Nurse dose: What's in a concept?

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.     

Assessing the relationships between nurse work hours/overtime and nurse and patient outcomes: Systematic literature review

Background

The effects of work hours/overtime on nurse and patient outcomes and specific components of work hours (per shift and per week) and overtime on these effects have not been systematically examined.

Purpose

The purpose of this review was to systematically evaluate the effect of nurse overtime and long work hours on nurse and patient outcomes.

Methods

An online search of six electronic bibliographic databases was conducted for research published from 2000 to 2013.

Discussion

Twenty-one nurse outcome measures and 19 patient outcome measures were found in relationships with work hours and overtime. A total of 67 relationships to nurse outcomes and 41 relationships to patient outcomes were examined.

Conclusions

The findings of this review suggested that evidence supporting positive relationships between working long hours and adverse outcomes to the nurses is strong. However, to make a conclusion of the positive relationship between long work hours and adverse patient outcomes, more evidence is needed.     

Quality and the nursing workforce: APNs, patient outcomes and health care costs

Quality in health care requires access, appropriate and acceptable treatment plans, responsible patient follow through, a workforce of sufficient numbers and qualification and agreement on health care quality indicators. The purpose of this article is to describe APN workforce and dose effects on quality, reflected in patient outcomes and health care costs with current quality indicators. Stakeholders measure “quality indicators” differently. Nursing practices are often absent in databases and systems of reimbursement. Research overwhelmingly indicates equal outcomes for physician and APN care plus value-added APN effects on use of preventive services, adjustment to illness, stress management, treatment compliance, satisfaction, and reduced emergency room visits and rehospitalizations. APN dose has an important positive effect on patient outcomes and healthcare costs. Research is needed on the level of APN dose, staff mix and use of APNs, and balance of physician and APN dose in different stages of patient health, illness, and recovery to achieve quality outcomes.     

Nurse turnover: a literature review

Ongoing instability in the nursing workforce is raising questions globally about the issue of nurse turnover. A comprehensive literature review was undertaken to examine the current state of knowledge about the scope of the nurse turnover problem, definitions of turnover, factors considered to be determinants of nurse turnover, turnover costs and the impact of turnover on patient, and nurse and system outcomes. Much of the research to date has focused on turnover determinants, and recent studies have provided cost estimations at the organizational level. Further research is needed to examine the impact of turnover on health system cost, and how nurse turnover influences patient and nurse outcomes.     

Assessing the relationships between nurse working conditions and patient outcomes: systematic literature review

bae s.-h . (2011) Journal of Nursing Management 19, 700–713
Assessing the relationships between nurse working conditions and patient outcomes: systematic literature review Aim The purpose of the study was to systematically evaluate nurse working conditions and to review the literature dealing with their association with patient outcomes. Background Improving nurse working conditions is essential to address nursing shortages. Although general reviews of the literature support the positive link between working conditions and patient outcomes, definitive evidence has been lacking. Evaluation A search of six electronic bibliographic databases was conducted for the primary research published in English, from January 2000 to October 2009. Key issues The concepts of working conditions were categorized into 10 groups of working conditions. A total of 69 relationships between working conditions and patient outcomes were examined. Conclusions Increased attention has been drawn to nurse working conditions resulting from nursing shortages. The findings of this review suggested that the evidence supporting positive relationships between working conditions and patient outcomes is inconclusive. Further studies of a longitudinal and interventional nature in various settings are needed to advance knowledge of the complex contextual and multivariate influences among nurse working conditions and patient outcomes. Implications for nursing management Efforts to improve working conditions should be made in various health-care work settings to ensure patient safety and improve patient quality of outcomes.     

Nurse staffing and nurse outcomes: A systematic review and meta-analysis

Background

A great number of studies have been conducted to examine the relationship between nurse staffing and patient outcomes. However, none of the reviews have rigorously assessed the evidence about the effect of nurse staffing on nurse outcomes through meta-analysis.

Nursing care and patient outcomes: international evidence

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.     

Effects of hospital care environment on patient mortality and nurse outcomes

OBJECTIVE: The objective of this study was to analyze the net effects of nurse practice environments on nurse and patient outcomes after accounting for nurse staffing and education. BACKGROUND: Staffing and education have well-documented associations with patient outcomes, but evidence on the effect of care environments on outcomes has been more limited. METHODS: Data from 10,184 nurses and 232,342 surgical patients in 168 Pennsylvania hospitals were analyzed. Care environments were measured using the practice environment scales of the Nursing Work Index. Outcomes included nurse job satisfaction, burnout, intent to leave, and reports of quality of care, as well as mortality and failure to rescue in patients. RESULTS: Nurses reported more positive job experiences and fewer concerns with care quality, and patients had significantly lower risks of death and failure to rescue in hospitals with better care environments. CONCLUSION: Care environment elements must be optimized alongside nurse staffing and education to achieve high quality of care.     

Nurse dose: validation and refinement of a concept

In this article, we report the results of two studies aimed at validating the concept of nurse dose. The first study examined the relevance of the critical attributes and empirical indicators in accurately reflecting the concept of nurse dose. Ten experts in staffing research rated the relevance of the attributes and indicators. The second study explored the factorial structure of the nurse dose concept. Data on the nurse dose indicators were obtained from 26 inpatient units. The operationalization of nurse dose was refined based on the two studies' results. Nurse dose is posited as a structural variable capturing nurses' capacity to deliver high quality care in acute care hospitals. It is defined as the level (i.e., number and type) of nursing staff required to provide care that produces intended patient outcomes. Nurse dose is reflected in two attributes: (1) active ingredients representing the essential elements that distinguish nurses from other health care professionals and operationalized in nurses' theoretical and practical knowledge, and skill mix; and (2) intensity representing the potential for nurse-patient interactions and operationalized in terms of amount (indicated by full-time equivalent) and frequency (indicated by nurse-patient ratio and hours per patient day). The concept of nurse dose has the potential for guiding future staffing research.     

Selecting and managing fluid therapy. Colloids versus crystalloids.

The critical care nurse is responsible for monitoring the effects of parenteral therapy. If the nurse is to collaborate with the physician on the type of solution appropriate for the patient, it is imperative that the nurse understand how the solution will impact the patient. Only through comprehending the effects and properties of each solution can the nurse provide quality care and ensure desirable patient outcomes.     

The effects of nurse staffing on adverse events,morbidity, mortality,and medical costs

BACKGROUND: Nurse staffing levels are an important working condition issue for nurses and believed to be a determinant of the quality of nursing care and patient outcomes. OBJECTIVES: To examine the effects of nurse staffing on adverse events, morbidity, mortality, and medical costs. METHODS: Using two existing databases, the study sample included 232 acute care California hospitals and 124,204 patients in 20 surgical diagnosis-related groups. The adverse events included patient fall/injury, pressure ulcer, adverse drug event, pneumonia, urinary tract infection, wound infection, and sepsis. Multilevel analysis was employed to examine, simultaneously, the effects of nurse staffing and patient and hospital characteristics on patient outcomes. RESULTS: Three statistically significant relationships were found between nurse staffing and adverse events. An increase of 1 hour worked by registered nurses (RN) per patient day was associated with an 8.9% decrease in the odds of pneumonia. Similarly, a 10% increase in RN Proportion was associated with a 9.5% decrease in the odds of pneumonia. Providing a greater number of nursing hours per patient day was associated with a higher probability of pressure ulcers. The occurrence of each adverse event was associated with a significantly prolonged length of stay and increased medical costs. Patients who had pneumonia, wound infection or sepsis had a greater probability of death during hospitalization. CONCLUSION: Patients are experiencing adverse events during hospitalization. Care systems to reduce adverse events and their consequences are needed. Having appropriate nurse staffing is a significant consideration in some cases.     

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

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. AORN J 87 (June 2008) 1191-1204. © AORN, Inc, 2008.     

The Influence of Race and Gender on Nursing Care Decisions: A Pain Management Intervention

Background: Understanding whether a patient's race or gender and/or the nurse's race or gender influence how nurses form care decisions can contribute to exploration of methods that can positively affect disparate treatment. Aims: This research examined how the variables of race and gender of both the nurse and the patient influence nurses' decision making about pain management. Design: A randomized four-group post-test–only experimental design was used to examine the variables and variable interactions. Settings: An investigator-developed case vignette tool hosted online was used to obtain data about nursing pain management decisions. The vignette intervention was developed to simulate four exact patient scenarios that differed only by patient race and gender. Participants/Subjects: A quota sample of 400 nurses was recruited using a self-selected face-to-face recruitment technique. Methods: A four-way between-groups analysis of variance assessed whether the gender of the nurse, race of the nurse, gender of the patient, or race of the patient made any differences in the dose intensity of pain medications selected by the nurse sample. Results: No significant interactions were noted between any combinations of the four independent variables. A significant main effect was noted in medication intensity for nurse gender (F [1,384] = 9.75, p = .002). Conclusions: Data trends suggested that gender stereotypes about how patients managed pain played a role in dose intensity decisions because female patients on average were given higher doses of pain medication than male patients were by all the nurses in the study. Further research is needed in this complex area of study.     

An integrated analysis of nurse staffing and related variables: effects on patient outcomes

The objective of this article is to synthesize much of the research done on nurse staffing and patient outcomes; the impact of organizational characteristics on nurse staffing patterns, patient outcomes, and costs; and the impact of nurses' experience on patient outcomes. The author concludes research indicates that nurse staffing has a definite and measurable impact on patient outcomes, medical errors, length of stay, nurse turnover, and patient mortality. Moreover, the literature reports data that help determine what is, indeed, appropriate staffing. Ratios are important--a consensus seems to be emerging supporting a range of from 4 to 6 patients per nurse in most acute care hospital inpatient settings, with no more than one to two patients per nurse in areas of high patient acuity. However, ratios must be modified by the nurses' level of experience, the organization's characteristics, and the quality of clinical interaction between and among physicians, nurses, and administrators.     

Nurse adoption of continuous patient monitoring on acute post-surgical units: managing technology implementation

jeskey m., card e., nelson d., mercaldo n.d., sanders n., higgins m.s., shi y., michaels d. & miller A. (2011) Journal of Nursing Management 19, 863–875 Nurse adoption of continuous patient monitoring on acute post-surgical units: managing technology implementation Aim To report an exploratory action-research process used during the implementation of continuous patient monitoring in acute post-surgical nursing units. Background Substantial US Federal funding has been committed to implementing new health care technology, but failure to manage implementation processes may limit successful adoption and the realisation of proposed benefits. Effective approaches for managing barriers to new technology implementation are needed. Method Continuous patient monitoring was implemented in three of 13 medical/surgical units. An exploratory action-feedback approach, using time-series nurse surveys, was used to identify barriers and develop and evaluate responses. Post-hoc interviews and document analysis were used to describe the change implementation process. Results Significant differences were identified in night- and dayshift nurses’ perceptions of technology benefits. Research nurses’ facilitated the change process by evolving ‘clinical nurse implementation specialist’ expertise. Conclusions Health information technology (HIT)-related patient outcomes are mediated through nurses’ acting on new information but HIT designed for critical care may not transfer to acute care settings. Exploratory action-feedback approaches can assist nurse managers in assessing and mitigating the real-world effects of HIT implementations. Implications for Nursing Management It is strongly recommended that nurse managers identify stakeholders and develop comprehensive plans for monitoring the effects of HIT in their units.     

Can just-in-time, evidence-based "reminders" improve pain management among home health care nurses and their patients?

The purpose of this randomized, controlled, home care intervention was to test the effectiveness of two nurse-targeted, e-mail-based interventions to increase home care nurses' adherence to pain assessment and management guidelines, and to improve patient outcomes. Nurses from a large urban non-profit home care organization were assigned to usual care or one of two interventions upon identification of an eligible cancer patient with pain. The basic intervention consisted of a patient-specific, one-time e-mail reminder highlighting six pain-specific clinical recommendations. The augmented intervention supplemented the initial e-mail reminder with provider prompts, patient education material, and clinical nurse specialist outreach. Over 300 nurses were randomized and outcomes of 673 of their patients were reviewed. Data collection involved clinical record abstraction of nurse care practices and patient interviews completed approximately 45 days after start of care. The intervention had limited effect on nurse-documented care practices but patient outcomes were positively influenced. Patients in the augmented group improved significantly over the control group in ratings of pain intensity at its worst, whereas patients in the basic group had better ratings of pain intensity on average. Other outcomes measures were also positively influenced but did not reach statistical significance. Our findings suggest that although reminders have some role in improving cancer pain management, a more intensive approach is needed for a generalized nursing workforce with limited recent exposure to state-of-the-art pain management practices.     

Nurse-patient ratios: a systematic review on the effects of nurse staffing on patient, nurse employee, and hospital outcomes

OBJECTIVE: To determine whether the peer-reviewed literature supports specific, minimum nurse-patient ratios for acute care hospitals and whether nurse staffing is associated with patient, nurse employee, or hospital outcomes. BACKGROUND: Hospital care may be compromised by forces that have increased patient acuity, reduced the ratio of caregivers to patients, and lowered the level of training of these caregivers. METHODS: We systematically reviewed studies of the effects of nurse staffing on patient, nurse employee, and hospital outcomes published between 1980 and 2003 to determine whether they could guide the setting of minimum licensed nurse-patient ratios in acute care hospitals. RESULTS: Of 2897 titles and abstracts of interest, 490 articles were retrieved, and 43 met the inclusion criteria. Although all adjusted for case mix and skill mix, only one recent study addressed minimum nurse staffing ratios. Patient outcomes were limited to in-hospital, adverse events. Evidence suggests that richer nurse staffing is associated with lower failure-to-rescue rates, lower inpatient mortality rates, and shorter hospital stays. CONCLUSION: The literature offers no support for specific, minimum nurse-patient ratios for acute care hospitals, especially in the absence of adjustments for skill and patient mix, although total nursing hours and skill mix do appear to affect some important patient outcomes.     

Perceived adverse patient outcomes correlated to nurses’ workload in medical and surgical wards of selected hospitals in Kuwait

Aim. This study was carried out to identify the perceived adverse patient outcomes as related to nurses’ workload. It also assessed nurses’ perception of variables contributing to the workload and adverse patient outcomes. Background. Several studies have been published on adverse patient outcomes in which a correlation was found between nurses’ workload and some adverse patient outcomes. Design. A cross‐sectional survey was conducted between registered nurses (n = 780) working in medical and surgical wards of five general governmental hospitals in Kuwait. Data collection instruments. Data were collected using a self‐administered questionnaire consisting of three sections to elicit information about the sample characteristics, perception of workload and perceived adverse patient outcomes during the last shift and last working week. Results. The three major perceived adverse outcomes reported by the nurses while on duty during their last shift were: complaints from patients and families (2%), patients received a late dose or missed a dose of medication (1·8%) and occurrences of pressure ulcer (1·5%). Similarly, the reported adverse outcomes over the past week were complaints from patients and families (5%), patients received a late dose or missed a dose of medication (5·3%) and discovery of a urinary tract infection (3·7%). Increases in nurse‐patient load, bed occupancy rate, unstable patients’ condition, extra ordinary life support efforts and non‐nursing tasks; all correlated positively with perceived adverse patient outcomes. Conclusion. This study sheds light on an important issue affecting patient safety and quality of care as perceived by the nurses themselves as caregivers. Relevance to clinical practice. Nurses’ perception of variables contributing to adverse patient outcomes and their workload could significantly affect the provided nursing care and nursing care recipients. The findings could help in policy formulation and planning strategies to decrease adverse patient outcomes in many countries with a health care structure similar to that of Kuwait.     

The effects of nurse prescribing: A systematic review

Background

In 2008, we conducted a systematic review on the effects of nurse prescribing using studies with a comparative design. In view of the growing number of countries that are introducing nurse prescribing and the fact that several studies into nurse prescribing have been conducted recently, there is a need for an updated review to reassess the available information on the effects of nurse prescribing when compared to physician prescribing.

Objective

To identify, appraise and synthesise the evidence on the effects of nurse prescribing when compared to physician prescribing on the quantity and types of medication prescribed and on patient outcomes.

Design

A systematic review.

Data sources

In addition to the previous review, which covered the literature up to 2005, 11 literature databases and four websites were searched for relevant studies from January 2006 up to January 2012 without limitations as to language or country. Moreover, full-text copies of all studies included in the previous review were reviewed.

Review methods

A three-stage inclusion process, consisting of an initial sifting, checking full-text papers for inclusion criteria and methodological assessment, was performed independently by two reviewers. Data on effects were synthesised using narrative and tabular methods.

Results

Thirty-five studies met the inclusion criteria. All but five studies had a high risk of bias. Nurses prescribe in comparable ways to physicians. They prescribe for equal numbers of patients and prescribe comparable types and doses of medicines. Studies comparing the total amount of medication prescribed by nurses and doctors show mixed results. There appear to be few differences between nurses and physicians in patient health outcomes: clinical parameters were the same or better for treatment by nurses, perceived quality of care was similar or better and patients treated by nurses were just as satisfied or more satisfied.

Conclusions

The effects of nurse prescribing on medication and patient outcomes seem positive when compared to physician prescribing. However, conclusions must remain tentative due to methodological weaknesses in this body of research. More randomised controlled designs in the field of nurse prescribing are required for definitive conclusions about the effects of nurse prescribing.