%) reported elevated sleepiness (Karolinska Sleepiness Scale score ≥7) after the night shift. The median reaction time (F1,139 = 42.12; P < .001), 10% fastest reaction time (F1,139 = 97.07; P < .001), minor lapses (F1,139 = 46.29; P < .001), and reaction time distribution (F1,139 = 60.13; P < .001) of nurses on backward-rotating schedules indicated a lower level of vigilance, which is negatively associated with neurobehavioral performance.

CONCLUSIONS AND RELEVANCE

In this study, both shift rotation models were negatively associated with health and cognitive performance. These findings suggest that forward shift rotation may be more beneficial than backward rotation for several measured performance attentional outcomes and sleepiness. Optimization of shift rotations should be implemented to decrease the combination of the negative outcomes associated with shift work and reduce the potential risk of medical errors in health care systems.

Alternative Approaches to Ensuring Adequate Nurse Staffing: The Effect of State Legislation on Hospital Nurse Staffing

OBJECTIVE

The objective of this study was to addresses the basic question of whether alternative legislative approaches are effective in encouraging hospitals to increase nurse staffing.

METHODS

Using 16 years of nationally representative hospital-level data from the American Hospital Association (AHA) annual survey, we employed a difference-in-difference design to compare changes in productive hours per patient day for registered nurses (RNs), licensed practical/vocational nurses (LPNs), and nursing assistive personnel (NAP) in the state that mandated staffing ratios, states that legislated staffing committees, and states that legislated public reporting, to changes in states that did not implement any nurse staffing legislation before and after the legislation was implemented. We constructed multivariate linear regression models to assess the effects with hospital and year fixed effects, controlling for hospital-level characteristics and state-level factors.

RESULTS

Compared with states with no legislation, the state that legislated minimum staffing ratios had an 0.996 (P<0.01) increase in RN hours per patient day and 0.224 (P<0.01) increase in NAP hours after the legislation was implemented, but no statistically significant changes in RN or NAP hours were found in states that legislated a staffing committee or public reporting. The staffing committee approach had a negative effect on LPN hours (difference-in-difference=-0.076, P<0.01), while the public reporting approach had a positive effect on LPN hours (difference-in-difference=0.115, P<0.01). There was no statistically significant effect of staffing mandate on LPN hours.

CONCLUSIONS

When we included California in the comparison, our model suggests that neither the staffing committee nor the public reporting approach alone are effective in increasing hospital RN staffing, although the public reporting approach appeared to have a positive effect on LPN staffing. When we excluded California form the model, public reporting also had a positive effect on RN staffing. Future research should examine patient outcomes associated with these policies, as well as potential cost savings for hospitals from reduced nurse turnover rates.

Mitigating COVID-19 outbreaks in workplaces and schools by hybrid telecommuting

The COVID-19 epidemic has forced most countries to impose contact-limiting restrictions at workplaces, universities, schools, and more broadly in our societies. Yet, the effectiveness of these unprecedented interventions in containing the virus spread remain largely unquantified. Here, we develop a simulation study to analyze COVID-19 outbreaks on three real-life contact networks stemming from a workplace, a primary school and a high school in France. Our study provides a fine-grained analysis of the impact of contact-limiting strategies at workplaces, schools and high schools, including: (1) Rotating strategies, in which workers are evenly split into two shifts that alternate on a daily or weekly basis; and (2) On-Off strategies, where the whole group alternates periods of normal work interactions with complete telecommuting. We model epidemics spread in these different setups using a stochastic discrete-time agent-based transmission model that includes the coronavirus most salient features: super-spreaders, infectious asymptomatic individuals, and pre-symptomatic infectious periods. Our study yields clear results: the ranking of the strategies, based on their ability to mitigate epidemic propagation in the network from a first index case, is the same for all network topologies (workplace, primary school and high school). Namely, from best to worst: Rotating week-by-week, Rotating day-by-day, On-Off week-by-week, and On-Off day-by-day. Moreover, our results show that below a certain threshold for the original local reproduction number [Formula: see text] within the network (< 1.52 for primary schools, < 1.30 for the workplace, < 1.38 for the high school, and < 1.55 for the random graph), all four strategies efficiently control outbreak by decreasing effective local reproduction number to [Formula: see text] < 1. These results can provide guidance for public health decisions related to telecommuting.

Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals

BACKGROUND

Substantial evidence indicates that patient outcomes are more favourable in hospitals with better nurse staffing. One policy designed to achieve better staffing is minimum nurse-to-patient ratio mandates, but such policies have rarely been implemented or evaluated. In 2016, Queensland (Australia) implemented minimum nurse-to-patient ratios in selected hospitals. We aimed to assess the effects of this policy on staffing levels and patient outcomes and whether both were associated.

METHODS

For this prospective panel study, we compared Queensland hospitals subject to the ratio policy (27 intervention hospitals) and those that discharged similar patients but were not subject to ratios (28 comparison hospitals) at two timepoints: before implementation of ratios (baseline) and 2 years after implementation (post-implementation). We used standardised Queensland Hospital Admitted Patient Data, linked with death records, to obtain data on patient characteristics and outcomes (30-day mortality, 7-day readmissions, and length of stay [LOS]) for medical-surgical patients and survey data from 17 010 medical-surgical nurses in the study hospitals before and after policy implementation. Survey data from nurses were used to measure nurse staffing and, after linking with standardised patient data, to estimate the differential change in outcomes between patients in intervention and comparison hospitals, and determine whether nurse staffing changes were related to it.

FINDINGS

We included 231 902 patients (142 986 in intervention hospitals and 88 916 in comparison hospitals) assessed at baseline (2016) and 257 253 patients (160 167 in intervention hospitals and 97 086 in comparison hospitals) assessed in the post-implementation period (2018). After implementation, mortality rates were not significantly higher than at baseline in comparison hospitals (adjusted odds ratio [OR] 1·07, 95% CI 0·97-1·17, p=0·18), but were significantly lower than at baseline in intervention hospitals (0·89, 0·84-0·95, p=0·0003). From baseline to post-implementation, readmissions increased in comparison hospitals (1·06, 1·01-1·12, p=0·015), but not in intervention hospitals (1·00, 0·95-1·04, p=0·92). Although LOS decreased in both groups post-implementation, the reduction was more pronounced in intervention hospitals than in comparison hospitals (adjusted incident rate ratio [IRR] 0·95, 95% CI 0·92-0·99, p=0·010). Staffing changed in hospitals from baseline to post-implementation: of the 36 hospitals with reliable staffing measures, 30 (83%) had more than 4·5 patients per nurse at baseline, with the number decreasing to 21 (58%) post-implementation. The majority of change was at intervention hospitals, and staffing improvements by one patient per nurse produced reductions in mortality (OR 0·93, 95% CI 0·86-0·99, p=0·045), readmissions (0·93, 0·89-0·97, p<0·0001), and LOS (IRR 0·97, 0·94-0·99, p=0·035). In addition to producing better outcomes, the costs avoided due to fewer readmissions and shorter LOS were more than twice the cost of the additional nurse staffing.

INTERPRETATION

Minimum nurse-to-patient ratio policies are a feasible approach to improve nurse staffing and patient outcomes with good return on investment.

FUNDING

Queensland Health, National Institutes of Health, National Institute of Nursing Research.

Redeployment of Certified Registered Nurse Anesthetists During the Coronavirus Disease 2019 Pandemic

Certified Registered Nurse Anesthetists (CRNAs) are uniquely skilled anesthesia providers with substantial experience managing critically ill patients. During the coronavirus disease 2019 (COVID) pandemic, CRNAs at a large academic medical center in the Mid-Atlantic United States experienced a shift in their daily responsibilities. As the hospital transitioned to the management of patients who tested positive for the virus that causes COVID, the severe acute respiratory syndrome-coronavirus type 2 (SARS-CoV-2), CRNAs were redeployed into the roles of respiratory therapists and intensive care unit registered nurses. Although facing the stress of the global pandemic, this facility's CRNAs proved to be flexible, capable, and necessary members of the care team for patients with COVID-19.

Prevalence and Characteristics of Non-US-Born and US-Born Health Care Professionals, 2010-2018

Importance

Immigration to the US results in greater racial/ethnic diversity. However, the contribution of immigration to the diversity of the US health care professional (HCP) work force and its contribution to health care are poorly documented.

Objective

To examine the sociodemographic characteristics and workforce outcomes of non-US-born and US-born HCPs.

Design, Setting, and Participants

This cross-sectional study used national US Census Bureau data on US-born and non-US-born HCPs from the American Community Survey between 2010 and 2018. Demographic characteristics and occupational data for physicians, advanced practice registered nurses, physician assistants, registered nurses, licensed practical nurses or licensed vocational nurses, and other HCPs were included for analysis. Data were analyzed between December 2020 and February 2021.

Exposures

Nativity status, defined as US-born HCP vs non-US-born HCP (further stratified by <10 years or ≥10 years of stay in the US).

Main Outcomes and Measures

Annual hours worked, proportion of work done at night, residence in medically underserved areas and populations, and work in skilled nursing/home health settings. Inverse probability weighting of 3 nativity status groups was carried out using logistic regression. F test statistics were used to test across-group differences. Data were weighted using American Community Survey sampling weights.

Results

Of a total of 657 455 HCPs analyzed (497 180 [75.5%] women; mean [SD] age, 43.7 [13.0] years; 518 317 [75.6%] White, 54 233 [10.8%] Black, and 60 680 [9.6%] Asian), non-US-born HCPs (105 331 in total) represented 17.3% (95% CI, 17.2%-17.4%) of HCPs between 2010 and 2018. They were older (mean [SD] age, 44.7 [11.6] years) and had more education (75 227 [70.1%] HCPs completed college) compared with US-born HCPs (mean [SD] age, 43.4 [13.3] years; 304 601 [55.2%] completed college). Nearly half of non-US-born HCPs (47 735 [43.0%]) were Asian. In major metropolitan areas, non-US-born HCPs represented 40% or more of all HCPs. Compared with US-born HCPs, non-US-born HCPs with less than 10 years and 10 or more years of stay worked 32.3 hours (95% CI, 19.2 to 45.4 hours) and 71.6 hours (95% CI, 65.1 to 78.2 hours) more per year, respectively. Compared with US-born HCPs, non-US-born HCPs were more likely to reside in areas with shortages of health care professionals (estimated percentage: <10 years, 75.3%; ≥10 years, 62.8% vs US-born, 8.3%) and work in home health settings (estimated percentage: <10 years, 17.5%; ≥10 years, 13.1% vs US-born, 12.8%).

Conclusions and Relevance

The contributions of non-US-born HCPs to US health care are substantial and vary by profession. Greater efforts should be made to streamline their immigration process and to harmonize training and licensure requirements.

The interplay of sleep duration, working hours, and obesity in Korean male workers: The 2010-2015 Korea National Health and Nutrition Examination Survey

The purpose of this study was to clarify the odds ratio for association between working hours and obesity in Korean male wage workers and investigate the role of sleep duration. This study is a cross-sectional one using large-scale national data from the Korea National Health and Nutrition Examination Survey collected between 2010 and 2015 to evaluate 2,592 male wage workers (between the ages of 19 and 60 years). Obesity was defined as 25kg/m² or more and working hours per week were categorized into <40, 40–49, 50–59, and ≥60 hours. Multiple regression analysis was performed to examine the odds ratio for association between working hours and obesity, after controlling for age, education, income, marital status, smoking, drinking, physical activity, daily energy intake, sleep duration, hypertension, diabetes, dyslipidemia, work schedule, and job category. Next, to study the mediating effect of sleep duration on the association between working hours and obesity, an analysis was performed using the Baron and Kenny method and the Sobel test. Results showed that workers with 50 to 59 hours had 1.4 times higher odds (odds ratio [OR] = 1.4, confidence interval [CI]: 1.11–1.85) of obesity and workers with 60 hours or more had 1.4 times higher odds (OR = 1.4, CI: 1.06–1.90) of obesity than workers with less than 40 hours. Sleep was found to have a mediating effect on the association between working time and body mass index. Therefore, the results of this analysis suggest that practitioners should identify potential factors such as working time and sleeping time when preventing work-related obesity.

Better Nurse Staffing Is Associated With Survival for Black Patients and Diminishes Racial Disparities in Survival After In-Hospital Cardiac Arrests

BACKGROUND

Racial disparities in survival among patients who had an in-hospital cardiac arrest (IHCA) have been linked to hospital-level factors.

OBJECTIVES

To determine whether nurse staffing is associated with survival disparities after IHCA.

RESEARCH DESIGN

Cross-sectional data from (1) the American Heart Association's Get With the Guidelines-Resuscitation database; (2) the University of Pennsylvania Multi-State Nursing Care and Patient Safety Survey; and (3) The American Hospital Association annual survey. Risk-adjusted logistic regression models, which took account of the hospital and patient characteristics, were used to determine the association of nurse staffing and survival to discharge for black and white patients.

SUBJECTS

A total of 14,132 adult patients aged 18 and older between 2004 and 2010 in 75 hospitals in 4 states.

RESULTS

In models that accounted for hospital and patient characteristics, the odds of survival to discharge was lower for black patients than white patients [odds ratio (OR)=0.70; 95% confidence interval (CI), 0.61-0.82]. A significant interaction was found between race and medical-surgical nurse staffing for survival to discharge, such that each additional patient per nurse lowered the odds of survival for black patients (OR=0.92; 95% CI, 0.87-0.97) more than white patients (OR=0.97; 95% CI, 0.93-1.00).

CONCLUSIONS

Our findings suggest that disparities in IHCA survival between black and white patients may be linked to the level of medical-surgical nurse staffing in the hospitals in which they receive care and that the benefit of being admitted to hospitals with better staffing may be especially pronounced for black patients.

Impact of overtime working and social interaction on the deterioration of mental well-being among full-time workers during the COVID-19 pandemic in Japan: Focusing on social isolation by household composition

OBJECTIVES

The coronavirus disease (COVID-19) pandemic has forced many employees to alter both their work style and lifestyle. This study aimed to examine how the combination of changes in overtime working hours and social interaction affects the full-time employees' mental well-being, focusing on the difference in household composition.

METHODS

In November 2020, we conducted a cross-sectional Internet survey that included 4388 Japanese men and women aged 25-64 years, who continued the same full-time job during the pandemic. We performed a logistic regression analysis using a combination of the changes in overtime working hours and social interaction as an independent variable, and the presence/absence of deterioration of mental well-being as the dependent variable.

RESULTS

Overall, 44% of participants reported the deterioration of mental well-being compared to before the outbreak. The multivariate analysis revealed that the participants coded as "increased overtime/decreased interaction" were significantly associated with the deterioration of mental well-being compared to those with "unchanged overtime/unchanged interaction" (odds ratio [OR] 2.14, 95% confidence interval [CI] 1.59-2.89). Moreover, this association was relatively stronger among single-person households (OR 2.66, 95% CI 1.50-4.69).

CONCLUSIONS

The negative combination of increasing overtime working hours and decreasing social interaction may have an impact on the deterioration of mental well-being during the COVID-19 pandemic, and this association was comparably strong among single-person households. In the pandemic, it is necessary to pay close attention to both overtime working hours and the presence of social interaction to address the mental well-being among employees.

The Association between Nursing Skill Mix and Mortality for Adult Medical and Surgical Patients: Protocol for a Systematic Review

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.

Assessment of Changes in Rural and Urban Primary Care Workforce in the United States From 2009 to 2017

IMPORTANCE

Access to primary care clinicians, including primary care physicians and nonphysician clinicians (nurse practitioners and physician assistants) is necessary to improving population health. However, rural-urban trends in primary care access in the US are not well studied.

OBJECTIVE

To assess the rural-urban trends in the primary care workforce from 2009 to 2017 across all counties in the US.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study of US counties, county rural-urban status was defined according to the national rural-urban classification scheme for counties used by the National Center for Health Statistics at the Centers for Disease Control and Prevention. Trends in the county-level distribution of primary care clinicians from 2009 to 2017 were examined. Data were analyzed from November 12, 2019, to February 10, 2020.

MAIN OUTCOMES AND MEASURES

Density of primary care clinicians measured as the number of primary care physicians, nurse practitioners, and physician assistants per 3500 population in each county. The average annual percentage change (APC) of the means of the density of primary care clinicians over time was calculated, and generalized estimating equations were used to adjust for county-level sociodemographic variables obtained from the American Community Survey.

RESULTS

The study included data from 3143 US counties (1167 [37%] urban and 1976 [63%] rural). The number of primary care clinicians per 3500 people increased significantly in rural counties (2009 median density: 2.04; interquartile range [IQR], 1.43-2.76; and 2017 median density: 2.29; IQR, 1.57-3.23; P < .001) and urban counties (2009 median density: 2.26; IQR. 1.52-3.23; and 2017 median density: 2.66; IQR, 1.72-4.02; P < .001). The APC of the mean density of primary care physicians in rural counties was 1.70% (95% CI, 0.84%-2.57%), nurse practitioners was 8.37% (95% CI, 7.11%-9.63%), and physician assistants was 5.14% (95% CI, 3.91%-6.37%); the APC of the mean density of primary care physicians in urban counties was 2.40% (95% CI, 1.19%-3.61%), nurse practitioners was 8.64% (95% CI, 7.72%-9.55%), and physician assistants was 6.42% (95% CI, 5.34%-7.50%). Results from the generalized estimating equations model showed that the density of primary care clinicians in urban counties increased faster than in rural counties (β = 0.04; 95% CI, 0.03 to 0.05; P < .001).

CONCLUSIONS AND RELEVANCE

Although the density of primary care clinicians increased in both rural and urban counties during the 2009-2017 period, the increase was more pronounced in urban than in rural counties. Closing rural-urban gaps in access to primary care clinicians may require increasingly intensive efforts targeting rural areas.

Instability in daily life and depression: The impact of sleep variance between weekday and weekend in South Korean workers

South Korean workers have problems getting optimal sleep because they work excessively, and this affects their sleep duration and quality. To compensate for their lack of sleep on weekdays, South Korean workers have a different lifestyle on weekends, which is reflected by the terms 'Hot Friday' and 'Monday Sickness'. However, an irregular lifestyle may be a risk factor for poor health even if insufficient sleep during weekdays is supplemented by sleep on the weekend. The objective of this study was to analyse the association between depressive mood and sleep duration variance on weekdays and weekends among South Korean workers. Data from the 2016 Korea National Health and Nutrition Examination Surveys were used. Linear regression analysis was performed to determine the association between variance in sleep duration and the Patient Health Questionnaire-9 (PHQ-9) score. Additional sub-group analyses were performed to evaluate associations between variance in sleep duration and sex, marital status and perceived health status. The average sleep duration was 419.44 min on weekdays and 463.29 min on weekends. The average sleep duration on weekends was 11.73% longer than on weekdays. There was a positive association between variance in sleep and PHQ-9 score (per 1% increased, β = 0.002, p = .0074), and variance in sleep duration affected health regardless of the direction of the change (positive: increased sleep or negative: decreased sleep). Further, sub-group analyses showed that variances in sleep duration are associated with increased PHQ-9 scores in females and in individuals who were single or who had problems in their marriage. Our findings suggest that there is a relationship between variance in sleep duration and depressive symptoms among South Korean workers. Thus, healthcare professionals should suggest alternatives for optimal sleep duration and sleep methods to ensure the psychiatric health of workers.

Long working hours and cardiovascular mortality: a census-based cohort study

OBJECTIVES

Long working hours have been associated with cardiovascular disease (CVD) mortality. However, results are inconsistent and large cohort studies are needed to confirm these findings.

METHODS

We conducted a census-based cohort study including 11,903,540 Italian workers aged 20-64 years, registered in the 2011 census, with a 5-year follow-up (2012-2016). We estimated cause-specific hazard ratios (cHRs) through Cox regression models to quantify the association between long working hours and CVD mortality.

RESULTS

Over 5 years of follow-up, 17,206 individuals died from CVD (15,262 men and 1944 women). Men working 55 or more hours per week had a cHR of 0.95 (95% confidence interval, CI 0.89-1.02) for all CVDs, while women showed a cHR of 1.19 (95% CI 0.95-1.49). Professional women working more than 55 h per week had a cHR of 1.98 (95% CI 0.87-4.52).

CONCLUSIONS

This study does not support an association between long working hours and CVD mortality among active Italian men, while it suggests a possible excess risk among women, although based on limited number of events.

Association Between Consecutive Days Worked by Intensivists and Outcomes for Critically Ill Patients

OBJECTIVE

To evaluate the association between consecutive days worked by intensivists and ICU patient outcomes.

DESIGN

Retrospective cohort study linked with survey data.

SETTING

Australia and New Zealand ICUs.

PATIENTS

Adults (16+ yr old) admitted to ICU in the Australia New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation Registries (July 1, 2016, to June 30, 2018).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We linked data on staffing schedules for each unit from the Critical Care Resources Registry 2016-2017 annual survey with patient-level data from the Adult Patient Database. The a priori chosen primary outcome was ICU length of stay. Secondary outcomes included hospital length of stay, ICU readmissions, and mortality (ICU and hospital). We used multilevel multivariable regression modeling to assess the association between days of consecutive intensivist service and patient outcomes; the predicted probability of death was included as a covariate and individual ICU as a random effect. The cohort included 225,034 patients in 109 ICUs. Intensivists were scheduled for seven or more consecutive days in 43 (39.4%) ICUs; 27 (24.7%) scheduled intensivists for 5 days, 22 (20.1%) for 4 days, seven (6.4%) for 3 days, four (3.7%) for 2 days, and six (5.5%) for less than or equal to 1 day. Compared with care by intensivists working 7+ consecutive days (adjusted ICU length of stay = 2.85 d), care by an intensivist working 3 or fewer consecutive days was associated with shorter ICU length of stay (3 consecutive days: 0.46 d fewer, p = 0.010; 2 consecutive days: 0.77 d fewer, p < 0.001; ≤ 1 consecutive days: 0.68 d fewer, p < 0.001). Shorter schedules of consecutive intensivist days worked were also associated with trends toward shorter hospital length of stay without increases in ICU readmissions or hospital mortality.

CONCLUSIONS

Care by intensivists working fewer consecutive days is associated with reduced ICU length of stay without negatively impacting mortality.

Severe burnout among critical care workers in Turkey

Objectives:

To determine the prevalence and risk factors for burnout in the intensive care units (ICU) staff in Turkey. Burnout is prevelant in physicians and nurses in the ICU worldwide. Most ICU workers with burnout plan to leave their professions. Frequent replacement of ICU staff increases cost and decreases the quality of care. Prevalence and risk factors of burnout in ICU staff in Turkey are largely unknown.

Methods:

This is a cross-sectional study. Data were gathered using the Maslach Burnout Inventory (MBI) which was distributed during August 2018, among all 1161 ICU workers in Turkey.

Results:

Burnout was detected in at least one subscale in 99% of participants and in all 3 subscales in 15% of the participants. Risk factors for emotional exhaustion included female gender (odds ratio [OR]=1.87 [95% CI: 1.26-2.78]; p<0.01), alternate-day shift (OR=3.93 [95% CI: 1.66-9.30]; p<0.01), and incidence of end of life care (OR=1.01 [95% CI: 1.00-1.03]; p<0.01). For depersonalization it included alternate-day shift (OR=2.22 [95% CI: 1.15-4.26]; p<0.05), incidence of end of life care (OR=1.02 [95% CI: 1.01-1.03]; p<0.01), and for reduced personal accomplishment it included incidence of end of life care (OR=0.97 [95% CI: 0.96-0.98]; p<0.01).

Conclusion:

The results indicated that ICU staff in Turkey had a high rate of burnout.

Hospitalists staffing levels and hospital performance

OBJECTIVE (OR STUDY QUESTION)

To examine the association between hospitalists staffing levels and contract type with CMS Total Performance Score (TPS).

DATA SOURCES/STUDY SETTING

Total performance scores were obtained from CMS, hospital-level data from the 2015 American Hospital Association Annual Survey Database, and unemployment rates from the Area Resource Health File.

STUDY DESIGN

We used cluster analysis to classify hospitals based on the distribution of various hospitalist contracts, and we used regression analysis to examine the association between TPS and hospitalist staffing levels and contract distributions. Hospital-level predictors included hospitalists staffing levels, RN staffing levels, and Magnet status. Market-level variables were unemployment rates and competition.

PRINCIPAL FINDINGS

Higher staffing levels of employed hospitalists or hospitalists with a group contract are associated with higher TPS (with coefficient estimates of 0.85 and 0.83, respectively, and the same standard error of 0.22). Higher staffing levels of hospitalists under individual contract are negatively associated with TPS (with coefficient estimate of -0.43 and standard error of 0.21). Based on the regression analysis using hospital clusters as independent variables, hospitals with individual contracts or without hospitalists providing care had significantly worse TPS compared to hospitals that predominantly employ hospitalists (with coefficient estimate of -1.80 and standard error of 0.61). Magnet status, RN staffing levels, and small and medium size were positively associated with TPS. Medicare share of inpatient days, teaching status, AMCs, and for-profit and public nonfederal ownership were negatively associated with TPS.

CONCLUSIONS

Adequate hospitalist staffing level is important for hospitals to achieve better performance. Hospitals need to consider the mix of arrangements or contracts that they have with hospitalists.

Eating Behavior (Duration, Content, and Timing) Among Workers Living under Different Levels of Urbanization

Urbanization has contributed to extended wakefulness, which may in turn be associated with eating over a longer period. Here, we present a field study conducted in four groups with different work hours and places of living in order to investigate eating behavior (duration, content, and timing). Anthropometric measures were taken from the participants (rural (n = 22); town (n = 19); city-day workers (n = 11); city-night workers (n = 14)). In addition, a sociodemographic questionnaire was self-answered and 24-h food recalls were applied for three days. The 24-h food recalls revealed that fat intake varied according to the groups, with the highest consumption by the city-day workers. By contrast, city-day workers had the lowest intake of carbohydrate, whereas the rural group had the highest. In general, all groups had some degree of inadequacy in food consumption. Eating duration was negatively correlated with total energy intake, fat, and protein consumption in the rural and town groups. There was a positive correlation between body mass index and eating duration in both city groups. The rural group had the earliest start time of eating, and this was associated with a lower body mass index. This study suggested that food content and timing, as well as eating duration, differed according to place of living, which in turn may be linked to lifestyle.

Nurse staffing and healthcare-associated infections in a national healthcare system that implemented a nurse staffing directive: Multi-level interrupted time series analyses

BACKGROUND

In 2010, the Veterans Health Administration Office of Nursing Services (VHA ONS) issued a Staffing Methodology (SM) Directive, standardizing the method of determining appropriate nurse staffing for VHA facilities.

OBJECTIVES

To assess associations between the Directive, nurse staffing trends, and healthcare-associated infections.

RESEARCH DESIGN

We conducted multi-level interrupted time series analyses of nurse staffing trends and the rates of two healthcare-associated infections before and after implementation of the Directive, October 1, 2008 - June 30, 2014.

SUBJECTS

Acute care, critical care, mental health acute care, and longterm care nursing units (called Community Living Centers, CLC in VHA) among 285 VHA facilities were included in nurse staffing trends analyses, while acute and critical care units in 123 facilities were used in the analysis of infection rates.

MEASURES

Monthly rates were calculated at the facility unit level and included nursing hours per patient day (NHPPD) for all nursing personnel and number of catheter-associated urinary tract infections (CAUTI) and central line-associated bloodstream infections (CLABSI) per 1000 device days.

RESULTS

Nursing hours per patient day increased in both time periods. However, the differential change in rate of nursing hours per patient day following implementation of the Directive was not statistically significant. On average, we found a statistically significant decrease of 0.05 unit in the post-Directive central line-associated bloodstream infection rates associated with a unit increase in nursing hours per patient day.

CONCLUSIONS

System-wide implementation of Staffing Methodology may be one contributing factor impacting patient outcomes.

Paramedics and Physician Assistants in Israel

Israeli emergency medicine is undergoing change. The paramedic is experiencing high separation rates because the position is understaffed, overworked, and underpaid. Physician assistants (PAs) were introduced into the emergency department by training paramedics and to date they seem satisfied with this new role. Experience in other countries indicates that PAs can improve access to care, reduce errors, increase efficiency and have satisfying roles in health systems. The Israeli health system will need to determine if additional roles for PAs will be accepted by the public and physicians alike.

Trends in admission timing and mechanism of injury can be used to improve general surgical trauma training

INTRODUCTION

The temporal patterns and unit-based distributions of trauma patients requiring surgical intervention are poorly described in the UK. We describe the distribution of trauma patients in the UK and assess whether changes in working patterns could provide greater exposure for operative trauma training.

METHODS

We searched the Trauma Audit and Research Network database to identify all patients between 1 January 2014 to 31 December 2016. Operative cases were defined as all patients who underwent laparotomy, thoracotomy or open vascular intervention. We assessed time of arrival, correlations between mechanism of injury and surgery, and the effect of changing shift patterns on exposure to trauma patients by reference to a standard 10-hour shift assuming a dedicated trauma rotation or fellowship.

RESULTS

There were 159,719 patients from 194 hospitals submitted to the Network between 2014 and 2016. The busiest 20 centres accounted for 57,568 (36.0%) of cases in total. Of these 2147/57,568 patients (3.7%) required a general surgical operation; 43% of penetrating admissions (925 cases) and 2.2% of blunt admissions (1222 cases). The number of operations correlated more closely with the number of penetrating rather than blunt admissions (r = 0.89 vs r = 0.51). A diurnal pattern in trauma admissions enabled significant increases in trauma exposure with later start times.

CONCLUSIONS

Centres with high volume and high penetrating rates are likely to require more general surgical input and should be identified as locations for operative trauma training. It is possible to improve the number of trauma patients seen in a shift by optimising shift start time.

Minimal effects of reduced teaching hours on undergraduate medical student learning outcomes and course evaluations

Introduction: Various pressures exist for curricular change, including economic forces, burgeoning knowledge, broadening learning outcomes, and improving quality and outcomes of learning experiences. In an Australian 5-year undergraduate medical course, staff were asked to reduce teaching hours by 20% to alleviate perceived overcrowded preclinical curriculum, achieve operating efficiencies and liberate time for students' self-directed learning.Methods: A case study design with mixed methods was used to evaluate outcomes.Results: Teaching hours were reduced by 198 hours (14%) overall, lectures by 153 hours (19%) and other learning activities by 45 hours (7%). Summative assessment scores did not change significantly after the reductions: 0.4% increase, 1.5% decrease and 1.7% increase in Years 1, 2 and 3, respectively. The percentage of students successfully completing their academic year did not change significantly: 94.4% before and 93.3% after the reductions. Student evaluations from eVALUate surveys changed little, except workload was perceived to be more reasonable.Conclusions: Teaching hours, particularly lectures, can be moderately reduced with little impact on student learning outcomes or satisfaction with an undergraduate medical course.

ONS Staffing Position Statement: Ambulatory Treatment Centers

Appropriate nurse staffing levels contribute to the delivery of safe quality care and optimal patient outcomes. However, developing nurse staffing models, particularly in the ambulatory setting, is an ongoing challenge. Within this position statement, the term ambulatory setting includes infusion centers that provide treatment to patients with cancer, including non-chemotherapy treatment centers (e.g., blood products) and radiation therapy treatment centers. These settings share commonalities, including rapid turnover of patients and the administration of some type of treatment or intervention. Nurse staffing refers to the clinical nurses in the setting and does not include advanced practice nurses or nurses in other roles.

Geographical Differences and the National Meeting Effect in Patients with Out-of-Hospital Cardiac Arrests: A JCS-ReSS Study Report

The "national meeting effect" refers to worse patient outcomes when medical professionals attend academic meetings and hospitals have reduced staffing. The aim of this study was to examine differences in outcomes of patients with out-of-hospital cardiac arrest (OHCA) admitted during, before, and after meeting days according to meeting location and considering regional variation of outcomes, which has not been investigated in previous studies. Using data from a nationwide, prospective, population-based, observational study in Japan, we analyzed adult OHCA patients who underwent resuscitation attempts between 2011 and 2015. Favorable one-month neurological outcomes were compared among patients admitted during the relevant annual meeting dates of three national scientific societies, those admitted on identical days the week before, and those one week after the meeting dates. We developed a multivariate logistic regression model after adjusting for confounding factors, including meeting location and regional variation (better vs. worse outcome areas), using the "during meeting days" group as the reference. A total of 40,849 patients were included in the study, with 14,490, 13,518, and 12,841 patients hospitalized during, before, and after meeting days, respectively. The rates of favorable neurological outcomes during, before, and after meeting days was 1.7, 1.6, and 1.8%, respectively. After adjusting for covariates, favorable neurological outcomes did not differ among the three groups (adjusted OR (95% CI) of the before and after meeting dates groups was 1.03 (0.83-1.28) and 1.01 (0.81-1.26), respectively. The "national meeting effect" did not exist in OHCA patients in Japan, even after comparing data during, before, and after meeting dates and considering meeting location and regional variation.

Addressing preceptor shortages with a novel structure of blended ambulatory care rotations

INTRODUCTION

Schools of pharmacy are challenged to ensure sufficient full-time ambulatory care advance pharmacy practice experiences (APPEs). University of Maryland designed an innovative solution to create additional rotations utilizing faculty with part-time ambulatory care practices, by combining two rotation blocks into a 10-week "blended" ambulatory care/community pharmacy experience. The objective of this study is to characterize perceptions and impact of this format on student and preceptor skills, performance, and overall satisfaction, compared with the traditional five-week ambulatory care rotation.

METHODS

Ambulatory care preceptors were surveyed regarding student skills in interviewing, documentation, patient assessment, building pharmacist-patient relationships, and mentorship opportunities. Students were surveyed regarding the number of preceptors and patient interactions/week, rotation hours, clinical abilities developed, patient relationships, patient population diversity, preceptor mentorship, clinical track participation, rotation expectations, professional benefit, career development, overall satisfaction, and likelihood to recommend the rotation. Chi-square test was used to evaluate statistically significant differences in cohort responses.

RESULTS

Survey responses from 74 students (49%) and 21 preceptors (46%) were included. Student perceptions were generally positive and comparable between groups. Statistically significant differences were observed between groups in students' perception of "patient diversity" and preceptors' perception of "patient-pharmacist relationship".

CONCLUSION

The 10-week blended format provides a unique and viable option that offers a solution to shortages of preceptor availability for ambulatory care APPEs by providing a rotation format that is more conducive to clinical practice faculty part-time ambulatory clinic schedules.

The impact of nurse staffing levels and nurse's education on patient mortality in medical and surgical wards: an observational multicentre study

BACKGROUND

Growing evidence indicates that improved nurse staffing in acute hospitals is associated with lower hospital mortality. Current research is limited to studies using hospital level data or without proper adjustment for confounders which makes the translation to practice difficult.

METHOD

In this observational study we analysed retrospectively the control group of a stepped wedge randomised controlled trial concerning 14 medical and 14 surgical wards in seven Belgian hospitals. All patients admitted to these wards during the control period were included in this study. Pregnant patients or children below 17 years of age were excluded. In all patients, we collected age, crude ward mortality, unexpected death, cardiac arrest with Cardiopulmonary Resuscitation (CPR), and unplanned admission to the Intensive Care Unit (ICU). A composite mortality measure was constructed including unexpected death and death up to 72 h after cardiac arrest with CPR or unplanned ICU admission. Every 4 months we obtained, from 30 consecutive patient admissions across all wards, the Charlson comorbidity index. The amount of nursing hours per patient days (NHPPD) were calculated every day for 15 days, once every 4 months. Data were aggregated to the ward level resulting in 68 estimates across wards and time. Linear mixed models were used since they are most appropriate in case of clustered and repeated measures data.

RESULTS

The unexpected death rate was 1.80 per 1000 patients. Up to 0.76 per 1000 patients died after CPR and 0.62 per 1000 patients died after unplanned admission to the ICU. The mean composite mortality was 3.18 per 1000 patients. The mean NHPPD and proportion of nurse Bachelor hours were respectively 2.48 and 0.59. We found a negative association between the nursing hours per patient day and the composite mortality rate adjusted for possible confounders (B = - 2.771, p = 0.002). The proportion of nurse Bachelor hours was negatively correlated with the composite mortality rate in the same analysis (B = - 8.845, p = 0.023). Using the regression equation, we calculated theoretically optimal NHPPDs.

CONCLUSIONS

This study confirms the association between higher nurse staffing levels and lower patient mortality controlled for relevant confounders.

Prospective associations of psychosocial work exposures with mortality in France: STRESSJEM study protocol

INTRODUCTION

Although evidence has been provided on the associations between psychosocial work exposures and morbidity outcomes in the literature, knowledge appears much more sparse on mortality outcomes. The objective of STRESSJEM is to explore the prospective associations between psychosocial work exposures and mortality outcomes among the national French working population. In this paper, we describe the study protocol, study population, data sources, method for exposure assessment, data analysis and future plans.

METHODS AND ANALYSIS

Data sources will include: the data from the national SUMER survey from DARES on the evaluation of psychosocial work exposures and the data from the COSMOP programme from Santé publique France linking job history (DADS data from INSEE) and mortality according to causes of death (data from the national death registry, INSERM-CépiDc). A sample of 1 511 456 individuals will form the studied prospective cohort for which data are available on both job history and mortality over the period 1976-2002. Psychosocial work exposures will be imputed via a job-exposure matrix using three job title variables that are available in both the SUMER and COSMOP data sets. Our objectives will be to study the associations between various psychosocial work exposures and mortality outcomes. Psychosocial work exposures will include the job strain model factors as well as other psychosocial work factors. Various measures of exposure over time will be used. All-cause and cause-specific mortality will be studied.

ETHICS AND DISSEMINATION

Both the SUMER survey and the COSMOP programme have been approved by French ethics committees. Dissemination of the study results will include a series of international peer-reviewed papers and at least one paper in French. The results will be presented in national and international conferences. This project will offer a unique opportunity to explore mortality outcomes in association with psychosocial work exposures in a large national representative sample of the working population.

Using Contingent Medical Librarians to Address Workforce Staffing Dilemmas

Experienced medical librarians have been recruited by Mayo Clinic to provide contingency staffing. Functioning as just-in-time librarians, a nontraditional staffing plan was introduced in 2016 to affordably lessen stressors caused by fluctuating demands for library services such as literature searching. Contingent medical librarians were also needed to provide staffing coverage during the absences of existing full-time librarians, particularly Mayo's librarians employed as solo librarians working in hospital and smaller academic libraries. A four-year, nontraditional staffing plan which incorporates contingent medical librarians has proved to be a helpful, affordable, and sustainable staffing alternative for the libraries at Mayo Clinic.

Working conditions and risk exposure of employees whose occupations require driving on public roads - Factorial analysis and classification

INTRODUCTION

Several studies of the working conditions of drivers, and in particular on their pace of work, have enabled a better understanding of the risk factors for road accidents that occur during work. However, few studies are available on the risk exposure and working conditions of employees whose occupations involve driving. The purpose of this paper is to identify the different groups of employees occupationally exposed to road risk and to classify them according to working conditions.

METHODOLOGY

A Multiple Correspondence Analysis (MCA) was implemented on the 41,727 individuals from the SUMER 2010 survey (Medical Monitoring of Occupational Risk Exposure: SUrveillance Médicale des Expositions aux Risques professionnels) and for 45 variables about working conditions. The analysis used 5 categories of weekly driving exposure as a supplementary variable (variable which is not used to perform the MCA): Non-exposure; Exposed <2 h; Exposed 2-10 hours; Exposed 10-20 hours; and Exposed >20 h. The results of the MCA were used to construct an ascending hierarchical classification.

RESULTS

The first factorial axis differentiates between conventional and unconventional work schedules. Axis 2 differentiates modalities corresponding to the working hours of the most recent working week. The third axis chiefly contrasts persons who have rules to follow with those who have none. An ascending hierarchical classification distinguishes 10 clusters of individuals according to working conditions. Four clusters of employees were excessively exposed to occupational driving. Clusters also have distinct demographic, occupational and psychosocial characteristics.

CONCLUSION

Analysis of data from the SUMER survey confirms that employees exposed to road risk are particularly affected by atypical work time characteristics, but can be found in all activity sectors and in all types of job.

The association between nurse staffing levels and the timeliness of vital signs monitoring: a retrospective observational study in the UK

OBJECTIVES

Omissions and delays in delivering nursing care are widely reported consequences of staffing shortages, with potentially serious impacts on patients. However, studies so far have relied almost exclusively on nurse self-reporting. Monitoring vital signs is a key part of nursing work and electronic recording provides an opportunity to objectively measure delays in care. This study aimed to determine the association between registered nurse (RN) and nursing assistant (NA) staffing levels and adherence to a vital signs monitoring protocol.

DESIGN

Retrospective observational study.

SETTING

32 medical and surgical wards in an acute general hospital in England.

PARTICIPANTS

538 238 nursing shifts taken over 30 982 ward days.

PRIMARY AND SECONDARY OUTCOME MEASURES

Vital signs observations were scheduled according to a protocol based on the National Early Warning Score (NEWS). The primary outcome was the daily rate of missed vital signs (overdue by ≥67% of the expected time to next observation). The secondary outcome was the daily rate of late vital signs observations (overdue by ≥33%). We undertook subgroup analysis by stratifying observations into low, medium and high acuity using NEWS.

RESULTS

Late and missed observations were frequent, particularly in high acuity patients (median=44%). Higher levels of RN staffing, measured in hours per patient per day (HPPD), were associated with a lower rate of missed observations in all (IRR 0.983, 95% CI 0.979 to 0.987) and high acuity patients (0.982, 95% CI 0.972 to 0.992). However, levels of NA staffing were only associated with the daily rate (0.954, CI 0.949 to 0.958) of all missed observations.

CONCLUSIONS

Adherence to vital signs monitoring protocols is sensitive to levels of nurse and NA staffing, although high acuity observations appeared unaffected by levels of NAs. We demonstrate that objectively measured omissions in care are related to nurse staffing levels, although the absolute effects are small.

STUDY REGISTRATION

The data and analyses presented here were part of the larger Missed Care study (ISRCTN registration: 17930973).

Risk factors for occupational accidents in agricultural enterprises in Japan

In Japan, the agricultural working environment has undergone significant changes from self-employment to enterprises and employees. As the structure of the agricultural industry changes, there has been a growing interest in occupational health and safety because agriculture is a hazardous industry. However, the public is not aware of the actual situation regarding occupational accidents in agricultural enterprises because most Japanese farmers are not necessarily required to report occupational accidents. The aim of this study is to explore the risk factors regarding occupational accidents for Japanese agricultural employees. We conducted a cross-sectional study among 1,606 employees at 101 agricultural enterprises in Japan. Information on occupational accidents, personal characteristics, and working conditions was collected by questionnaires. A total of 337 valid responses were obtained. Of these respondents, 104 (30.9%) experienced occupational accidents. Multiple logistic regression analysis revealed that permanent employment (OR 3.67, 95% CI, 1.84-7.33), pesticide use (OR 2.61, 95% CI, 1.52-4.47), and long working hours (OR 1.76, 95% CI, 1.15-2.68) were associated with the risk of occupational accidents. This study revealed the risk factors for occupational accidents for Japanese agricultural employees. It is suggested that work-hour restrictions for permanent employees might contribute to reducing occupational accidents.

Mediation analysis for new recognition criteria, working hours and overwork-related disease: a nationwide ecological study using 11-year follow-up data in Taiwan

OBJECTIVES

Taiwan revised its criteria for overwork-related cerebrovascular and cardiovascular disease (CCVD) in 2010. A new definition of overwork increased the number of recognised cases. Meanwhile, actual average working hours decreased. We estimated the effects of the revised criteria on the number of overwork-related CCVD cases and the mediation effect through reduced working hours.

METHODS

From the Labor Insurance of Taiwan, we collected data on the total number of overwork-related CCVD cases from 2006 to 2016 and average monthly working hours for 13 industry groups. We conducted causal mediation analysis to investigate the mechanism of the effect of new criteria on CCVD mediated by working hours.

RESULTS

From 2006 to 2016, 594 overwork-related cases of CCVD were recognised across 13 industry groups. After introducing the new criteria, overwork-related CCVD increased by 8.40 cases (per one million person-years) (95% CI 4.53 to 15.05), which resulted from a decrease of 1.54 (95% CI 0.22 to 3.82) cases due to reduced working hours (mediation effect) and an increase of 9.93 (95% CI 5.24 to 18.17) cases related to the effect of the criteria change and other covariates excluding working hours (alternative effect).

CONCLUSIONS

Working hours are an important mediator of the effect of policy on the rate of overwork-related CCVD. Introducing new criteria for recognising overwork-related disease might raise awareness and prompt reductions in working hours, which also help to reduce CCVD. Our findings suggest that understanding mediation effects is important to evaluating national health policies.

Variation in Licensed Nurse Staffing Characteristics by State Requirements in Residential Care

Research on licensed nurses in assisted living and residential care communities (RCCs) is sparse compared to that on licensed nurses in nursing homes. RCCs are state-regulated; thus, staffing requirements vary considerably. The current study analyzed variation in characteristics of licensed nurses by state-specific requirements for licensed nurses in RCCs. A significantly higher percentage of RCCs with one or more RNs (68.87%) and licensed practical nurses (LPNs) or licensed vocational nurses (LVNs) (56.85%) were found among states with licensed nurse requirements compared to states with no such requirements (37.35% and 29.08%, respectively; p < 0.05). LPN/LVN hours were higher among RCCs in states with licensed nurse requirements compared to RCCs in states with no such requirements (17 minutes and 8 minutes, respectively; p < 0.05). The findings provide the first evidence of variation in characteristics of licensed nurses by state-specific requirements for licensed nurses. [Res Gerontol Nurs. 2019; 12(1):27-33.].

A comparison between cognitive and affective job insecurities

Cognitive and affective job insecurity are compared in six aspects related to employment: job loss, worsening of tasks, schedule, salary and workplace, and difficulties over finding an alternative job (also known as labor market insecurity). Methods: Cross-sectional study. Data comes from the third Spanish Psychosocial Risks Survey (2016) which is a representative sample of the Spanish salaried population. Results: Affective responses are more variable than cognitive ones resulting in a low degree of answer concordance (IC95% Kappa = 0.08-0.13 to 0.18-0.23). There is a significant percentage of workers (22.5-50.3%) highly concerned about their future despite perceiving low probabilities of experiencing the specific insecurity threat, except for the labor market insecurity question. Conclusion: The differences observed in the degree of insecurity between the affective and the cognitive forms confirm that they are measuring different components of the insecurity construct. These differences are partly due to the economic situation of their households.

How shift scheduling practices contribute to fatigue amongst freight rail operating employees: Findings from Canadian accident investigations

Canada's freight rail system moves 70% of the country's surface goods and almost half of all exports (RAC, 2016). These include dangerous goods. Anonymous survey of freight rail operating employees conducted by the Teamsters Canada Rail Conference (TCRC, 2014) revealed that many do not report getting enough sleep because of their work schedules, and that fatigue may be affecting their performance at work. Besides general impairments in attention and cognitive functioning, fatigue in railway operating employees slows reaction time to safety alarms and impairs conformance to train operating requirements. Shift scheduling practices can contribute to sleep-related fatigue by restricting sleep opportunities, requiring extended periods of wakefulness and by disrupting daily (circadian) rhythms. The primary goal of accident investigation is to identify causal and contributing factors so that similar occurrences can be prevented. A database search of Transportation Safety Board (TSB) rail investigation reports published in the 21-year period from 1995 to 2015 identified 18 that cited sleep-related fatigue of freight rail operating employees as a causal, contributing, or risk finding. This number represents about 20% of TSB rail investigations from the same period in which a human factors aspect of freight train activities was a primary cause. Exploration of accident themes suggests that management of fatigue and shift scheduling in the freight rail industry is a complex issue that is often not conducive to employee circadian rhythms and sleep requirements. It also suggests that current shift scheduling and fatigue management practices may be insufficient to mitigate the associated safety risk. Railway fatigue management systems that are based on the principles of modern sleep science are needed to improve scheduling practices and mitigate the ongoing safety risk.

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

BACKGROUND

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

DESIGN

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

RESULTS

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

CONCLUSION

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

The conference effect: National surgery meetings are associated with increased mortality at trauma centers without American College of Surgeons verification

Background

Thousands of physicians attend scientific conferences each year. While recent data indicate that variation in staffing during such meetings impacts survival of non-surgical patients, the association between treatment during conferences and outcomes of a surgical population remain unknown. The purpose of this study was to examine mortality resulting from traumatic injuries and the influence of hospital admission during national surgery meetings.

Study design

Retrospective analysis of in-hospital mortality using data from the Trauma Quality Improvement Program (2010–2011). Identified patients admitted during four annual meetings and compared their mortality with that of patients admitted during non-conference periods. Analysis included 155 hospitals with 12,256 patients admitted on 42 conference days and 82,399 patients admitted on 270 non-conference days. Multivariate analysis performed separately for hospitals with different levels of trauma center verification by state and American College of Surgeons (ACS) criteria.

Results

Patient characteristics were similar between meeting and non-meeting dates. At ACS level I and level II trauma centers during conference versus non-conference dates, adjusted mortality was not significantly different. However, adjusted mortality increased significantly for patients admitted to trauma centers that lacked ACS trauma verification during conferences versus non-conference days (OR 1.2, p = 0.008), particularly for patients with penetrating injuries, whose mortality rose from 11.6% to 15.9% (p = 0.006).

Conclusions

Trauma mortality increased during surgery conferences compared to non-conference dates for patients admitted to hospitals that lacked ACS trauma level verification. The mortality difference at those hospitals was greatest for patients who presented with penetrating injuries.

Impact of work hours and sleep on well-being and burnout for physicians-in-training: the Resident Activity Tracker Evaluation Study

OBJECTIVE

The Resident Activity Tracker Evaluation (RATE) is a prospective observational study evaluating the impact of work hours, sleep and physical activity on resident well-being, burnout and job satisfaction.

BACKGROUND

Physician burnout is common and its incidence is increasing. The impact of work hours and sleep on resident well-being and burnout remains elusive. Activity trackers are an innovative tool for measuring sleep and physical activity.

METHODS

Residents were recruited from (i) general surgery and orthopaedics (SURG), (ii) internal medicine and neurology (MED) and (iii) anaesthesia and radiology (RCD). Groups 1 and 2 do not enforce restrictions on the duration of being on-call, and group 3 had restricted the duration of being on-call to 12 hours. Participants wore FitBit trackers for 14 days. Total hours worked, daily sleep, sleep on-call and daily steps were recorded. Participants completed validated surveys assessing self-reported well-being (Short-Form Health Survey), burnout (Maslach Burnout Inventory), and satisfaction with medicine.

RESULTS

Surgical residents worked the most hours per week, followed by medical and RCD residents (SURG, 84.3 hours, 95% CI, 80.2-88.5; MED, 69.2 hours, 95% CI, 65.3-73.2; RCD, 52.2 hours, 95% CI, 48.2-56.1; p < 0.001). Surgical residents obtained fewer hours of sleep per day (SURG, 5.9 hours, 95% CI, 5.5-6.3; MED, 6.9 hours, 95% CI, 6.5-7.3; RCD, 6.8 hours, 95% CI, 5.6-7.2; p < 0.001). Nearly two-thirds of participants (61%) scored high burnout on the Maslach depersonalisation subscore. Total steps per day and well-being, burnout and job satisfaction were comparable between groups. Total hours worked, daily sleep and steps per day did not predict burnout or well-being.

CONCLUSIONS

Work hours and average daily sleep did not affect burnout. Physical activity did not prevent burnout. Work hour restrictions may lead to increased sleep but may not affect resident burnout or well-being.

ICU Staffing: Identification and Survey of Staff Involved in Providing Technical Support Services to Australian and New Zealand Intensive Care Units

We conducted a survey of all (200) Australian and New Zealand intensive care units to determine the presence and nature of staff employed in a technical support role. Specifically, we attempted to identify staff who are formally employed in a role where they are directly responsible for the equipment used in intensive care. Of 130 returned surveys, 80 units (62%) reported not having any personnel in this role. In these units technical tasks were most commonly performed by registered nurses (79%) but were also performed by a variety of other personnel. Fifty units (38%), consisting of approximately 105 individuals providing a total of 84.3 EFTs and most commonly in public (84%) or metropolitan (70%) hospitals or level 3 (64%) intensive care units, did have one or more staff acting in a formal technical support role. The most common groups filling the technical support role were nurses (42%), technicians (24%), biomedical engineers (10%) and technologists (6%). The most common duties performed were equipment troubleshooting (92%), training (80%), equipment evaluation (80%), ordering supplies (77%), consumable evaluation (75%), equipment cleaning (73%), delivery of supplies (70%), handling product recalls (65%), equipment maintenance (65%) and sitting on hospital committees (52%). This is the first attempt to identify and understand the technical support role in Australian and New Zealand intensive care units. Numerous issues remain and future work will hopefully add to our findings, with the possibility of formal recognition of the role, training and/or accreditation and its extension into other hospital departments.

[Working hour preferences of female and male residents : Developments over 4 years of postgraduate medical training in Germany]

OBJECTIVES

This article addresses developments regarding working hours and working hour preferences of residents undergoing postgraduate training in Germany and analyses if, and for what reasons, full-time or part-time working models are preferred.

METHODS

The source of data is the KarMed study, which is based on yearly postal surveys carried out among graduates of the year 2008/2009 from seven medical faculties in Germany. The interviews took place during the entire postgraduate training period. Response rates were 48% in the first year, with subsequent rates of above 85%. For analysis, descriptive statistics and regression models were applied.

RESULTS

There is a considerable discrepancy between the actual and the preferred working hours of residents undergoing postgraduate training. Postgraduate training is mostly linked to full-time contracts, usually with additional overtime, even though a considerable proportion of doctors prefer a part-time position. More female residents want to work part-time than male doctors. The same applies for the period after medical specialism: in particular, female doctors with children, female doctors trained in former Western Germany states, and those seeking an occupation in outpatient care request part-time contracts for their professional future. A similar trend has been increasingly observed over the years for male doctors.

CONCLUSION

Despite the huge number of residents requesting part-time contracts - during postgraduate training and afterward - the reality is still far behind this model. It is apparent that measures should be taken for both genders. Those measures should facilitate the implementation of the favored working-time model.

Documenting or Operating: Where Is Time Spent in General Surgery Residency?

OBJECTIVE

The utilization of electronic health records (EHR) has become essential in the daily activities of physicians for documentation and as an information source. However, the amount of time spent by residents utilizing the EHR has not been thoroughly evaluated, particularly within surgical specialties. This study aims to analyze EHR usage by general surgery residents and to assess the association between this use and case volume at a single academic institution.

DESIGN

For general surgery residents in clinical years (CY) 1-5, de-identified login and logout time data between September 2016 and June 2017 were retrospectively extracted from the Epic EHR (Verona, WI). A binary time series was created for each resident to indicate and track over time whether he or she was utilizing the EHR system. Comparisons between categorical variables were performed with Fisher's exact test. Continuous variables were compared using Wilcoxon rank sum test. Longitudinal linear mixed-effects models were used to assess the EHR usage among the surgery residents. The association between EHR time and the number of operative cases logged was evaluated with Pearson's correlation coefficient.

SETTING

This study was performed by the Department of Surgery in conjunction with the Office of Graduate Medical Education at Duke University Health System.

PARTICIPANTS

All active general surgery residents during the 2016-2017 academic year.

RESULTS

Thirty-six general surgery residents (28 males, 8 females) spent a median of 2.4 hours per day and 23.7 hours per week using the EHR. CY2 had the highest median usage per week (28.9 hours), while CY3 had the lowest (16.7 hours) but no significant difference based on EHR usage was found among the analyzed CYs (p = 0.164). Residents spent significantly more time logged into the EHR during the week compared to weekends and during the day compared to nights (all p < 0.001). For the residency program as a whole, a median of 151.5 total work hours per day was dedicated to documentation. On average, interns on dedicated night rotations spent 7% of their login time outside regularly scheduled duty hours while interns on dedicated day rotations spent 27%. There was no overall correlation between monthly case logs and EHR usage (r = 0.06, p = 0.30); however, CY2 had a significant negative correlation (r = -0.2, p = 0.038).

CONCLUSIONS

In the era of a maximum 80-hour work week, general surgery residents spend a substantial portion, at least 30%, of their time utilizing the EHR. One third of EHR usage by interns occurred outside the scheduled 12-hour shift, demonstrating the difficulties of completing paperwork as part of the scheduled work day. Additionally, the lack of correlation to case logs is likely due to an underestimation of the documentation burden associated with operating, which includes preparatory effort and operative notes. Ultimately, these quantitative EHR usage results will be correlated to burnout prior to implementing programs to improve efficiency and decrease the burden of charting.

Findings from Healthcare in Danger Project: Pakistan security assessment of a public and private tertiary care hospital in Karachi: Gaps and way forward

OBJECTIVE

To identify and compare security gaps in a public and private tertiary care hospital.

METHODS

The study was conducted in January 2016 using a tool adopted from Ingersoll Rand Security Technologies, Occupational Safety and Health Association and findings of baseline research carried out by Health Care in Danger Project at a public and private sector hospital in Karachi. The names of hospitals were kept confidential. Areas assessed included adequacy of workforce, existing institutional mechanisms and campus security. The tool was completed by interviewing administration, security department, and healthcare workers in wards and the emergency departments as well as patients, attendants and through observation visits.

RESULTS

The burden of doctors at the private-sector hospital was higher compared to the publicsector hospital (40 versus 22 patients per doctor per day) in the outpatient department. Privatesector hospital scored better than public-sector hospital with regards to compliance to security management standards (68% versus 50%), security perception of staff (90% versus 50%), security staffing (60% versus 50%), and visitor management (80% versus 40%). Campus security was better at private-sector hospital (56% versus 31%). Scores for employee orientation and training were low (30% and 20%), while scores for organisational partnerships were high in both hospitals (80% each). .

CONCLUSIONS

Four-pronged strategic framework is recommended that shall comprise restricting access of attendants/visitors/vendors, improving interaction between patients/healthcare workers/guards, mechanisms of reporting and responding to violent events, and maintaining sufficient resources for enhancing and improving security in hospitals.

Later careers - regenerating the medical workforce

We have a medical workforce crisis where we have insufficient trainees, demonstrated by rota gaps, and in turn nearly half of advertised consultant physician posts cannot be appointed to. Most physicians retire around age 62, and already 5% of the total consultant workforce is those who have retired and returned. If those reaching retirement age chose not to retire but continue working less than full time this would, at least in part, benefit the workforce and utilise valuable skills and experience to the benefit of the individual, the wider medical community and therefore our patients.

The design of an estimation norm to assess nurses required for educational and non-educational hospitals using workload indicators of staffing need in Iran

BACKGROUND

One of the effective strategies in the fair distribution of human resources is the use of estimation norm of human workforce. A norm is a coefficient or an indicator for estimating the required human resources in an organization. Due to the changes in the available working hours of nurses in recent years and to use of a standard method, the Iranian Ministry of Health decided to update nursing estimation norm in hospitals in 2014-2015. This study aimed to design a nurse-required estimation norm for educational and non-educational hospitals based on the workload indicator in Iran.

METHODS

This was a descriptive cross-sectional study, carried out from December 2015 to November 2016 in 49 wards in 12 educational and 17 non-educational hospitals in Mashhad, Iran. The wards and hospitals who had the best performance in nursing care quality indicators were selected. Focus group, work study, consensus, interview, and reviewing documents, staff and patient records, and the calculations of modified Workload Indicators of Staffing Needs (WISN) were used to collect the data.

RESULTS

Patient care, cardiopulmonary resuscitation, and transfer out of the hospital were identified as the main activities of holding focus groups. Interviews and reviewing documents led to the identification of 10 factors associated with nurses' available working time. In both educational and non-educational hospitals, the annual working time of all nurses except nurses working in the burn and psychiatric, burn ICU, and pediatric psychiatry wards, which was 1302 h per year, was 1411 h per year. The calculations of the modified WISN method showed that the lowest norm in educational hospitals was for psychiatric, eye surgery, and dermatology wards (0.53) and in non-educational hospitals was for ENT ward (0.57). The highest norm in educational and non-educational hospitals was for burn ICU (3.95) and general ICU (3.07) wards, respectively.

CONCLUSION

The nursing estimation norm in different wards of the hospital varies, considering that the time available to nurses and their workload in different wards and hospitals are different, and each ward has its special norm therefore, a single norm for all wards and hospitals cannot be used for a fair distribution of nurses.