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 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.

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.

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.

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.

Student nurses' views on shift patterns: What do they prefer and why? Results from a Tweetchat

Aim

The main aim of the study was to understand student nurses’ views around shift patterns.

Design

Qualitative study.

Method

We held a Tweetchat in May 2019, where we asked questions around the frequency of 12‐hr shifts working on placement; schedule flexibility while on placement; which shift patterns they preferred and why. Data from the Tweetchat were analysed using reflexive thematic analysis to generate themes from initial codes.

Results

Seventy‐three nursing students participated in the Tweetchat. The majority reported that they work 12‐hr shifts on placements, particularly when based in a hospital. We identified three themes: ‘Achieving a personal equilibrium’; ‘Meeting the needs of the care environment’; ‘Factors affecting negotiation capacity’. Data highlighted a conflict for most students, where they preferred 12‐hr shifts because of more time off for study, paid work and leisure, while acknowledging 12‐hr shifts negatively affected their fatigue, exhaustion and led them to follow a poor diet and neglect exercise and sleep.

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.

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.

Are long shifts, overtime and staffing levels associated with nurses' opportunity for educational activities, communication and continuity of care assignments? A cross-sectional study

Background & Objectives

Previous research demonstrates the impact of workforce organisation variables on quality of care and nurse wellbeing. However, the extent to which these variables influence completion of important "ancillary" nursing work is unexplored. This type of work can include discussion of care information between colleagues, promoting continuity of care during shift changes, and participating in continuing professional development programs. Although ancillary work is not usually classified as direct nursing care, it remains critical to the delivery of safe and effective care, as well as for building nurse resiliency and workforce capacity. Our aim was to examine the relationship between ≥12-hour shifts, overtime, and lower staffing levels and opportunities for completing ancillary work.

Design & Methods

Cross-sectional survey of 2990 registered nurses in 48 hospitals in England. Relationships were estimated through generalised linear mixed models.

Results

When compared to ≤8 hour shifts, nurses working ≥12-hour shifts were less likely to report having staff education programs (OR=0.58, 95% CI [0.43, 0.76]) and enough opportunity to discuss patient care with other nurses (OR=0.72, 95% CI [0.56, 0.92]). When compared to working overtime, nurses working only scheduled hours reported more opportunities these activities (OR=1.31, 95% CI [1.07, 1.61] and OR=2.06, 95% CI [1.72, 2.47] respectively), and reported fewer cases of losing care information during handovers (OR=0.72, 95% CI [0.60, 0.86]). Furthermore, with each additional patient per nurse (i.e., higher workloads), poorer outcomes for all variables of interest were observed.

Conclusion

Long shifts, overtime, and lower staffing levels are associated with fewer reported opportunities for completing ancillary work. Our findings contribute to the large body of literature exploring the drawbacks of implementing short-term solutions for nurse shortages and warrant careful consideration when establishing nursing shift rotas and staffing policies.

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.

What is the nursing time and workload involved in taking and recording patients' vital signs? A systematic review

AIMS AND OBJECTIVES

To synthesise evidence regarding the time nurses take to monitor and record vital signs observations and to calculate early warning scores.

BACKGROUND

While the importance of vital signs' monitoring is increasingly highlighted as a fundamental means of maintaining patient safety and avoiding patient deterioration, the time and associated workload involved in vital signs activities for nurses are currently unknown.

DESIGN

Systematic review.

METHODS

A literature search was performed up to 17 December 2019 in CINAHL, Medline, EMBASE and the Cochrane Library using the following terms: vital signs; monitoring; surveillance; observation; recording; early warning scores; workload; time; and nursing. We included studies performed in secondary or tertiary ward settings, where vital signs activities were performed by nurses, and we excluded qualitative studies and any research conducted exclusively in paediatric or maternity settings. The study methods were compliant with the PRISMA checklist.

RESULTS

Of 1,277 articles, we included 16 papers. Studies described taking vital signs observations as the time to measure/collect vital signs and time to record/document vital signs. As well as mean times being variable between studies, there was considerable variation in the time taken within some studies as standard deviations were high. Documenting vital signs observations electronically at the bedside was faster than documenting vital signs away from the bed.

CONCLUSIONS

Variation in the method(s) of vital signs measurement, the timing of entry into the patient record, the method of recording and the calculation of early warning scores values across the literature make direct comparisons of their influence on total time taken difficult or impossible.

RELEVANCE TO CLINICAL PRACTICE

There is a very limited body of research that might inform workload planning around vital signs observations. This uncertainty means the resource implications of any recommendation to change the frequency of observations associated with early warning scores are unknown.

12-hr shifts in nursing: Do they remove unproductive time and information loss or do they reduce education and discussion opportunities for nurses? A cross-sectional study in 12 European countries

Aims and objectives

To examine the association between registered nurses' (referred to as “nurses” for brevity) shifts of 12 hr or more and presence of continuing educational programmes; ability to discuss patient care with other nurses; assignments that foster continuity of care; and patient care information being lost during handovers.

Background

The introduction of long shifts (i.e., shifts of 12 hr or more) remains controversial. While there are claims of efficiency, studies have shown long shifts to be associated with adverse effects on quality of care. Efficiency claims are predicated on the assumption that long shifts reduce overlaps between shifts; these overlaps are believed to be unproductive and dangerous. However, there are potentially valuable educational and communication activities that occur during these overlaps.

Design

Cross‐sectional survey of 31,627 nurses within 487 hospitals in 12 European countries.

Methods

The associations were measured through generalised linear mixed models. The study methods were compliant with the STROBE checklist.

Results

When nurses worked shifts of 12 hr or more, they were less likely to report having continuing educational programmes; and time to discuss patient care with other nurses, compared to nurses working 8 hr or less. Nurses working shifts of 12 hr or more were less likely to report assignments that foster continuity of care, albeit the association was not significant. Similarly, working long shifts was associated with reports of patient care information being lost during handovers, although association was not significant.

Conclusion

Working shifts of 12 hr or more is associated with reduced educational activities and fewer opportunities to discuss patient care, with potential negative consequences for safe and effective care.

Relevance to clinical practice

Implementation of long shifts should be questioned, as reduced opportunity to discuss care or participate in educational activities may jeopardise the quality and safety of care for patients.

Nurse staffing, nursing assistants and hospital mortality: retrospective longitudinal cohort study

Objective

To determine the association between daily levels of registered nurse (RN) and nursing assistant staffing and hospital mortality.

Design

This is a retrospective longitudinal observational study using routinely collected data. We used multilevel/hierarchical mixed-effects regression models to explore the association between patient outcomes and daily variation in RN and nursing assistant staffing, measured as hours per patient per day relative to ward mean. Analyses were controlled for ward and patient risk.

Participants

138 133 adult patients spending >1 days on general wards between 1 April 2012 and 31 March 2015.

Outcomes

In-hospital deaths.

Results

Hospital mortality was 4.1%. The hazard of death was increased by 3% for every day a patient experienced RN staffing below ward mean (adjusted HR (aHR) 1.03, 95% CI 1.01 to 1.05). Relative to ward mean, each additional hour of RN care available over the first 5 days of a patient’s stay was associated with 3% reduction in the hazard of death (aHR 0.97, 95% CI 0.94 to 1.0). Days where admissions per RN exceeded 125% of the ward mean were associated with an increased hazard of death (aHR 1.05, 95% CI 1.01 1.09). Although low nursing assistant staffing was associated with increases in mortality, high nursing assistant staffing was also associated with increased mortality.

Conclusion

Lower RN staffing and higher levels of admissions per RN are associated with increased risk of death during an admission to hospital. These findings highlight the possible consequences of reduced nurse staffing and do not give support to policies that encourage the use of nursing assistants to compensate for shortages of RNs.

Association between 12-hr shifts and nursing resource use in an acute hospital: Longitudinal study

Aim

To evaluate whether ≥12‐hr shifts are associated with a decrease in resource use, in terms of care hours per patient day and staffing costs per patient day.

Background

Nurses working long shifts may become less productive and no research has investigated whether potential cost savings are realized.

Method

A retrospective longitudinal study using routinely collected data from 32 wards within an English hospital across 3 years (1 April 2012–31 March 2015). There were 24,005 ward‐days. Hierarchical linear mixed models measured the association between the proportion of ≥12‐hr shifts worked on a ward‐day, care hours per patient day and staffing costs per patient day.

Results

Compared with days with no ≥12‐hr shifts, days with between 50% and 75% ≥12‐hr shifts had more care hours per patient day and higher costs (estimate for care hours per patient day: 0.32; 95% CI: 0.28–0.36; estimate for staffing costs per patient day: £8.86; 95% CI: 7.59–10.12).

Conclusions

We did not find reductions in total care hours and costs associated with the use of ≥12‐hr shifts. The reason why mixed shift patterns are associated with increased cost needs further exploration.

Implications for Nursing Management

Increases in resource use could result in additional costs or loss of productivity for hospitals. Implementation of long shifts should be questioned.

Are long nursing shifts on hospital wards associated with sickness absence? A longitudinal retrospective observational study

Objective

To investigate whether working 12 hr shifts is associated with increased sickness absence among registered nurses and health care assistants.

Background

Previous studies reported negative impacts on nurses’ 12 hr shifts; however, these studies used cross‐sectional techniques and subjective nurse‐reported data.

Methods

A retrospective longitudinal study using routinely collected data across 32 general inpatient wards at an acute hospital in England. We used generalized linear mixed models to explore the association between shift patterns and the subsequent occurrence of short (<7 days) or long‐term (≥7 days) sickness absence.

Results

We analysed 601,282 shifts and 8,090 distinct episodes of sickness absence. When more than 75% of shifts worked in the past 7 days were 12 hr in length, the odds of both a short‐term (adjusted odds ratio = 1.28; 95% confidence index: 1.18–1.39) and long‐term sickness episode (adjusted odds ratio = 1.22; 95% confidence index: 1.08–1.37) were increased compared with working none.

Conclusion

Working long shifts on hospital wards is associated with a higher risk of sickness absence for registered nurses and health care assistants.

Implications for Nursing Management

The higher sickness absence rates associated with long shifts could result in additional costs or loss of productivity for hospitals. The routine implementation of long shifts should be avoided.

The association between nurse staffing and omissions in nursing care: A systematic review

AIMS

To identify nursing care most frequently missed in acute adult inpatient wards and to determine evidence for the association of missed care with nurse staffing.

BACKGROUND

Research has established associations between nurse staffing levels and adverse patient outcomes including in-hospital mortality. However, the causal nature of this relationship is uncertain and omissions of nursing care (referred as missed care, care left undone or rationed care) have been proposed as a factor which may provide a more direct indicator of nurse staffing adequacy.

DESIGN

Systematic review.

DATA SOURCES

We searched the Cochrane Library, CINAHL, Embase and Medline for quantitative studies of associations between staffing and missed care. We searched key journals, personal libraries and reference lists of articles.

REVIEW METHODS

Two reviewers independently selected studies. Quality appraisal was based on the National Institute for Health and Care Excellence quality appraisal checklist for studies reporting correlations and associations. Data were abstracted on study design, missed care prevalence and measures of association. Synthesis was narrative.

RESULTS

Eighteen studies gave subjective reports of missed care. Seventy-five per cent or more nurses reported omitting some care. Fourteen studies found low nurse staffing levels were significantly associated with higher reports of missed care. There was little evidence that adding support workers to the team reduced missed care.

CONCLUSIONS

Low Registered Nurse staffing is associated with reports of missed nursing care in hospitals. Missed care is a promising indicator of nurse staffing adequacy. The extent to which the relationships observed represent actual failures, is yet to be investigated.

What impact does nursing care left undone have on patient outcomes? Review of the literature

Aims and objectives

Systematic review of the impact of missed nursing care on outcomes in adults, on acute hospital wards and in nursing homes.

Background

A considerable body of evidence supports the hypothesis that lower levels of registered nurses on duty increase the likelihood of patients dying on hospital wards, and the risk of many aspects of care being either delayed or left undone (missed). However, the direct consequence of missed care remains unclear.

Design

Systematic review.

Methods

We searched Medline (via Ovid), CINAHL (EBSCOhost) and Scopus for studies examining the association of missed nursing care and at least one patient outcome. Studies regarding registered nurses, healthcare assistants/support workers/nurses’ aides were retained. Only adult settings were included. Because of the nature of the review, qualitative studies, editorials, letters and commentaries were excluded. PRISMA guidelines were followed in reporting the review.

Results

Fourteen studies reported associations between missed care and patient outcomes. Some studies were secondary analyses of a large parent study. Most of the studies used nurse or patient reports to capture outcomes, with some using administrative data. Four studies found significantly decreased patient satisfaction associated with missed care. Seven studies reported associations with one or more patient outcomes including medication errors, urinary tract infections, patient falls, pressure ulcers, critical incidents, quality of care and patient readmissions. Three studies investigated whether there was a link between missed care and mortality and from these results no clear associations emerged.

Conclusions

The review shows the modest evidence base of studies exploring missed care and patient outcomes generated mostly from nurse and patient self‐reported data. To support the assertion that nurse staffing levels and skill mix are associated with adverse outcomes as a result of missed care, more research that uses objective staffing and outcome measures is required.

Relevance to clinical practice

Although nurses may exercise judgements in rationing care in the face of pressure, there are nonetheless adverse consequences for patients (ranging from poor experience of care to increased risk of infection, readmissions and complications due to critical incidents from undetected physiological deterioration). Hospitals should pay attention to nurses’ reports of missed care and consider routine monitoring as a quality and safety indicator.

Cross-sectional examination of the association between shift length and hospital nurses job satisfaction and nurse reported quality measures

Background

Twenty-four hour nursing care involves shift work including 12-h shifts. England is unusual in deploying a mix of shift patterns. International evidence on the effects of such shifts is growing. A secondary analysis of data collected in England exploring outcomes with 12-h shifts examined the association between shift length, job satisfaction, scheduling flexibility, care quality, patient safety, and care left undone.

Methods

Data were collected from a questionnaire survey of nurses in a sample of English hospitals, conducted as part of the RN4CAST study, an EU 7^th Framework funded study. The sample comprised 31 NHS acute hospital Trusts from 401 wards, in 46 acute hospital sites. Descriptive analysis included frequencies, percentages and mean scores by shift length, working beyond contracted hours and day or night shift. Multi-level regression models established statistical associations between shift length and nurse self-reported measures.

Results

Seventy-four percent (1898) of nurses worked a day shift and 26% (670) a night shift. Most Trusts had a mixture of shifts lengths. Self-reported quality of care was higher amongst nurses working ≤8 h (15.9%) compared to those working longer hours (20.0 to 21.1%). The odds of poor quality care were 1.64 times higher for nurses working ≥12 h (OR = 1.64, 95% CI 1.18–2.28, p = 0.003).

Mean ‘care left undone’ scores varied by shift length: 3.85 (≤8 h), 3.72 (8.01–10.00 h), 3.80 (10.01–11.99 h) and were highest amongst those working ≥12 h (4.23) (p < 0.001). The rate of care left undone was 1.13 times higher for nurses working ≥12 h (RR = 1.13, 95% CI 1.06–1.20, p < 0.001).

Job dissatisfaction was higher the longer the shift length: 42.9% (≥12 h (OR = 1.51, 95% CI 1.17–1.95, p = .001); 35.1% (≤8 h) 45.0% (8.01–10.00 h), 39.5% (10.01–11.99 h).

Conclusions

Our findings add to the growing international body of evidence reporting that ≥12 shifts are associated with poor ratings of quality of care and higher rates of care left undone. Future research should focus on how 12-h shifts can be optimised to minimise potential risks.

Twelve-hour shifts: burnout or job satisfaction?

Job satisfaction and burnout in the nursing workforce are global concerns. Not only do job satisfaction and burnout affect the quality and safety of care, but job satisfaction is also a factor in nurses' decisions to stay or leave their jobs. Shift patterns may be an important aspect influencing wellbeing and satisfaction among nurses. Many hospitals worldwide are moving to 12-hour shifts in an effort to improve efficiency and cope with nursing shortages. But what is the effect of these work patterns on the wellbeing of nurses working on hospital wards? This article reports on the results of a study performed in 12 European countries exploring whether 12-hour shifts are associated with burnout, job satisfaction and intention to leave the job.

Association of 12 h shifts and nurses' job satisfaction, burnout and intention to leave: findings from a cross-sectional study of 12 European countries

OBJECTIVES

12 h shifts are becoming increasingly common for hospital nurses but there is concern that long shifts adversely affect nurses' well-being, job satisfaction and intention to leave their job. The aim of this study is to examine the association between working long shifts and burnout, job dissatisfaction, dissatisfaction with work schedule flexibility and intention to leave current job among hospital nurses.

METHODS

Cross-sectional survey of 31,627 registered nurses in 2170 general medical/surgical units within 488 hospitals across 12 European countries.

RESULTS

Nurses working shifts of ≥12 h were more likely than nurses working shorter hours (≤8) to experience burnout, in terms of emotional exhaustion (adjusted OR (aOR)=1.26; 95% CI 1.09 to 1.46), depersonalisation (aOR=1.21; 95% CI 1.01 to 1.47) and low personal accomplishment (aOR=1.39; 95% CI 1.20 to 1.62). Nurses working shifts of ≥12 h were more likely to experience job dissatisfaction (aOR=1.40; 95% CI 1.20 to 1.62), dissatisfaction with work schedule flexibility (aOR=1.15; 95% CI 1.00 to 1.35) and report intention to leave their job due to dissatisfaction (aOR=1.29; 95% CI 1.12 to 1.48).

CONCLUSIONS

Longer working hours for hospital nurses are associated with adverse outcomes for nurses. Some of these adverse outcomes, such as high burnout, may pose safety risks for patients as well as nurses.

A literature review on self-care of chronic illness: definition, assessment and related outcomes

INTRODUCTION

Chronic illnesses care represents a challenging issue for people well-being and future health systems' sustainability. Promotion of self-care is considered a key point for chronically ill patients' care. The aim of this literature was to explore: how self-care of chronic illness has been theoretically defined; how self-care can be assessed in clinical and research settings; what associations exist between self-care and health outcomes of chronically ill patients.

RESULTS

A wide range of definitions and terminologies related to self-care of chronic illness has been found in the literature. Although some common elements useful to explain the concept of self-care have been identified, the physical, cognitive, emotional and social processes underlying self-care remain controversial and poorly defined. Valid and reliable disease-specific assessment tools have been developed and used in a growing number of studies; however, the lack of utilization of standardized instruments in clinical practice has been referred by many authors. Significant correlations between self-care of chronic illness and outcome measures e.g. general health status, quality of life and healthcare costs, are reported by a limited number of studies.

CONCLUSION

Supporting patient self-care is recognized as a crucial factor in chronic illness care. A deeper analysis of variables and processes influencing self-care could help for a full description of the phenomenon. A systematic evaluation of self-care in health professionals' everyday clinical practice is strongly recommended. The development of general non-disease-specific assessment tools could facilitate the evaluation of complex patients, especially those with multiple co-morbidities. Although self-care has been recognized as a vital intermediate outcome, further large-scale studies clarifying the association between self-care and patients' and health systems' outcomes are needed.