Relationships between patient dependency, nursing workload and quality

The nature and value of dependency-acuity-quality (DAQ) demand-side nursing workforce planning methods are set in the context of nursing workforce planning and development. Extensive DAQ data from one of the largest UK nursing workforce studies (347 wards) involving 64 high-quality and 62 low-quality hospital wards, are reconsidered in a workload and quality context. Results generate new insights; for example, poor quality care is more likely to be a feature of larger wards with fluctuating workloads than smaller wards with consistently high workloads owing to inflexible nurse staffing. Nursing activity and staffing differences between high- and low-quality wards are highlighted. Recommendations are made to improve nursing management and practice as well as the next phase of DAQ studies.     

病区开放式护理信息网站应用效果探讨

目的:探讨应用信息网络技术,提高病房护理管理水平.方法:在病区建立开放式护理信息网站,便于病人查询相关的护理信息.结果:390例病人对护理质量满意率达98.72％,未发生护理纠纷和差错.结论:病区建立开放式护理信息网站,使各项护理信息透明,护患关系良好互动,减少了护患纠纷,有效提高了护理质量,值得推广.     

Nursing staffing, nursing workload, the work environment and patient outcomes

Nurse staffing (fewer RNs), increased workload, and unstable nursing unit environments were linked to negative patient outcomes including falls and medication errors on medical/surgical units in a mixed method study combining longitudinal data (5 years) and primary data collection.     

精细化管理在耳鼻喉科病房护理工作中的应用

目的 探究在耳鼻咽喉科病房护理工作中应用精细化管理的效果。方法 以我院眼耳鼻喉病区耳鼻咽喉科疾病患者为对象,共92例。采用系统抽样法对研究对象进行分组,对照组和研究组各46例,其中对对照组应用常规护理,研究组应用精细化管理,以病房护理、专科护理、基础护理为观察指标,对比两组护理效果。结果 研究组护理人员的基础护理评分(89.11±3.70)、专科护理评分(90.37±4.27)、病房护理评分(91.37±4.97)均优于对照组各指标,且差异有统计学意义(P<0.05)。除此之外,研究组患者护理满意度是95.65%,远高于对照组的80.43%(P<0.05)。结论 在耳鼻咽喉科疾病患者应用精细化管理,不仅有效提高护理质量,还得到患者更高的满意评价度,护理效果显著,可进一步推广,广泛应用于临床。     

The impact of adding assistants in nursing to acute care hospital ward nurse staffing on adverse patient outcomes: An analysis of administrative health data

ObjectivesThe aim of this study was to assess the impact of adding assistants in nursing to acute care hospital ward nurse staffing on adverse patient outcomes using administrative health data.DesignLogistic regression modelling was used with linked administrative health data to examine the association between seven adverse patient outcomes and use of assistants in nursing utilising a pre-test/post-test design. Outcomes included were in-hospital 30-day mortality, failure to rescue, urinary tract infection, pressure injury, pneumonia, sepsis and falls with injury.SettingEleven acute care metropolitan hospitals in Western Australia.SamplePatients were retained in the dataset if they spent any time on a medical, surgical or rehabilitation ward during their admission and excluded if they only spent time on other ward types, as the outcomes used in this study are only validated for these patient populations. There were 256,302 patient records in the total sample with 125,762 in the pre-test period (2006–2007) and 130,540 in the post-test period (2009–2010).ResultsThe results showed three significant increases in observed to expected adverse outcomes on the assistant in nursing wards (failure to rescue, urinary tract infection, falls with injury), with one significant decrease (mortality). On the non-assistant in nursing wards there was one significant decrease (pneumonia) in the observed to expected adverse outcomes and one significant increase (falls with injury). Post-test analysis showed that spending time on assistant in nursing wards was a significant predictor for urinary tract infection and pneumonia. For every 10% of extra time patients spent on assistant in nursing wards they had a 1% increase in the odds of developing a urinary tract infection and a 2% increase in the odds of developing pneumonia.ConclusionThe results suggest that the introduction of assistants in nursing into ward staffing in an additive role should be done under a protocol which clearly defines their role, scope of practice, and working relationship with registered nurses, and the impact on patient care should be monitored.     

Intensive care 1980–1995: change in patient characteristics, nursing workload and outcome

Objective: To assess temporal changes in patient characteristics, nursing workload and outcome of the patients and to compare the actual amount of available nursing staff with the estimated needs in a medical-surgical ICU. Design: Retrospective analysis of prospectively collected data. Setting: A medical-surgical adult intensive care unit (ICU) in a Swiss university hospital. Patients: Data of all patients staying in the ICU between January 1980 and December 1995 were included. Interventions: None. Measurements and results: The estimated number of nurses needed was defined according to the Swiss Society of Intensive Care Medicine (SGI) grading system: category I = one nurse/patient/shift ( = 8 h), category II = one nurse/two patients/shift, category III = one nurse/three patients/shift. An intervention score (IS) was obtained, based on a number of specific activities in the ICU. There was a total of 35,327 patients (32 % medical and 68 % postoperative/trauma patients). Over time, the number of patients per year increased (1980/1995: 1,825/2,305, p < 0.001) and the length of ICU stay (LOS) decreased (4.1/3.8 days, p < 0.013). There was an increase in the number of patients aged > 70 years (19 %/28 %, p < 0.001), and a decrease in the number of patients < 60 years (58 % /41 %, p < 0.001). During the same time period, the IS increased two-fold. Measurement of nursing workload showed an increase over time. The number of nursing days per year increased (1980/1995: 7454/8681, p < 0.019), as did the relative amount of patients in category I (49 %/71 %, p < 0.001), whereas the portion of patients in category II (41 %/28 %, p < 0.019) and category III (10 %/0 %) decreased. During the same time period, mortality at ICU discharge decreased (9.0 %/7.0 %, p < 0.002). Conclusions: During the last 16 years, there has been a marked increase in workload at this medical-surgical ICU. Despite an increase in the number of severely sick patients (as defined by the nursing grading system) and patient age, ICU mortality and LOS declined from 1980 to 1995. This may be ascribed to improved patient treatment or care. Whether an increasingly liberal discharge policy (transfer to newly opened intermediate care units, transfer of patients expected to die to the ward) or a more rigorous triage (denying admission to patients with a very poor prognosis) are confounding factors cannot be answered by this investigation. The present data provide support for the tenet that there is a trend toward more complex therapies in increasingly older patients in tertiary care ICUs. Calculations for the number or nurses needed in an ICU should take into account the increased turnover of patients and the changing patient characteristics. Received: 30. April 1997 / Accepted: 8 August 1997     

某地级三级甲等医院病区护理工作量测算研究

目的探讨某三级甲等医院护理人员直接护理时间、间接护理时间的分配比例及不同病区之间的差异,为科学、合理配置普通病房护理人员提供依据。方法对咸宁市某三级甲等医院25个病区进行调查分析。采用观察法和记录法对确定的83项直接护理项目和30项间接护理项目进行护理时间测定,计算出护理工作量和护理人员编制。结果直接护理时间占护理总时间的62.26%,80%的病区存在不同程度的缺编现象。病区日均总护理时间为4874.60min(81.24h),适宜的床护比为1∶0.55。结论应对护理工作量进行测定,以确定适宜的护理人力资源。     

Nurse staffing,medical staffing and mortality in Intensive Care: An observational study

Objectives

To investigate whether the size of the workforce (nurses, doctors and support staff) has an impact on the survival chances of critically ill patients both in the intensive care unit (ICU) and in the hospital.

Background

Investigations of intensive care outcomes suggest that some of the variation in patient survival rates might be related to staffing levels and workload, but the evidence is still equivocal.

Data

Information about patients, including the outcome of care (whether the patient lived or died) came from the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme. An Audit Commission survey of ICUs conducted in 1998 gave information about staffing levels. The merged dataset had information on 65 ICUs and 38,168 patients. This is currently the best available dataset for testing the relationship between staffing and outcomes in UK ICUs.

Design

A cross-sectional, retrospective, risk adjusted observational study.

Methods

Multivariable, multilevel logistic regression.

Outcome Measures

ICU and in-hospital mortality.

Results

After controlling for patient characteristics and workload we found that higher numbers of nurses per bed (odds ratio: 0.90, 95% confidence interval: [0.83, 0.97]) and higher numbers of consultants (0.85, [0.76, 0.95]) were associated with higher survival rates. Further exploration revealed that the number of nurses had the greatest impact on patients at high risk of death (0.98, [0.96, 0.99]) whereas the effect of medical staffing was unchanged across the range of patient acuity (1.00, [0.97, 1.03]). No relationship between patient outcomes and the number of support staff (administrative, clerical, technical and scientific staff) was found. Distinguishing between direct care and supernumerary nurses and restricting the analysis to patients who had been in the unit for more than 8 h made little difference to the results. Separate analysis of in-unit and in-hospital survival showed that the clinical workforce in intensive care had a greater impact on ICU mortality than on hospital mortality which gives the study additional credibility.

Conclusion

This study supports claims that the availability of medical and nursing staff is associated with the survival of critically ill patients and suggests that future studies should focus on the resources of the health care team. The results emphasise the urgent need for a prospective study of staffing levels and the organisation of care in ICUs.     

Missed nursing care, staffing, and patient falls

Patient falls in hospitals continue to be a major and costly problem. This study tested the mediating effect of missed nursing care on the relationship of staffing levels (hours per patient day [HPPD]) and patient falls. The sample was 124 patient units in 11 hospitals. The HPPD was negatively associated with patient falls (r = -0.36, P < .01), and missed nursing care was found to mediate the relationship between HPPD and patient falls.     

循证护理学指导的病房管理工作初探

探讨循证护理学指导的病房管理工作方法和效果.在中国医院知识库网站搜集有关护理差错的文献,分类整理后找出病房管理的重点,实施改进措施后与往年的差错数量比较.在2006～2007年的文献中搜集到10年间发生的2 181件临床护理差错,与药物使用有关的差错占81.2%,其他依次为医嘱处理11.0%、护理记录5.2%、护理处置2.5%.按新模式进行病房管理后,1年内的差错由17～18件减少到5件.在循证护理学指导下,病房管理工作重点突出,有条不紊,护理差错明显下降.     

The daily relationships between staffing,safety perceptions and personality in hospital nursing: A longitudinal on-line diary study

BackgroundThe association between poor staffing conditions and negative patient safety consequences is well established within hospital nursing. However, many studies have been limited to nurse population level associations, and have used routine data to examine relationships. As a result, it is less clear how these relationships might be manifested at the individual nurse level on a day-to-day basis. Furthermore, personality may have direct and moderating roles in terms of work environment and patient safety associations, but limited research has explored personality in this context.ObjectiveTo further our understanding of these associations, this paper takes a within-person approach to examine nurses’ daily perceptions of staffing and patient safety. In addition, we explore the potential role of personality factors as moderators of daily level associations.MethodWe recruited eighty-three hospital nurses from three acute NHS Trusts in the UK between March and July 2013. Nurses completed online end-of-shift diaries over three–five shifts which collected information on perceptions of staffing, patient–nurse ratio and patient safety (perceptions of patient safety, ability to act as a safe practitioner, and workplace cognitive failure). Personality was also assessed within a baseline questionnaire. Data were analysed using hierarchical linear modelling, and moderation effects of personality factors were examined using simple slopes analyses, which decomposed relationships at high and low levels of the moderator.ResultsOn days when lower patient–nurse ratios were indicated, nurses reported being more able to act as a safe practitioner (p = .011) and more favourable perceptions of patient safety (p = <.001). Additionally, when staffing was perceived more favourably, nurses reported being more able to act as a safe practitioner (p = <.001), more favourable perceptions of patient safety (p = <.001) and experienced less workplace cognitive failure (p = <.001). Conscientiousness and emotional stability emerged as key moderators of daily level associations between staffing and patient safety variables, with many relationships differing at high and low levels of these personality factors.ConclusionThe findings elucidate the potential mechanisms by which patient safety risks arise within hospital nursing, and suggest that nurses may not respond to staffing conditions in the same way, dependent upon personality. Further understanding of these relationships will enable staff to be supported in terms of work environment conditions on an individual basis.     

流程重组影响护理服务效率的研究

目的 比较2种穿刺方法对自体动静脉内瘘功能状态的影响，探讨科学的内瘘穿刺法。方法 将52例维持性血液透析患者随机分为2组，每组26例。观察组26例患者内瘘采用动脉端向心方向穿刺法，对照组26例患者内瘘采用动脉端离心方向穿刺法，比较2种穿刺方式的透析效率有无差异及2组患者内瘘并发症发生率。结果 2种穿刺方式的透析效率差异无显著性（P〉0．05），观察组患者内瘘并发症发生率比对照组明显减少（P〈0．05）。结论 动脉端向心方向穿刺法能保证透析效率，减少内瘘并发症的发生率，自体动静脉内瘘的穿刺可选择动脉端向心方向穿刺法。     

A rejoinder to Leaf: What constitutes efficient,applied, and trial and error

In my response to Leaf (2011 Leaf, JB. (2011). An experimental approach for selecting a response-prompting strategy for children with developmental disabilities: A reply to Gast. Evidence-Based Communication Assessment and Intervention, 5, 226–233 [Google Scholar]), we agree that more comparative studies on response prompting procedures need to be conducted, and that it is “hard to justify the use of any trial and error procedure”. There appears to be disagreement, however, on several points, including: a) the need to separate the discussion of a procedure's effectiveness and efficiency; b) what constitutes an applied or functional skill; c) that NNP is a trial and error procedure; d) the importance of researchers explicitly reporting multiple measures of efficiency so that readers can independently evaluate the efficiency of the prompting strategies being compared; and e) that error correction procedures are inappropriate during early stages of learning. I briefly address my position regarding each.

Source of funding: No source of funding reported.     

Safety culture and an invisible nursing workload

Background

Nursing workload remains an issue in current health care contexts. The use of quantitative methodologies, methods and tools to measure workload has not produced adequate data to inform workforce policy to resolve workforce concerns about workload.

整体护理模式病房评审方法与分析

目的:对整体护理进行阶段性总结以确定今后发展方向.方法:制定评审标准,满分100分,＜85分为不达标,对16个模式病房整体护理开展情况分为5个方面考评.结果:16个科室全部达标,各项达标水平分别为护理管理品质98%;护理业务品质77.7%;护理效果品质94%;文件资料品质89.4%;护理人员业务品质90.2%.结论:院内开展整体护理模式病房评审,对整体护理的发展有促进作用.     

Measuring nursing workload in intensive care: an observational study using closed circuit video cameras

BACKGROUND: There is an increasing demand for intensive care provision in the United Kingdom (UK), partly because of a national shortage of intensive care beds. The problem is compounded by the current method for calculating the nurse: patient ratio using a Nurse Workload Patient Category scoring system or similar adaptations used in many intensive care units. This ratio is calculated by using patient category or dependency scales, which operate on the assumption that the more critically ill the patient, the more nurse time is needed to care for the patient. However, many mechanically ventilated critically ill patients (allocated a high category of care) may need less nursing care than patients who are self-ventilating and allocated a lower level of dependence. PURPOSE: In this study, a video recorder was used to document nurse activity for 48 continuous shifts in two intensive care units to determine the accuracy of the Nursing Workload Patient Category scoring system in measuring nurse workload. METHODS: The video data were correlated later with the Patient Category allocated to the patient by the nurse at the time. RESULTS: The results of this observational study demonstrated that, despite complex care needs, a high percentage of nursing activities observed in each unit consisted of low skill activity. Furthermore, nurses spent less time with patients categorized as in need of intensive care than those in need of high dependency care in both units. CONCLUSION: The findings suggest that existing nurse:patient ratio classifications may be inappropriate, since nurses spent less time with critically ill patients. Radical reconsideration of nursing levels and skill mix might make it possible to increase intensive care provision because fewer nurses would be needed to staff each bed. The findings support alternative and more flexible systems for assessing workload and the use of different nurse:patient ratios.     

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

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.