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.     

Nursing workload assessment in an intensive care unit: A retrospective observational study using the Nursing Activities Score

Background

Nursing Activities Score (NAS) is a promising tool for calculating the nursing workload in intensive care units (ICU). However, data on intensive care nursing activities in Portugal are practically non-existent.

Aim

To assess the nursing workload in a Portuguese ICU using the NAS.

Study Design

Retrospective cohort study developed throughout the analysis of the electronic health record database from 56 adult patients admitted to a six-bed Portuguese ICU between 1 June–31 August 2020. The nursing workload was assessed by the Portuguese version of the NAS. The study was approved by the Hospital Council Board and Ethics Committee. The study report followed the STROBE guidelines.

Results

The average occupancy rate was 73.55% (±16.60%). The average nursing workload per participant was 67.52 (±10.91) points. There was a correlation between the occupancy rate and the nursing workload. In 35.78% of the days, the nursing workload was higher than the available human resources, overloading nurse staffing/team.

Conclusions

The nursing workload reported follows the trend of the international studies and the results reinforce the importance of adjusting the nursing staffing to the complexity of nursing care in this ICU. This study highlighted periods of nursing workload that could compromise patient safety.

Relevance to Clinical Practice

This was one of the first studies carried out with the NAS after its cross-cultural adaptation and validation for the Portuguese population. The nursing workload at the patient level was higher in the first 24 h of ICU stays. Because of the ‘administrative and management activities’ related to the ‘patient discharge procedures’, the last 24 h of ICU stays also presented high levels of nursing workload. The implementation of a nurse-to-patient ratio of 1:1 may contribute to safer nurse staffing and to improve patient safety in this Tertiary (level 3) ICU.     

The Zebra index: one method for comparing units in terms of nursing care

levenstam a.-k. & bergbom i. (2011) Journal of Nursing Management 19, 260–268
The Zebra index: one method for comparing units in terms of nursing care Aim To describe an approach for developing a nursing index that is based on the patients’ needs of nursing care and enables nursing costs to be calculated. Background Usually staffing resources are calculated as the ratio between the number of staff and the number of occupied beds per unit. Method The index was developed from two parts of the Zebra method. The index factor per patient category of care was calculated first. The patient days per category of care was multiplied next with the index factor for the category, which gives the same value in terms of nursing care given for all the patient days. The third step was the calculation of the Zebra index (ZI). Results The ZI shows ‘the intensity of nursing care’ given. The index makes it possible to follow changes in the nursing care given over a period of time and it can also explain why two similar units with the same number of staff per patient can have a totally different workload situation. Conclusion The ZI obtains reliable information about the changing nursing situations over a period of time. Implications for nursing management The approach described can be used in different settings and is not bound to Sweden but can be looked upon as a general method. The index is useful for comparing different units and clinics in terms of nursing care and staffing.     

Comparison of nurse workload approaches

beswick s. , hill p.d. & anderson m.a. (2010) Journal of Nursing Management 18, 592–598
Comparison of nurse workload approaches Background For hospitals in the United States, the number of patients who lie in beds at midnight is considered to be the standard indicator of nursing workload; relatively little attention is given to the total number of patients cared for in a 24-hour day. Staffing decisions are related to cost of care. Such decisions are made on a per-shift basis, calculating hours per patient day (HPPD) based upon midnight census provides little decision-making support about variable staffing needs over a 24-hour period. The discrepancy between nurse managers’ staffing based on real-time patient needs and financial analysts looking only at units of service captured at midnight clearly speaks to the need for a new metric of measurement. Objective To describe the variations in nursing workload across two medical units using a comparison of intra-day census recommendations for staffing and those projected based on the midnight census alone. Methods Data were retrieved from a primary data set that included: (1) the number of patients lying in beds at four different times during a 24-hour period: 06.00, 14.00, 22.00 hours and at midnight; (2) projected nursing hours needed based on the numbers of patients lying in beds at different times during the 24-hour period; and (3) the number of projected nursing hours needed for the numbers of patients lying in bed and those who were admitted and discharged in an 8-hour period of time. Results Statistically significant increases in 06.00 hour patient counts were found with statistically lower patient counts at both 14.00 and 22.00 hours compared with the midnight census alone. Nursing hour projections per day did not show any significance when projected based on intra day vs. midnight census alone. Statistically significant increases in nursing hour projections were seen on all three shifts when admissions and discharges and the nursing workload associated with those procedures were calculated. Conclusions Findings suggest that the midnight census alone may well not be the most precise measure to predict nursing workload or to cost out nursing care. To accurately capture the realities of a 24-hour nursing workload, the nursing work associated with patient admissions and discharges has to be a part of the equation. Implications for nursing management The tradition of using the midnight census to budget 24 hours of nursing services in the hospital setting does not capture the totality of nursing workload. A model that costs out direct nursing care in the hospital and ultimately bills separately for that care is needed to reflect the realities of hospital nursing workload.     

Effects of work environments on nurse and patient outcomes

purdy n., laschinger h.k.s., finegan j., kerr m. & olivera f. (2010) Journal of Nursing Management 18, 901–913
Effects of work environments on nurse and patient outcomes Aim To determine the relationship between nurses’ perceptions of their work environment and quality/risk outcomes for patients and nurses in acute care settings. Background Nurses are leaving the profession as a result of high levels of job dissatisfaction arising from current working conditions. To gain organizational support for workplace improvements, evidence is needed to demonstrate the impact of the work environment on patient care. Method A multi-level design was used to collect data from nurses (n = 679) and patients (n = 1005) within 61 medical and surgical units in 21 hospitals in Canada. Results Using multilevel structural equation modelling, the hypothesized model fitted well with the data [χ² = 21.074, d.f. = 10, Comparative Fit Index (CFI) = 0.985, Tucker-Lewis Index (TLI) = 0.921, Root Mean Square Error of Approximation (RMSEA) = 0.041, Standardized Root Mean Square Residual (SRMR) 0.002 (within) and 0.054 (between)]. Empowering workplaces had positive effects on nurse-assessed quality of care and predicted fewer falls and nurse-assessed risks as mediated through group processes. These conditions positively impacted individual psychological empowerment which, in turn, had significant direct effects on empowered behaviour, job satisfaction and care quality. Conclusions Empowered workplaces support positive outcomes for both nurses and patients. Implications for nursing management Managers employing strategies to create more empowered workplaces have the potential to improve nursing teamwork that supports higher quality care, less patient risk and more satisfied nurses.     

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.     

Patients' perceptions of barriers for participation in nursing care

Scand J Caring Sci; 2011; 25; 575–582
Patients’ perceptions of barriers for participation in nursing care Background: In many Western countries as in Sweden, patients have legal right to participate in own care individually adjusted to each patient’s wishes and abilities. There are still few empirical studies of patients’ perceptions of barriers for participation. Accordingly, there is a need to identify what may prevent patients from playing an active role in own nursing care. Such knowledge is highly valuable for the nursing profession when it comes to implementation of individual patient participation. Aim and objective: To explore barriers for patient participation in nursing care with a special focus on adult patients with experience of inpatient physical care. Methodological design and justification: Data were collected through 6 focus groups with 26 Swedish informants recruited from physical inpatient care as well as discharged patients from such a setting. A content analysis with qualitative approach of the tape‐recorded interview material was made. Ethical issues and approval: The ethics of scientific work was adhered to. Each study participant gave informed consent after verbal and written information. The Ethics Committee of Göteborg University approved the study. Results: The barriers for patient participation were identified as four categories: Facing own inability, meeting lack of empathy, meeting a paternalistic attitude and sensing structural barriers, and their 10 underlying subcategories. Conclusions: Our study contributes knowledge and understanding of patients’ experiences of barriers for participation. The findings point to remaining structures and nurse attitudes that are of disadvantage for patients’ participation. The findings may increase the understanding of patient participation and may serve as an incentive in practice and nursing education to meet and eliminate these barriers, in quality assurance of care, work organization and further research.     

The patient satisfaction with nursing care quality: the psychometric study of the Serbian version of PSNCQ questionnaire

Scand J Caring Sci; 2012; 26; 598–606 The patient satisfaction with nursing care quality: the psychometric study of the Serbian version of PSNCQ questionnaire Introduction: Patient satisfaction with nursing is the most important predictor of patients’ overall satisfaction with their hospital care. According to the Law of Health Care of Republic of Serbia monitoring of patients’ satisfaction with hospital service is mandatory; however, the questionnaire applied to that purpose includes only several questions directly addressing the nursing care issue. Aim: The aim of the present study was to evaluate psychometric properties of the Serbian version Patient Satisfaction Nursing Care Quality Questionnaire (PSNCQQ) and explore patients’ satisfaction of nursing care they received and assess the relationship between patient satisfaction and patient characteristics. Methods: This cross‐sectional study included a sample population of 240 patients who were discharged from surgical clinics of the Clinical Center of Vojvodina in Novi Sad. The PSNCQQ was translated into Serbian according to standard procedures for forward and backward translation. Factor analysis was used to determine the construct validity, and predictive validity of the questionnaire was previously assessed. Cronbach’s α coefficient and item analysis was conducted to evaluate reliability of the scale. Results: The Serbian version Patient Satisfaction Nursing Care Quality Questionnaire (PSNCQQ) showed a one‐factor structure, Cronbach’s α reliability coefficient was excellent 0.94 and was similar across hospital categories. The correlation coefficient between 19 items and the total scale was high, and ranged from 0.56 to 0.76. Patients’ age, educational level and previous hospitalization period were important factors that affected their satisfaction with nursing care. Conclusion: The study provides a new tool for measuring patient satisfaction with nursing care in Serbia that may present a useful instrument for nursing care managers in improving the nursing care process.     

A nursing care classification system for assessing workload and determining optimal nurse staffing in a teaching hospital in China: A pre‐post intervention study

We aimed to evaluate the effectiveness of a nursing care classification system for re‐assessing nurse workload and determining staffing needs. Adequate bed–nurse ratios help manage hospital cost‐efficiency, quality of care and patient safety. A prospective pre‐post intervention study was conducted from January 2010 to December 2012 in 16 medical‐surgical units of a tertiary teaching hospital. Nursing tasks were classified into four grades of care reflecting actual workload. Units were re‐staffed accordingly and bed–nurse ratios compared with government‐authorized bed–nurse ratios. Patient satisfaction, hospital stays and mortality were evaluated pre‐ and poststaffing changes. Average bed–nurse ratio (1:0.41) exceeded the national standard (1:0.40) in 16 units, but was inadequate in five units. Re‐staffing increased average bed–nurse ratio from 1:0.41 to 1:0.48. Patients' satisfaction increased from 96.9% to 97.6%, and hospital stays decreased significantly. Nursing care classification effectively distributes nurse staffing to match patients' care levels, improving patient outcomes.     

Post-operative mortality,missed care and nurse staffing in nine countries: A cross-sectional study

BackgroundVariation in post-operative mortality rates has been associated with differences in registered nurse staffing levels. When nurse staffing levels are lower there is also a higher incidence of necessary but missed nursing care. Missed nursing care may be a significant predictor of patient mortality following surgery.AimExamine if missed nursing care mediates the observed association between nurse staffing levels and mortality.MethodData from the RN4CAST study (2009–2011) combined routinely collected data on 422,730 surgical patients from 300 general acute hospitals in 9 countries, with survey data from 26,516 registered nurses, to examine associations between nurses’ staffing, missed care and 30-day in-patient mortality. Staffing and missed care measures were derived from the nurse survey. A generalized estimation approach was used to examine the relationship between first staffing, and then missed care, on mortality. Bayesian methods were used to test for mediation.ResultsNurse staffing and missed nursing care were significantly associated with 30-day case-mix adjusted mortality. An increase in a nurse’s workload by one patient and a 10% increase in the percent of missed nursing care were associated with a 7% (OR 1.068, 95% CI 1.031–1.106) and 16% (OR 1.159 95% CI 1.039–1.294) increase in the odds of a patient dying within 30 days of admission respectively. Mediation analysis shows an association between nurse staffing and missed care and a subsequent association between missed care and mortality.ConclusionMissed nursing care, which is highly related to nurse staffing, is associated with increased odds of patients dying in hospital following common surgical procedures. The analyses support the hypothesis that missed nursing care mediates the relationship between registered nurse staffing and risk of patient mortality. Measuring missed care may provide an ‘early warning’ indicator of higher risk for poor patient outcomes.     

Evaluating nurse staffing patterns and neonatal intensive care unit outcomes using Levine's Conservation Model of Nursing

mefford l.c. & alligood m.r. (2011) Journal of Nursing Management 19, 998–1011
Evaluating nurse staffing patterns and neonatal intensive care unit outcomes using Levine’s conservation model of nursing Aims To explore the influences of intensity of nursing care and consistency of nursing caregivers on health and economic outcomes using Levine’s Conservation Model of Nursing as the guiding theoretical framework. Background Professional nursing practice models are increasingly being used although limited research is available regarding their efficacy. Method A structural equation modelling approach tested the influence of intensity of nursing care (direct care by professional nurses and patient–nurse ratio) and consistency of nursing caregivers on morbidity and resource utilization in a neonatal intensive care unit (NICU) setting using primary nursing. Results Consistency of nursing caregivers served as a powerful mediator of length of stay and the duration of mechanical ventilation, supplemental oxygen therapy and parenteral nutrition. Analysis of nursing intensity indicators revealed that a mix of professional nurses and assistive personnel was effective. Conclusions Providing consistency of nursing caregivers may significantly improve both health and economic outcomes. New evidence was found to support the efficacy of the primary nursing model in the NICU. Implications for nursing management Designing nursing care delivery systems in acute inpatient settings with an emphasis on consistency of nursing caregivers could improve health outcomes, increase organizational effectiveness, and enhance satisfaction of nursing staff, patients, and families.     

A review of workload measures: a context for a new staffing methodology in Western Australia

Objectives

This paper critically reviews various approaches to measuring nursing workload to provide a context for the introduction of a different approach to staffing. Nurse hours per patient day (NHPPD), which classifies wards into various groupings, was applied to all public hospitals in Western Australia.

Results

This method was introduced in response to industrial imperatives to determine reasonable workloads for nurses. As a result, the limited evaluation has focused only on the impact on workload management; reporting target versus actual nurse hours, staff retention and nurse feedback. This method improved ward staffing significantly without imposing restrictive nurse-to-patient ratios and facilitates the use of professional discretion within ward groupings to enable diversion of resources to match reported acuity changes.

Conclusion

While successful in attracting nurses back into hospitals and increasing nursing numbers, there is no empirical evidence of the impact this method had on patient outcomes or whether the guiding principles used in the development of this method are appropriate. The model would also benefit from further refinement to be more sensitive to direct acuity measures.     

Are nurses’ assessments of their workload affected by non‐patient factors? An analysis of the RAFAELA system

Aims To identify (1) the contribution of non‐patient factors to patient classification systems and (2) the explanatory power of nursing care intensity and non‐patient factors to Professional Assessment of Optimal Nursing Care Intensity Level workload. Background In the Rainio, Fagerström and Rauhala (RAFAELA) patient classification system, nursing care intensity per nurse is measured daily by the Oulu Patient Classification/Qualisan instrument. The optimal nursing care intensity is determined using Professional Assessment of Optimal Nursing Care Intensity Level instrument. However, nurses’ workload may be affected by factors other than nursing care intensity. Therefore, RAFAELA contains 12 non‐patient questions. Methods A retrospective study of all 22 somatic wards of a secondary healthcare hospital in Finland. Results Non‐patient questions were answered in 26% of 4870 questionnaires. They added to workload in 62%. Eight questions were grouped into four factors: administration; staff resources and mental stress; co‐operation within and between units. The explanatory value between Oulu Patient Classification/Qualisan and Professional Assessment of Optimal Nursing Care Intensity Level had a median of 0.45. Including the non‐patient questions raised it to 0.55. Conclusions Non‐patient factors affect the nurses’ assessments of their workload, but less than nursing care intensity. They contribute valuable information on the functioning and problems of wards.     

Using transprofessional care in the emergency department to reduce patient admissions: A retrospective audit of medical histories

The demand for emergency department (ED) services has increased significantly, due to our increasingly ageing population and limited access to primary care. This article reports outcomes from a transprofessional model of care in an ED in Victoria, Australia. Nurses, physiotherapists, social workers, and occupational therapists undertook additional education to increase the range of services they could provide and thereby expedite patient flow through the ED. One hundred patients who received this service were matched against 50 patients who did not. The most common reasons for patient admission were limb injury/limb pain (n = 47, 23.5%) and falls (n = 46, 23.0%). Transprofessional interventions included applying supportive bandages, slings, zimmer splints and controlled ankle motion (CAM) boots, and referral to new services such as case management and mental health teams. The rate of hospital admissions was significantly lower in the transprofessional group (n = 27, 18.0%) than in the reference group (n = 19, 38%, p = 0.005). This group also had a slightly lower re-presentation rate (n = 4, 2.7%) than patients in the reference group (n = 2, 4.0%). There are many benefits that support this model of care that in turn reduces ED overcrowding and work stress. A transprofessional model may offer a creative solution to meeting the varied needs of patients presenting for emergency care.     

Patient participation in clinical decision-making in nursing: A comparative study of nurses' and patients' perceptions

Aims and objectives. The aim of this study was to compare the degree of concordance between patients and Registered Nurses’ perceptions of the patients’ preferences for participation in clinical decision‐making in nursing care. A further aim was to compare patients’ experienced participation with their preferred participatory role. Background. Patient participation in clinical decision‐making is valuable and has an effect on quality of care. However, there is limited knowledge about patient preferences for participation and how nurses perceive their patients’ preferences. Methods. A comparative design was adopted with a convenient sample of 80 nurse–patient dyads. A modified version of the Control Preference Scale was used in conjunction with a questionnaire developed to elicit the experienced participation of the patient. Results. A majority of the Registered Nurses perceived that their patients preferred a higher degree of participation in decision‐making than did the patients. Differences in patient preferences were found in relation to age and social status but not to gender. Patients often experienced having a different role than what was initially preferred, e.g. a more passive role concerning needs related to communication, breathing and pain and a more active role related to activity and emotions/roles. Conclusions. Registered Nurses are not always aware of their patients’ perspective and tend to overestimate patients’ willingness to assume an active role. Registered Nurses do not successfully involve patients in clinical decision‐making in nursing care according to their own perceptions and not even to the patients’ more moderate preferences of participation. Relevance to clinical practice. A thorough assessment of the individual's preferences for participation in decision‐making seems to be the most appropriate approach to ascertain patient's involvement to the preferred level of participation. The categorization of patients as preferring a passive role, collaborative role or active role is seen as valuable information for Registered Nurses to tailor nursing care.     

Interdisciplinary communication in general medical and surgical wards using two different models of nursing care delivery

fernandez r., tran d.t., johnson m. & jones s . (2010) Journal of Nursing Management 18, 265–274
Interdisciplinary communication in general medical and surgical wards using two different models of nursing care delivery Aim To compare two models of care on nurses’ perception of interdisciplinary communication in general medical and surgical wards. Background Effective interdisciplinary collaboration remains the cornerstone of efficient and successful functioning of health care teams and contributes substantially to patient safety. Methods  In May 2007, participants were recruited from a tertiary teaching hospital in Australia. The multifaceted Shared Care in Nursing (SCN) model of nursing care involved team work, leadership and professional development. In the Patient Allocation (PA) model one nurse was responsible for the care of a discrete group of patients. Differences in interdisciplinary communication were assessed at the 6-month follow-up. Results Completed questionnaires were returned by 125 participants. At the 6-month follow-up, there was a significant reduction in scores in the SCN group in the subscales relating to communication openness (P = 0.03) and communication accuracy (P = 0.02) when compared with baseline values. There were no significant differences in the two groups at the 6-month follow-up in any of the other subscales. Conclusions There is a need for effective training programmes to assist nurses in working together within a nursing team and an interdisciplinary ward team. The SCN and the PA models of care have been found by nurses to support most aspects of interdisciplinary and intradisciplinary communication. The applicability of both models of care to wards with a varying skill mix of nurses is suggested. Further studies of larger samples with varying compositions of skill mix and varying models of care are required. Implications for nursing management Nurse managers can use varying models of care to support interdisciplinary communication and enhance patient safety.     

Perceived barriers and enablers for implementing water protocols in acute stroke care: A qualitative study using the Theoretical Domains Framework

Abstract

Purpose: To identify perceived enablers and barriers that may influence the implementation of water protocols (WPs) as an intervention for dysphagia in acute stroke settings.

Method: Semi-structured interviews were conducted with nine nurses, eight speech-language pathologists (SLPs), five doctors and four dietitians working in acute stroke units in a major city in Australia. Data were thematically analysed and themes were mapped to the Theoretical Domains Framework.

Result: Ten barriers and nine enablers were identified. Key barriers were: nurses lack oral care skills and agency nurses lack stroke-specific skills; only SLPs are perceived to be involved with WPs; WP rules will not get followed and may lead to adverse patient outcomes; WPs increase nursing workload; transient workforce impacts efficiency of implementation; and established culture of using thickened fluids. Key enablers were: patients would benefit from WPs; communication and education systems are already in place; acute hospital brings unique benefits; and peer support and modelling support implementation.

Conclusion: The perceptions of barriers and enablers to implementation of WPs can be used to inform future studies designed to evaluate the safety and efficacy of WPs and subsequently facilitate their uptake in acute stroke as an alternate dysphagia management strategy.