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Search completed for: Tracy Pilcher

Search required by: 5th October 2012

Search completed on: 4th October 2012

Search completed by: Richard Bridgen

Search details

Nurse staffing levels in hospitals and improved patient outcomes

Resources searched

NHS Evidence; TRIP Database; Cochrane Library; BNI; CINAHL; EMBASE; HMIC MEDLINE; Google Scholar

Database search terms: nurs*; “staffing level*”; staff* adj2 level*; staff* adj2 mix; staff adj2 ratio*; outcome*; NURSE-PATIENT RATIO; exp OUTCOMES (HEALTH CARE); NURSING OUTCOMES; quality adj2 care; improve*; better*; recovery; exp OUTCOMES AND PROGNOSIS; exp HEALTH CARE QUALITY;

Evidence search string(s): nurs* "staff* (level* OR ratio OR mix)

Google search string(s): ~nursing ~staff (~level OR ~ratio OR ~mix)

Summary

There is a great deal of research on the impact of nurse staffing levels on patient outcomes, much of it equating increased nurse staffing with improved outcomes, but there is also research which reports that outcomes did not improve or that if they did it’s not all about staffing levels – skill mix and aspects of the job being performed may be as important.

Guidelines

British Association of Critical Care Nurses

Standards for Nurse Staffing in Critical Care 2009

The nurse patient ratio within any Critical Care Unit should not go below 1 nurse to 2 patients.

British Association of Perinatal Medicine

Service standards for hospitals providing neonatal care 2010

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i) Intensive Care:

Due to the complex needs of both the baby and their family the ratio of neonatal nurses QIS to baby should be 1 nurse: 1 baby. This nurse should have no other managerial responsibilities during the time of clinical care but may be involved in the support of a less experienced nurse working alongside her in caring for the same baby.

ii) High Dependency Care:

The ratio of neonatal nurses QIS responsible for the care of babies requiring high dependency care should be 1 nurse: 2 babies. The more stable and less dependent babies may be cared for by registered nurses not QIS, but who are under the direct supervision and responsibility of a neonatal nurse QIS.

iii) Special Care:

The ratio of nurses looking after special care babies should be at least 1 nurse: 4 babies. It is essential that staffing in special care is sufficient to ensure that discharge is properly planned and organised including the adequate support for parents. Registered nurses and non-registered clinical staff may care for these babies under the direct supervision and responsibility of a neonatal nurse QIS.

NHS Institute for Innovation and Improvement

Safer Nursing Care Tool (SNCT)

Helps to review the impact of actual staffing levels on the quality and care delivered to the monitoring of nurse sensitive indicators (NSIs).

Helps NHS teams determine or evaluate ward team size and mix easily and quickly. Teams can benchmark their staffing and NSIs against similar wards and departments internally and externally.

Royal College of Nursing

Mandatory Nurse Staffing Levels 2012

Safe staffing for older people’s wards 2012

The RCN report did not recommend a universal minimum staffing level; preferring senior nurses in each ward to have the final say. It also noted that evidence relating to older people’s wards indicates that there is a threshold of staffing numbers, below which care is compromised. It went on to outline recommendations for the skills mix and staffing levels required for basic safe care, and also for ideal, good quality care in older people’s wards.

For basic safe care, the RCN recommended:

a 50:50 mix of registered nurses to health care assistants

at least one registered nurse per seven patients

at least one member of staff per 3.3 to 3.8 patients

at least four registered nurses for a typical 28-bed ward

at least eight nursing staff on duty for a typical 28-bed ward

The recommendations for ideal, good quality care are:

a 65:35 mix of registered nurses to health care assistants

at least one registered nurse for every five to seven patients

at least one member of staff per 3.3 to 3.8 patients

four to six registered nurses for a typical 28-bed ward

at least eight nursing staff on duty for a typical 28-bed ward

These numbers exclude the ward sister or senior charge nurse, who is in a supervisory role. The RCN also said that the ward sister or senior charge nurse must be the final arbiter of whether the staffing for that day is appropriate for the specific needs and case mix of

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patients on the ward. Hospital nursing levels and care of older people, NHS Choices 20/3/2012

Guidance on safe nurse staffing levels in the UK 2010

Skill-mix and staffing in children's wards and departments 2008

Setting appropriate ward nurse staffing levels in NHS Acute Trusts 2006

RCN policy position: evidence-based nurse staffing levels

Royal College of Obstetricians and Gynaecologists

Safer Childbirth - Minimum Standards for the Organisation and Delivery of Care in Labour 2007

See chapter 4 of staffing levels and 7 on recommended minimum standards.

Evidence-based reviews

Agency for Healthcare Research and Quality

Nurse Staffing and Quality of Patient Care 2007

Increased nursing staffing in hospitals was associated with lower hospital-related mortality, failure to rescue, and other patient outcomes, but the association is not necessarily causal. The effect size varied with the nurse staffing measure, the reduction in relative risk was greater and more consistent across the studies, corresponding to an increased registered nurse to patient ratio but not hours and skill mix. Estimates of the size of the nursing effect must be tempered by provider characteristics including hospital commitment to high quality care not considered in most of the studies. Greater nurse staffing was associated with better outcomes in intensive care units and in surgical patients.

BMC Health Services Research

The relationship between staff skill mix, costs and outcomes in intermediate care services 2010

Increased skill mix (raising the number of different types of staff by one) is associated with a 17% reduction in service costs (p = 0.011). There is weak evidence (p = 0.090) that a higher ratio of support staff to qualified staff leads to greater improvements in EQ-5D scores of patients.

BMC Nursing

Nurse forecasting in Europe (RN4CAST): Rationale,design and methodology 2011

Study aims innovative forecasting methods by addressing not only volumes, but quality of nursing staff as well as quality of patient care. Has yet to report findings.

Canadian Agency for Drugs and Technologies in Health – Rapid Review

Multidisciplinary Nursing Mix in Hospital Settings: Guidelines 2012

The evidence identified regarding ideal staffing ratios and multidisciplinary nursing mix in order to provide best patient outcomes in hospitals was inconsistent; however, nursing staffing levels likely have an effect on patient outcomes. The identified guideline found evidence for a strong association between type of nurse and health outcomes for patients.

The Centre for Market and Public Organisation

The effect of a hospital nurse staffing mandate on patient health outcomes: evidence from California’s minimum staffing regulation 2012

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We evaluate the impact of California Assembly Bill 394, which mandated maximum levels of patients per nurse in the hospital setting. When the law was passed, some hospitals already met the requirements, while others did not. Thus changes in staffing ratios from the pre- to post-mandate periods are driven in part by the legislation. We find persuasive evidence that AB394 had the intended effect of decreasing patient/nurse ratios in hospitals that previously did not meet mandated standards. However, these improvements in staffing ratios do not appear to be associated with relative improvements in measured patient safety in affected hospitals.

Cochrane Database of Systematic Reviews

Hospital nurse staffing models and patient and staff-related outcomes 2012

The findings suggest interventions relating to hospital nurse staffing models may improve some patient outcomes, particularly the addition of specialist nursing and specialist support roles to the nursing workforce. Interventions relating to hospital nurse staffing models may also improve staff-related outcomes, particularly the introduction of primary nursing and self-scheduling. However, these findings should be treated with extreme caution due to the limited evidence available from the research conducted to date.

Effectiveness of staffing models in residential, subacute, extended aged care settings on patient and staff outcomes 2011

art from two small studies evaluating primary care, no evidence in the form of concurrently controlled trials could be identified. While these two studies generally favour the use of primary care, the research designs of both ITS and CBA studies are considered prone to bias, specifically selection and blinding of participants and assessors. Therefore, these studies should be regarded with caution and there is little clear evidence for the effective use of any specific model of care in residential aged care to benefit either residents or care staff. Research in this area is clearly needed.

Database of Abstracts of Reviews of Effects

Nurse staffing levels and hospital mortality in critical care settings: literature review and meta-analysis 2009

This review concluded that there was no reliable evidence about the impact of nurse staffing levels on mortality rates in critical care settings, due to the poor quality of the available studies. The authors' cautious conclusions appear to be reasonable given the limitations of the included data.

East Cheshire NHS Trust

Maternity Service Staffing Levels & Labour Ward Staffing 2012

Human Resources for Health

From staff-mix to skill-mix and beyond: towards a systemic approach to health workforce management 2009

Throughout the world, countries are experiencing shortages of health care workers. Policy-makers and system managers have developed a range of methods and initiatives to optimise the available workforce and achieve the right number and mix of personnel needed to provide high-quality care. Our literature review found that such initiatives often focus more on staff types than on staff members' skills and the effective use of those skills. Our review describes evidence about the benefits and pitfalls of current approaches to human resources optimisation in health care. We conclude that in order to use human resources most effectively, health care organisations must consider a more systemic approach - one that accounts for factors beyond narrowly defined human resources management practices and includes organisational and institutional conditions.

International Journal of evidence Based Health

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The effect of nurse staffing on clinical outcomes of children in hospital: A systematic review 2011

Increased Registered Nurse nursing hours per patient day was associated with decreases in eight adverse events. Similarly, higher Registered Nurse skill mix contributed positively to three clinical outcomes in children. However, there appears to be a level where increasing Registered Nurse hours no longer has a significant effect on decreasing adverse events. Results reporting association between children's outcomes and casual/agency nurses are equivocal.

King’s College, London

The association between midwifery staffing and outcomes in maternity services in England 2010

National Institute for Health Research (NIHR)

The impact of changing workforce patterns in emergency and urgent out-of-hours care on patient experience, staff practice and health system performance 2010

The relationship between workforce flexibility and the costs and outcomes of older peoples' services 2010

Patient outcomes (TOMS and EQ-5D) were positively and significantly associated with five key staffing variables:

Having care delivered by a higher proportion of support workers (coefficient 0.164 (95%CI 0.001 - 0.330, p=0.052)

Being treated by staff from a team which has fewer senior staff

Being treated by fewer different types of practitioners during the episode of

care

Being treated by staff who belong to a larger team, and

Increasing total amount of face to face contact time with the patient (log scale 0.159(0.100-0.219, p>0.001).

NHS East of England

Principles for Safe Nurse Staffing Levels 2010

Ward Staffing skills mix should be based on achieving quality patient care outcomes, meeting organisational objectives, and ensuring that the quality of nurses’ work life is appropriate.

A ward staffing establishment skill mix ratio of 65% Registered Nurses and 35% Unregistered will be maintained as a benchmark for general wards

All changes to ward staffing skills mix will be authorised by the Executive Nurses and will be based on staffing reviews

Ward Staffing reviews must be done regularly and systematically with the engagement of ward leaders and be transparent and at least anually

Two or more recognised methods to measure and model ward staffing levels should be used to increase the validity of the results – Safer Nursing Care Tool & NHPPD

The Executive Nurse must communicate the findings to the Trust Executive team and Board to inform decisions about risk management and financial investment

All wards/units providing overnight care for patients must have a minimum of two registered nurses

All wards/units must have a minimum of one Band 7 Registered Nurse who has

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accountability

for patient outcomes, has the necessary skills, infrastructure and support to operate effectively and efficiently

All unregistered staff must have the appropriate Registered Nurse support to ensure operational effectiveness & efficiency.

NHS Economic Evaluation Database

Improving nurse-to-patient staffing ratios as a cost-effective safety intervention 2006

A staffing ratio of 5.3 patients per nurse was associated with a mean 30-day mortality rate of 2.0%. For each additional patient cared for by a nurse, the adjusted mortality rates increased by 7% over the range from 4 patients per nurse to 8 patients per nurse.

Cost-effectiveness of recommended nurse staffing levels for short-stay skilled nursing facility patients 2005

An intervention to increase nurse staffing to recommended levels for short-stay patients would not be cost-effective on the basis of a reduction in hospital transfer rates alone.

Effect of nurse-to-patient ratio in the intensive care unit on pulmonary complications and resource use after hepatectomy 2005

Patients undergoing hepatic surgery, who received postoperative care in intensive care units (ICUs) where one nurse provided care for 3 or more patients at night, presented a significant increase in postoperative pulmonary complications and use of resources and, therefore, incurred higher direct hospital costs. This supported the hypothesis that ICU nurse-to-patient ratios can contribute directly to the patients' outcomes.

PEDSCCM Evidence-Based Journal Club

Nurse staffing and unplanned extubation in the pediatric intensive care unit 2005

1. In this study, using a logistic regression model, mechanically ventilated patients in a 1:2 nurse-to-patient ratio scenario were 4 X more likely to experience unplanned extubations than those in a 1:1 ratio scenario (OR 4.24, 95% CI 1.00-19.10).

2. As the study suggests, a 1:1 nurse-to-patient ratio may be ideal in avoiding unplanned extubations in mechanically ventilated patients. Certainly, various diagnoses and patients with higher severity of illness may prompt healthcare staff to assign 1:1 nursing. However, the current shortage of available nurses will likely make this impossible for many institutions. Moreover, it is not definitive whether or not this is the only effective intervention. As cited in the article, agitation was a significant contributor to unplanned extubation events. Implementation of sedation protocols and educational programs has reduced the number of unplanned extubations in other centers (2,3). However the trade-off of better sedated patients may result in delayed scheduled extubations, as demonstrated by Randolph et al. (4).

Royal Devon and Exeter NHS Foundation Trust

Ward Staffing Benchmarking Review 2009

UNISON

Care in the balance : a UNISON survey into staff/patient ratios on our wards 2012

World Health Organization

How can optimal skill mix be effectively implemented and why? 2008

Published research

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1. Influence of full-time intensivist and the nurse-to-patient ratio on the implementation of severe sepsis bundles in Korean intensive care units.

Author(s) Kim, Je Hyeong, Hong, Suk-Kyung, Kim, Kyung Chan, Lee, Myung-Goo, Lee, Ki Man, Jung, Sung Soo, Choi, Hye Sook, Lee, Jin Hwa, Jung, Ki-Suk, Lee, Sung-Soon, Cho, Jae Hwa, Koh, Shin Ok, Park, Moo Suk, Seo, Kwang Won, Koh, Younsuck

Citation: Journal of Critical Care, 01 August 2012, vol./is. 27/4(0-), 08839441

Publication Date: 01 August 2012

Abstract: Abstract: Purpose: The reported actual compliance for severe sepsis bundles was very low, suggesting the presence of barriers to their implementation. The purpose of this study was to assess the influence of full-time intensivist and nurse-to-patient ratio in Korean intensive care units (ICUs) on the implementation of the severe sepsis bundles and clinical outcome. Materials and Methods: A total of 251 patients with severe sepsis were enrolled from 28 adult ICUs during the July, 2009. We recorded the organizational characteristics of ICUs, patients'' characteristics and clinical outcomes, and the compliance for severe sepsis bundles. Results: Complete compliance with the resuscitation bundle and totally complete compliance with all element targets for resuscitation and management bundles were significantly higher in the ICU with full-time intensivist and a nurse-to-patient ratio of 1:2 (P < .05). The hazard ratio (HR) for hospital mortality was independently reduced by the presence of full-time intensivist (HR, 0.456; 95% confidence interval, 0.223-0.932), and a nurse-to-patient ratio of 1:2 was independently associated with a lower 28-day mortality (HR, 0.459; 95% confidence interval, 0.211-0.998). Conclusions: The full-time intensivist and the nurse-to-patient ratio had a substantial influence on the implementation of severe sepsis bundles and the mortalities of patients with severe sepsis.

Source: CINAHL

Available in print at ULHT journal article requests. Complete the online form to obtain articles.

2. It is time we took a firm stand in the battle for safe staff levels.

Author(s) Waters, Adele

Citation: Nursing Standard, Aug 2012, vol. 26, no. 50, p. 16-19, 0029-6570 (August 15, 2012)

Publication Date: August 2012

Abstract: Findings of an expert panel convened as part of the Nursing Standard and Florence Nightingale Foundation campaign to improve patient care. Their views on the need to identify the evidence of a link between nurse staffing levels and good patient outcomes are discussed. The statement produced by the panel is given. [Original] 0 references

Source: BNI

Available in fulltext at EBSCOhost

Available in print at Grantham Hospital Staff Library

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Available in print at Louth County Hospital Medical Library

Available in print at Pilgrim Hospital Staff Library

Available in print at Lincoln County Hospital Professional Library

3. Care quality and staffing levels are two sides of the same coin.

Author(s) Hughes, Rhidian

Citation: British Journal of Healthcare Assistants, Jul 2012, vol. 6, no. 7, p. 354-355, 1753-1586 (July 2012)

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Publication Date: July 2012

Abstract: Findings of the Care Quality Commission's inspections of services, highlighting areas of concern. The effect of inadequate staffing on the quality of patient care is discussed. [ORIGINAL] 4 references

Source: BNI

Available in print at Grantham Hospital Staff Library

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4. Nursing activities, nurse staffing and adverse patient outcomes as perceived by hospital nurses.

Author(s) Hinno, Saima, Partanen, Pirjo, Vehviläinen-Julkunen, Katri

Citation: Journal of Clinical Nursing, 01 June 2012, vol./is. 21/11/12(1584-1593), 09621067

Publication Date: 01 June 2012

Abstract: Aim. To investigate the relationships between nursing activities, nurse staffing and adverse patient outcomes in hospital settings as perceived by registered nurses in Finland and the Netherlands and to compare the results obtained in the two countries. Background. Previous research indicates that a higher proportion of registered nurses in the staff mix results in better patient outcomes. Knowledge of the relationship between nurse staffing and adverse patient outcomes is crucial to optimise the management of professional nursing resources and patient care. Design. A cross-sectional, descriptive questionnaire survey. Methods. Registered nurses employed in hospitals in Finland ( n = 535) and the Netherlands ( n = 334), with overall response rates of 44·9% and 33·4%, respectively, participated. Results. The patient-to-nurse ratio was on average 8·74:1 and did not vary significantly between the countries. However, there were fewer registered nurses and significantly more licensed practical nurses among the Dutch hospital staff than the Finnish staff. In addition, Finnish nurses performed non-nursing and administrative activities more frequently than the Dutch nurses and reported more dissatisfaction with the availability of support services. Frequencies of patient falls were related to the patient-to-nurse ratio in both countries. Finnish participants reported the occurrence of adverse patient outcomes more frequently. Conclusions. Significant associations were found between nurse staffing and adverse patient outcomes in hospital settings. Compared with the Netherlands, in Finland, nurses appear to have higher workloads, there are higher patient-to-nurse ratios, and these adverse staffing conditions are associated with higher rates of adverse patient outcomes. Relevance to clinical practice. The findings provide valuable insights into the potential effects of major changes or reductions in nursing staff on the occurrence of adverse patient outcomes in hospital settings.

Source: CINAHL

Available in fulltext at the ULHT Library and Knowledge Services' eJournal collection

5. Influence of unit-level staffing on medication errors and falls in military hospitals.

Author(s) Breckenridge-Sproat, Sara, Johantgen, Meg, Patrician, Patricia

Citation: Western Journal of Nursing Research, Jun 2012, vol. 34, no. 4, p. 455-474, 0193-9459 (June 2012)

Publication Date: June 2012

Abstract: This study examined unit-level associations of nurse staffing and workload, and the effect of the practice environment on adverse patient events. A secondary analysis was conducted of a longitudinal data set of 23 Army inpatient units from the Military Nursing Outcomes Database. Generalized Linear Mixed Modeling accommodated nested, nonparametric data. Staff category was found to be a significant predictor of medication

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errors and patient falls, but the relationship varied by unit type. Patient census had no effect on either outcome; however, a higher patient acuity was associated with an increase in both adverse events. The nursing practice environment mediated medication errors but not falls, in all unit types. Skill mix is important; however, additional components of staffing need consideration in producing positive patient outcomes. [PUBLICATION]

Source: BNI

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6. Nurse staffing levels and the incidence of mortality and morbidity in the adult intensive care unit: A literature review.

Author(s) McGahan, Matthew, Kucharski, Geraldine, Coyer, Fiona

Citation: Australian Critical Care, 01 May 2012, vol./is. 25/2(64-77), 10367314

Publication Date: 01 May 2012

Abstract: BACKGROUND: Studies have shown that nurse staffing levels, among many other factors in the hospital setting, contribute to adverse patient outcomes. Concerns about patient safety and quality of care have resulted in numerous studies being conducted to examine the relationship between nurse staffing levels and the incidence of adverse patient events in both general wards and intensive care units. AIM: The aim of this paper is to review literature published in the previous 10 years which examines the relationship between nurse staffing levels and the incidence of mortality and morbidity in adult intensive care unit patients. METHODS: A literature search from 2002 to 2011 using the MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, and Australian digital thesis databases was undertaken. The keywords used were: intensive care; critical care; staffing; nurse staffing; understaffing; nurse-patient ratios; adverse outcomes; mortality; ventilator-associated pneumonia; ventilator-acquired pneumonia; infection; length of stay; pressure ulcer/injury; unplanned extubation; medication error; readmission; myocardial infarction; and renal failure. A total of 19 articles were included in the review. Outcomes of interest are patient mortality and morbidity, particularly infection and pressure ulcers. RESULTS: Most of the studies were observational in nature with variables obtained retrospectively from large hospital databases. Nurse staffing measures and patient outcomes varied widely across the studies. While an overall statistical association between increased nurse staffing levels and decreased adverse patient outcomes was not found in this review, most studies concluded that a trend exists between increased nurse staffing levels and decreased adverse events. CONCLUSION: While an overall statistical association between increased nurse staffing levels and decreased adverse patient outcomes was not found in this review, most studies demonstrated a trend between increased nurse staffing levels and decreased adverse patient outcomes in the intensive care unit which is consistent with previous literature. While further more robust research methodologies need to be tested in order to more confidently demonstrate this association and decrease the influence of the many other confounders to patient outcomes; this would be difficult to achieve in this field of research.

Source: CINAHL

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7. Major study confirms link between nurse staff levels and care quality.

Author(s) Duffin, Christian

Citation: Nursing Standard, 28 March 2012, vol./is. 26/30(7-7), 00296570

Publication Date: 28 March 2012

Abstract: High nurse-to-patient ratios and well-managed working environments lead to higher care quality and improved patient satisfaction, a major international research study reveals.

Source: CINAHL

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Available in fulltext at EBSCOhost

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8. Effects of Nurse Staffing Ratios on Patient Mortality in Taiwan Acute Care Hospitals: A Longitudinal Study.

Author(s) Yia-Wun Liang, Shwu-Feng Tsay, Wen-Yi Chen

Citation: Journal of Nursing Research (Lippincott Williams & Wilkins), 01 March 2012, vol./is. 20/1(1-8), 16823141

Publication Date: 01 March 2012

Abstract: Background: The nurse workload in Taiwan averages two to seven times more than that in the United States and other developed countries. Previous studies have indicated heavy nursing workload as an underlying cause of preventable patient death. No studies have yet explored the relationship between nurse staffing ratio and patient mortality in Taiwan. Purpose: This study explored the effect of nurse staffing ratios on patient mortality in acute care hospitals in Taiwan and considered the implications in terms of policy. Methods: Using stratified random sampling, 108 hospital nursing units in 32 of Taiwan's 441 accredited Western medicine district/regional hospitals and medical centers were included in the study. Variables were retrospectively measured from 108 wards by using monthly data during a 7-month period. A generalized estimating equation logistic model was used to obtain more precise estimates of the nurse staffing effect by controlling for hospital characteristic and patient acuity variables. Results: The population-averaged odds ratio for the incidence of death between the low and high patient-nurse ratio groups was 3.617 (95% CI = [1.930, 6.776]). The risk of death in the high patient-nurse ratio group was significantly higher than in the low patient-nurse ratio group. Conclusions: Nurse staffing levels affect patient outcomes. Faced with the problem of inadequate nurses for hospital healthcare needs, Taiwanese policymakers should work to implement a legislatively mandated minimum patient-nurse ratio on a shift-by-shift basis to regulate nurse staffing. In setting guidelines for nurse staffing, policymakers must consider nursing staff characteristics in addition to the number of nurses.

Source: CINAHL

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9. Effects of Nurse Staffing and Nurse Education on Patient Deaths in Hospitals with Different Nurse Work Environment.

Author(s) Ward-Smith, Peggy

Citation: Urologic Nursing, 01 March 2012, vol./is. 32/2(93-93), 1053816X

Publication Date: 01 March 2012

Source: CINAHL

Available in fulltext at EBSCOhost

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10. Higher staffing levels reduce falls rate.

Author(s) Hurst, Keith

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Citation: Nursing Standard, Mar 2012, vol. 26, no. 28, p. 18-19, 0029-6570 (March 14, 2012)

Publication Date: March 2012

Abstract: Brief summary of research evidence that demonstrates a link between staff shortages and patient falls on acute wards. Findings from a secondary examination of patient safety data for NHS trusts in England, obtained from the National Patient Safety Agency (NPSA) and the Care Quality Commission (CQC) are discussed. [Original] 1 references

Source: BNI

Available in fulltext at EBSCOhost

Available in print at Grantham Hospital Staff Library

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Available in print at Louth County Hospital Medical Library

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11. Impact of nurse staffing mandates on safety-net hospitals: lessons from California.

Author(s) McHugh MD, Brooks Carthon M, Sloane DM, Wu E, Kelly L, Aiken LH

Citation: Milbank Quarterly, March 2012, vol./is. 90/1(160-86), 0887-378X;1468-0009 (2012 Mar)

Publication Date: March 2012

Abstract: CONTEXT: California is the first and only state to implement a patient-to-nurse ratio mandate for hospitals. Increasing nurse staffing is an important organizational intervention for improving patient outcomes. Evidence suggests that staffing improved in California hospitals after the mandate was enacted, but the outcome for hospitals bearing a disproportionate share of uncompensated care-safety-net hospitals-remains unclear. One concern was that California's mandate would burden safety-net hospitals without improving staffing or that hospitals would reduce their skill mix, that is, the proportion of registered nurses of all nursing staff. We examined the differential effect of California's staffing mandate on safety-net and non-safety-net hospitals.METHODS: We used a time-series design with Annual Hospital Disclosure data files from the California Office of Statewide Health Planning and Development (OSHPD) for the years 1998 to 2007 to assess differences in the effect of California's mandate on staffing outcomes in safety-net and non-safety-net hospitals.FINDINGS: The mandate resulted in significant staffing improvements, on average nearly a full patient per nurse fewer (-0.98) for all California hospitals. The greatest effect was in those hospitals with the lowest staffing levels at the outset, both safety-net and non-safety-net hospitals, as the legislation intended. The mandate led to significantly improved staffing levels for safety-net hospitals, although there was a small but significant difference in the effect on staffing levels of safety-net and non-safety-net hospitals. Regarding skill mix, a marginally higher proportion of registered nurses was seen in non-safety-net hospitals following the mandate, while the skill mix remained essentially unchanged for safety-net hospitals. The difference between the two groups of hospitals was not significant.CONCLUSIONS: California's mandate improved staffing for all hospitals, including safety-net hospitals. Furthermore, improvement did not come at the cost of a reduced skill mix, as was feared. Alternative and more targeted designs, however, might yield further improvement for safety-net hospitals and reduce potential disparities in the staffing and skill mix of safety-net and non-safety-net hospitals. Copyright 2012 Milbank Memorial Fund.

Source: Medline

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articles.

12. Safe staffing in neurosciences.

Author(s) Braine, Mary E., Quirke, Mary

Citation: British Journal of Neuroscience Nursing, Feb 2012, vol. 8, no. 1, p. 40-42, 1747-0307 (February 2012)

Publication Date: February 2012

Abstract: BANN Pages series. Discussion on nurses' duty of care to ensure adequate staffing levels. Related RCN policy, NMC codes, NHS Acts and constitution and Care Quality Commission requirements, the online Safer Nursing Care Tool (SNCT) and the planned 2012 BANN staffing review of neuroscience nursing are discussed. [ORIGINAL] 30 references

Source: BNI

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13. One nurse to seven older patients : RCN recommends a safe staff ratio.

Author(s) Duffin, Christian

Citation: Nursing Standard, 2012, vol./is. 26/29(12-13), 0029-6570

Publication Date: 2012

Abstract: The RCN has issued guidance to hospital managers on staffing levels and skill mix for older people's wards. For the first time in its history the RCN is calling for minimum nurse-to-patient ratios on older people's wards. The recommendation, made in a landmark RCN report published this week, states that good quality care will only be achieved if each nurse oversees between five and seven patients at a time. [Introduction]

Source: HMIC

Available in fulltext at EBSCOhost

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Available in print at Louth County Hospital Medical Library

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14. Using staffing ratios for workforce planning : evidence on nine allied health professions.

Author(s) Cartmill, Linda, Comans, Tracy A., Clark, Michele J.

Citation: Human Resources for Health, 2012, vol./is. 10/2, 1478-4491

Publication Date: 2012

Abstract: BACKGROUND: Modern healthcare managers are faced with pressure to deliver effective, efficient services within the context of fixed budget constraints. Managers are required to make decisions regarding the skill mix of the workforce particularly when staffing new services. One measure used to identify numbers and mix of staff in healthcare settings is workforce ratio. The aim of this study was to identify workforce ratios in nine allied health professions and to identify whether these measures are useful for planning allied health workforce requirements. METHODS: A systematic literature search using relevant MeSH headings of business, medical and allied health databases and relevant grey literature for the period 2000-2008 was undertaken. RESULTS: Twelve articles were identified which described the use of workforce ratios in allied health services. Only one of

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these was a staffing ratio linked to clinical outcomes. The most comprehensive measures were identified in rehabilitation medicine. CONCLUSIONS: The evidence for use of staffing ratios for allied health practitioners is scarce and lags behind the fields of nursing and medicine. [Abstract]

Source: HMIC

Available in fulltext at BioMedCentral

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15. How skill mix affects quality of care.

Author(s) Robb, Elizabeth, Maxwell, Elaine, Elcock, Karen S

Citation: Nursing Times, 29 November 2011, vol./is. 107/47(12-13), 09547762

Publication Date: 29 November 2011

Abstract: While the media has reported failings in care as failures in nursing, it has not distinguished between care delivered by nurses and that delivered by unregistered healthcare assistants and other support staff. This article examines the role of nurses in an evolving healthcare climate.

Source: CINAHL

Available in print at Grantham Hospital Staff Library

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16. Quality watch.

Author(s) Hurst, Keith

Citation: Nursing Standard, Nov 2011, vol. 26, no. 10, p. 20-21, 0029-6570 (November 9, 2011)

Publication Date: November 2011

Abstract: Analysis of findings from research investigating staff activity, skill mix and nurse and support worker staffing levels on UK wards that provide high and low quality care. [ORIGINAL] 0 references

Source: BNI

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17. Armchair experts must face the facts: staffing levels affect care.

Author(s) Ball, J

Citation: Nursing Times, Nov 2011, vol. 107, no. 43, p. 7., 0954-7762 (November 1, 2011)

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Publication Date: November 2011

Abstract: Comments on the latest Care Quality Commission report on the quality of hospital care, highlighting the obvious relationship between nurse staffing levels and care quality. [(BNI unique abstract)] 0 references

Source: BNI

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18. Quality and cost analysis of nurse staffing, discharge preparation, and postdischarge utilization.

Author(s) Weiss ME, Yakusheva O, Bobay KL

Citation: Health Services Research, October 2011, vol./is. 46/5(1473-94), 0017-9124;1475-6773 (2011 Oct)

Publication Date: October 2011

Abstract: OBJECTIVES: To determine the impact of unit-level nurse staffing on quality of discharge teaching, patient perception of discharge readiness, and postdischarge readmission and emergency department (ED) visits, and cost-benefit of adjustments to unit nurse staffing.DATA SOURCES: Patient questionnaires, electronic medical records, and administrative data for 1,892 medical-surgical patients from 16 nursing units within four acute care hospitals between January and July 2008.DESIGN: Nested panel data with hospital and unit-level fixed effects and patient and unit-level control variables.DATA COLLECTION/EXTRACTION: Registered nurse (RN) staffing was recorded monthly in hours-per-patient-day. Patient questionnaires were completed before discharge. Thirty-day readmission and ED use with reimbursement data were obtained by cross-hospital electronic searches.PRINCIPAL FINDINGS: Higher RN nonovertime staffing decreased odds of readmission (OR=0.56); higher RN overtime staffing increased odds of ED visit (OR=1.70). RN nonovertime staffing reduced ED visits indirectly, via a sequential path through discharge teaching quality and discharge readiness. Cost analysis projected total savings from 1 SD increase in RN nonovertime staffing and decrease in RN overtime of U.S.$11.64 million and U.S.$544,000 annually for the 16 study units.CONCLUSIONS: Postdischarge utilization costs could potentially be reduced by investment in nursing care hours to better prepare patients before hospital discharge. Copyright Health Research and Educational Trust.

Source: Medline

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19. California Mandated Nurse-Patient Ratios Deemed Successful.

Author(s) Rosenberg, Karen

Citation: American Journal of Nursing, 01 October 2011, vol./is. 111/10(17-17), 0002936X

Publication Date: 01 October 2011

Source: CINAHL

Available in fulltext at Ovid

Available in fulltext at the ULHT Library and Knowledge Services' eJournal collection

20. Do Higher Hospital-wide Nurse Staffing Levels Reduce In-hospital Mortality in

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Elderly Patients with Hip Fractures: A Pilot Study.

Author(s) Schilling P, Goulet JA, Dougherty PJ

Citation: Clinical Orthopaedics & Related Research, 01 October 2011, vol./is. 469/10(2932-2940), 0009921X

Publication Date: 01 October 2011

Source: CINAHL

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21. Nurse Staffing in Critical Access Hospitals: Structural Factors Linked to Quality Care.

Author(s) Cramer, Mary E, Jones, Katherine J, Hertzog, Melody

Citation: Journal of Nursing Care Quality, 01 October 2011, vol./is. 26/4(335-343), 10573631

Publication Date: 01 October 2011

Abstract: Evidence links the amount of registered nurse care to improved patient outcomes in large hospitals, but little is known about registered nurse staffing in small critical access hospitals, which comprise 30% of all US hospitals. Our study findings show that the unique work environment of critical access hospitals means registered nurses are often overextended, reassigned from inpatient care, and/or interrupted creating potential safety and quality risks. Further research is needed to understand what critical access hospitals consider "safe" levels of nurse staffing and what processes are implemented to mitigate these risks.

Source: CINAHL

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22. Adequacy of dialysis clinic staffing and quality of care: a review of evidence and areas of needed research.

Author(s) Wolfe WA

Citation: American Journal of Kidney Diseases, 01 August 2011, vol./is. 58/2(166-176), 02726386

Publication Date: 01 August 2011

Abstract: Improving the quality of care delivered to patients receiving in-center dialysis treatment remains a perpetual concern with stakeholders. Quality indicators traditionally have focused on such items as adequacy of dialysis, anemia management, patient survival, and, most recently, the percentage using arteriovenous fistulas. Largely overlooked in the quest for improvement has been adequate consideration of dialysis clinic staffing levels. Staffing is important because it has been identified as a structural measure of quality. With 326,671 (93.1%) of all dialysis patients receiving in-center treatments, this is a potentially critical issue. This article reviews evidence related to inadequacies in clinic staffing and how they may be contributing to suboptimal care and outcomes. Focusing on nephrologists, nurses, patient care technicians, dietitians, and social workers, this article suggests areas of needed research.

Source: CINAHL

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23. Nurse staffing, hospital operations, care quality, and common sense.

Author(s) Litvak, Eugene, Laskowski-Jones, Linda

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Citation: Nursing, 01 August 2011, vol./is. 41/8(6-7), 03604039

Publication Date: 01 August 2011

Source: CINAHL

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24. Nurse staffing and patient care costs in acute inpatient nursing units.

Author(s) Li YF, Wong ES, Sales AE, Sharp ND, Needleman J, Maciejewski ML, Lowy E, Alt-White AC, Liu CF

Citation: Medical Care, August 2011, vol./is. 49/8(708-15), 0025-7079;1537-1948 (2011 Aug)

Publication Date: August 2011

Abstract: OBJECTIVE: Studies suggest that a business case for improving nurse staffing can be made to increase registered nurse (RN) skill mix without changing total licensed nursing hours. It is unclear whether a business case for increasing RN skill mix can be justified equally among patients of varying health needs. This study evaluated whether nursing hours per patient day (HPPD) and skill mix are associated with higher inpatient care costs within acute medical/surgical inpatient units using data from the Veterans Health Administration.METHODS: Retrospective cross-sectional study, including 139,360 inpatient admissions to 292 acute medical/surgical units at 125 Veterans Health Administration medical centers between February and June 2003, was conducted. Dependent variables were inpatient costs per admission and costs per patient day.RESULTS: The average costs per surgical and medical admission were $18,624 and $6,636, respectively. Costs per admission were positively associated with total nursing HPPD among medical admissions ($164.49 per additional HPPD, P<0.001), but not among surgical admissions. Total nursing HPPD and RN skill mix were associated with higher costs per hospital day for both medical admissions ($79.02 per additional HPPD and $5.64 per 1% point increase in nursing skill mix, both P<0.001) and surgical admissions ($112.47 per additional HPPD and $13.31 per 1% point increase in nursing skill mix, both P<0.001). Patients experiencing complications or transferring to an intensive care unit had higher inpatient costs than other patients.CONCLUSIONS: The association of nurse staffing level with costs per admission differed for medical versus surgical admissions.

Source: Medline

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25. Hospital nurse staffing models and patient and staff-related outcomes.

Author(s) Butler M, Collins R, Drennan J, Halligan P, O'Mathúna DP, Schultz TJ, Sheridan A, Vilis E

Citation: Cochrane Database of Systematic Reviews, 01 July 2011, vol./is. /7(0-), 1469493X

Publication Date: 01 July 2011

Abstract: Background:

Source: CINAHL

Available in fulltext at Wiley

26. The effects of California minimum nurse staffing laws on nurse labor and patient mortality in skilled nursing facilities.

Author(s) Tong PK

Citation: Health Economics, 01 July 2011, vol./is. 20/7(802-816), 10579230

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Publication Date: 01 July 2011

Abstract: This article investigates how a change in minimum nurse staffing regulation for California skilled nursing facilities (SNFs) affects nurse employment and how induced changes in nurse staffing affect patient mortality. In 2000, legislation increased the minimum nurse staffing standard and altered the calculation of nurse staffing, which created incentives to shift employment to lower skilled nurse labor. SNFs constrained by the new regulation increase absolute and relative hours worked by the lowest skilled type of nurse. Using this regulation change to instrument for measured nurse staffing levels, it is determined that increases in nurse staffing reduce on-site SNF patient mortality. Copyright © 2010 John Wiley & Sons, Ltd.

Source: CINAHL

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27. Nurse Dose: Linking Staffing Variables to Adverse Patient Outcomes.

Author(s) Manojlovich, Milisa, Sidani, Souraya, Covell, Christine L., Antonakos, Cathy L.

Citation: Nursing Research, 01 July 2011, vol./is. 60/4(214-220), 00296562

Publication Date: 01 July 2011

Source: CINAHL

Available in fulltext at the ULHT Library and Knowledge Services' eJournal collection

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28. Link between staffing levels and outcomes cannot be ignored.

Author(s) Kendall-Raynor, Petra

Citation: Nursing Standard, 01 June 2011, vol./is. 25/39(12-13), 00296570

Publication Date: 01 June 2011

Abstract: Nurse academics behind one of the largest nursing workforce studies have been presenting their preliminary findings to audiences worldwide.

Source: CINAHL

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29. Association between staffing levels and quality standards on stroke units

Author(s) Henssge U., Roughton M., Lowe D., Hoffman A., Cloud G., Rudd A.

Citation: Cerebrovascular Diseases, May 2011, vol./is. 31/(81), 1015-9770 (May 2011)

Publication Date: May 2011

Abstract: Background: The performance and quality of stroke services may be influenced by the number of qualified nurses and therapists (physiotherapy, occupational therapy, speech and language therapy). Methods: Data were obtained from the National Sentinel Stroke Audit 2010 of 201 NHS hospitals in England, Wales and Northern Ireland treating acute stroke patients. Nurse staffing levels (mean per 10 stroke unit beds) were correlated with quality standards of acute stroke care (continuous physiological monitoring, immediate access to scanning, direct admission to stroke unit from A&E, specialist ward rounds on

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seven days a week, acute stroke protocols/guidelines in place, nurses trained in swallow screening as well as stroke assessment and management) and other aspects of stroke service organisation. Results: Units that have all quality standards for acute stroke care had more qualified nurses (10.2 whole time equivalents (wte) /10 beds) in place than units with less features (5.5 wte/10 beds; p<0.001). Hospitals where all patients were in stroke unit beds (or in intensive care) on the day of audit had 7.8 wte/10 beds whereas there were 7.0 wte/10 beds (p=0.038) if patients were also located on other wards. Hospitals offering thrombolysis were found to have more nurses available (7.8 wte/10 beds) compared to hospitals that do not have thrombolysis service (6.4 wte/10 beds; p=0.036). No such association has been observed for any of the therapists. Conclusions: There is a clear association between the number of qualified nurses working on the stroke unit and better quality of stroke care in acute hospitals although this may not be the only factor for performance. The low variations in each therapist staffing levels may be a reason that no association has been found for these professions.

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30. The National Database of Nursing Quality Indicators (NDNQI): linking nurse staffing with patient outcomes.

Author(s) Hinshaw, Pam

Citation: Arizona Nurse, 01 May 2011, vol./is. 64/2(6-6), 00041599

Publication Date: 01 May 2011

Source: CINAHL

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31. Make sure nurse numbers add up.

Author(s) Ball, J, Catton, H

Citation: Health Service Journal, May 2011, vol. 121, no. 6256, p. 20-22, 0952-2271 (May 12, 2011)

Publication Date: May 2011

Abstract: Guidance from the RCN on identifying the optimum nurse staffing levels and skill mix. The essential elements of staffing reviews are listed and the need for regular review of patient outcomes and staffing profile is highlighted. Key staffing indicators to assess the strength of the workforce are outlined. [(BNI unique abstract)] 0 references

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32. Economic evaluation of nurse staffing and nurse substitution in health care: A scoping review.

Author(s) Goryakin, Yevgeniy, Griffiths, Peter, Maben, Jill

Citation: International Journal of Nursing Studies, 01 April 2011, vol./is. 48/4(501-512), 00207489

19

Publication Date: 01 April 2011

Abstract: Abstract: Objective: Several systematic reviews have suggested that greater nurse staffing as well as a greater proportion of registered nurses in the health workforce is associated with better patient outcomes. Others have found that nurses can substitute for doctors safely and effectively in a variety of settings. However, these reviews do not generally consider the effect of nurse staff on both patient outcomes and costs of care, and therefore say little about the cost-effectiveness of nurse-provided care. Therefore, we conducted a scoping literature review of economic evaluation studies which consider the link between nurse staffing, skill mix within the nursing team and between nurses and other medical staff to determine the nature of the available economic evidence. Design: Scoping literature review. Data sources: English-language manuscripts, published between 1989 and 2009, focussing on the relationship between costs and effects of care and the level of registered nurse staffing or nurse–physician substitution/nursing skill mix in the clinical team, using cost-effectiveness, cost-utility, or cost–benefit analysis. Articles selected for the review were identified through Medline, CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and Google Scholar database searches. Review methods: After selecting 17 articles representing 16 unique studies for review, we summarized their main findings, and assessed their methodological quality using criteria derived from recommendations from the guidelines proposed by the Panel on Cost-Effectiveness in Health Care. Results: In general, it was found that nurses can provide cost effective care, compared to other health professionals. On the other hand, more intensive nurse staffing was associated with both better outcomes and more expensive care, and therefore cost effectiveness was not easy to assess. Conclusions: Although considerable progress in economic evaluation studies has been reached in recent years, a number of methodological issues remain. In the future, nurse researchers should be more actively engaged in the design and implementation of economic evaluation studies of the services they provide.

Source: CINAHL

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33. Effects of nursing care and staff skill mix on patient outcomes within acute care nursing units.

Author(s) Hart, Patricia, Davis, Nancy

Citation: Journal of Nursing Care Quality, 01 April 2011, vol./is. 26/2(161-168), 10573631

Publication Date: 01 April 2011

Abstract: This article presents the findings from a study that evaluates the relationships between staffing indicators and patient outcomes at the hospital unit level. Nursing administrators should not only evaluate the impact staffing decisions have on patient outcomes at the hospital level but also examine these relationships at the unit level. The findings from this study have implications for nursing practice in the areas of staff orientation, education, and patient outcome monitoring.

Source: CINAHL

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34. Safe Nursing Staffing in Paediatric Hospitals.

Author(s) Vlachioti, Efrosini, Dousis, Ãvagelos, Matziou, Vasiliki

Citation: Nosileftiki, 01 April 2011, vol./is. 50/2(177-184), 11056843

Publication Date: 01 April 2011

Abstract: Background: The calibre of the nursing staff of paediatric hospitals is inextricably linked to the quality of care and safety of hospitalized children. Studies show a positive effect of staff/patient ratio in reducing mortality, infections and errors in medication. Aim: To

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investigate the staffing ratios in paediatric hospitals internationally. Method: A literature review was performed in the PubMed, CINAHL and Medline databases for the period from 2000 to 2010 using and combining the key-words: "children", "hospital", "nurses", "staff". Results: In hospitals with the lowest staffing levels, located in European countries such as Belgium, Holland, Iceland, the UK and Greece, two paediatric nurses correspond to every shift throughout the course of 24 hours. In the US and Australia the ratios of nurses/ children show hardly any change and have remained stable over recent years. The European Network suggests that in every shift, 70% of nurses should be paediatric nurses and 30% non-specialized nurses. It is proposed that one registered paediatric nurse should care for each 3 children aged less than 2 years, 4 children of older ages and 5 children during the night shift. For the specialized units where usually 1/3 of the children require increased medical care, one registered paediatric nurse should nurse 2-3 children who need increased medical care. The main concern of managers is to find mechanisms and strategies for the recruitment of qualified nurses and to pay special attention to their training. Conclusions: Adequate nursing staffing of paediatric hospitals should be maintained and institutionalized in accordance with the documented needs of child care.

Source: CINAHL

35. Nurse Staffing Levels and Teamwork: A Cross-Sectional Study of Patient Care Units in Acute Care Hospitals.

Author(s) Kalisch, Beatrice J., Lee, Kyung Hee

Citation: Journal of Nursing Scholarship, 01 March 2011, vol./is. 43/1(82-88), 15276546

Publication Date: 01 March 2011

Abstract: To determine if nurse staffing predicts teamwork. A cross-sectional, descriptive design with a sample of nursing staff ( N= 2,545) on 52 patient care units in four hospitals was utilized. The Nursing Teamwork Survey was utilized to collect data on the level of perceived nursing teamwork on each of the study units. In addition, nursing staffing data were collected for each study unit. Higher levels of nurse staffing were related to better teamwork. Specifically, the greater the hours per patient day, the higher the level of overall teamwork on the unit (β= 0.417, p= .033). Also the greater the skill mix, the higher the level of overall teamwork on the unit (β= 0.436, p= .009). Adequate levels of staffing are needed to ensure nursing teamwork. The ability to provide quality and safe care is associated with teamwork, which in turn requires adequate staffing.

Source: CINAHL

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36. Outcomes and Cost Analysis of the Impact of Unit-Level Nurse Staffing On Post-Discharge Utilization.

Author(s) Bobay, Kathleen L., Yakusheva, Olga, Weiss, Marianne E.

Citation: Nursing Economic$, 01 March 2011, vol./is. 29/2(69-87), 07461739

Publication Date: 01 March 2011

Abstract: XXX Under a proposal from the Centers for Medicare and Medicaid Services, hospitals would no longer be reimbursed for 30-day re-admissions or emergency department (ED) visits. XXX Increasing RN staffing to reduce post-discharge utilization is one possible solution, but one that is not financially attractive to hospitals. XXX This study demonstrates the impact of fluctuating staffing levels on ED visits within 30 days of discharge. XXX RN overtime and RN vacancies also affected subsequent ED visits. XXX It is important for nurse managers, directors, and administrators to recognize the impact of RN staffing on patient outcomes. XXX Reimbursement models will need to be realigned to benefit both hospitals and payers.

Source: CINAHL

21

Available in fulltext at EBSCOhost

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37. Nurse staffing levels and teamwork: a cross-sectional study of patient care units in acute care hospitals.

Author(s) Kalisch BJ, Lee KH

Citation: Journal of Nursing Scholarship, March 2011, vol./is. 43/1(82-8), 1527-6546;1547-5069 (2011 Mar)

Publication Date: March 2011

Abstract: PURPOSE: To determine if nurse staffing predicts teamwork.DESIGN: A cross-sectional, descriptive design with a sample of nursing staff (N = 2,545) on 52 patient care units in four hospitals was utilized.METHODS: The Nursing Teamwork Survey was utilized to collect data on the level of perceived nursing teamwork on each of the study units. In addition, nursing staffing data were collected for each study unit.FINDINGS: Higher levels of nurse staffing were related to better teamwork. Specifically, the greater the hours per patient day, the higher the level of overall teamwork on the unit (beta = 0.417, p = .033). Also the greater the skill mix, the higher the level of overall teamwork on the unit (beta = 0.436, p = .009).CONCLUSIONS: Adequate levels of staffing are needed to ensure nursing teamwork.CLINICAL RELEVANCE: The ability to provide quality and safe care is associated with teamwork, which in turn requires adequate staffing. Copyright 2011 Sigma Theta Tau International.

Source: Medline

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38. Nurse: Patient ratio and achievement of oxygen saturation goals in premature infants

Author(s) Sink D.W., Hope S.A.E., Hagadorn J.I.

Citation: Archives of Disease in Childhood: Fetal and Neonatal Edition, March 2011, vol./is. 96/2(F93-F98), 1359-2998;1468-2052 (March 2011)

Publication Date: March 2011

Abstract: Background: Premature newborns often experience oxygen saturations outside policy-specified targets, which may be associated with increased morbidity. Nurse workload may affect oxygen management. Objective: To examine the relationship between number of patients assigned to neonatal intensive care unit (NICU) nurses and achievement of oxygen saturation goals in premature newborns. Design: The authors linked nurse-patient assignment data with continuous oxygen saturation data for infants <29 weeks' gestation in a single NICU between January and June 2008. The proportion of time oxygen saturation was in policy-specified target range (85-92%) and proportion of time hyperoxaemic (98-100%) were determined for multiple 6 h monitoring periods. Each period was characterised by a single nurse, respiratory support mode and fraction of inspired oxygen (Fio₂) level (0.22-0.49 or >=0.5). The nurse:patient ratio for the infant's nurse for each monitoring period was determined. Factors associated with Spo₂ target achievement and hyperoxaemia were identified. Results: The authors analysed 1019 monitoring periods from 14 infants with a mean (SD) birth weight of 860 (270) g and gestational age of 26.6 (1.6) weeks. The mean (range) postmenstrual age for all monitoring periods was 31.6 (24.1-40.7) weeks. Eighty-seven nurses provided care. In a multivariate cross-classified hierarchical regression, the nurse:patient ratio, postmenstrual age, respiratory support mode and Fio ₂ were significantly associated with oxygen saturation outcomes. Fewer patients per nurse was significantly associated with a higher saturation target achievement among patients on high-frequency ventilation, and with

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reduced hyperoxaemia among patients on nasal cannula. Conclusions: Fewer patients per nurse may be associated with improved achievement of oxygen saturation goals and may be an important modifiable factor influencing oxygen-related outcomes in premature newborns. This effect may vary with mode of respiratory support.

Source: EMBASE

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39. Inpatient satisfaction and job satisfaction/stress of medical workers in a hospital with the 7:1 nursing care system (in which 1 nurse cares for 7 patients at a time)

Author(s) Fujimura Y., Tanii H., Saijoh K.

Citation: Environmental Health and Preventive Medicine, March 2011, vol./is. 16/2(113-122), 1342-078X;1347-4715 (March 2011)

Publication Date: March 2011

Abstract: Objectives: Inpatient satisfaction, job satisfaction/stress of medical workers, and hospital profitability under the 7:1 nursing care system (in which 1 nurse cares for 7 patients at a time) were compared with those under the 10:1 system at a hospital with the diagnosis procedure combination (DPC) payment system. Methods: A total of 202 inpatients discharged from the Departments of Cardiology and Metabolism completed an inpatient satisfaction questionnaire. A total of 108 medical workers were recruited to survey their job satisfaction/stress and to estimate the effects of the DPC. The profits for 10 cardiac and metabolic diseases in 2008 were compared with those in 2007. Results: Mean inpatient satisfaction scores were around 4 ("somewhat satisfied") under both the 10:1 and 7:1 systems, and increased significantly to 4.14-4.38 under the 7:1 system. Excluding workload of physicians, the other stresses of physicians/nurses remained unaltered, as did their low job satisfaction. They estimated their understanding of the DPC as insufficient but felt that introducing the DPC neither shortened length of stay nor improved "the quality of medical/nursing care," regardless of the system. Total percentage profit increased to 1.17% in 2008 from 0.73% in 2007, whereas 7 of 10 diseases showed deficits in 2008. Conclusions: The 7:1 system was somewhat beneficial for inpatients but not always for medical worker quality of life (QOL) or for hospital income, which are important to maintain high quality of medical/nursing care. It is important to further explore factors increasing QOL of medical workers and hospital income. 2010 The Japanese Society for Hygiene.

Source: EMBASE

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40. The Association of Shift-Level Nurse Staffing With Adverse Patient Events.

Author(s) Patrician, Patricia A., Loan, Lori, McCarthy, Mary, Fridman, Moshe, Donaldson, Nancy, Bingham, Mona, Brosch, Laura R.

Citation: Journal of Nursing Administration, 01 February 2011, vol./is. 41/2(64-70), 00020443

Publication Date: 01 February 2011

Abstract: Objective: The objective of this study was to demonstrate the association between nurse staffing and adverse events at the shift level. Background: Despite a growing body of research linking nurse staffing and patient outcomes, the relationship of staffing to patient falls and medication errors remains equivocal, possibly due to dependence on aggregated data. Methods: Thirteen military hospitals participated in creating a longitudinal nursing outcomes database to monitor nurse staffing, patient falls and medication errors, and other outcomes. Unit types were analyzed separately to stratify patient and nurse staffing characteristics. Bayesian hierarchical logistic regression modeling was used to examine associations between staffing and adverse events. Results:

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RN skill mix, total nursing care hours, and experience, measured by a proxy variable, were associated with shift-level adverse events. Conclusions: Consideration must be given to nurse staffing and experience levels on every shift.

Source: CINAHL

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41. Link between staffing levels and outcomes cannot be ignored

Author(s) Kendall Raynor, Petra

Citation: Nursing Standard, 2011, vol./is. 25/39, 0029-6570

Publication Date: 2011

Abstract: A major global nursing workforce study has uncovered a wide variety of nurse-to-patient ratios. The author looks at the implications. [Journal abstract]

Source: HMIC

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42. Do staffing levels predict missed nursing care?

Author(s) Kalisch, Beatrice J, Tschannen, Dana, Lee, Kyung Hee

Citation: International Journal for Quality in Health Care, 2011, vol./is. 23/3, 1353-4505

Publication Date: 2011

Abstract: Record in progressThe objective of the study was to examine whether actual nurse staffing predicts missed nursing care, controlling for other unit characteristics. This study utilised a cross-sectional, descriptive design. The setting was 10 hospitals in the Midwestern region of the USA. The participants were nursing staff members with direct care responsibilities (n=4,288) on 110 care units. The MISSCARE Survey was utilised to capture resopndents' perceptions of missed nursing care as well as other unit characteristics (i.e. demographics, work schedules and absenteeism). Actual staffing data (hours per patient day (HPPD), registered nurse hours per patient day (RN HPPD), skill mix) and unit level case mix index were collected from the participating hospitals for the mean scores of two months during survey distribution. The results were, HPPD was a significant predictor of missed nursing care (B = -0.45, P = 0.002). The conclusions were, findings from this study suggest that missed nursing care may explain, at least in part, the relationship between staffing levels and patient outcomes. Cites 38 references. [Journal abstract]

Source: HMIC

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43. A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life.

Author(s) Holden, Richard J, Scanlon, Matthew C, Patel, Neal R, Kaushal, Rainu, Escoto, Kamisha Hamilton, Brown, Roger L, Alper, Samuel J, Arnold, Judi M, Shalaby, Theresa M,

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Murkowski, Kathleen, Karsh, Ben-Tzion

Citation: BMJ Quality & Safety, 01 January 2011, vol./is. 20/1(15-24), 20445415

Publication Date: 01 January 2011

Abstract: BACKGROUND: Nursing workload is increasingly thought to contribute to both nurses' quality of working life and quality/safety of care. Prior studies lack a coherent model for conceptualising and measuring the effects of workload in healthcare. In contrast, we conceptualised a human factors model for workload specifying workload at three distinct levels of analysis and having multiple nurse and patient outcomes. METHODS: To test this model, we analysed results from a cross-sectional survey of a volunteer sample of nurses in six units of two academic tertiary care paediatric hospitals. RESULTS: Workload measures were generally correlated with outcomes of interest. A multivariate structural model revealed that: the unit-level measure of staffing adequacy was significantly related to job dissatisfaction (path loading=0.31) and burnout (path loading=0.45); the task-level measure of mental workload related to interruptions, divided attention, and being rushed was associated with burnout (path loading=0.25) and medication error likelihood (path loading=1.04). Job-level workload was not uniquely and significantly associated with any outcomes. DISCUSSION: The human factors engineering model of nursing workload was supported by data from two paediatric hospitals. The findings provided a novel insight into specific ways that different types of workload could affect nurse and patient outcomes. These findings suggest further research and yield a number of human factors design suggestions.

Source: CINAHL

Available in fulltext at Highwire Press

44. The effect of mandatory nurse ratios on patient care in an emergency department

Author(s) Weichenthal L., Hendey G.W.

Citation: Journal of Emergency Medicine, January 2011, vol./is. 40/1(76-81), 0736-4679 (January 2011)

Publication Date: January 2011

Abstract: Abstract: Background: In 2004, California enacted mandatory nurse-to-patient ratios in an effort to improve patient care. Objectives: The aim of the study was to look at the association between nursing ratios and quality of care in an urban teaching Emergency Department (ED). Methods: This was an observational study, looking at indicators of quality care before and after the introduction of nursing ratios in an urban California ED serving a mainly indigent population. Indicators examined included wait times; patients who left without being seen (LWBS); medication errors; acute coronary syndrome (ACS) patients receiving aspirin; and time to antibiotics in pneumonia patients. Means and proportions were analyzed using t-tests and chi-squared, as appropriate. Results: All measured wait times increased significantly in 2004 compared to 2003, including room time (from 79 to 123 min, p = 0.0001), throughput time (from 365 to 397 min, p = 0.001), and admission time (from 447 to 552 min, p = 0.0001). Patients who LWBS decreased (from 11.9 % to 11.2%, p = 0.0002). Time to antibiotics in pneumonia patients decreased (from 103 to 62 min, p = 0.002). There were no statistically significant differences in medication errors or administration of aspirin in ACS patients. Conclusions: All wait times increased after implementation of mandatory nursing ratios. Some indicators of quality care improved, whereas others showed no measurable differences. Further research is needed to further define the effect of nursing ratios on quality of patient care. 2011 Elsevier Inc.

Source: EMBASE

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45. Effectiveness of staffing models in residential, subacute, extended aged care settings on patient and staff outcomes.

Author(s) Hodgkinson B, Haesler EJ, Nay R, O'Donnell MH, McAuliffe LP

25

Citation: Cochrane Database of Systematic Reviews, 2011, vol./is. /6(CD006563), 1361-6137;1469-493X (2011)

Publication Date: 2011

Abstract: BACKGROUND: A key concern for managers and nurse administrators of healthcare settings is staffing. Determining and maintaining an appropriate level and mix of staff is especially problematic for those working in the long-term aged-care sector, where resident needs are complex and recruitment and retention of staff is challenging.OBJECTIVES: To identify which staffing models are associated with the best patient and staff outcomes.SEARCH STRATEGY: We searched the Effective Practice and Organisation of Care (EPOC) Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effectiveness (DARE) in The Cochrane Library and the databases MEDLINE, EMBASE, Ageline, CINAHL, and Dissertation abstracts. We also handsearched the reference lists and bibliographies of all retrieved articles.SELECTION CRITERIA: This review considered interrupted time series studies and studies with concurrent control designs of care staff or residents of residential or subacute or extended aged-care settings that evaluated the effectiveness of staffing models and skill mixes on resident and care staff outcomes.DATA COLLECTION AND ANALYSIS: Two review authors critically appraised all studies that were retrieved based on the screening of titles and abstracts according to the EPOC Group's data collection checklist.The same two review authors independently extracted and summarised details of eligible studies using the data abstraction form developed by EPOC.MAIN RESULTS: We included two studies (one interrupted time series and one controlled before-and-after study); both evaluated a primary-care model compared with a either a team-nursing model or a usual-care model. The primary-care model was found to provide slightly better results than the comparator for some outcomes such as resident well-being or behaviour. While nursing staff favoured the primary-care model in one study, neither study found significant improvements in staff outcomes using the primary model compared with the comparator. One study evaluated the uptake of the primary-care model within their facilities and found incorporation of this model into their practice was limited.AUTHORS' CONCLUSIONS: Apart from two small studies evaluating primary care, no evidence in the form of concurrently controlled trials could be identified. While these two studies generally favour the use of primary care, the research designs of both ITS and CBA studies are considered prone to bias, specifically selection and blinding of participants and assessors. Therefore, these studies should be regarded with caution and there is little clear evidence for the effective use of any specific model of care in residential aged care to benefit either residents or care staff. Research in this area is clearly needed.

Source: Medline

Available in fulltext at Wiley

46. The effect of nurse staffing on clinical outcomes of children in hospital: a systematic review.

Author(s) Wilson, S, Bremner, A, Hauck, Y

Citation: International Journal of Evidence-Based Healthcare, Jan 2011, vol. 9, no. 2, p. 97-121, 1744-1595 (2011)

Publication Date: January 2011

Abstract: Systematic review and synthesis of quantitative research measuring the impact on nurse staffing levels on clinical outcomes in hospitalised children and adolescents. Studies involving measures of nursing hours per day, nurse-to-patient ratio, skill mix and nurses' education and work characteristics were included in the statistical meta-analysis. [(BNI unique abstract)] 61 references

Source: BNI

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26

47. Evaluation of a patient care delivery model: system outcomes in acute cardiac care.

Author(s) O'Brien-Pallas, Linda, Li, Mingyang, Wang, Sping, Meyer, Raquel M., Thomson, Donna

Citation: Canadian Journal of Nursing Research, 01 December 2010, vol./is. 42/4(98-120), 08445621

Publication Date: 01 December 2010

Abstract: Hierarchical linear modelling was used to evaluate the influence of nurse staffing, work environment, and nurse and patient variables on system outcomes based on data collected in Canadian cardiac and cardiovascular inpatient units. Staffing utilization levels below 80% at the unit level and less overtime optimized perceived care quality and the completion of therapeutic interventions. Fewer patients per nurse improved perceived care quality and reduced longer-thanexpected length of stay. Nurse reports of greater resource adequacy were associated with less absenteeism and fewer uncompleted or delayed nursing interventions. System outcomes were also influenced by patient characteristics (health, pre-operative education, nursing diagnoses); nurse characteristics (experience, expertise, health, effort-reward imbalance); and work-environment factors (autonomy, unit instability).

Source: CINAHL

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48. Staffing, skill mix and the model of care.

Author(s) Duffield C, Roche M, Diers D, Catling-Paull C, Blay N

Citation: Journal of Clinical Nursing, 01 August 2010, vol./is. 19/15-16(2242-2251), 09621067

Publication Date: 01 August 2010

Abstract: Aims and objectives. The study aimed to explore whether nurse staffing, experience and skill mix influenced the model of nursing care in medical-surgical wards. Background. Methods of allocating nurses to patients are typically divided into four types: primary nursing, patient allocation, task assignment and team nursing. Research findings are varied in regard to the relationship between these models of care and outcomes such as satisfaction and quality. Skill mix has been associated with various models, with implications for collegial support, teamwork and patient outcomes. Design. Secondary analysis of data collected on 80 randomly selected medical-surgical wards in 19 public hospitals in New South Wales, Australia during 2004-2005. Methods. Nurses ( n = 2278, 80·9% response rate) were surveyed using The Nursing Care Delivery System and the Nursing Work Index-Revised. Staffing and skill mix was obtained from the ward roster and other data from the patient record. Models of care were examined in relation to these practice environment and organisational variables. Results. The models of nursing care most frequently reported by nurses in medical-surgical wards in this study were patient allocation (91%) and team nursing (80%). Primary nursing and task based models were unlikely to be practised. Skill mix, nurse experience, nursing workload and factors in the ward environment significantly influenced the model of care in use. Wards with a higher ratio of degree qualified, experienced registered nurses, working on their 'usual' ward were more likely to practice patient allocation while wards with greater variability in staffing levels and skill mix were more likely to practice team nursing. Conclusions. Models of care are not prescriptive but are varied according to ward circumstances and staffing levels based on complex clinical decision making skills. Relevance to clinical practice. Variability in the models of care reported by ward nurses indicates that nurses adapt the model of nursing care on a daily or shift basis, according to patients' needs, skill mix and individual ward environments.

Source: CINAHL

Available in fulltext at EBSCOhost

Available in fulltext at the ULHT Library and Knowledge Services' eJournal collection

27

49. Impact of california mandated acute care hospital nurse staffing ratios: a literature synthesis.

Author(s) Donaldson N, Shapiro S

Citation: Policy, Politics & Nursing Practice, 01 August 2010, vol./is. 11/3(184-201), 15271544

Publication Date: 01 August 2010

Abstract: California is the first state to enact legislation mandating minimum nurse-to-patient ratios at all times in acute care hospitals. This synthesis examines 12 studies of the impact of California’s ratios on patient care cost, quality, and outcomes in acute care hospitals. A key finding from this synthesis is that the implementation of minimum nurse-to-patient ratios reduced the number of patients per licensed nurse and increased the number of worked nursing hours per patient day in hospitals. Another finding is that there were no significant impacts of these improved staffing measures on measures of nursing quality and patient safety indicators across hospitals. A critical observation may be that adverse outcomes did not increase despite the increasing patient severity reflected in case mix index. We cautiously posit that this finding may actually suggest an impact of ratios in preventing adverse events in the presence of increased patient risk.

Source: CINAHL

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50. Safety in numbers.

Author(s) Aiken L

Citation: Nursing Standard, 07 July 2010, vol./is. 24/44(62-63), 00296570

Publication Date: 07 July 2010

Abstract: A mandatory minimum nurse to patient ratio improves outcomes. Linda Aiken reports on her research.

Source: CINAHL

Available in fulltext at EBSCOhost

Available in print at Grantham Hospital Staff Library

Available in print at ULHT journal article requests. Complete the online form to obtain articles.

Available in print at Louth County Hospital Medical Library

Available in print at Lincoln County Hospital Professional Library

51. The jury's in---staffing laws work: California's staffing ratio benefits both patients and nurses.

Author(s) Aiken LH, Potera C

Citation: American Journal of Nursing, 01 July 2010, vol./is. 110/7(15-15), 0002936X

Publication Date: 01 July 2010

Source: CINAHL

Available in fulltext at Ovid

Available in fulltext at the ULHT Library and Knowledge Services' eJournal collection

52. Patient-to-nurse ratio in neonatal ICU associated with daily weight gain, but not other clinical outcomes in moderately preterm infants.

Author(s) Tucker J

28

Citation: Evidence Based Nursing, 01 July 2010, vol./is. 13/3(89-90), 13676539

Publication Date: 01 July 2010

Source: CINAHL

Available in fulltext at Highwire Press

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53. Nurse staffing and quality of care with direct measurement of inpatient staffing.

Author(s) Harless DW, Mark BA

Citation: Medical Care, 01 July 2010, vol./is. 48/7(659-663), 00257079

Publication Date: 01 July 2010

Abstract: BACKGROUND:: Studies of the impact of registered nurse (RN) staffing on hospital quality of care for hospital inpatients often rely on data sources that do not distinguish inpatient from outpatient staffing, thus requiring imputation of staffing level. As a result, estimates of the impact of staffing on quality may be biased. OBJECTIVE:: To estimate the impact of changes in RN staffing on changes in quality of care with direct measurement of staffing levels. RESEARCH DESIGN:: Longitudinal regression analysis of California general acute care hospitals where inpatient staffing is measured directly. SUBJECTS:: Estimation sample reflects outcomes for 11,945,276 adult inpatients at 283 hospitals from 1996 to 2001. MEASURES:: Patient outcomes are in-hospital mortality ratio and surgical failure-to-rescue ratio after nurse-sensitive complications with risk adjustment through calculation of the expected number of adverse outcomes using the Medstat disease staging algorithm. Staffing levels were measured as the number of full-time equivalent nurses per 1000 inpatient days. RESULTS:: Estimates suggest that changes in RN staffing were associated with reductions in mortality and failure to rescue. At 2.97 RN full-time equivalents per 1000 inpatient days, a 1-unit increase in staffing was associated with a 0.043 decrease in the mortality ratio (P < 0.05), and the estimated effect was smaller at hospitals with higher staffing levels. Estimates for failure to rescue ratio were statistically significant only at higher staffing levels. CONCLUSIONS:: Results are compared with those from similar studies, including studies using imputation of inpatient staffing, and are found to be consistent with attenuation bias induced by imputation.

Source: CINAHL

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54. Clinical rounds. Nurse staffing levels: California's mandated staff ratios reduce mortality.

Author(s)

Citation: Nursing, 01 June 2010, vol./is. 40/6(21-21), 03604039

Publication Date: 01 June 2010

Source: CINAHL

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55. How many nurses does your hospital need?

Author(s) Cohen, J

Citation: Nursing Management (USA), Jun 2010, vol. 41, no. 6, p. 20-25, 0744-6314 (June 2010)

Publication Date: June 2010

Abstract: Guidance on calculating the optimal number of nurses and support staff required

29

to maintain quality outcomes. Budgeting, patient dependency and acuity, skill mix and staffing levels are discussed and formulae for determining hiring levels are explained. [(BNI unique abstract)] 9 references

Source: BNI

Available in fulltext at Ovid

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56. The relationship of nurse staffing, skill mix, and MAGNET recognition to institutional volume and mortality for congenital heart surgery.

Author(s) Hickey P, Gauvreau K, Connor J, Sporing E, Jenkins K

Citation: Journal of Nursing Administration, 01 May 2010, vol./is. 40/5(226-232), 00020443

Publication Date: 01 May 2010

Abstract: OBJECTIVE: The aim of this study was to examine the relationship of nurse staffing, skill mix, and Magnet(R) recognition to institutional volume and mortality for congenital heart surgery at children's hospitals. BACKGROUND: Little is known about how nurse staffing, skill mix, and Magnet recognition influence outcomes in children's hospitals. METHODS: Cases of congenital heart surgery were identified from the 2005-2006 Pediatric Health Information System Database using International Classification of Diseases, Ninth Revision, Clinical Modification codes. The National Association of Children's Hospitals and Related Institution database was used for staffing data and verified by chief nursing officers; Magnet recognition was obtained from the American Nurses Credentialing Center Web site. Relationships among nursing characteristics, volume, and mortality were examined. RESULTS: Among children undergoing congenital heart surgery at major children's hospitals, there was marked variation in intensive care unit (ICU) nursing hours per patient day (14.96-32.31). Variation in ICU nursing skill mix was less extreme (80%-100%); 20 hospitals had 100% registered nurse staffing in ICUs. There was a significant difference in median nursing skill mix between Magnet and non-Magnet hospitals (P = .02). None of the nursing characteristics was associated with mortality. However, higher nursing worked hours was significantly associated with higher volume (rs = 0.39, P = .027). Hospital volume was significantly associated with risk-adjusted mortality. CONCLUSION: Nursing characteristics varied in ICUs in children's hospitals treating congenital heart surgery but were not associated with mortality. There was a significant relationship between ICU nursing worked hours and institutional volume. Nursing skill mix was lower in Magnet hospitals.

Source: CINAHL

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57. Standards for nurse staffing in critical care units determined by: The British Association of Critical Care Nurses, The Critical Care Networks National Nurse Leads, Royal College of Nursing Critical Care and In-flight Forum.

Author(s) Bray K, Wren I, Baldwin A, St. Ledger U, Gibson V, Goodman S, Walsh D

Citation: Nursing in Critical Care, 01 May 2010, vol./is. 15/3(109-111), 13621017

Publication Date: 01 May 2010

Abstract: Background: Since 1967 the gold standard for nurse staffing levels in intensive care and subsequently critical care units has been one nurse for each patient. However, critical care has changed substantially since that time and in recent years this standard has been challenged. Previously individual nursing organisations such as the British Association of Critical Care Nurses (BACCN) and the Royal College of Nursing have produced guidance on staffing levels for critical care units. This paper represents the first time all three UK Professional Critical Care Associations have collaborated to produce standards for nurse staffing in critical care units. These standards have evolved from previous works and are endorsed by BACCN, Critical Care Networks National Nurse Leads

30

Group (CC3N) and the Royal College of Nursing Critical Care and In-flight Forum. Aim: The aim of this paper is to provide an overview of the much more detailed document 'Standards for Nurse Staffing in Critical Care', which can be found on the BACCN web site at . The full paper has extensively reviewed the evidence, whereas this short paper provides essential detail and the 12 standard statements. Methods: Representation was sort from each of the critical care associations. The authors extensively reviewed the literature using the terms: (1) critical care nursing, (2) nursing, (3) nurse staffing, (4) skill mix, (5) adverse events, (6) health care assistants and critical care, (7) length of stay, (8) critical care, (9) intensive care, (10) technology, (11) infection control. Outcomes: Comprehensive review of the evidence has culminated in 12 standard statements endorsed by BACCN, CC3N and the Royal College of Nursing Critical Care and In-flight Forum. The standards act as a reference for nursing staff, managers and commissioners associated with critical care to provide and support safe patient care. Conclusion: The review of the evidence has shown that the contribution of nursing can be difficult to measure and consequently support nurse staffing ratios. However, there is a growing body of evidence which associates higher number of registered nursing staff to patient ratio relates to improved safety and better outcomes for patients. The challenge for nurses is to produce accurate and meaningful outcome measures for nursing and collect data that accurately reflect the input of nursing on patient outcomes and safety.

Source: CINAHL

Available in fulltext at EBSCOhost

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58. Ward staffing levels significantly affect timing of insulin administration in hospital

Author(s) Aye M.M., Ng J.M., Mellor D.D., French M., Atkin S.L., Allan B.J.

Citation: Diabetic Medicine, March 2010, vol./is. 27/2 SUPPL. 1(149), 0742-3071 (March 2010)

Publication Date: March 2010

Abstract: Introduction: Good glycaemic control is associated with overall better outcome in a hospital setting. Recent data shows that a well staffed ward is associated with shorter time to biochemical correction of hypoglycaemia. We decide to study the effect of staffing levels with regards to timing of insulin administration. Methods: We included all patients who were admitted to a diabetes specialist unit in our Trust who required insulin nurse supervision or nurse administration from March to April 2009. Well Staffed (WS) days were defined as days where there was full nursing staff levels with a on site nurse coordinator and Low Staff (LS) days were defined as days where there was nursing staff levels of 75% or less. Insulin was considered delayed if it was administered more than 30 minutes later than the prescribed time. (Trust protocol). Results: There were a total of 92 insulin injections (39 WS and 53 LS) administered over the study period. Of this there were 8 occasions (1 WS (2.5%) and +/- LS (13.2%) in which insulin was not administered to patients within the recommended 30 minutes. (p< 0.05, chi square test). Conclusions: Staffing levels in hospital significantly affect time of insulin administration in patients who require nurse administration or supervision. Our study highlights the importance of adequate staffing levels on timing of insulin injections. On days when the ward has low staffing levels, the risk of insulin not administered within the recommended 1/2 hour is increased almost five fold.

Source: EMBASE

Available in fulltext at EBSCOhost

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59. What is the harm in imposing mandatory hospital nurse staffing regulations?

31

Author(s) Buerhaus PI

Citation: Nursing Economic$, 01 March 2010, vol./is. 28/2(87-93), 07461739

Publication Date: 01 March 2010

Abstract: · Efforts to establish mandated staffing ratios are shortsighted, and, though proponents may have the best intentions, many negative outcomes would flow from the public airing of this issue. · The Institute of Medicine concluded in 1996 that there was insufficient quality outcome evidence to support the imposition of mandated nurse staffing ratios. · The Massachusetts Nursing Association got legislation introduced in early 1996 which, if passed, would turn over to state lawmakers decisions governing nurse staffing in hospitals and other employment settings. · There are high opportunity costs. Staffing regulations (if imposed) would force employers to ignore the dynamic interactions of economic, technology, capital, and labor supply variables, and thus needlessly impose the effect of increased labor costs on hospitals, taxpayers, and nurses themselves. · Chance for passage of this highly controversial legislation is unlikely, but the expenditure of political chips (and the loss of credibility) will increase the difficulty of obtaining a hearing from legislators the next time a nursing issue comes up.

Source: CINAHL

Available in fulltext at EBSCOhost

Available in fulltext at EBSCOhost

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60. The more nurses, the better the care, concludes nursing research unit.

Author(s) Doherty L

Citation: Nursing Management - UK, 01 March 2010, vol./is. 16/10(7-7), 13545760

Publication Date: 01 March 2010

Source: CINAHL

Available in fulltext at EBSCOhost

Available in fulltext at EBSCOhost

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61. Establishing the relationship between nurse staffing and hospital mortality using a clustered discrete-time logistic model.

Author(s) Diya L, Lesaffre E, Van den Heede K, Sermeus W, Vleugels A

Citation: Statistics in Medicine, March 2010, vol./is. 29/7-8(778-85), 0277-6715;1097-0258 (2010 Mar 30)

Publication Date: March 2010

Abstract: Studies based on aggregated hospital outcome data have established that there is a relationship between nurse staffing and adverse events. However, this result could not be confirmed in Belgium where 96 per cent of the variability of nurse staffing levels over nursing units (belonging to different hospitals) is explained by within-hospital variability. To better appreciate the possible impact of nurse staffing levels on adverse events, we propose a multilevel approach reflecting the complex nature of the data. In particular we suggest a clustered discrete-time logistic model that captures the risks associated with a given unit in the patient's trajectory through the hospital. The model also allows for nurse staffing levels to affect the current and subsequent nursing unit (carry-over effect). In the model 'time' is represented by the sequential number of the nursing unit that the patient is passing through. The model incorporates hospital and nursing unit random effects to express that patients treated in the same hospital and taken care of by nurses of the same unit share a common environment. In this study we used Belgian national administrative databases for the year 2003 to assess the relationship between nurse staffing levels and

32

nurse education variables with in-hospital mortality. The analysis was restricted to elective cardiac surgery patients. Lower nursing unit staffing levels in the general nursing units were associated with high in-hospital mortality in units past the traditional cardiac surgery nursing units.

Source: Medline

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62. Safe staffing in the post anaesthetic care unit: no magic formula.

Author(s) Smedley, P

Citation: British Journal of Anaesthetic & Recovery Nursing, Feb 2010, vol. 11, no. 1, p. 3-8, 1742-6456 (February 2010)

Publication Date: February 2010

Abstract: Report of the outcomes of a symposium on staffing in post anaesthesia care units (PACU). The issues discussed include minimum safe standards, ensuring peak activity can be safely handled, surgical sequencing and discharge, workforce planning for PACUs, staff-patient ratios, and skill mix. Job satisfaction related to staffing issues was also considered. [(BNI unique abstract)] 12 references

Source: BNI

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63. Patient-to-nurse ratios and outcomes of moderately preterm infants.

Author(s) Profit J, Petersen LA, McCormick MC, Escobar GJ, Coleman-Phox K, Zheng Z, Pietz K, Zupancic JAF

Citation: Pediatrics, 01 February 2010, vol./is. 125/2(320-326), 00314005

Publication Date: 01 February 2010

Abstract: OBJECTIVE: Moderately preterm infants (30-34 6/7 weeks' gestational age) represent the largest population of NICU residents. Whether their clinical outcomes are associated with differences in NICU nurse-staffing arrangements has not been assessed. The objective of this study was to test the influence of patient-to-nurse ratios (PNRs) on outcomes of care provided to moderately preterm infants. PATIENTS AND METHODS: Using data from a prospective, multicenter, observational cohort study of 850 moderately preterm infants from 10 NICUs in California and Massachusetts, we tested for associations between PNR and several important clinical outcomes by using multivariate random-effects models. To correct for the influence of NICU size, we dichotomized the sample into those with an average daily census of <20 or > or =20 infants. RESULTS: Overall, we found few clinically significant associations between PNR and clinical outcomes of care. Mean PNRs were higher in large compared with small NICUs (2.7 vs 2.1; P < .001). In bivariate analyses, an increase in PNR was associated with a slightly higher daily weight gain (5 g/day), greater gestational age at discharge, any intraventricular hemorrhage, and severe retinopathy of prematurity. After controlling for case mix, NICU size, and site of care, an additional patient per nurse was associated with a decrease in daily weight gain by 24%. Other variables were no longer independently associated with PNR. CONCLUSIONS: In this population of moderately preterm infants, the PNR was associated with a decrease in daily weight gain, but was not associated with other measures of quality. In contrast with findings in the adult intensive care literature, measured clinical outcomes were similar across the range of nurse-staffing arrangements among participating NICUs. We conclude that the PNR is not useful for profiling hospitals' quality of care delivery to moderately preterm infants.

Source: CINAHL

Available in fulltext at American Academy of Pediatrics

Available in fulltext at Highwire Press

33

Available in print at ULHT journal article requests. Complete the online form to obtain articles.

64. Nurse staffing and quality of care with direct measurement of inpatient staffing

Author(s) Harless, David W, Mark, Barbara A

Citation: Medical Care, 2010, vol./is. 48/7, 0025-7079

Publication Date: 2010

Abstract: Studies of the impact of registered nurse (RN) staffing on hospital quality of care for hospital inpatients often rely on data sources that do not distinguish inpatient from outpatient staffing, thus requiring imputation of staffing level. As a result, estimates of the impact of staffing on quality may be biased. The objective of the study was to estimate the impact of changes in RN staffing on changes in quality of care with direct measurement of staffing levels. The research design was, longitudinal regression analysis of California general acute care hospitals where inpatient staffing is measured directly. The subjects were, estimation sample reflects outcomes for 11,945,276 adult inpatients at 283 hospitals from 1996 to 2001. Patients outcomes are in-hospital mortality ratio and surgical failure-to-rescue ratio after nurse-sensitive complications with risk adjustment through calculation of the expected number of adverse outcomes using the Medstat disease staging algorithm. Staffing levels were measured as the number of full-time equivalent nurses per 1,000 inpatient days. Estimates suggest that changes in RN staffing were associated with reductions in mortality and failure to rescue. At 2.97 RN full-time equivalents per 1,000 inpatient days, a one-unit increase in staffing was associated with a 0.043 decrease in the mortality ratio (P<0.05), and the estimated effect was smaller at hospitals with higher staffing levels. Estimates for failure to rescue ratio were statistically significant only at higher staffing levels. The conclusions were, results are compared with those from similar studies, including studies using imputation of inpatient staffing, and are found to be consistent with attenuation bias induced by imputation. Cites 20 references. [Journal abstract]

Source: HMIC

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65. The relationship between staff skill mix, costs and outcomes in intermediate care services.

Author(s) Dixon, Simon, Kaambwa, Billingsley, Nancarrow, Susan

Citation: BMC Health Services Research, 2010, vol./is. 10/221, 1472-6963

Publication Date: 2010

Abstract: BACKGROUND: The purpose of this study was to assess the relationship between skill mix, patient outcomes, length of stay and service costs in older peoples' intermediate care services in England. METHODS: We undertook multivariate analysis of data collected as part of the National Evaluation of Intermediate Care Services. Data were analysed on between 337 and 403 older people admitted to 14 different intermediate care teams. Independent variables were the numbers of different types of staff within a team and the ratio of support staff to professionally qualified staff within teams. Outcome measures include the Barthel index, EQ-5D, length of service provision and costs of care. RESULTS: Increased skill mix (raising the number of different types of staff by one) is associated with a 17 per cent reduction in service costs (p = 0.011). There is weak evidence (p = 0.090) that a higher ratio of support staff to qualified staff leads to greater improvements in EQ-5D scores of patients. CONCLUSIONS: This study provides limited evidence on the relationship between multidisciplinary skill mix and outcomes in intermediate care services. [Abstract]

Source: HMIC

Available in fulltext at EBSCOhost

Available in fulltext at BioMedCentral

34

Available in fulltext at National Library of Medicine

66. Nurse staffing and skill mix patterns: are there differences in outcomes?

Author(s) Esparza, Salvador J

Citation: , 01 January 2010, vol./is. /(0-92),

Publication Date: 01 January 2010

Abstract: Hospital executives experience constant tension between running their organizations efficiently and providing effective, high quality patient care. Because nursing consumes the majority of labor resources, it is imperative that hospital executives identify staffing/skill mix decisions that will yield the best patient outcomes.

Source: CINAHL

67. The impact of staffing ratios, magnet recognition, and institutional characteristics on risk adjusted mortality, risk adjusted complications, and risk adjusted resource utilization for pediatric cardiac surgery programs in California before and after enactment of the California Safe Staffing Law and relative to other states combined.

Author(s) Hickey, Patricia A

Citation: , 01 January 2010, vol./is. /(0-111),

Publication Date: 01 January 2010

Abstract: Objective: To examine the impact of staffing ratios, Magnet Recognition, and institutional characteristics on risk adjusted outcomes for pediatric cardiac surgery programs in California before and after enactment of the California Safe Staffing Law and relative to other states combined.

Source: CINAHL

68. Nurse staffing levels and nursing outcomes: a Bayesian analysis of Finnish-registered nurse survey data.

Author(s) Tervo-Heikkinen T, Kiviniemi V, Partanen P, Vehviläinen-Julkunen K

Citation: Journal of Nursing Management, 01 December 2009, vol./is. 17/8(986-993), 09660429

Publication Date: 01 December 2009

Abstract: Aim: The aim of the present study was to assess the relationship between patient-toregistered nurse (RN) ratios and nursing outcomes: job satisfaction and stress, nursing care quality, control of own practise, intent to leave, adequacy of material resources and attitudes towards technical equipment.

Source: CINAHL

Available in fulltext at EBSCOhost

Available in fulltext at the ULHT Library and Knowledge Services' eJournal collection

69. Evaluation of a patient care delivery model: patient outcomes in acute cardiac care.

Author(s) Meyer RM, Wang S, Li X, Thomson D, O'Brien-Pallas L

Citation: Journal of Nursing Scholarship, 01 December 2009, vol./is. 41/4(399-410), 15276546

Publication Date: 01 December 2009

Abstract: Purpose: To evaluate the influence of nurse staffing and work environment variables on patient outcomes by testing a conceptual model. Design: A prospective,

35

correlational design with cross-sectional and longitudinal components was conducted in Canadian cardiac and cardiovascular care inpatient units. Methods: Data were collected from multiple sources. Hierarchical linear modeling was used to examine relationships among variables. Conclusions: The findings indicate that patient outcomes are influenced not only by patient and nurse characteristics, but also by organizational staffing practices. Organizations that manage the complexity of work conditions and target staffing utilization levels between 80% and 88% at the unit level can optimize patient outcomes. Clinical Relevance: Empirical validation of the model provides evidence to inform management decisions about hospital nurse staffing.

Source: CINAHL

Available in fulltext at EBSCOhost

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70. Mandating nurse staffing in Pennsylvania: more than a numbers game.

Author(s) DeVandry SN, Cooper J

Citation: Journal of Nursing Administration, 01 November 2009, vol./is. 39/11(470-478), 00020443

Publication Date: 01 November 2009

Abstract: Current federal and state legislation for mandated nurse staffing falls short of the ideal plan. Hospital nurse-staffing ratios are inadequate to maintain patient safety and quality nursing care. Mandating fixed nurse-to-patient ratios does not accommodate changes in patients' needs, evolving technology, and experience of nursing staff and will be immediately obsolete. Ideal measurement of nurse staffing incorporates nurse skill level and patient acuity. The Pennsylvania State Nurses Association supports legislation to establish patient acuity-based nurse staffing.

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71. Staffing levels and patient outcomes.

Author(s) Griffiths P

Citation: Nursing Management - UK, 01 October 2009, vol./is. 16/6(22-23), 13545760

Publication Date: 01 October 2009

Abstract: There is considerable evidence of an association between nurse staffing levels and patient outcomes. The evidence has been used to support calls for mandatory nurse-patient ratios although the precise significance of the relationship remains unclear. In this article, the evidence is examined to establish what is known and, crucially, what is not known about this relationship.

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72. How have mandated nurse staffing ratios affected hospitals? Perspectives from California hospital leaders

Author(s) Chapman S.A., Spetz J., Seago J.A., Kaiser J., Dower C., Herrera C.

Citation: Journal of Healthcare Management, September 2009, vol./is. 54/5(321-333), 1096-9012 (September-October 2009)

36

Publication Date: September 2009

Abstract: In 1999, California became the first state to pass legislation mandating minimum nurse-to-patient ratios. Regulations detailing specific ratios by type of hospital unit were released in 2002, with phased-in implementation beginning in 2004 and completed in 2008. These ratios were implemented at a time of severe registered nurse (RN) shortage in the state and a worsening financial position for many hospitals. This article presents an analysis of qualitative data from interviews with healthcare leaders about the impact of nurse staffing ratios. Twenty hospitals (including public, not-for-profit, and for-profit institutions) representing major geographic regions of California were approached. Twelve agreed to participate; semistructured in-person and telephone interviews were conducted with 23 hospital leaders. Several key themes emerged from the analysis. Most hospitals found it difficult and expensive to find more RNs to hire to meet the ratios. Meeting the staffing requirements on all units, at all times, was challenging and had negative impacts, such as a backlog of patients in the emergency department and a decrease of other ancillary staff. Hospital leaders do not believe that ratios have had an impact on patient quality of care. Findings related to nurse satisfaction were mixed. Increased RN staffing improved satisfaction with patient workload, but dissatisfaction with issues of decision-making control (e.g., decisions on when best to take a meal break) were taken out of the nurse's hands to meet ratio requirements. Further research should continue to monitor patient outcomes as other states consider similar ratio regulations. Results of this study will be useful to healthcare managers searching for ways to reduce unnecessary administrative costs while continuing to maintain the level of administrative activities required for the provision of safe, effective, high-quality care.

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73. Nurse labor data: the collection and interpretation of nurse-to-patient ratios.

Author(s) Minnick AF, Mion LC

Citation: Journal of Nursing Administration, 01 September 2009, vol./is. 39/9(377-381), 00020443

Publication Date: 01 September 2009

Abstract: Nurse labor has been shown to be related to some patient outcomes, but varying definitions and measurement approaches have resulted in conflicting findings about the nature of the relationship. Nurse administrators and researchers need to know rates of missing data and error in labor data to better inform decision making. The authors compare the degree of completeness and the agreement between these approaches (nurse survey and nurse-to-patient ratio staffing plans) to obtain patient-to-nurse ratios at the unit level.

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74. Nurse staffing levels revisited: a consideration of key issues in nurse staffing levels and skill mix research.

Author(s) Flynn M, McKeown M

Citation: Journal of Nursing Management, 01 September 2009, vol./is. 17/6(759-766), 09660429

Publication Date: 01 September 2009

Abstract: Aim This paper revisits the published evidence relating to how nurse staffing levels impact on patient, nurse and service outcomes and considers the implications of this

37

body of research for nurse managers in their quest to determine optimum nursing numbers. Background Within the context of the recognized global nursing shortage and particular local pressures within international health services, questions of appropriate nurse staffing levels and skill mix are once again becoming increasingly important. It would seem that the determination of optimum nurse staffing levels and skill mix is a central issue in relation to health service governance, service user involvement, as well as in the recruitment, retention and well-being of nursing staff across the service sectors. Methods A review of published evidence was carried out, applying key principles of the systematic method, in order to facilitate the identification of current factors and issues in nurse staffing levels research. The review did not seek to address a specific research question. The search covered 10 years from 1998 to 2008 and identified more than 500 relevant papers, giving a wide international perspective. Key issues The majority of research in the field relates to the acute service sector and there are considerable similarities in issues that transcend international boundaries. Much of the research focuses on the impact on patients and nurses of 'poor' nurse staffing levels. More recent studies have explored the impact of nurse staffing levels on the service organization itself. However, while there may be an association between models of nurse staffing and outcomes, there is insufficient evidence to establish a causal relationship between these factors. In this context it is perhaps time to reconsider how nursing outcomes are defined and measured. Implications for nursing management and conclusion Nurse managers, commissioners of services and workforce planners need to be cognisant of key issues and analyses in the consideration of nurse staffing levels. Not least of these is the need for a healthy degree of caution regarding the supposed objectivity, scientific basis, or evidence base, for rational calculation of optimum nurse staffing levels.

Source: CINAHL

Available in fulltext at EBSCOhost

Available in fulltext at the ULHT Library and Knowledge Services' eJournal collection

75. Bed-to-nurse ratios, provision of basic nursing care, and in-hospital and 30-day mortality among acute stroke patients admitted to an intensive care unit: cross-sectional analysis of survey and administrative data.

Author(s) Cho S, Yun S

Citation: International Journal of Nursing Studies, 01 August 2009, vol./is. 46/8(1092-1101), 00207489

Publication Date: 01 August 2009

Abstract: BACKGROUND: The literature reports inconsistent evidence of the effects of nurse staffing on mortality despite continuing examination of this association. OBJECTIVE: To examine differences in provision of basic nursing care and in-hospital and 30-day mortality by nurse staffing of ICUs and general wards among acute stroke patients admitted to ICUs during hospitalization. DESIGN: A cross-sectional design that included survey and administrative data. SETTINGS AND PARTICIPANTS: The study included 6957 patients with hemorrhagic and ischemic stroke who were admitted to ICUs of 185 Korean hospitals. METHODS: Nurse staffing of ICUs and general wards was graded based on the bed-to-nurse ratios of each hospital. Provision of basic care was measured by whether five activities, such as bathing and feeding assistance, were fully provided by ICU nursing staff without delegation to patient families. Hospitals were categorized into low, middle, and high mortality groups for in-hospital and 30-day mortality based on z-scores that indicated standardized difference between observed and expected mortality after controlling for patient characteristics. RESULTS: In 83.8% of hospitals, basic care was provided fully by ICU nursing staff. The overall in-hospital and 30-day mortality rates were 21.9 and 25.4%, respectively. Hospitals with higher ICU staffing were more likely to fully provide basic care. Better ICU and general staffing tended to be associated with lower in-hospital and 30-day mortality. Compared with in-hospital mortality, 30-day mortality had a more distinct increase as nurse staffing became worse. CONCLUSION: The findings provide evidence that nurse staffing may impact provision of basic care and patient mortality and suggest the need for policies for providing adequate nurse staffing.

Source: CINAHL

38

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76. New tool to reveal nursing quality.

Author(s) Lomas, C

Citation: Nursing Times, Aug 2009, vol. 105, no. 30/31, p. 1., 0954-7762 (August 4, 2009)

Publication Date: August 2009

Abstract: Report of a new tool to enable nurses to benchmark the quality of patient care, as part of the Energise for Excellence in Care initiative. The role of the tool in assessing patient acuity and dependency, to inform staffing levels, is explained. [(BNI unique abstract)] 0 references

Source: BNI

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77. A top down answer to patient safety.

Author(s) Buchan J

Citation: Nursing Standard, 22 July 2009, vol./is. 23/46(24-25), 00296570

Publication Date: 22 July 2009

Abstract: Staffing ratios are popular with nurses but do they improve quality of care? James Buchan reports.

Source: CINAHL

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78. The relationship between nurse staffing and patient outcomes: A case study

Author(s) Shuldham C., Parkin C., Firouzi A., Roughton M., Lau-Walker M.

Citation: International Journal of Nursing Studies, July 2009, vol./is. 46/7(986-992), 0020-7489 (July 2009)

Publication Date: July 2009

Abstract: Background: Research has shown a direct relationship between staffing levels and patient outcomes for specific nurse-sensitive indicators, with lower patient to nurse ratios (i.e. less patients per nurse) associated with better outcomes. Objectives: To explore the relationship between nurse staffing characteristics (the nursing hours worked by permanent and temporary staff and nurse hours per patient day) and patient outcomes: pressure sores, patient falls, upper gastrointestinal bleed, pneumonia, sepsis, shock and deep vein thrombosis. Design: A case study using retrospective hospital data, at ward level. Setting: A tertiary cardio-respiratory NHS Trust in England, comprising two hospitals. Participants: All patients, including day cases, who were admitted to either hospital as an

39

in-patient over 12 months. Methods: Data were extracted from corporate hospital systems. The clinical areas were categorised as lower dependency, i.e. wards, or critical care which included ICU and high dependency units. The relationship between nurse staffing characteristics and patient outcomes was assessed using either a Poisson or negative binomial regression model as appropriate. We sought to establish whether the outcomes were affected by the nurse hours per patient day, the permanent nurse hours worked as a percentage of the total hours, and the permanent nurse hours worked as a percentage of the permanent and bank hours combined. Results: In the lower dependency category wards there was only a weak association demonstrated between nurse staffing and the majority of the outcomes. The results from the high dependency critical care areas showed few significant results with only the rate of sepsis being significantly reduced as the ratio of permanent staff hours increased. Conclusions: The study demonstrated the possibility of using existing hospital data to examine the relationship between nurse staffing and patient outcomes, however the associations found were weak and did not replicate reliably the findings from previous work. 2008 Elsevier Ltd. All rights reserved.

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79. Nurse staffing and patient outcomes in Belgian acute hospitals: cross-sectional analysis of administrative data.

Author(s) Van den Heede K, Sermeus W, Diya L, Clarke SP, Lesaffre E, Vleugels A, Aiken LH

Citation: International Journal of Nursing Studies, 01 July 2009, vol./is. 46/7(928-939), 00207489

Publication Date: 01 July 2009

Abstract: BACKGROUND: Studies have linked nurse staffing levels (number and skill mix) to several nurse-sensitive patient outcomes. However, evidence from European countries has been limited. OBJECTIVES: This study examines the association between nurse staffing levels (i.e. acuity-adjusted Nursing Hours per Patient Day, the proportion of registered nurses with a Bachelor's degree) and 10 different patient outcomes potentially sensitive to nursing care. DESIGN-SETTING-PARTICIPANTS: Cross-sectional analyses of linked data from the Belgian Nursing Minimum Dataset (general acute care and intensive care nursing units: n=1403) and Belgian Hospital Discharge Dataset (general, orthopedic and vascular surgery patients: n=260,923) of the year 2003 from all acute hospitals (n=115). METHODS: Logistic regression analyses, estimated by using a Generalized Estimation Equation Model, were used to study the association between nurse staffing and patient outcomes. RESULTS: The mean acuity-adjusted Nursing Hours per Patient Day in Belgian hospitals was 2.62 (S.D.=0.29). The variability in patient outcome rates between hospitals is considerable. The inter-quartile ranges for the 10 patient outcomes go from 0.35 for Deep Venous Thrombosis to 3.77 for failure-to-rescue. No significant association was found between the acuity-adjusted Nursing Hours per Patient Day, proportion of registered nurses with a Bachelor's degree and the selected patient outcomes. CONCLUSION: The absence of associations between hospital-level nurse staffing measures and patient outcomes should not be inferred as implying that nurse staffing does not have an impact on patient outcomes in Belgian hospitals. To better understand the dynamics of the nurse staffing and patient outcomes relationship in acute hospitals, further analyses (i.e. nursing unit level analyses) of these and other outcomes are recommended, in addition to inclusion of other study variables, including data about nursing practice environments in hospitals.

Source: CINAHL

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40

80. Nursing resources and patient outcomes in intensive care: a systematic review of the literature.

Author(s) West E, Mays N, Rafferty AM, Rowan K, Sanderson C

Citation: International Journal of Nursing Studies, 01 July 2009, vol./is. 46/7(993-1011), 00207489

Publication Date: 01 July 2009

Abstract: OBJECTIVES: To evaluate the empirical evidence linking nursing resources to patient outcomes in intensive care settings as a framework for future research in this area. BACKGROUND: Concerns about patient safety and the quality of care are driving research on the clinical and cost-effectiveness of health care interventions, including the deployment of human resources. This is particularly important in intensive care where a large proportion of the health care budget is consumed and where nursing staff is the main item of expenditure. Recommendations about staffing levels have been made but may not be evidence based and may not always be achieved in practice. METHODS: We searched systematically for studies of the impact of nursing resources (e.g. nurse-patient ratios, nurses' level of education, training and experience) on patient outcomes, including mortality and adverse events, in adult intensive care. Abstracts of articles were reviewed and retrieved if they investigated the relationship between nursing resources and patient outcomes. Characteristics of the studies were tabulated and the quality of the studies assessed. RESULTS: Of the 15 studies included in this review, two reported a statistical relationship between nursing resources and both mortality and adverse events, one reported an association to mortality only, seven studies reported that they could not reject the null hypothesis of no relationship to mortality and 10 studies (out of 10 that tested the hypothesis) reported a relationship to adverse events. The main explanatory mechanisms were the lack of time for nurses to perform preventative measures, or for patient surveillance. The nurses' role in pain control was noted by one author. Studies were mainly observational and retrospective and varied in scope from 1 to 52 units. Recommendations for future research include developing the mechanisms linking nursing resources to patient outcomes, and designing large multi-centre prospective studies that link patient's exposure to nursing care on a shift-by-shift basis over time.

Source: CINAHL

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81. Nurse staffing and patient outcomes in Belgian acute hospitals: cross-sectional analysis of administrative data.

Author(s) Van den Heede, K, Sermeus, W, Diya, L

Citation: International Journal of Nursing Studies, Jul 2009, vol. 46, no. 7, p. 928-939, 0020-7489 (July 2009)

Publication Date: July 2009

Abstract: Research in Belgium to examine the relationship between nurse staffing levels in acute care hospitals and the outcome rates among patients. Administrative data for 2003 were examined to find the impact of average nurse staffing levels per hospital on adverse outcomes, corrected for differences in intensity of nursing care, risk-adjusted patient outcome rates and hospital characteristics. [(BNI unique abstract)] 31 references

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82. Nurse staffing, quality of nursing care and nurse job outcomes in intensive care units.

41

Author(s) Cho S, June KJ, Kim YM, Cho YA, Yoo CS, Yun S, Sung YH

Citation: Journal of Clinical Nursing, 15 June 2009, vol./is. 18/12(1729-1737), 09621067

Publication Date: 15 June 2009

Abstract: Aim. To examine the relationship between nurse staffing and nurse-rated quality of nursing care and job outcomes. Background. Nurse staffing has been reported to influence patient and nurse outcomes. Design. A cross-sectional study with a survey conducted August-October 2007. Methods. The survey included 1365 nurses from 65 intensive care units in 22 hospitals in Korea. Staffing was measured using two indicators: the number of patients per nurse measured at the unit level and perception of staffing adequacy at the nurse level. Quality of care and job dissatisfaction were measured with a four-point scale and burnout measured by the Maslach Burnout Inventory. Multilevel logistic regression models were used to determine the relationships between staffing and quality of care and job outcomes. Results. The average patient-to-nurse ratio was 2·8 patients per nurse. A fifth of nurses perceived that there were enough nurses to provide quality care, one third were dissatisfied, half were highly burnt out and a quarter planned to leave in the next year. Nurses were more likely to rate quality of care as high when they cared for two or fewer patients (odds ratio, 3·26; 95% confidence interval, 1·14-9·31) or 2·0-2·5 patients (odds ratio, 2·44; 95% confidence interval, 1·32-4·52), compared with having more than three patients. Perceived adequate staffing was related to a threefold increase (odds ratio, 2·97; 95% confidence interval, 2·22-3·97) in the odds of nurses' rating high quality and decreases in the odds of dissatisfaction (odds ratio, 0·30; 95% confidence interval, 0·23-0·40), burnout (odds ratio, 0·50; 95% confidence interval, 0·34-0·73) and plan to leave (odds ratio, 0·40; 95% confidence interval, 0·28-0·56). Conclusions. Nurse staffing was associated with quality of care and job outcomes in the context of Korean intensive care units. Relevance to clinical practice. Adequate staffing must be assured to achieve better quality of care and job outcomes.

Source: CINAHL

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83. The relationship between inpatient cardiac surgery mortality and nurse numbers and educational level: analysis of administrative data.

Author(s) Van den Heede K, Lesaffre E, Diya L, Vleugels A, Clarke SP, Aiken LH, Sermeus W

Citation: International Journal of Nursing Studies, 01 June 2009, vol./is. 46/6(796-803), 00207489

Publication Date: 01 June 2009

Abstract: BACKGROUND: In most multicenter studies that examine the relationship between nurse staffing and patient safety, nurse-staffing levels are measured per hospital. This can obscure relationships between staffing and outcomes at the unit level and lead to invalid inferences. OBJECTIVE: In the present study, we examined the association between nurse-staffing levels in nursing units that treat postoperative cardiac surgery patients and the in-hospital mortality of these patients. DESIGN-SETTING-PARTICIPANTS: We illustrated our approach by using administrative databases (Year 2003) representing all Belgian cardiac centers (n=28), which included data from 58 intensive care and 75 general nursing units and 9054 patients. METHODS: We used multilevel logistic regression models and controlled for differences in patient characteristics, nursing care intensity, and cardiac procedural volume. RESULTS: Increased nurse staffing in postoperative general nursing units was significantly associated with decreased mortality. Nurse staffing in postoperative intensive care units was not significantly associated with in-hospital mortality possibly due to lack of variation in ICU staffing across hospitals. CONCLUSION: This study, together with the international body of evidence, suggests that nurse staffing is one of several variables influencing patient safety. These findings further suggest the need to study the impact of nurse-staffing levels on in-hospital mortality using nursing-unit-level specific data.

Source: CINAHL

42

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84. Time to raise our standards and take action on nurse to patient ratios.

Author(s) Slater C

Citation: Nursing Standard, 06 May 2009, vol./is. 23/35(32-32), 00296570

Publication Date: 06 May 2009

Source: CINAHL

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85. Moving toward evidence-based nurse staffing model.

Author(s) Loan LA, Rolph S

Citation: Communicating Nursing Research, 01 March 2009, vol./is. 42/(174-174), 01601652

Publication Date: 01 March 2009

Source: CINAHL

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86. Avoiding mandatory hospital nurse staffing ratios: an economic commentary.

Author(s) Buerhaus PI

Citation: Nursing Outlook, 01 March 2009, vol./is. 57/2(107-112), 00296554

Publication Date: 01 March 2009

Abstract: The imposition of mandatory hospital nurse staffing ratios is among the more visible public policy initiatives affecting the nursing profession. Although the practice is intended to address problems in hospital nurse staffing and quality of patient care, this commentary argues that staffing ratios will lead to negative consequences for nurses involving the equity, efficiency, and costs of producing nursing care in hospitals. Rather than spend time and effort attempting to regulate nurse staffing, this commentary offers alternatives strategies that are directed at fixing the problems that motivate the advocates of staffing ratios.

Source: CINAHL

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87. The effect of variations in nurse staffing on patient length of stay in the acute care setting.

Author(s) Tschannen D, Kalisch BJ

Citation: Western Journal of Nursing Research, 01 March 2009, vol./is. 31/2(153-170),

43

01939459

Publication Date: 01 March 2009

Abstract: This study examines the relationship between nurse staffing and patient length of stay (LOS). Data were collected on nurses employed and patients admitted to one of four study units located in two Midwest hospitals. Three nursing variables (hours per patient day [HPPD], skill mix, and nursing expertise) were collected through survey and administrative forms. The nursing data were then linked with patient-specific characteristics (deviation from expected LOS) to test the relationship at the patient level of analysis. Average HPPD was a positive predictor of deviation from expected LOS, whereas overall expertise was a negative predictor of deviation from expected LOS. Higher staffing levels may result in patients being discharged sooner than expected. Nurse administrators must consider the quantity as well as quality of staff when determining optimal staffing levels. Unit staffing levels must include nurses who have both experiential and theoretical knowledge in order to achieve optimal patient outcomes.

Source: CINAHL

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88. More nurses means better care.

Author(s) Ford, S

Citation: Nursing Times, Mar 2009, vol. 105, no. 12, p. 8-10, 0954-7762 (March 31, 2009)

Publication Date: March 2009

Abstract: Statistics from Dr Foster Intelligence about staffing levels and the relationship to patient outcomes. National hospital activity data were analysed to examine the correlation between nurse to bed ratios and hospital standardised mortality ratios. Other staffing implications are discussed and a list of trusts ranked by nurse per bed ratio is included. [(BNI unique abstract)] 0 references

Source: BNI

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89. [RN+RN better care: what do we know about the association between registered nurse staffing levels and patient outcomes?]

Author(s)

Citation: Policy+, 2009

Publication Date: 2009

Abstract: There is considerable evidence of an association between nurse staffing levels and patient outcomes. The evidence has been used to support calls for mandatory nurse patient ratios but the precise significance of the relationship remains unclear. This Policy+ examines the evidence in order to establish what is known, and crucially, what is not known? [Book abstract]. Cites 13 references.

Source: HMIC

90. Nurse staffing levels revisited : a consideration of key issues in nurse staffing levels and skill mix research.

Author(s) Flynn, Maria, McKeown, Mick

Citation: Journal of Nursing Management, 2009, vol./is. 17/6(759-766), 0966-0429

44

Publication Date: 2009

Abstract: AIM: This paper revisits the published evidence relating to how nurse staffing levels impact on patient, nurse and service outcomes and considers the implications of this body of research for nurse managers in their quest to determine optimum nursing numbers. BACKGROUND: Within the context of the recognized global nursing shortage and particular local pressures within international health services, questions of appropriate nurse staffing levels and skill mix are once again becoming increasingly important. It would seem that the determination of optimum nurse staffing levels and skill mix is a central issue in relation to health service governance, service user involvement, as well as in the recruitment, retention and well-being of nursing staff across the service sectors. METHODS: A review of published evidence was carried out, applying key principles of the systematic method, in order to facilitate the identification of current factors and issues in nurse staffing levels research. The review did not seek to address a specific research question. The search covered tenyears from 1998 to 2008 and identified more than 500 relevant papers, giving a wide international perspective. KEY ISSUES: The majority of research in the field relates to the acute service sector and there are considerable similarities in issues that transcend international boundaries. Much of the research focuses on the impact on patients and nurses of `poor' nurse staffing levels. More recent studies have explored the impact of nurse staffing levels on the service organization itself. However, while there may be an association between models of nurse staffing and outcomes, there is insufficient evidence to establish a causal relationship between these factors. In this context it is perhaps time to reconsider how nursing outcomes are defined and measured. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers, commissioners of services and workforce planners need to be cognisant of key issues and analyses in the consideration of nurse staffing levels. Not least of these is the need for a healthy degree of caution regarding the supposed objectivity, scientific basis, or evidence base, for rational calculation of optimum nurse staffing levels. 57 refs. [Abstract]

Source: HMIC

Available in fulltext at EBSCOhost

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91. An analysis of variance in nursing-sensitive patient safety indicators related to magnet status, nurse staffing, and other hospital characteristics.

Author(s) Solomita JB

Citation: , 01 January 2009, vol./is. /(0-242),

Publication Date: 01 January 2009

Abstract: The purpose of this research was to identify if there was a significant difference in the risk-adjusted rates for a subset of five of the Agency for Healthcare Research and Quality's (AHRQ) Patient Safety Indicators (PSIs) in relation to ANCC's MagnetRTM designation in U.S. hospitals. This exploratory, cross-sectional study involved the analysis of organizational characteristics, including magnet status, nurse staffing, bed size (categorical and number of operated beds), and other organizational characteristics in relation to 5 of 20 of AHRQ's PSIs. The five PSIs were selected based on previous research findings that showed associations between nurse staffing and complications of care. Data from AHRQ's Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) for Calendar Year (CY) 2006 were combined with CY 2006 American Hospital Association (AHA) data, and hospitals with ANCC MagnetRTM designation were identified.

Source: CINAHL

92. Effect of nurse staffing and education on the outcomes of surgical patients with comorbid serious mental illness.

Author(s) Kutney-Lee A, Aiken LH

Citation: Psychiatric Services, 01 December 2008, vol./is. 59/12(1466-1469), 10752730

45

Publication Date: 01 December 2008

Abstract: OBJECTIVE: This study of surgical patients compared outcomes of those with and those without serious mental illness and examined effects of patient-to-nurse ratios and nurses' education levels on outcomes, including death within 30 days of admission, failure to rescue (death resulting from surgery complication), and length of stay. METHODS: Cross-sectional data from a nurse survey and from patient and administrative records were linked. Data for 9,989 nurses and 228,433 surgical patients discharged from 157 Pennsylvania hospitals were analyzed by using generalized estimating equations. RESULTS: Records indicated that 4.7% (N=10,666) of the sample had a diagnosis of serious mental illness. A higher level of nurse staffing had a stronger effect on prevention of death among patients with serious mental illness than among those without it. Length of stay for patients with serious mental illness was shorter in hospitals with higher proportions of baccalaureate-prepared nurses. CONCLUSIONS: Better nurse staffing and higher education level mitigated poor patient outcomes among highly vulnerable patients with serious mental illness.

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93. Relationships among nurse staffing, adherence to practice guidelines, and patient outcomes in the treatment of hypoglycemia.

Author(s) Anthony M

Citation: Quality Management in Health Care, 01 October 2008, vol./is. 17/4(312-319), 10638628

Publication Date: 01 October 2008

Abstract: BACKGROUND: Despite a growing body of research that suggests a relationship between nurse staffing and patient outcomes, little is known about the mediators of this relationship. Understanding the unique contribution of nursing in achieving patient outcomes is important for policy recommendations and quality improvement initiatives. PURPOSE: The purpose of this study was to explore the relationship of registered nurse (RN) staffing and RN adherence to practice guidelines as a possible mediator of the nurse staffing-patient outcome relationship. METHOD: A retrospective, correlational design was used to examine the relationships among nurse staffing, nurse adherence to practice guidelines, and patient outcomes in the treatment of hypoglycemia in hospitalized patients. DISCUSSION: Adherence to practice guidelines was low. Nurse staffing was not found to be related to RN adherence to practice guidelines in the treatment of hypoglycemia. Skill mix at 1 study hospital was found to be related to total number of hypoglycemic episodes. Notification of the physician was significantly related to a subsequent change in medication.

Source: CINAHL

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94. The association between nursing factors and patient mortality in the Veterans Health Administration: the view from the nursing unit level.

Author(s) Sales A, Sharp N, Li YF, Lowy E, Greiner G, Liu CF, Alt-White A, Rick C, Sochalski J, Mitchell PH, Rosenthal G, Stetler C, Cournoyer P, Needleman J

Citation: Medical Care, 01 September 2008, vol./is. 46/9(938-945), 00257079

Publication Date: 01 September 2008

Abstract: CONTEXT: Nurse staffing is not the same across an entire hospital. Nursing care is delivered in geographically-based units, with wide variation in staffing levels. In particular, staffing in intensive care is much richer than in nonintensive care acute units. OBJECTIVE: To evaluate the association of in-hospital patient mortality with registered nurse staffing and skill mix comparing hospital and unit level analysis using data from the

46

Veterans Health Administration (VHA). DESIGN, SETTINGS, AND PATIENTS: A retrospective observational study using administrative data from 129,579 patients from 453 nursing units (171 ICU and 282 non-ICU) in 123 VHA hospitals. METHODS: We used hierarchical multilevel regression models to adjust for patient, unit, and hospital characteristics, stratifying by whether or not patients had an ICU stay during admission. MAIN OUTCOME MEASURE: In-hospital mortality. RESULTS:: Of the 129,579 patients, mortality was 2.9% overall: 6.7% for patients with an ICU stay compared with 1.6% for those without. Whether the analysis was done at the hospital or unit level affected findings. RN staffing was not significantly associated with in-hospital mortality for patients with an ICU stay (OR, 1.02; 95% CI, 0.99-1.03). For non-ICU patients, increased RN staffing was significantly associated with decreased mortality risk (OR, 0.91; 95% CI, 0.86-0.96). RN education was not significantly associated with mortality. CONCLUSIONS: Our findings suggest that the association between RN staffing and skill mix and in-hospital patient mortality depends on whether the analysis is conducted at the hospital or unit level. Variable staffing on non-ICU units may significantly contribute to in-hospital mortality risk.

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95. New Aiken study compares nurse staffing and patient outcomes.

Author(s)

Citation: Minnesota Nursing Accent, 01 September 2008, vol./is. 80/5(13-13), 00265586

Publication Date: 01 September 2008

Source: CINAHL

Available in fulltext at EBSCOhost

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96. Nurse staffing and patient mortality in intensive care units.

Author(s) Cho S, Hwang JH, Kim J

Citation: Nursing Research, 01 September 2008, vol./is. 57/5(322-330), 00296562

Publication Date: 01 September 2008

Abstract: Background: Research evidence suggests that nurse staffing influences patient outcomes.

Source: CINAHL

Available in fulltext at the ULHT Library and Knowledge Services' eJournal collection

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97. Nurse staffing and patient mortality in intensive care units.

Author(s) Cho, S, Hwang, J, Kim, J

Citation: Nursing Research, Sep 2008, vol. 57, no. 5, p. 322-330, 0029-6562 (Sep-Oct 2008)

Publication Date: September 2008

Abstract: Research in South Korea to explore the relationship between ICU nurse staffing levels and characteristics and patient mortality in intensive care units in tertiary and secondary hospitals. Hospital, unit and patient characteristics were examined, including bed numbers, nurses' level of experience, RN-to-patient ratios and presence/absence of physicians. [(BNI unique abstract)] 44 references

Source: BNI

47

Available in fulltext at the ULHT Library and Knowledge Services' eJournal collection

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98. Nurse dose: what's in a concept?

Author(s) Manojlovich M, Sidani S

Citation: Research in Nursing & Health, 01 August 2008, vol./is. 31/4(310-319), 01606891

Publication Date: 01 August 2008

Abstract: Many researchers have sought to address the relationship between nursing care and patient outcomes, with inconsistent and contradictory findings. We conducted a concept analysis and concept derivation, basing our work on theoretical and empirical literature, to derive nurse dose as a concept that pulls into a coherent whole disparate variables used in staffing studies. We defined nurse dose as the level of nursing reflected in the purity, amount, frequency, and duration of nursing care needed to produce favorable outcomes. All four parameters of nurse dose used together can facilitate our understanding of how nursing contributes to patient outcomes. Ongoing investigation will help to identify the parameters of nurse dose that have the greatest effect on outcomes. © 2008 Wiley Periodicals, Inc. Res Nurs Health 31:310-319, 2008

Source: CINAHL

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99. The effect of nurse staffing patterns on medical errors and nurse burnout.

Author(s) Garrett C

Citation: AORN Journal, 01 June 2008, vol./is. 87/6(1191-), 00012092

Publication Date: 01 June 2008

Abstract: HOSPITAL ADMINISTRATORS frequently rely on the use of mandatory or voluntary overtime to cover staff nurse vacancies. This practice is common in the perioperative setting, but it can lead to staff-member fatigue that may adversely affect patient safety. THIS LITERATURE REVIEW explores the effect that nurse staffing patterns have on the frequency of medical errors, fatigue, and nurse burnout. THE EVIDENCE INDICATES that inadequate nurse staffing leads to adverse patient outcomes and increased nurse burnout. Hospital administrators should invest in adequate nurse staffing to improve patient safety and increase nurse retention.

Source: CINAHL

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100. Will mandated minimum nurse staffing ratios lead to better patient outcomes?

Author(s) Sochalski J, Konetzka RT, Zhu J, Volpp K

Citation: Medical Care, 01 June 2008, vol./is. 46/6(606-613), 00257079

Publication Date: 01 June 2008

Abstract: BACKGROUND: Mandatory hospital nurse staffing ratios are under consideration in a number of states without strong empirical evidence of the optimal ratio. OBJECTIVE: To determine whether increases in medical-surgical licensed nurse staffing levels are associated with improvements in patient outcomes for hospitals having different baseline staffing levels. RESEARCH DESIGN: Cross-sectional and fixed-effects regression analyses using a 1993-2001 panel of patient and hospital data from California. Splines define 4 staffing ratios. SUBJECTS: Adult acute myocardial infarction (AMI) (n = 348,720)

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and surgical failure to rescue (FTR) (n = 109,066) patients discharged between 1993 and 2001 from 343 California acute care general hospitals. MEASURES: Patient outcomes are 30-day AMI mortality and surgical FTR; 4 baseline staffing levels-4 to 7 patients per licensed nurse [registered nurses (RN) and licensed vocational nurses (LVN)]. RESULTS: Significant cross-sectional associations between higher nurse staffing and AMI mortality are reduced in the fixed-effects analyses. Improvements in outcomes were smaller in hospitals with higher baseline staffing: for each RN and RN + LVN increase, respectively, AMI mortality declined by 0.71 (P < 0.05) and by 2.75 percentage points for hospitals with more than 7 patients per nurse compared with 0.19 (P = NS) and 0.28 percentage points (P < 0.05) in hospitals with more than 4 patients per nurse. Significant cross-sectional associations between higher nurse staffing and FTR were not found in the fixed-effects analyses. CONCLUSIONS: Strong diminishing returns to nurse staffing improvements and lack of significant evidence that staffing uniformly increases improve outcomes raise questions about the likely cost-effectiveness of implementing state-wide mandatory nurse staffing ratios.

Source: CINAHL

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101. Inpatient nursing care quality: response to Kane et al, December 2007 Medical Care... Kane RL, Shamliyan Ta, Mueller C, et al. The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis. Med Care 2007;45:1195-204.

Author(s) Welton JM, Kane RL, Mueller C, Shamliyan T

Citation: Medical Care, 01 June 2008, vol./is. 46/6(644-644), 00257079

Publication Date: 01 June 2008

Source: CINAHL

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102. When costs count: the impact of staff size, skill mix and treatment intensity on patient outcome for psychotherapeutic day treatment programmes.

Author(s) Halsteinli V, Karterud S, Pedersen G

Citation: Health Policy, 01 May 2008, vol./is. 86/2-3(255-265), 01688510

Publication Date: 01 May 2008

Abstract: The objective was to explore the relationship between staff related variables and patient outcome in day treatment programmes for patients with personality disorders. The importance of staff size, skill mix and treatment intensity (hours of treatment per week) was examined, in addition to location-specific effects. Multi-centre data routinely collected under non-experimental conditions from nine units, all members of a cooperative network in Norway, were analysed using a multilevel analysis. The data set consisted of treatment unit characteristics for the period 1993-2005, constituting an unbalanced panel of 71 units, together with information from 1574 patients who completed day treatment according to the plan. Patient outcome was measured by change in Global Assessment of Functioning Scale (GAF). Twelve per cent of variation in patient outcome was attributed to the treatment unit level. Staff size and treatment intensity influenced outcome to a minor extent, while an increased proportion of nurses or other college-educated personnel was associated with improved patient outcome. A positive location-specific effect was found in one unit attached to a university. Potential cost savings seem to be apparent with respect to staff size and, to some extent, skill mix.

Source: CINAHL

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49

103. The cost of nurse-sensitive adverse events.

Author(s) Pappas SH

Citation: Journal of Nursing Administration, 01 May 2008, vol./is. 38/5(230-236), 00020443

Publication Date: 01 May 2008

Abstract: Objective: The aim of this study was to describe the methodology for nursing leaders to determine the cost of adverse events and effective levels of nurse staffing. Background: The growing transparency of quality and cost outcomes motivates healthcare leaders to optimize the effectiveness of nurse staffing. Most hospitals have robust cost accounting systems that provide actual patient-level direct costs. These systems allow an analysis of the cost consumed by patients during a hospital stay. By knowing the cost of complications, leaders have the ability to justify the cost of improved staffing when quality evidence shows that higher nurse staffing improves quality. Methods: An analysis was performed on financial and clinical data from hospital databases of 3,200 inpatients. The purpose was to establish a methodology to determine actual cost per case. Three diagnosis-related groups were the focus of the analysis. Five adverse events were analyzed along with the costs. Results: A regression analysis reported that the actual direct cost of an adverse event was $1,029 per case in the congestive heart failure cases and $903 in the surgical cases. There was a significant increase in the cost per case in medical patients with urinary tract infection and pressure ulcers and in surgical patients with urinary tract infection and pneumonia. The odds of pneumonia occurring in surgical patients decreased with additional registered nurse hours per patient day. Conclusion: Hospital cost accounting systems are useful in determining the cost of adverse events and can aid in decision making about nurse staffing. Adverse events add costs to patient care and should be measured at the unit level to adjust staffing to reduce adverse events and avoid costs.

Source: CINAHL

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104. The balancing act: patient care time versus cost.

Author(s) Storfjell JL, Omoike O, Ohlson S

Citation: Journal of Nursing Administration, 01 May 2008, vol./is. 38/5(244-249), 00020443

Publication Date: 01 May 2008

Abstract: Background: With demands to improve patients' clinical outcomes and decrease the escalating costs of inpatient care, nurse executives are focusing on how nurses spend their time rather than just raising staffing levels to positively impact patient outcomes. Because nursing wages constitute a high proportion of a hospital's budget, understanding the costs of nursing activities is critical to managing them. Methods: An activity-based costing approach was used in 14 medical-surgical nursing units to study nursing activities and their related costs. Time use for 4 patient care activities (assess, teach, treat, provide psychosocial support) and 2 support activities (coordinate care and manage clinical records) including the percent of non-value-added (NVA) time for each of these activities was identified through focus groups, interviews, and timed observations. Annualized wage costs were assigned to these activities to determine average wage-related costs of each activity as well as NVA-related costs. Results: More than one-third of nurses' time was considered NVA, averaging $757,000 per nursing unit in wage costs annually. Nurses spent more time on support activities (56%) than in providing patient care (44%), with the least amount of time being spent on patient teaching and psychosocial support. Conclusion: Findings indicate a huge opportunity to both improve clinical outcomes in these units and, at the same time, reduce costs by focusing on processes to reduce the high amount time spent performing NVA and support activities and increase patient care time, particularly patient teaching and psychosocial support.

Source: CINAHL

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105. Evidence-based staffing: potential roles for informatics.

Author(s) Hyun S, Gakken S, Douglas K, Stone PW

Citation: Nursing Economic$, 01 May 2008, vol./is. 26/3(151-159), 07461739

Publication Date: 01 May 2008

Abstract: Over the last 15 years, evidence has been accumulating relating higher levels of nurse staffing in both quantity and experience to lower rates of adverse patient outcomes. Consequently, to promote quality patient outcomes efficiently, making staffing decisions based in evidence is of increasing importance. However, there is still limited data to help decide how to effectively allocate scarce nurse resources in practice. Existing principles, frameworks, and guidelines provide a foundation for nurse staffing decisions but face poor adoption. To determine optimal nurse staffing practices and provide evidence-based recommendations for policy, and integration into operations, comprehensive data are necessary. Information technology can assist nurse staffing decisions. Four informatics processes that may support evidence-based nurse staffing are described: (a) Data acquisition from multiple data sources, (b) Representation of data in a way it can be re-used for multiple purposes, (c) Sophisticated data processing and mining, and (d) Presentation of data in standardized and user-configurable ways.

Source: CINAHL

Available in fulltext at EBSCOhost

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106. UK ward design: patient dependency, nursing workload, staffing and quality--an observational study.

Author(s) Hurst K

Citation: International Journal of Nursing Studies, 01 March 2008, vol./is. 45/3(370-381), 00207489

Publication Date: 01 March 2008

Abstract: BACKGROUND: There are important relationships between ward design, patient welfare and staff activity in the literature but studies seem not to have tested all the variables. Whether ward designs influence nursing structures, processes and outcomes, therefore, has not been fully answered. While studies provide helpful guidance, nursing efficiency and effectiveness implications are speculative. OBJECTIVES: To improve nursing efficiency and effectiveness by capitalising on the best ward design features. SETTING: A database consisting of 375 UK wards, constructed for other research and development purposes, was revisited and reconfigured for the present study. The database was updated between 2003 and 2004. PARTICIPANTS: Of 390 wards approached, 375 generated usable data. METHOD: Patient dependency, nursing activity, workload, nursing quality and staffing data in the original database were obtained using mainly non-participation observation methods. Later, wards were classified in eight ways and differences between ward types examined. RESULTS: Patient dependency did not stand out in any ward type but as the literature predicted, direct patient care was higher in Nightingale wards. Racetrack ward nursing activity was also close to idyllic. Bay wards, owing to their greater occupancy peaks and troughs, had a propensity to generate heavier workloads. Time-out and down-time were not excessive in any ward type, and it is likely that ward leadership may be compensating for some variables' negative effects. Racetrack wards were considerably less-well staffed and grade-mix dilute and consequently the cheapest. Quality scores were higher in Nightingale wards-nurses' greater observation capability was a significant factor. Wards' central-core configurations also influenced nursing efficiency and effectiveness. CONCLUSIONS: Racetrack wards have an edge over other ward designs. However, replicating Nightingale conditions by, for example, equalising occupancy, throughput and staffing and maximising nurses' substations, could engender similar outcomes elsewhere.

Source: CINAHL

51

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107. Relationships between registered nurse staffing, processes of nursing care, and nurse-reported patient outcomes in chronic hemodialysis units.

Author(s) Thomas-Hawkins C, Flynn L, Clarke SP

Citation: Nephrology Nursing Journal, 01 March 2008, vol./is. 35/2(123-132), 1526744X

Publication Date: 01 March 2008

Abstract: Little attention has been given to the effects of registered nurse (RN) staffing and processes of nursing care on patient outcomes in hemodialysis units. This research examined the effects of patient-to-RN ratios and necessary tasks left undone by RNs on the likelihood of nurse-reported frequent occurrences of adverse patient events in chronic hemodialysis units. Study findings revealed that high patient-to-RN ratios and increased numbers of tasks left undone by RNs were associated with an increased likelihood of frequent occurrences of dialysis hypotension, skipped dialysis treatments, shortened dialysis treatments, and patient complaints in hemodialysis units. These findings indicate that federal, state, and dialysis organization policies must foster staffing structures and processes of care in dialysis units that effectively utilize the invaluable skills and services of professional, registered nurses.

Source: CINAHL

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108. Nurse staffing and patient, nurse, and financial outcomes.

Author(s) Unruh L

Citation: American Journal of Nursing, 01 January 2008, vol./is. 108/1(62-72), 0002936X

Publication Date: 01 January 2008

Abstract: Because there's no scientific evidence to support specific nurse-patient ratios, and in order to assess the impact of hospital nurse staffing levels on given patient, nurse, and financial outcomes, the author conducted a literature review. The evidence shows that adequate staffing and balanced workloads are central to achieving good outcomes, and the author offers recommendations for ensuring appropriate nurse staffing and for further research.

Source: CINAHL

Available in fulltext at Ovid

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109. Study links nurse staffing ratios to patient outcomes.

Author(s)

Citation: Nurses World Magazine, 01 January 2008, vol./is. /(8-8),

Publication Date: 01 January 2008

Source: CINAHL

110. The effect of nurse staffing on selected outcomes of care.

Author(s) Saleh AM

Citation: , 01 January 2008, vol./is. /(0-131),

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Publication Date: 01 January 2008

Abstract: Many researchers have examined the effects of nurse staffing on aspects of the quality of health care. However, these studies are neither exhaustive nor consistent. The need for studying nurse staffing is critical due to factors such as the nursing shortage, hospital restructuring, the growing concern for patient safety, and recent policies mandating nurse to patient ratios. The purpose of this study was to examine the effects of nurse staffing on patient satisfaction, patient adverse events, patient length of stay, and nurse job satisfaction.

Source: CINAHL

111. Nurse staffing and patient, nurse, and financial outcomes.

Author(s) Unruh, L

Citation: American Journal of Nursing, Jan 2008, vol. 108, no. 1, p. 62-72, 0002-936X (January 2008)

Publication Date: January 2008

Abstract: Literature review of research on the impact of registered nurse staffing levels on patient safety and care, nurses' working conditions, job satisfaction and hospitals' financial outcomes. The effects of nurse-patient ratios on staffing workloads and staff retention are considered. [(BNI unique abstract)] 90 references

Source: BNI

Available in fulltext at Ovid

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112. Nursing care and patient outcomes: International evidence

Author(s) Cheung R.B., Aiken L.H., Clarke S.P., Sloane D.M.

Citation: Enfermeria Clinica, January 2008, vol./is. 18/1(35-40), 1130-8621;1579-2013 (01 Jan 2008)

Publication Date: January 2008

Abstract: Countries across the globe are experiencing nursing shortages. In hospitals, supportive practice environments have positive effects on both nurse and patient outcomes. However, these relationships have been established primarily in the US. International studies of the effects of nurse staffing levels and the practice environment on nurse outcomes and the quality of care mirror the findings from the US, thus raising these issues to the international level. The solutions that have been successful in the US for improving the practice environment and patient outcomes are solutions that should be successful in any country, thus putting them on a global scale. The Magnet hospital program is one model that has been shown to improve nurse and patient outcomes and is one solution to the shortage of hospital nurses.

Source: EMBASE

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113. International experts' perspectives on the state of the nurse staffing and patient outcomes literature.

Author(s) Van den Heede K, Clarke SP, Sermeus W, Vleugels A, Aiken LH

Citation: Journal of Nursing Scholarship, 01 December 2007, vol./is. 39/4(290-297), 15276546

Publication Date: 01 December 2007

Source: CINAHL

53

Available in fulltext at EBSCOhost

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114. The association of registered nurse staffing levels and patient outcomes. Systematic review and meta-analysis.

Author(s) Kane RL, Shamliyan TA, Mueller C, Duval S, Wilt TJ

Citation: Medical Care, 01 December 2007, vol./is. 45/12(1195-1204), 00257079

Publication Date: 01 December 2007

Abstract: OBJECTIVE: To examine the association between registered nurse (RN) staffing and patient outcomes in acute care hospitals. STUDY SELECTION: Twenty-eight studies reported adjusted odds ratios of patient outcomes in categories of RN-to-patient ratio, and met inclusion criteria. Information was abstracted using a standardized protocol. DATA SYNTHESIS: Random effects models assessed heterogeneity and pooled data from individual studies. Increased RN staffing was associated with lower hospital related mortality in intensive care units (ICUs) [odds ratios (OR), 0.91; 95% confidence interval (CI), 0.86-0.96], in surgical (OR, 0.84; 95% CI, 0.80-0.89), and in medical patients (OR, 0.94; 95% CI, 0.94-0.95) per additional full time equivalent per patient day. An increase by 1 RN per patient day was associated with a decreased odds ratio of hospital acquired pneumonia (OR, 0.70; 95% CI, 0.56-0.88), unplanned extubation (OR, 0.49; 95% CI, 0.36-0.67), respiratory failure (OR, 0.40; 95% CI, 0.27-0.59), and cardiac arrest (OR, 0.72; 95% CI, 0.62-0.84) in ICUs, with a lower risk of failure to rescue (OR, 0.84; 95% CI, 0.79-0.90) in surgical patients. Length of stay was shorter by 24% in ICUs (OR, 0.76; 95% CI, 0.62-0.94) and by 31% in surgical patients (OR, 0.69; 95% CI, 0.55-0.86). CONCLUSIONS: Studies with different design show associations between increased RN staffing and lower odds of hospital related mortality and adverse patient events. Patient and hospital characteristics, including hospitals' commitment to quality of medical care, likely contribute to the actual causal pathway.

Source: CINAHL

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115. Nurse staffing in acute care settings: research perspectives and practice implications.

Author(s) Clarke SP

Citation: Joint Commission Journal on Quality & Patient Safety, 02 November 2007, vol./is. 33/11(30-44), 15537250

Publication Date: 02 November 2007

Abstract: Background: The research literature linking nurse staffing and outcomes has expanded radically at a time of profound changes in human resources and financial management in hospitals and health care systems.

Source: CINAHL

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116. The evidence. Nurse staffing and quality of patient outcomes.

Author(s) Diemert C

Citation: Minnesota Nursing Accent, 01 November 2007, vol./is. 79/7(5-5), 00265586

Publication Date: 01 November 2007

Source: CINAHL

54

Available in fulltext at EBSCOhost

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117. Mandated nurse staffing ratios in California: a comparison of staffing and nursing-sensitive outcomes pre- and postregulation.

Author(s) Bolton LB, Aydin CE, Donaldson N, Brown DS, Sandhu M, Fridman M, Aronow HU

Citation: Policy, Politics & Nursing Practice, 01 November 2007, vol./is. 8/4(238-250), 15271544

Publication Date: 01 November 2007

Abstract: This article examines the impact of mandated nursing ratios in California on key measures of nursing quality among adults in acute care hospitals. This study is a follow-up and extension of our first analysis exploring nurse staffing and nursing-sensitive outcomes comparing 2002 pre-ratios regulation data to 2004 postratios regulation data. For the current study we used postregulation ratios data from 2004 and 2006 to assess trends in staffing and outcomes. Findings for nurse staffing affirmed the trends noted in 2005 and indicated that changes in nurse staffing were consistent with expected increases in the proportion of licensed staff per patient. This report includes an exploratory examination of the relationship between staffing and nursing-sensitive patient outcomes. However anticipated improvements in nursing-sensitive patient outcomes were not observed. This report contributes to the growing understanding of the impacts of regulatory staffing mandates on hospital operations and patient outcomes.

Source: CINAHL

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118. Outcomes associated with skill mix interventions in acute mental health wards: a synthesis of evidence.

Author(s) Munro, S, Baker, J

Citation: Journal of Mental Health, Training, Education and Practice, Nov 2007, vol. 2, no. 3, p. 25-33, 1755-6228 (November 2007)

Publication Date: November 2007

Abstract: Literature review and review of practice on staffing and skill mix in acute mental health care wards and the impact on service user outcomes. Staffing levels and staff mix are examined and the effects and possibilities of new roles and responsibilities are discussed. [(BNI unique abstract)] 30 references

Source: BNI

119. Mandatory hospital nurse to patient staffing ratios: time to take a different approach.

Author(s) Welton JM

Citation: Online Journal of Issues in Nursing, 01 September 2007, vol./is. 12/3(0-12), 10913734

Publication Date: 01 September 2007

Abstract: Proponents of mandatory, inpatient nurse-to-patient staffing ratios have lobbied state legislatures and the United States Congress to enact laws to improve overall working conditions in hospitals. Proposed minimum, nurse-to-patient staffing ratios, such as those enacted by California, are intended to address a growing concern that patients are being harmed by inadequate staffing related to increasing severity of illness and complexity of care. However, mandatory ratios, if imposed nationally, may result in increased overall costs of care with no guarantees for improvement in quality or positive outcomes of

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hospitalization. The costs associated with the additional registered nurses that will be needed for the higher, mandated ratios will not be offset by additional payments to hospitals, resulting in mandates that will be unfunded. An alternative approach would be to provide a market-based incentive to hospitals to optimize nurse staffing levels by unbundling nursing care from current room and board charges, billing for nursing care time (intensity) for individual patients, and adjusting hospital payments for optimum nursing care. The revenue code data, used to charge for inpatient nursing care, could be used to benchmark and evaluate inpatient nursing care performance by case mix across hospitals. A nursing intensity adjustment to hospital payment, such as that described above, has already been endorsed by national nursing organizations. Efforts to implement this model nationwide within the next few years have already been initiated. This article will argue for the benefits of implementing a nursing intensity adjustment for nursing care by briefly reviewing the process by which nurses lost their economic independence; describing the gap between the supply and demand for registered nurses; presenting the arguments for and against mandatory, nurse-to-patient staffing ratios; offering a different approach for increasing the number of registered nurses at the bedside, namely nursing intensity billing; proposing sources of funding to pay for nursing intensity billing; and identifying limitations of nursing intensity billing. © 2007 OJIN: The Online Journal of Issues in Nursing Article published September 30, 2007

Source: CINAHL

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120. Nurse staffing and patient outcomes in inpatient rehabilitation settings.

Author(s) Nelson A, Powell-Cope G, Palacios P, Luther SL, Black T, Hillman T, Christiansen B, Nathenson P, Gross JC

Citation: Rehabilitation Nursing, 01 September 2007, vol./is. 32/5(179-202), 02784807

Publication Date: 01 September 2007

Abstract: In rehabilitation nursing, the patient classification systems or acuity models and nurse-staffing ratios are not supported by empirical evidence. Moreover there are no studies published characterizing nursing hours per patient day, proportion of RN staff and impact of agency nurses in inpatient rehabilitation settings. The purpose of this prospective observational study was to describe rehabilitation nurse staffing patterns, to validate the impact of rehabilitation nursing on patient outcomes, and to test whether existing patient measures on severity and outcomes in rehabilitation could be used as a proxy for burden of care to predict rehabilitation nurse staffing ceilings and daily nurse staffing requirements. A total of 54 rehabilitation facilities in the United States, stratified by geography, were randomly selected to participate in the study.

Source: CINAHL

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121. ICU nurse staffing levels affect patient outcomes.

Author(s) Orlovsky C

Citation: Nursing News, 01 July 2007, vol./is. 31/3(10-10), 00296538

Publication Date: 01 July 2007

Source: CINAHL

Available in fulltext at EBSCOhost

122. Value-added care: a new way of assessing nursing staffing ratios and workload variability.

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Author(s) Upenieks VV, Akhavan J, Kottlerman J, Esser J, Ngo MJ

Citation: Journal of Nursing Administration, 01 May 2007, vol./is. 37/5(243-252), 00020443

Publication Date: 01 May 2007

Abstract: OBJECTIVE: To thoroughly understand the implications of California regulatory staffing ratios on nursing units, the present study examines the relative amounts of time allocated to workload activities among registered nurses. BACKGROUND: Nursing is a synergistic, intuitive process and may not be capable of being translated into minimum patient-to-nurse ratios that work across an entire region or state. A fundamental step in evaluating the appropriateness of prescribed ratios lies in assessing how registered nurses spend their time while caring for patients. Once workload intensity is assessed, additional factors can be identified to design mandated staffing levels for acute care settings. METHODS: Variability in workload intensity was assessed using the Robert Woods Johnson Foundation "Transforming Care at the Bedside" work flow methodology approach in evaluating value-added care and assessing the amount of time nurses spent on direct care and other categorical activities. RESULTS: The results revealed a marked variation in the medical-surgical unit compared with the 2 telemetry units regarding the amount of time spent by registered nurses on value-added, necessary, and non-value-added activities, as well as variability in the amount of time that registered nurses spent on direct care, indirect care, documentation, waste, and other activities. CONCLUSION: By evaluating patient quality of care in acute care settings, we can return to a basic aspect of how nurses spend their time caring for patients-the activities that not only involve direct care but also benefit the patient.

Source: CINAHL

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123. Outcomes of variation in hospital nurse staffing in English hospitals: cross-sectional analysis of survey data and discharge records.

Author(s) Rafferty AM, Clarke SP, Coles J, Ball J, James P, McKee M, Aiken LH

Citation: International Journal of Nursing Studies, 01 February 2007, vol./is. 44/2(175-182), 00207489

Publication Date: 01 February 2007

Abstract: CONTEXT: Despite growing evidence in the US, little evidence has been available to evaluate whether internationally, hospitals in which nurses care for fewer patients have better outcomes in terms of patient survival and nurse retention. OBJECTIVES: To examine the effects of hospital-wide nurse staffing levels (patient-to-nurse ratios) on patient mortality, failure to rescue (mortality risk for patients with complicated stays) and nurse job dissatisfaction, burnout and nurse-rated quality of care. DESIGN AND SETTING: Cross-sectional analysis combining nurse survey data with discharge abstracts. PARTICIPANTS: Nurses (N=3984) and general, orthopaedic, and vascular surgery patients (N=118752) in 30 English acute trusts. RESULTS: Patients and nurses in the quartile of hospitals with the most favourable staffing levels (the lowest patient-to-nurse ratios) had consistently better outcomes than those in hospitals with less favourable staffing. Patients in the hospitals with the highest patient to nurse ratios had 26% higher mortality (95% CI: 12-49%); the nurses in those hospitals were approximately twice as likely to be dissatisfied with their jobs, to show high burnout levels, and to report low or deteriorating quality of care on their wards and hospitals. CONCLUSIONS: Nurse staffing levels in NHS hospitals appear to have the same impact on patient outcomes and factors influencing nurse retention as have been found in the USA.

Source: CINAHL

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57

124. Assessing nursing staffing ratios: variability in workload intensity.

Author(s) Upenieks VV, Kotlerman J, Akhavan J, Esser J, Ngo MJ

Citation: Policy, Politics & Nursing Practice, 01 February 2007, vol./is. 8/1(7-19), 15271544

Publication Date: 01 February 2007

Abstract: In 2004, California became the first state to implement specific nurse-to-patient ratios for all hospitals. These mandated enactments have caused significant controversy among health care professionals as well as nursing unions and professional organizations. Supporters of minimum nurse-to-patient ratios cite patient care quality, safety, and outcomes, whereas critics point to the lack of solid data and the use of a universally standardized acuity tool. Much more remains to be learned about staffing policies before mature links may be made regarding set staffing ratios and patient outcomes-specifically, how nurses spend their time in terms of variability in their daily work. This study examines two comparable telemetry units with a 1:3 staffing ratio within a California hospital system to determine the relative rates of variability in nursing activities. The results demonstrate significant differences in categorical nursing activities (e.g., direct care, indirect care, etc.) between the two telemetry units ( chi(2) = 91.2028; p </= .0001). No correlation was noted between workload categories with daily staffing ratios and staffing mix between the two units. Although patients were grouped in a similar telemetry classification category and care was mandated at a set ratio, patient needs were variable, creating a significant difference in registered nurse (RN) categorical activities on the two units.

Source: CINAHL

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125. Outcomes of variation in hospital nurse staffing in English hospitals: more nurses, working differently?

Author(s) Bridges, J, Hyde, P

Citation: International Journal of Nursing Studies, Feb 2007, vol. 44, no. 2, p. 171-174, 0020-7489 (February 2007)

Publication Date: February 2007

Abstract: Editorial on nurse staffing levels and the impact on outcomes, arguing that staff roles should be redesigned and expanded to improve efficiency. New roles introduced as part of the Changing Workforce Programme are discussed. [(BNI unique abstract)] 22 references

Source: BNI

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126. 5-20: a model of minimum nurse-to-patient ratios in Victoria, Australia.

Author(s) Gerdtz MF, Nelson S

Citation: Journal of Nursing Management, 01 January 2007, vol./is. 15/1(64-71), 09660429

Publication Date: 01 January 2007

Abstract: Aim This study presents a critique of a new model of minimum nurse-to- patient ratio and considers its utility alongside established Patient Dependency Systems. Background Since 2001 legislation mandating minimum nurse-to-patient ratios has been enacted throughout large public hospitals in the state of Victoria, Australia. The Victorian model mandates minimum staffing of five nurses to 20 patients in acute medical and surgical wards. In conjunction with this approach, Patient Dependency Systems are employed to anticipate short-term resource needs. Key issues Although this legislation has been successful in attracting nurses back into the public sector workforce, no published empirical evidence exists to support specific ratios. In addition, neither ratio nor Patient

58

Dependency Systems approaches account for the critical influence of skill mix on hospital, employee, or patient outcomes. Conclusion There is an urgent need for further research that specifically examines relationships between models of staffing, skill mix and quality outcomes.

Source: CINAHL

Available in fulltext at EBSCOhost

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127. The effect of nurse staffing on organizational outcomes.

Author(s) Pappas SH

Citation: , 01 January 2007, vol./is. /(0-194),

Publication Date: 01 January 2007

Abstract: The rationale for understanding the relationship between the cost of patient care and nurse staffing is based on the evidence that clinical outcomes are sensitive to direct nursing care. Evidence of these relationships motivates the use of more nurses to improve care; therefore financial justification for this change must be developed.

Source: CINAHL

128. Safer childbirth: minimum standards for the organisation and delivery of care in labour

Author(s) Arulkumaran, sabaratriam, Elliott, Maggie

Citation: , 2007

Publication Date: 2007

Abstract: Record in progressThis report on safer childbirth carries the logos of four royal colleges, those of obstetricians and gynaecologists, midwives, anaesthetists and paediatrics and child health. The document sets minimum standards for the provision of care before, during and after childbirth. The report is applicable to all services in the UK. It has been prepared under the supervision of an extensive working party drawn from all four royal colleges. In the executive summary the role of midwives is recognised as central to childbirth services, whether they are acting as independent practitioners in normal births or as partners in a team where births are subject to complications. The roles of other members of the team, acting as a team are also discussed. Service staffing levels are a serious concern if standards are to be achieved and this is recognised in this report. A number of appendices deal with matters such as individual roles and the management of labour wards. Ten standards are stated including one for outcomes. Cites numerous references.

Source: HMIC

129. Dying for a nurse.

Author(s) Vere-Jones, E

Citation: Nursing Times, Dec 2006, vol. 102, no. 49, p. 18-19, 0954-7762 (December 5, 2006)

Publication Date: December 2006

Abstract: The impact of nurse staffing levels on patient mortality, with reference to a recent research study which indicated that too few nurses or the wrong skill mix can result in more patients dying. The negative effects of low staffing levels on patient satisfaction and staff wellbeing are also discussed, suggesting the need to maintain staffing despite NHS cuts. [(BNI unique abstract)] 0 references

Source: BNI

Available in print at Grantham Hospital Staff Library

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Available in fulltext at the ULHT Library and Knowledge Services' eJournal collection

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130. Nurse staffing and patient safety.

Author(s) MacPhee M, Ellis J, McCutheon AS

Citation: Canadian Nurse, 01 October 2006, vol./is. 102/8(18-23), 00084581

Publication Date: 01 October 2006

Abstract: Safe, effective and ethical nurse staffing requires that there is a sufficient number and appropriate use and mix of competent nurses available to care for patients. Because of its close connections with patient safety, nurse staffing has become an important concern for governments, health-care providers and the public. This article provides highlights from the Canadian Health Services Research Foundation research report Evaluation of Patient Safety and Nurse Staffing (2005), which focused on the connections between nurse staffing and patient safety. The report findings were discussed at a roundtable of decision-makers and experts, and these deliberations and the literature evidence were used to create the final synthesis. The authors present one of the key recommendations for nurse staffing that arose from the synthesis.

Source: CINAHL

Available in fulltext at EBSCOhost

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131. Nurse staffing levels and hospital mortality in critical care settings: literature review and meta-analysis.

Author(s) Numata, Y, Schulzer, M, Van der Wal, R

Citation: Journal of Advanced Nursing, Aug 2006, vol. 55, no. 4, p. 435-448, 0309-2402 (August 2006)

Publication Date: August 2006

Abstract: Literature review with meta-analysis of research evidence on the association between nursing staffing levels and patient mortality during and after critical and intensive care. The review identified methodological problems in such studies concerning measurement of staffing levels and possible lack of sensitivity concerning mortality as the outcome measure in such settings. [(BNI unique abstract)] 44 references

Source: BNI

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132. Safe staffing saves lives.

Author(s) Armstrong, F

Citation: Australian Nursing Journal, May 2006, vol. 13, no. 10, p. 22., 1320-3185 (May 2006)

Publication Date: May 2006

Abstract: Positive effects of safe staffing levels on patient safety outcomes and job satisfaction. [(BNI unique abstract)] 6 references

60

Source: BNI

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133. Developing a staffing matrix using CMI as acuity indicator

Author(s) Romito D.

Citation: Rehabilitation nursing : the official journal of the Association of Rehabilitation Nurses, May 2006, vol./is. 31/3(102-105, 122), 0278-4807 (2006 May-Jun)

Publication Date: May 2006

Abstract: Adequate staffing levels on an acute rehabilitation unit may not be maintained because staffing needs fluctuate according to the needs of patient groupings. Acuity regulations from some state agencies and the Joint Commission on Accreditation of Healthcare Organizations require that staffing address patient acuity needs. Proposed ratio laws either require concrete patient-to-nurse ratios or neglect to consider acute rehabilitation. Neither have practical working tools to support their proposals. The questions of what to measure and how to translate this into effective nursing staffing remain unanswered. At the same time, nursing dissatisfaction grows with increased workloads, overtime, and perceptions of ineffectiveness. This article describes one effort to define and use a working tool for staffing acute rehabilitation units. The study used case mix index as an indicator of nursing time, integrated into a shift staffing matrix. Early results have shown it to be effective, quick, flexible, and efficient. Using this tool, quality patient outcomes within national length of stay benchmarks were maintained and staff satisfaction on this unit improved.

Source: EMBASE

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134. Nurse dose as a concept.

Author(s) Brooten D, Youngblut JM

Citation: Journal of Nursing Scholarship, 01 March 2006, vol./is. 38/1(94-99), 15276546

Publication Date: 01 March 2006

Abstract: Purpose: To describe the concept of Nurse Dose. Methods: The concept of nurse dose has been identified from decades of clinical research as a concept essential in the delivery of safe and high quality health care. The components of nurse dose were conceptualized through review of the literature from nursing, medicine, and health services research. Findings: Nurse dose is conceptualized as having three equally essential components: dose, nurse, and host and host response. Dose in the macro view includes the number of nurses per patient or per population in cities, states, regions, or countries. Dose in a micro view includes the amount of nurse time and the number of contacts. The nurse component consists of the education, expertise, and experience of the nurse. Host is represented by an organization and its characteristics (culture, autonomy, practice control) in a macro view and by the patient and characteristics (beliefs, values, culture) in a micro view. Host response includes response to the autonomy and acceptability of the nurse. Conclusions: Greater nurse dose has been associated with decreases in patient mortality, morbidity, and healthcare costs.

Source: CINAHL

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135. RUG-III for exploring the association between staffing levels and cost-efficiency

61

in nursing facility care in Finland.

Author(s) Laine J

Citation: Health Care Management Review, January 2006, vol./is. 31/1(73-7), 0361-6274;0361-6274 (2006 Jan-Mar)

Publication Date: January 2006

Abstract: The current health policy of the Finnish government with regard to the production of health services strongly emphasizes productivity and efficiency. On the other hand, the staff generally demand better staffing for nursing facility care. This study incorporates the Resource Utilization Groups (RUG-III) in the calculation of the staffing levels and cost-efficiency and explores the association between cost-efficiency and staff levels in nursing facility care in Finland. The results indicate an improvement potential in case-mix-based staffing. Existing labor resources can be used more fairly and effectively while cost-efficiency differences can be diminished by applying the RUG-III for the allocation of the staff.

Source: Medline

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136. Nurse-to-patient ratios: what do we know?

Author(s) Greenberg, Patricia B

Citation: Policy, 2006, vol./is. 7/1, 1527-1544

Publication Date: 2006

Abstract: In the United States, improving nurse to patient staffing ratios has shown to be beneficial on several grounds, including patient outcomes and financial grounds - the resulting decrease in mortality and morbidity has saved 136,000 dollars per patient. Other advantages include patients preferring to attend hospitals with higher staffing ratios, and improved nurse recruitment. In California a 1:4 nurse to patient ratio has become law although this is so far the only state to legislate. However there had been fears that following legislation, ratios would never go above this level, even if patient care demanded it. Concern was also voiced that there would be insufficient nurses to staff hospitals.. Evidence has shown that according to the author, these fears have proved to be unfounded and that this evidence should not be ignored. Cites 6 references.

Source: HMIC

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137. Longitudinal analyses of nurse staffing and patient outcomes : more about failure to rescue

Author(s) Seago, Jean Ann, Williamson, Ann, Atwood, Christina

Citation: Journal of Nursing Administration, 2006, vol./is. 36/1, 0002-0443

Publication Date: 2006

Abstract: Numerous studies have examined cross-sectional data to determine the relationships between nurse staffing and patient outcomes. Questions have been raised about some of the studies now in the literature regarding the use of the hospital as the unit of analysis and the cross-sectional design of the studies. Additionally, there is a concern that the primary outcomes being studied are negative. Objectives of this study are to (1) compare the relationships between nurse staffing and positive patient outcomes for three adult medical-surgical nursing units in one university teaching hospital across four years (16 fiscal quarters); and (2) explore the use of two new failure-to-rescue (FTR) rates as outcomes, specifically FTR from medication errors and FTR from decubitus ulcers. This study uses secondary analyses of data viewed retrospectively with a longitudinal repeated-

62

measures design to estimate the relationships between nurse staffing and the outcomes of interest. Accounting for total dollars and case mix, all patient satisfaction measures increased as total hours of care per patient day increased, and as the skill mix became richer (more RN hours/total hours) there was a higher satisfaction with pain management and physical care requests. There was an increase in FTR from medication error as the non-RN (Other) hours of care per patient day increased and there was an increase in FTR from decubitus ulcers as patient severity increased. The overall conclusion is that it will likely be necessary to vary staffing hours and staffing mix depending on which positive patient outcome or outcomes you wish to achieve. Cites 38 references. [Journal abstract]

Source: HMIC

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138. You get what you pay for: news flash: higher nurse-patient ratios still save lives.

Author(s) Sofer D

Citation: American Journal of Nursing, 01 November 2005, vol./is. 105/11(20-20), 0002936X

Publication Date: 01 November 2005

Source: CINAHL

Available in fulltext at Ovid

Available in fulltext at the ULHT Library and Knowledge Services' eJournal collection

139. Focus on health care delivery, quality, and nursing.

Author(s) Sparkman CAG

Citation: AORN Journal, 01 October 2005, vol./is. 82/4(656-660), 00012092

Publication Date: 01 October 2005

Source: CINAHL

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140. A certain ratio? The policy implications of minimum staffing ratios in nursing.

Author(s) Buchan J

Citation: Journal of Health Services & Research Policy, October 2005, vol./is. 10/4(239-44), 1355-8196;1355-8196 (2005 Oct)

Publication Date: October 2005

Abstract: The debate about how best to determine nurse staffing levels continues. The conventional wisdom is that determining staffing levels is something best left to local management, taking account of local workload and resources. This 'bottom up' philosophy has now been challenged by the use of a different approach--the use of 'top down'standardized, and mandatory, nurse:patient or nurse:bed ratios. This paper examines the characteristics and early results of the use of staffing ratios in the two health systems where nurse staffing ratios are now mandatory--the states of Victoria (Australia) and California (USA). It then discusses the policy implications of using ratios. The paper identifies the main weaknesses of the use of nurse:patient ratios as being their relative inflexibility and their potential inefficiency, if they are wrongly calibrated. Their strength is their simplicity and their transparency. Their impact will be most pronounced when ratios are mandatory and where they offer a mechanism to improve and then to maintain staffing levels at some pre-determined level. The biggest challenges in their use are calibration (what is 'safe'? or 'minimum'?) and achieving the support of all stake-holders. The paper concludes that nurse:patient ratios are a blunt instrument for achieving employer

63

compliance, where reliance on alternative, voluntary (and often more sophisticated) methods of determining nurse staffing have not been effective.

Source: Medline

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141. Hospital nurse staffing and patient mortality, emotional exhaustion, and job dissatisfaction.

Author(s) Halm M, Peterson M, Kandels M, Sabo J, Blalock M, Braden R, Gryczman A, Krisko-Hagel K, Larson D, Lemay D, Sisler B, Strom L, Topham D

Citation: Clinical Nurse Specialist: The Journal for Advanced Nursing Practice, 01 September 2005, vol./is. 19/5(241-254), 08876274

Publication Date: 01 September 2005

Abstract: OBJECTIVE: To conduct an investigation similar to a landmark study that investigated the association between nurse-to-patient ratio and patient mortality, failure-to-rescue, emotional exhaustion and job satisfaction of nurses. METHODS: Cross-sectional analysis of 2709 general, orthopedic, and vascular surgery patients, and 140 staff nurses (42% response rate) caring for these patients in a large Midwestern institution. The main outcome measures were mortality, failure-to-rescue, emotional exhaustion, and job dissatisfaction. RESULTS AND CONCLUSIONS: Staffing was not a significant predictor of mortality or failure-to-rescue, nor did clinical specialty predict emotional exhaustion or job dissatisfaction. Although these findings reinforce adequate staffing ratios at this institution, programs that support nurses in their daily practice and positively impact job satisfaction need to be explored. The Nursing Research Council not only has heightened awareness of how staffing ratios affect patient and nurse outcomes, but also a broader understanding of how the research process can be used to effectively shape nurse's practice and work environments.

Source: CINAHL

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142. Nurse staffing levels and quality of care in Northern Pennsylvania nursing homes.

Author(s) Akinci F, Krolikowski D

Citation: Applied Nursing Research, 01 August 2005, vol./is. 18/3(130-137), 08971897

Publication Date: 01 August 2005

Abstract: This study evaluated current nurse staffing levels in 90 licensed nursing homes in Northeastern Pennsylvania to determine whether they are significantly different from state and national averages. It further examined the association between nurse staffing and quality of patient care provided to nursing home residents. Findings indicate that although nurse staffing levels appear to be comparable with state and national averages, quality of care might be negatively affected when nurse staffing levels are reduced. Practical recommendations for solutions to the current nurse recruitment and retention crises are presented to ensure adequate nurse staffing and quality of care to elderly citizens. Copyright © 2005 by Elsevier Science (USA).

Source: CINAHL

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143. Improving nurse-to-patient staffing ratios as a cost-effective safety intervention.

64

Author(s) Rothberg MB, Abraham I, Lindenauer PK, Rose DN

Citation: Medical Care, 01 August 2005, vol./is. 43/8(785-791), 00257079

Publication Date: 01 August 2005

Abstract: BACKGROUND: Responding to research confirming the link between nurse staffing and patient outcomes, 14 states have introduced legislation to limit patient-to-nurse ratios. However, increased staffing places a considerable financial burden on hospitals. OBJECTIVE: We sought to determine the cost-effectiveness of various nurse staffing ratios. RESEARCH DESIGN: This was a cost-effectiveness analysis from the institutional perspective comparing patient-to-nurse ratios ranging from 8:1 to 4:1. Cost estimates were drawn from the medical literature and the Bureau of Labor Statistics. Patient mortality and length of stay data for different ratios were based on 2 large hospital level studies. Incremental cost-effectiveness was calculated for each ratio and sensitivity and Monte Carlo analyses performed. SUBJECTS: The study included general medical and surgical patients. MEASURES:: We sought to measure costs per life saved in 2003 US dollars. RESULTS OF BASE CASE ANALYSIS: Eight patients per nurse was the least expensive ratio but was associated with the highest patient mortality. Decreasing the number of patients per nurse improved mortality and increased costs, becoming progressively less cost-effective as the ratio declined from 8:1 to 4:1. Nonetheless, the incremental cost-effectiveness did not exceed US dollars 136,000 (95% CI US dollars 53,000-402,000) per life saved. RESULTS OF SENSITIVITY ANALYSIS: The model was most sensitive to the effects of patient-to-nurse ratios on mortality. Lower ratios were most cost-effective when lower ratios shortened length of stay, and hourly wages were low. However, throughout the ranges of all these variables, the incremental cost-effectiveness of limiting the ratio to 4:1 never exceeded US dollars 449,000 per life saved. CONCLUSIONS: As a patient safety intervention, patient-to-nurse ratios of 4:1 are reasonably cost-effective and in the range of other commonly accepted interventions.

Source: CINAHL

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144. Impact of California's licensed nurse-patient ratios on unit-level nurse staffing and patient outcomes.

Author(s) Donaldson N, Bolton LB, Aydin C, Brown D, Elashoff JD, Sandhu M

Citation: Policy, Politics & Nursing Practice, 01 August 2005, vol./is. 6/3(198-210), 15271544

Publication Date: 01 August 2005

Abstract: This article presents the first analysis of the impact of mandated minimum-staffing ratios on nursing hours of care and skill mix in adult medical and surgical and definitive-observation units in a convenience sample of 68 acute hospitals participating in the California Nursing Outcomes Coalition project. Findings, stratified by unit type and hospital size, reveal expected changes as hospitals made observable efforts toward regulatory compliance. These data cannot affirm compliance with ratios per shift, per unit, at all times; however, they give evidence of overall compliance. Assessment of the impacts of the mandated ratios on two common indicators of patient care quality, the incidence of patient falls and the prevalence of pressure ulcers, did not reveal significant changes despite research linking nurse staffing with these measures. These findings contribute to understanding unit level impacts of regulatory staffing mandates and the preliminary effect of this legislation on core quality of care indicators.

Source: CINAHL

Available in print at ULHT journal article requests. Complete the online form to obtain articles.

145. Relationship between quality of care, staffing levels, skill mix and nurse autonomy: literature review.

65

Author(s) Currie V, Harvey G, West E, McKenna H, Keeney S

Citation: Journal of Advanced Nursing, 01 July 2005, vol./is. 51/1(73-82), 03092402

Publication Date: 01 July 2005

Abstract: AIMS: This paper reports a literature review exploring the relationship between quality of care and selected organizational variables through a consideration of what is meant by perceptions of quality, whose perceptions are accorded prominence, and whether changes in staffing, skill mix and autonomy affect perceptions of quality. BACKGROUND: Three basic ideas underpin this literature review: the growing focus on quality improvement in health care, concerns about the quality of care, and the move towards patient involvement and consultation. Of particular interest is the way in which changes in nurse staffing, skill mix and autonomy may affect the delivery of quality patient care. METHODS: A search was conducted using the CINAHL, Medline and Embase databases. Key words used were quality of health care; quality of nursing care; nurse; patient; skill mix; nurse-patient ratio; outcomes; adverse health care events and autonomy. The objective was to draw together a diverse collection of literature related to the field of health care quality. Papers were included for their relevance to the field of enquiry. The original search was conducted in 2003 and updated in 2004. FINDINGS: Quality of care is a complex, multi-dimensional concept which presents researchers with a challenge when attempting to evaluate it. Traditional nursing assessment tools have fallen out of use, partly because they have failed to provide opportunities to engage with and access the views of patients or nurses. There is also evidence that patient satisfaction as an indicator of quality is compromised on a number of fronts. There is conflicting information on how nurses and patients think about quality. Research looking at the relationship between the selected organizational variables and perceptions of quality also suffers from a number of limitations. We argue that there is a requirement for more patient-centred research exploring perceptions of quality and differences in nurse staffing, skill mix and autonomy.

Source: CINAHL

Available in print at Pilgrim Hospital Staff Library

Available in print at Lincoln County Hospital Professional Library

Available in fulltext at EBSCOhost

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146. Nurse staffing and healthcare outcomes: a systematic review of the international research evidence.

Author(s) Lankshear, A, Sheldon, T, Maynard, A

Citation: Advances in Nursing Science, Apr 2005, vol. 28, no. 2, p. 163-174, 0161-9268 (Apr-Jun 2005)

Publication Date: April 2005

Abstract: Systematic review of research on the relationship between the nursing workforce and patient outcomes in acute hospital care. The effects of staffing levels and skill mix on outcomes, including mortality, failure-to-rescue and complications, are examined. [(BNI unique abstract)] 38 references

Source: BNI

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147. Safe and adequate nurse staffing.

Author(s) Zondagh C

66

Citation: Nursing Update, 01 April 2005, vol./is. 29/3(38-42),

Publication Date: 01 April 2005

Source: CINAHL

148. Perioperative nurses and patient outcomes -- mortality, complications, and length of stay.

Author(s) Newhouse RP, Johantgen M, Pronovost PJ, Johnson E

Citation: AORN Journal, 01 March 2005, vol./is. 81/3(508-), 00012092

Publication Date: 01 March 2005

Abstract: THE PURPOSE OF THE STUDY described in this article was to identify the relationship between RN staffing factors in the OR and surgical patient outcomes. THE STUDY ADDRESSED two main questions: whether the level of RN staffing in the OR is related to postoperative complications, mortality, and length of stay (LOS) and whether certification, RN agency use, 24-hour staffing, and the performance of multidisciplinary code drills are related to complications, mortality, and LOS. ACCORDING TO THIS STUDY, selected organizational factors in ORs had a significant influence on patient outcomes.

Source: CINAHL

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149. Nurse staffing and outcomes: differentiating care delivery by education preparation.

Author(s) Page JS

Citation: Journal of Nursing Administration, 01 January 2005, vol./is. 35/1(7-7), 00020443

Publication Date: 01 January 2005

Source: CINAHL

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150. Professional update. Nurse-patient ratios not sole factor in quality care.

Author(s)

Citation: RN, 01 January 2005, vol./is. 68/1(17-17), 00337021

Publication Date: 01 January 2005

Source: CINAHL

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151. Nurse staffing and outcomes: differentiating care delivery by education preparation.

Author(s) Page JS

Citation: Journal of Nursing Administration, 01 January 2005, vol./is. 35/1(7-7), 00020443

Publication Date: 01 January 2005

Source: CINAHL

67

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152. Professional update. Nurse-patient ratios not sole factor in quality care.

Author(s)

Citation: RN, 01 January 2005, vol./is. 68/1(17-17), 00337021

Publication Date: 01 January 2005

Source: CINAHL

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153. Nurse staffing levels and patient outcomes.

Author(s) Houser EP

Citation: , 01 January 2005, vol./is. /(0-207),

Publication Date: 01 January 2005

Abstract: Inadequate nurse staffing has resulted in increased morbidity, mortality, and medical costs in hospitalized patients (American Nurses Association & Lewin-VHI, Inc., 1995; Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Flood & Diers, 1988). Evidence of poor patient outcomes has not resulted in public policy initiatives largely because there is "an insufficient body of evidence that links changes in hospital nurse staffing to adverse effects on quality of patient care" (Buerhaus & Needleman, 2000, p. 12).

Source: CINAHL

154. Cost-effectiveness of recommended nurse staffing levels for short-stay skilled nursing facility patients.

Author(s) Ganz DA, Simmons SF, Schnelle JF

Citation: BMC Health Services Research, 2005, vol./is. 5/(35), 1472-6963;1472-6963 (2005)

Publication Date: 2005

Abstract: BACKGROUND: Among patients in skilled nursing facilities for post-acute care, increased registered nurse, total licensed staff, and nurse assistant staffing is associated with a decreased rate of hospital transfer for selected diagnoses. However, the cost-effectiveness of increasing staffing to recommended levels is unknown.METHODS: Using a Markov cohort simulation, we estimated the incremental cost-effectiveness of recommended staffing versus median staffing in patients admitted to skilled nursing facilities for post-acute care. The outcomes of interest were life expectancy, quality-adjusted life expectancy, and incremental cost-effectiveness.RESULTS: The incremental cost-effectiveness of recommended staffing versus median staffing was $321,000 per discounted quality-adjusted life year gained. One-way sensitivity analyses demonstrated that the cost-effectiveness ratio was most sensitive to the likelihood of acute hospitalization from the nursing home. The cost-effectiveness ratio was also sensitive to the rapidity with which patients in the recommended staffing scenario recovered health-related quality of life as compared to the median staffing scenario. The cost-effectiveness ratio was not sensitive to other parameters.CONCLUSION: Adopting recommended nurse staffing for short-stay nursing home patients cannot be justified on the basis of decreased hospital transfer rates alone, except in facilities with high baseline hospital transfer rates. Increasing nurse staffing would be justified if health-related quality of life of nursing home patients improved substantially from greater nurse and nurse assistant presence.

Source: Medline

68

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