The synergy professional practice model and its patient characteristics tool: a staff empowerment strategy

Nurse leaders can positively influence practice environments through a number of empowerment strategies, among them professional practice models. These models encompass the philosophy, structures and processes that support nurses' control over their practice and their voice within healthcare organizations. Nurse-driven professional practice models can serve as a framework for collaborative decision-making among nursing and other staff. This paper describes a provincewide pilot project in which eight nurse-led project teams in four healthcare sectors worked with the synergy professional practice model and its patient characteristics tool. The teams learned how the model and tool can be used to classify patients' acuity levels and make staffing assignments based on a "best fit" between patient needs and staff competencies. The patient characteristics tool scores patients' acuities on eight characteristics such as stability, vulnerability and resource availability. This tool can be used to make real-time patient assessments. Other potential applications for the model and tool are presented, such as care planning, team-building and determining appropriate staffing levels. Our pilot project evidence suggests that the synergy model and its patient characteristics tool may be an empowerment strategy that nursing leaders can use to enhance their practice environments.     

Nurse staffing and patient outcomes: Strengths and limitations of the evidence to inform policy and practice. A review and discussion paper based on evidence reviewed for the National Institute for Health and Care Excellence Safe Staffing guideline development

A large and increasing number of studies have reported a relationship between low nurse staffing levels and adverse outcomes, including higher mortality rates. Despite the evidence being extensive in size, and having been sometimes described as “compelling” and “overwhelming”, there are limitations that existing studies have not yet been able to address. One result of these weaknesses can be observed in the guidelines on safe staffing in acute hospital wards issued by the influential body that sets standards for the National Health Service in England, the National Institute for Health and Care Excellence, which concluded there is insufficient good quality evidence available to fully inform practice.In this paper we explore this apparent contradiction. After summarising the evidence review that informed the National Institute for Health and Care Excellence guideline on safe staffing and related evidence, we move on to discussing the complex challenges that arise when attempting to apply this evidence to practice. Among these, we introduce the concept of endogeneity, a form of bias in the estimation of causal effects. Although current evidence is broadly consistent with a cause and effect relationship, endogeneity means that estimates of the size of effect, essential for building an economic case, may be biased and in some cases qualitatively wrong. We expand on three limitations that are likely to lead to endogeneity in many previous studies: omitted variables, which refers to the absence of control for variables such as medical staffing and patient case mix; simultaneity, which occurs when the outcome can influence the level of staffing just as staffing influences outcome; and common-method variance, which may be present when both outcomes and staffing levels variables are derived from the same survey.Thus while current evidence is important and has influenced policy because it illustrates the potential risks and benefits associated with changes in nurse staffing, it may not provide operational solutions. We conclude by posing a series of questions about design and methods for future researchers who intend to further explore this complex relationship between nurse staffing levels and outcomes. These questions are intended to reflect on the potential added value of new research given what is already known, and to encourage those conducting research to take opportunities to produce research that fills gaps in the existing knowledge for practice. By doing this we hope that future studies can better quantify both the benefits and costs of changes in nurse staffing levels and, therefore, serve as a more useful tool for those delivering services.     

Nurse staffing and patient, nurse, and financial outcomes

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.     

Decision making for nurse staffing: Canadian perspectives

The effectiveness of methods for determining nurse staffing is unknown. Despite a great deal of interest in Canada, efforts conducted to date indicate that there is a lack of consensus on nurse staffing decision-making processes. This study explored nurse staffing decision-making processes, supports in place for nurses, nursing workload being experienced, and perceptions of nursing care and outcomes in Canada. Substantial information was provided from participants about the nurse staffing decision-making methods currently employed in Canada including frameworks for nurse staffing, nurse-to-patient ratios, workload measurement systems, and "gut" instinct. A number of key themes emerged from the study that can form the basis for policy and practice changes related to determining appropriate workload for nursing in Canada. These include the use of (a) staffing principles and frameworks, (b) nursing workload measurement systems, (c) nurse-to-patient ratios, and (d) the need for uptake of evidence related to nurse staffing.     

Development and testing of the theory of collaborative decision-making in nursing practice for triads

BACKGROUND: Although nurses depend heavily on informal family caregivers to provide care to clients and to be involved in care planning and decision-making, no nursing theories that include the client, the caregiver, and the nurse were available to guide collaborative care planning and decision-making. AIM: The purpose of this paper is to describe the construction and initial testing of the theory of collaborative decision-making in nursing practice for a triad. The theory represents an extension of Kim's theory of collaborative decision-making in nursing practice. Kim's theory was developed to describe and explain collaborative decision-making in a dyad (client and nurse). The inclusion of a third person (family caregiver) in the theory required the addition of concepts about the caregiver, coalition formation, and nurse and caregiver outcomes. The expansion of Kim's dyadic theory to a triadic theory was achieved by means of a modified version of the theory derivation process described by Walker and Avant. CONCLUSIONS: The theory of collaborative decision-making in nursing practice for a triad can be used to guide further research and clinical practice. The theory provides a framework for researchers who are interested in studying the effects of collaboration regarding decision-making among nurses, family caregivers, and clients. The initial testing of the new theory in home health care nursing revealed variety in the nature of the client-caregiver-nurse relationships, the many processes used by the nurses in proceeding with the home visits, a multitude of decisions considered and different collaborative, noncollaborative, and coalition-forming interactions. The limited evidence of the empirical adequacy of the theory precludes development of definitive guidelines for clinical practice at this time. More studies are required before clinical practice guidelines can be developed.     

Impact of skill mix variations on patient outcomes following implementation of nursing hours per patient day staffing: a retrospective study

Aims. This article is a report of a study of the association between skill mix and 14 nursing‐sensitive outcomes following implementation of the nursing hours per patient day staffing method in Western Australian public hospitals in 2002, which determined nursing hours by ward category but not skill mix. Background. Findings from previous studies indicate that higher nurse staffing levels and a richer skill mix are associated with improved patient outcomes. Measuring skill mix at a hospital level for specific staffing methods and associated nursing‐sensitive patient outcomes are important in providing staffing for optimal patient care. Design. The research design for the larger study was retrospectively analysing patient and staffing administrative data from three adult tertiary hospitals in metropolitan Perth over 4 years. Methods. A subset of data was used to determine the impact of skill mix on nursing‐sensitive outcomes following implementation of the staffing method. All patient records (N = 103,330) and nurse staffing records (N = 73,770) from nursing hours per patient day wards from October 2002–June 2004 following implementation were included. Results. Increases in Registered Nurse hours were associated with important decreases in eight nursing‐sensitive outcomes at hospital level and increases in three nursing‐sensitive outcomes. The lowest skill mix saw the greatest reduction in nursing‐sensitive outcome rates. Conclusions. The skill mix of nurses providing care could impact patient outcomes and is an important consideration in strategies to improve nurse staffing. Levels of hospital nurse staffing and skill mix are important organizational characteristics when predicting patient outcomes.     

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.     

Are patient falls and pressure ulcers sensitive to nurse staffing?

Research has demonstrated an association between more nurses and more qualified nursing staff in hospitals and better patient outcomes. Patient falls and pressure ulcers have been advanced as nursing-sensitive outcomes. This article evaluates the state of the science linking nurse staffing to falls and pressure ulcers. Studies that employed multivariate analysis to discern the effect of nurse staffing on patient falls and pressure ulcers in hospitals were evaluated. Eleven studies that met inclusion criteria were contrasted on their data sources and measures, data analysis, risk adjustment, and results. The evidence of an effect of nursing hours or skill mix on patient falls and pressure ulcers is equivocal. Substantial differences in research methods across studies may account for the mixed findings. Two study types were identified based on the level at which nurse staffing was measured, hospital or nursing unit, which exhibited systematic differences in measures and methods. Improvements in measurement and methods are suggested.     

Defining and measuring nursing productivity: a concept analysis and pilot study

AIMS: The purpose of this article is fourfold. First we report a concept analysis of nursing productivity to show the complexity of the concept and its measurement. We then show how the concept analysis was used to design a method for measuring nursing productivity. Third, we describe how we used this measure in a pilot study of the impact of a differentiated Registered Nurse (RN) practice model on productivity. Finally, we identify the challenges encountered and present recommendations for nurse executives and researchers based on our findings. RATIONALE: We believe our experience can be useful to nurse executives and researchers who are interested in studying the impact of care delivery models on nursing productivity. DESIGN: We defined productivity as the ratio of output (patient care hours per patient day) to input (paid salary and benefit dollars). We conducted a pilot test using the productivity measure developed from the concept analysis to determine the effects of a differentiated RN practice model on patient, staff, and organizational outcomes. The purpose of the pilot study was to determine whether the data needed to measure productivity could be obtained from administrative databases and to develop the steps and process for the analysis. We analysed data by 2-week pay periods for two quarters prior to implementation of the differentiated nursing practice model and for two quarters after implementation to assess for changes in nursing productivity. RESULTS: Pilot testing showed that we could detect changes in productivity using this measurement approach. It also revealed several challenges in using administrative databases to measure productivity. CONCLUSIONS: We discuss these challenges with recommendations for both nurse executives and researchers. The most reasonable approach for operational decision-making is longitudinal monitoring of productivity by organizational units combined with indicators of quality of patient care.     

The relationship between nurse staffing and patient outcomes

OBJECTIVES: To examine the association between in-hospital mortality and four nurse staffing variables-the ratio of total nursing staff to patients, the proportion of RNs to total nursing staff, the mean years of RN experience, and the percentage of nurses with bachelor of science in nursing degrees. BACKGROUND: Studies suggest that nurse staffing changes affect patient and organizational outcomes, but the impact of nurse staffing on patient outcomes has not been studied sufficiently and the results of the previous studies are equivocal. Additionally, the studies of the relationship between nurse staffing and patient outcomes or the impact of nurse staffing on patient outcomes had not been previously examined in Thailand. METHODS: A retrospective, cross-sectional, observational research design was employed to study the research questions. Data of 2531 patients admitted to seven medical units and 10 surgical units of a 2300-bed university hospital in Thailand was used. All data of patients admitted to this hospital with four common groups of principal diagnoses (diseases of the heart, malignant neoplasms [cancer of all forms], hypertension and cerebrovascular diseases, and pneumonia and other diseases of the lung) was extracted from patient charts and discharge summaries in the calendar year 1999. Nurse staffing variables for each nursing unit in 1999 came from nursing service department databases. Multivariate logistic regression was used to determine the relationship between nurse staffing variables and in-hospital mortality. RESULTS: The findings of this study revealed that the ratio of total nurse staffing to patients was significantly related to in-hospital mortality in both partial and marginal analyses, controlling for patient characteristics. In addition, the ratio of total nursing staff to patients was found to be the best predictor of in-hospital mortality among the four nurse staffing variables, controlling for patient characteristics. The study did not find any significant relationship between in-hospital mortality and three nurse staffing variables (the proportion of RNs to total nursing staff, the mean years of RN experience, and the percentage of bachelor degree prepared nurses) probably due to the low variation of these variables across nursing units or because they may have correlated with other variables. CONCLUSIONS: The findings of this study add to our understanding of the importance of nurse staffing and its relationship to the patient outcome of hospital mortality. Further, the findings also provide information for hospital and nursing administrators to use when restructuring the clinical workforce, revising hospital policies, or making contractual decisions on behalf of nursing and public beneficiaries.     

Enhancing collaborative communication of nurse and physician leadership in two intensive care units

OBJECTIVE: To test an intervention to enhance collaborative communication among nurse and physician leaders (eg, nurse manager, medical director, clinical nurse specialist) in two diverse intensive care units (ICUs). BACKGROUND: Collaborative communication is associated with positive patient, nurse, and physician outcomes. However, to date, intervention-focused research that seeks to improve collaborative communication is lacking. METHODS: A pretest-posttest repeated measures design incorporated baseline data collection, implementation of the intervention over 8 months, and immediate and 6-months-post data collection. FINDINGS: Communication skills of ICU nurse and physician leaders improved significantly. Leaders also reported increased satisfaction with their own communication and leadership skills. In addition, staff nurse and physician perceptions of nursing leadership and problem solving between groups increased. Staff nurses reported lower personal stress (eg, more respect from co-workers, physicians, and managers), even though they perceived significantly more situational stress (eg, less staffing and time). CONCLUSION: Study findings provide evidence that nurse-physician collaborative communication can be improved.     

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

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) 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.     

Development and pilot testing of the collaborative practice assessment tool

Collaborative practice is receiving increased attention as a model of healthcare delivery that positively influences the effectiveness and efficiency of patient care while improving the work environment of healthcare providers. The collaborative practice assessment tool (CPAT) was developed from the literature to enable interprofessional teams to assess their collaborative practice. The CPAT survey included 56 items across nine domains including: mission and goals; relationships; leadership; role responsibilities and autonomy; communication; decision-making and conflict management; community linkages and coordination; perceived effectiveness and patient involvement; in addition to three open-ended questions. The tool was developed for use in a variety of settings involving a diversity of healthcare providers with the aim of helping teams to identify professional development needs and corresponding educational interventions. The results of two pilot tests indicated that the CPAT is a valid and reliable tool for assessing levels of collaborative practice within teams. This article describes the development of the tool, the pilot testing and validation process, as well as limitations of the tool.     

Development and pilot testing of the collaborative practice assessment tool

Collaborative practice is receiving increased attention as a model of healthcare delivery that positively influences the effectiveness and efficiency of patient care while improving the work environment of healthcare providers. The collaborative practice assessment tool (CPAT) was developed from the literature to enable interprofessional teams to assess their collaborative practice. The CPAT survey included 56 items across nine domains including: mission and goals; relationships; leadership; role responsibilities and autonomy; communication; decision-making and conflict management; community linkages and coordination; perceived effectiveness and patient involvement; in addition to three open-ended questions. The tool was developed for use in a variety of settings involving a diversity of healthcare providers with the aim of helping teams to identify professional development needs and corresponding educational interventions. The results of two pilot tests indicated that the CPAT is a valid and reliable tool for assessing levels of collaborative practice within teams. This article describes the development of the tool, the pilot testing and validation process, as well as limitations of the tool.     

Nurse-sensitive patient outcomes: an annotated bibliography

This article is an annotated bibliography on the topic of nurse staffing and patient care outcomes in the acute care setting. The authors have been involved in the developmental and pilot phase of the Veterans Affairs Nursing Outcomes Database project to build a database of acute care nursing-sensitive quality indicators. In the section preceding the annotated bibliography, a context for the development of this literature review is explained and a summary synthesizing key issues is presented.     

International Experts'' Perspectives on the State of the Nurse Staffing and Patient Outcomes Literature

PURPOSE: To assess the key variables used in research on nurse staffing and patient outcomes from the perspective of an international panel. DESIGN: A Delphi survey (November 2005-February 2006) of a purposively-selected expert panel from 10 countries consisting of 24 researchers specializing in nurse staffing and quality of health care and 8 nurse administrators. METHODS: Each participant was sent by e-mail an up-to-date review of all evidence related to 39 patient-outcome, 14 nurse-staffing and 31 background variables and asked to rate the importance/usefulness of each variable for research on nurse staffing and patient outcomes. In two subsequent rounds the group median, mode, frequencies, and earlier responses were sent to each respondent. FINDINGS: Twenty-nine participants responded to the first round (90.6%), of whom 28 (87.5%) responded to the second round. The Delphi panel generated 7 patient-outcome, 2 nurse-staffing and 12 background variables in the first round, not well-investigated in previous research, to be added to the list. At the end of the second round the predefined level of consensus (85%) was reached for 32 patient outcomes, 10 nurse staffing measures and 29 background variables. The highest consensus levels regarding measure sensitivity to nurse staffing were found for nurse perceived quality of care, patient satisfaction and pain, and the lowest for renal failure, cardiac failure, and central nervous system complications. Nursing Hours per Patient Day received the highest consensus score as a valid measure of the number of nursing staff. As a skill mix variable the proportion of RNs to total nursing staff achieved the highest consensus level. Both age and comorbidities were rated as important background variables by all the respondents. CONCLUSIONS: These results provide a snapshot of the state of the science on nurse-staffing and patient-outcomes research as of 2005. The results portray an area of nursing science in evolution and an understanding of the connections between human resource issues and healthcare quality based on both empirical findings and opinion.     

An advanced practice nurse--nurse researcher collaborative model

The advanced practice nurse (APN)--nurse researcher collaborative model proposed in this article emerged through an APN and a nurse researcher working together on a pilot research study and a project to describe advanced nursing practice in the outpatient setting. The model demonstrates how, through the observation and discussion of practice and research, the needs of both the NR and the APN are identified. Further discussion identifies outcomes important for each professional role as well as for the discipline of nursing. Results of such collaboration include practice-relevant nursing research, research-based practice, and more reflective APNs and nurse researchers.     

Nursing Research Priorities for Ireland

PURPOSE: The purpose of the study was to identify and rate clinical, managerial, and educational nursing research priorities in Ireland. DESIGN: The study design was a three-round, decision Delphi survey to identify and rate the importance of clinical, managerial, and educational research issues. A discussion group workshop was also undertaken to identify timeframes within which research on the issues identified should be conducted. A total of 1,695 nurses from all divisions of the nursing register in Ireland were initially surveyed. Response rates varied over the three rounds of the Delphi survey. A total of 122 nurses attended the discussion group workshop. This is the largest known survey of nurses to identify research priorities reported in the literature. RESULTS: Twenty-four nursing research priorities were identified. The five highest priorities were three clinical issues: outcomes of care delivery, staffing issues in practice, communication in clinical practice; and two managerial issues: recruitment and retention of nurses, and nursing input into health policy and decision-making. CONCLUSIONS: These research priorities identified for nursing in Ireland indicate, to an extent, the nursing research priorities identified in other European countries and in North America. The research priorities identified in this survey indicate that outcomes of care and the need to make nursing visible are attaining a higher priority than seen in previous studies. Also evident is that nursing shortages and increasing skill-mix in the clinical area have indicated a need for research into nurse recruitment, staff turnover, and staffing levels and how these issues affect patient outcomes. The priorities suggest research programmes that target the health service concerns identified in the national health agenda, such as the need to identify protocols and procedures that improve patient and client care outcomes and to examine and test solutions to workforce problems.