1
|
Abstract
BACKGROUND Nurses working long shifts (≥12 h) experience higher levels of burnout. Yet other shift characteristics, including fixed versus rotating night work, weekly hours and breaks have not been considered. Choice over shift length may moderate the relationship; however, this has not been tested. AIMS To examine the association between shift work characteristics and burnout and exhaustion, and whether choice over shift length influences burnout and exhaustion. METHODS Cross-sectional online survey of nursing staff working in the UK and Ireland. We recruited two large National Health Service Trusts, through trade union membership, online/print nursing magazines and social media. We assessed associations using both univariable and multivariable generalized linear models. RESULTS We had 873 valid responses. Reports of inadequate staffing levels (odds ratio [OR] = 2.84; 95% confidence interval [CI] 2.08-3.90) and less choice over shift length (OR = 0.20; 95% CI 0.06-0.54) were associated with higher burnout in multivariable models. Similar associations were found for exhaustion, where rarely or never taking breaks was also a predictor (OR = 1.61; 95% CI 1.05-2.52). Nurses who worked long shifts had less choice than those working shifts of 8 h or less (66% of 12-h shift nurses versus 44% 8-h shift nurses reporting having no choice), but choice did not moderate the relationship between shift length and burnout and exhaustion. CONCLUSIONS The relationship between long shifts and increased burnout reported previously might have arisen from a lack of choice for those staff working long shifts. Whether limited choice for staff is intrinsically linked to long shifts is unclear.
Collapse
Affiliation(s)
- C Dall’Ora
- School of Health Sciences, University of Southampton, Southampton, UK
- National Institute for Health Research Applied Research Collaboration, Wessex SO16 7NP, UK
| | - O-Z Ejebu
- School of Health Sciences, University of Southampton, Southampton, UK
- National Institute for Health Research Applied Research Collaboration, Wessex SO16 7NP, UK
| | - J Ball
- School of Health Sciences, University of Southampton, Southampton, UK
| | - P Griffiths
- School of Health Sciences, University of Southampton, Southampton, UK
- National Institute for Health Research Applied Research Collaboration, Wessex SO16 7NP, UK
| |
Collapse
|
2
|
Dall’Ora C, Maruotti A, Griffiths P. Temporary Staffing and Patient Death in Acute Care Hospitals: A Retrospective Longitudinal Study. J Nurs Scholarsh 2019; 52:210-216. [DOI: 10.1111/jnu.12537] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Chiara Dall’Ora
- Research Fellow in Nursing Workforce University of Southampton, School of Health Sciences, and visiting researcher NIHR CLAHRC Wessex, University of Southampton, School of Health Sciences Southampton UK
| | - Antonello Maruotti
- Professor, Dipartimento di Scienze Economiche Politiche e delle Lingue Moderne – Libera Università Maria Ss Assunta Roma Italy
| | - Peter Griffiths
- Chair of Health Services Research University of Southampton, School of Health Sciences, and NIHR CLAHRC Wessex, University of Southampton, School of Health Sciences Southampton UK
| |
Collapse
|
3
|
Dall’Ora C, Griffiths P, Redfern O, Recio-Saucedo A, Meredith P, Ball J. Nurses' 12-hour shifts and missed or delayed vital signs observations on hospital wards: retrospective observational study. BMJ Open 2019; 9:e024778. [PMID: 30782743 PMCID: PMC6361343 DOI: 10.1136/bmjopen-2018-024778] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES 12-hour shifts worked by nurses on acute hospital wards have been associated with increased rates of missed care reported by nurses. This study aimed to measure the association between nurses working shifts of at least 12 hours and an objective measure of missed care: vital signs observations taken on time according to an acuity-based surveillance protocol. DESIGN A retrospective observational study using routinely collected data from March 2012 to March 2015. SETTING 32 general inpatient wards at a large acute hospital in England. PARTICIPANTS 658 628 nursing shifts nested in 24 069 ward days. OUTCOME MEASURES The rate of daily delayed and missed vital signs observations. We focused on situations where vital signs observations were required at least every 4 hours and measured the number of instances where observations were delayed or missed, per 24-hour period. For each ward and each day, shift patterns were characterised in terms of proportion of care hours per patient day deriving from 'long' shifts (≥12 hours) for both registered nurses and healthcare assistants. RESULTS On 99 043 occasions (53%), observations were significantly delayed, and on 81 568 occasions (44%), observations were missed. Observations were more likely to be delayed when a higher proportion of the hours worked by healthcare assistants were part of long shifts (IRR=1.05; 95% CI 1.00 to 1.10). No significant association was found in relation to the proportion of hours registered nurses worked as long shifts. CONCLUSION On days when a higher proportion of hours worked by healthcare assistants are from long shifts, the risk of delaying vital signs observations is higher, suggesting lower job performance. While longer shifts are thought to require fewer staff resources to maintain nurse-to-patient ratios, any benefits may be lost if staff become less productive.
Collapse
Affiliation(s)
- Chiara Dall’Ora
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (Wessex), University of Southampton, Southampton, UK
- School of Health Sciences, University of Southampton, UK
| | - Peter Griffiths
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (Wessex), University of Southampton, Southampton, UK
- School of Health Sciences, University of Southampton, UK
| | - Oliver Redfern
- School of Computing, University of Portsmouth, Portsmouth, UK
- Nuffield Department of Clinical Neurosciences, Kadoorie Centre for Critical Care Research and Education, University of Oxford, Oxford, UK
| | | | - Paul Meredith
- Research and Innovation Department, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Jane Ball
- School of Health Sciences, University of Southampton, UK
| | | |
Collapse
|
4
|
Griffiths P, Ball J, Bloor K, Böhning D, Briggs J, Dall’Ora C, Iongh AD, Jones J, Kovacs C, Maruotti A, Meredith P, Prytherch D, Saucedo AR, Redfern O, Schmidt P, Sinden N, Smith G. Nurse staffing levels, missed vital signs and mortality in hospitals: retrospective longitudinal observational study. Health Serv Deliv Res 2018. [DOI: 10.3310/hsdr06380] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background
Low nurse staffing levels are associated with adverse patient outcomes from hospital care, but the causal relationship is unclear. Limited capacity to observe patients has been hypothesised as a causal mechanism.
Objectives
This study determines whether or not adverse outcomes are more likely to occur after patients experience low nurse staffing levels, and whether or not missed vital signs observations mediate any relationship.
Design
Retrospective longitudinal observational study. Multilevel/hierarchical mixed-effects regression models were used to explore the association between registered nurse (RN) and health-care assistant (HCA) staffing levels and outcomes, controlling for ward and patient factors.
Setting and participants
A total of 138,133 admissions to 32 general adult wards of an acute hospital from 2012 to 2015.
Main outcomes
Death in hospital, adverse event (death, cardiac arrest or unplanned intensive care unit admission), length of stay and missed vital signs observations.
Data sources
Patient administration system, cardiac arrest database, eRoster, temporary staff bookings and the Vitalpac system (System C Healthcare Ltd, Maidstone, Kent; formerly The Learning Clinic Limited) for observations.
Results
Over the first 5 days of stay, each additional hour of RN care was associated with a 3% reduction in the hazard of death [hazard ratio (HR) 0.97, 95% confidence interval (CI) 0.94 to 1.0]. Days on which the HCA staffing level fell below the mean were associated with an increased hazard of death (HR 1.04, 95% CI 1.02 to 1.07), but the hazard of death increased as cumulative staffing exposures varied from the mean in either direction. Higher levels of temporary staffing were associated with increased mortality. Adverse events and length of stay were reduced with higher RN staffing. Overall, 16% of observations were missed. Higher RN staffing was associated with fewer missed observations in high-acuity patients (incidence rate ratio 0.98, 95% CI 0.97 to 0.99), whereas the overall rate of missed observations was related to overall care hours (RN + HCA) but not to skill mix. The relationship between low RN staffing and mortality was mediated by missed observations, but other relationships between staffing and mortality were not. Changing average skill mix and staffing levels to the levels planned by the Trust, involving an increase of 0.32 RN hours per patient day (HPPD) and a similar decrease in HCA HPPD, would be associated with reduced mortality, an increase in staffing costs of £28 per patient and a saving of £0.52 per patient per hospital stay, after accounting for the value of reduced stays.
Limitations
This was an observational study in a single site. Evidence of cause is not definitive. Variation in staffing could be influenced by variation in the assessed need for staff. Our economic analysis did not consider quality or length of life.
Conclusions
Higher RN staffing levels are associated with lower mortality, and this study provides evidence of a causal mechanism. There may be several causal pathways and the absolute rate of missed observations cannot be used to guide staffing decisions. Increases in nursing skill mix may be cost-effective for improving patient safety.
Future work
More evidence is required to validate approaches to setting staffing levels. Other aspects of missed nursing care should be explored using objective data. The implications of findings about both costs and temporary staffing need further exploration.
Trial registration
This study is registered as ISRCTN17930973.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 6, No. 38. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Peter Griffiths
- Health Sciences, University of Southampton, Southampton, UK
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, Southampton, UK
| | - Jane Ball
- Health Sciences, University of Southampton, Southampton, UK
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, Southampton, UK
| | - Karen Bloor
- Health Sciences, University of York, York, UK
| | - Dankmar Böhning
- Mathematical Sciences, University of Southampton, Southampton, UK
| | - Jim Briggs
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | - Chiara Dall’Ora
- Health Sciences, University of Southampton, Southampton, UK
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, Southampton, UK
| | - Anya De Iongh
- Independent lay researcher c/o National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care, Southampton, UK
| | - Jeremy Jones
- Health Sciences, University of Southampton, Southampton, UK
| | - Caroline Kovacs
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | | | - Paul Meredith
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, Southampton, UK
- Clinical Outcomes Research Group, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - David Prytherch
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, Southampton, UK
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
- Clinical Outcomes Research Group, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - Alejandra Recio Saucedo
- Health Sciences, University of Southampton, Southampton, UK
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, Southampton, UK
| | - Oliver Redfern
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | - Paul Schmidt
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, Southampton, UK
- Clinical Outcomes Research Group, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - Nicola Sinden
- Clinical Outcomes Research Group, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - Gary Smith
- Health and Social Sciences, Bournemouth University, Bournemouth, UK
| |
Collapse
|
6
|
Ball J, Ballinger C, De Iongh A, Dall’Ora C, Crowe S, Griffiths P. Determining priorities for research to improve fundamental care on hospital wards. Res Involv Engagem 2016; 2:31. [PMID: 29507765 PMCID: PMC5831884 DOI: 10.1186/s40900-016-0045-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 09/30/2016] [Indexed: 05/13/2023]
Abstract
PLAIN ENGLISH SUMMARY The aim of this project was to find out the priorities for research that could improve fundamental care. 'Fundamental care' covers all aspects of basic care in hospital wards, such as helping with core physical needs, building positive relationships and keeping patients safe.By setting the priorities with patients, carers, the public and health care professionals, research can look at the issues that really matter to people who are receiving or delivering care in hospital wards.Previously, prioritisation exercises have started with a menu of options and asked people to choose from that list. They have also been focused on specific health conditions. Traditionally, there has been little opportunity for patients, carers and the public to contribute to identifying the issues to be prioritised.To develop the priorities for research, we started by exploring what is meant by 'fundamental care', looking at patient and carer accounts and academic and policy reports. Patients, carers, staff, and members of the public were consulted via surveys, interviews and group discussions to share experiences and issues.A list of 15 topics was identified based on what was most commonly mentioned by patients, carers and healthcare professionals as well as what was practical for the CLAHRC Wessex team to research. A workshop with patients, carers and healthcare professionals was held, to decide the top 5 areas.The five priority areas identified were:Nurse staffingIndividualised patient careStaff communicationStaff attitudes and relationships with patientsInformation about care/communication. ABSTRACT Background The provision of high quality fundamental care in hospitals is a top priority for the NHS. Recent reports and investigations highlight that at times care has fallen below standard. It is unclear what research should be prioritised to improve care. The aim of this work is to involve patients/carers/public, clinicians and other stakeholders to identify issues that are priorities for research which could improve fundamental care in hospital. Methods Patient and public involvement was integral to this project, with a patient leader/service user being a member of the core team who designed and executed this research. After consideration of existing priority setting approaches, we developed an inclusive approach which consisted of six main phases: 1) Development of a conceptual framework of fundamental care, based on reports and literature 2) Consultation with a wide range of stakeholders through a survey, focus groups and interviews 3) Identifying themes from the responses to the consultation phase (76 themes identified) 4) Analysis to identify the 15 topics most frequently cited 5) Prioritisation of the top 15 themes through a half day workshop, which led to a shortlist of five themes 6) Development of the top 5 themes into research areas. Results Three hundred forty stakeholders (29 % of whom were patients/carers/public) completed the consultation survey. Analysis of the survey responses and of focus groups and interviews led us to identify 15 high scoring themes. We presented these at the prioritisation workshop, attended by 39 participants (23 of whom patients/carers/public). After a voting exercise, the 5 top research priorities which emerged were: nurse staffing; individualised patient care; staff communication; staff attitudes and relationships with patients; and information about care. Conclusions We involved a range of stakeholders in identifying topics for research to improve fundamental care and asked them to prioritise these. The process provided a means of reaching consensus as to the important issues for future research to focus on to improve fundamental care on hospital wards.
Collapse
Affiliation(s)
- Jane Ball
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC), Wessex, UK
- University of Southampton, Building 67, Highfield Campus, Southampton, SO17 1BJ UK
- Doctoral Student, Karolinska Insitutet, Stockholm, Sweden
| | - Claire Ballinger
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC), Wessex, UK
| | - Anya De Iongh
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC), Wessex, UK
| | - Chiara Dall’Ora
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC), Wessex, UK
- University of Southampton, Building 67, Highfield Campus, Southampton, SO17 1BJ UK
| | | | - Peter Griffiths
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC), Wessex, UK
- University of Southampton, Building 67, Highfield Campus, Southampton, SO17 1BJ UK
| |
Collapse
|