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.     

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

Background

Studies have linked nurse staffing levels (number and skill mix) to several nurse-sensitive patient outcomes. However, evidence from European countries has been limited.

Objectives

This study examines the association between nurse staffing levels (i.e. acuity-adjusted Nursing Hours per Patient Day, the proportion of registered nurses with a Bachelor's degree) and 10 different patient outcomes potentially sensitive to nursing care.

Design-setting-participants

Cross-sectional analyses of linked data from the Belgian Nursing Minimum Dataset (general acute care and intensive care nursing units: n = 1403) and Belgian Hospital Discharge Dataset (general, orthopedic and vascular surgery patients: n = 260,923) of the year 2003 from all acute hospitals (n = 115).

Methods

Logistic regression analyses, estimated by using a Generalized Estimation Equation Model, were used to study the association between nurse staffing and patient outcomes.

Results

The mean acuity-adjusted Nursing Hours per Patient Day in Belgian hospitals was 2.62 (S.D. = 0.29). The variability in patient outcome rates between hospitals is considerable. The inter-quartile ranges for the 10 patient outcomes go from 0.35 for Deep Venous Thrombosis to 3.77 for failure-to-rescue. No significant association was found between the acuity-adjusted Nursing Hours per Patient Day, proportion of registered nurses with a Bachelor's degree and the selected patient outcomes.

Conclusion

The absence of associations between hospital-level nurse staffing measures and patient outcomes should not be inferred as implying that nurse staffing does not have an impact on patient outcomes in Belgian hospitals. To better understand the dynamics of the nurse staffing and patient outcomes relationship in acute hospitals, further analyses (i.e. nursing unit level analyses) of these and other outcomes are recommended, in addition to inclusion of other study variables, including data about nursing practice environments in hospitals.     

The relationship between nurse staffing and patient outcomes: a case study

Background

Research has shown a direct relationship between staffing levels and patient outcomes for specific nurse-sensitive indicators, with lower patient to nurse ratios (i.e. less patients per nurse) associated with better outcomes.

Objectives

To explore the relationship between nurse staffing characteristics (the nursing hours worked by permanent and temporary staff and nurse hours per patient day) and patient outcomes: pressure sores, patient falls, upper gastrointestinal bleed, pneumonia, sepsis, shock and deep vein thrombosis.

Design

A case study using retrospective hospital data, at ward level.

Setting

A tertiary cardio-respiratory NHS Trust in England, comprising two hospitals.

Participants

All patients, including day cases, who were admitted to either hospital as an in-patient over 12 months.

Methods

Data were extracted from corporate hospital systems. The clinical areas were categorised as lower dependency, i.e. wards, or critical care which included ICU and high dependency units. The relationship between nurse staffing characteristics and patient outcomes was assessed using either a Poisson or negative binomial regression model as appropriate. We sought to establish whether the outcomes were affected by the nurse hours per patient day, the permanent nurse hours worked as a percentage of the total hours, and the permanent nurse hours worked as a percentage of the permanent and bank hours combined.

Results

In the lower dependency category wards there was only a weak association demonstrated between nurse staffing and the majority of the outcomes. The results from the high dependency critical care areas showed few significant results with only the rate of sepsis being significantly reduced as the ratio of permanent staff hours increased.

Conclusions

The study demonstrated the possibility of using existing hospital data to examine the relationship between nurse staffing and patient outcomes, however the associations found were weak and did not replicate reliably the findings from previous work.     

The effects of RN staffing hours on nursing home quality: A two-stage model

Objectives/background

Based on structure-process-outcome approach, this study examined the association of registered nurse (RN) staffing hours and five quality indicators, including two process measures (catheter use and antipsychotic drug use) and three outcome measures (pressure ulcers, urinary tract infections, and weight loss).

Setting/participants

We used data on resident assessments, RN staffing, organizational characteristics, and market factors to examine the quality of 195 nursing homes operating in a rural state of United States — Colorado.

Design/methods

Two-stage least squares regression models were performed to address the endogenous relationships between RN staffing and the outcome-related quality indicators, and ordinary least squares regression was used for the process-related ones. This analysis focused on the relationship of RN staffing to nursing home quality indicators, controlling for organizational characteristics, resources, resident casemix, and market factors with clustering to control for geographical differences.

Results

Higher RN hours were associated with fewer pressure ulcers, but RN hours were not related to the other quality indicators.

Conclusions

The study finding shows the importance of understanding the role of ‘nurse staffing’ under nursing home care, as well as the significance of associated/contextual factors with nursing home quality even in a small rural state.     

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.

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.     

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

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

Three metaphors and a (mis)quote: thinking about staffing-outcomes research, health policy and the future of nursing

Conducting research on nurse staffing and outcomes is very challenging, and the application of staffing-outcomes research in practice is both fraught with controversy and vitally important for the safety of our patients and the future of the profession. As I stand back and think about being involved in staffing-outcomes research for nearly a decade and sharing many of my thoughts about this rapidly growing literature in reviews and commentaries in print, certain metaphors for trends in this field come to mind. I won't claim originality for the insights that follow or attempt to thoroughly trace the genealogy of the stories and metaphors here, but offer them to provide what I hope is a fresh perspective to material that I and many of my colleagues have visited and revisited on numerous occasions.     

The relationship between nurse staffing and quality of care in nursing homes: a systematic review

Background

Nursing homes have an important role in the provision of care for dependent older people. Ensuring quality of care for residents in these settings is the subject of ongoing international debates. Poor quality care has been associated with inadequate nurse staffing and poor skills mix.

Objectives

To review the evidence-base for the relationship between nursing home nurse staffing (proportion of RNs and support workers) and how this affects quality of care for nursing home residents and to explore methodological lessons for future international studies.

Design

A systematic mapping review of the literature.

Data sources

Published reports of studies of nurse staffing and quality in care homes.

Review methods

Systematic search of OVID databases. A total of 13,411 references were identified. References were screened to meet inclusion criteria. 80 papers were subjected to full scrutiny and checked for additional references (n = 3). Of the 83 papers, 50 were included. Paper selection and data extraction completed by one reviewer and checked by another. Content analysis was used to synthesise the findings to provide a systematic technique for categorising data and summarising findings.

Results

A growing body of literature is examining the relationships between nurse staffing levels in nursing homes and quality of care provided to residents, but predominantly focuses on US nursing facilities. The studies present a wide range and varied mass of findings that use disparate methods for defining and measuring quality (42 measures of quality identified) and nurse staffing (52 ways of measuring staffing identified).

Conclusions

A focus on numbers of nurses fails to address the influence of other staffing factors (e.g. turnover, agency staff use), training and experience of staff, and care organisation and management. ‘Quality’ is a difficult concept to capture directly and the measures used focus mainly on ‘clinical’ outcomes for residents. This systematic mapping review highlights important methodological lessons for future international studies and makes an important contribution to the evidence-base of a relationship between the nursing workforce and quality of care and resident outcomes in nursing home settings.     

Association between nursing cost and patient outcomes in intensive care units: A retrospective cohort study of Belgian hospitals

IntroductionHospitals with better nursing resources report more favourable patient outcomes with almost no difference in cost as compared to those with worse nursing resources. The aim of this study was to assess the association between nursing cost per intensive care unit bed and patient outcomes (mortality, readmission, and length of stay).MethodologyThis was a retrospective cohort study using data collected from the intensive care units of 17 Belgian hospitals from January 01 to December 31, 2018. Hospitals were dichotomized using median annual nursing cost per bed. A total of 18,235 intensive care unit stays were included in the study with 5,664 stays in the low-cost nursing group and 12,571 in the high-cost nursing group.ResultsThe rate of high length of stay outliers in the intensive care unit was significantly lower in the high-cost nursing group (9.2% vs 14.4%) compared to the low-cost nursing group. Intensive care unit readmission was not significantly different in the two groups. Mortality was lower in the high-cost nursing group for intensive care unit (9.9% vs 11.3%) and hospital (13.1% vs 14.6%) mortality. The nursing cost per intensive care bed was different in the two groups, with a median [IQR] cost of 159,387€ [140,307–166,690] for the low-cost nursing group and 214,032€ [198,094–230,058] for the high-cost group.In multivariate analysis, intensive care unit mortality (OR = 0.80, 95% CI: 0.69–0.92, p < 0.0001), in-hospital mortality (OR = 0.82, 95% CI: 0.72–0.93, p < 0.0001), and high length of stay outliers (OR = 0.48, 95% CI: 0.42–0.55, p < 0.0001) were lower in the high-cost nursing group. However, there was no significant effect on intensive care readmission between the two groups (OR = 1.24, 95% CI: 0.97–1.51, p > 0.05).ConclusionsThis study found that higher-cost nursing per bed was associated with significantly lower intensive care unit and in-hospital mortality rates, as well as fewer high length of stay outliers, but had no significant effect on readmission to the intensive care unit..     

Patient outcomes in the field of nursing: A concept analysis

PurposeThis paper reports an analysis of the concept of patient outcomes.MethodsThe Walker and Avant concept analysis approach was applied.ResultsThe attributes of patient outcomes include (1) patient functional status (maintained or improved), (2) patient safety (protected or unharmed), and (3) patient satisfaction (patient reporting of comfort and contentment). These attributes are influenced by the antecedents of individual patient characteristics and health problems, the structure of healthcare organizations and received health interventions. Additionally, patient outcomes do significantly impact the quality of nursing care, the cost of effective care and healthcare policy making formulation.ConclusionProviding good nursing care to all patients is a central goal of nursing. Patient outcomes in nursing are primarily about the results for the patient receiving nursing care. This analysis provides nurses with a new perspective by helping them to understand all the components within the concept of patient 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.     

Using linked hospitalisation data to detect nursing sensitive outcomes: A retrospective cohort study

Background

Nursing sensitive outcomes are adverse patient health outcomes that have been shown to be associated with nursing care. Researchers have developed specific algorithms to identify nursing sensitive outcomes using administrative data sources, although contention still surrounds the ability to adjust for pre-existing conditions. Existing nursing sensitive outcome detection methods could be improved by using look-back periods that incorporate relevant health information from patient's previous hospitalisations.

Design and setting

Retrospective cohort study at three tertiary metropolitan hospitals in Perth, Western Australia.

Objectives

The objective of this research was to explore the effect of using linked hospitalisation data on estimated incidence rates of eleven adverse nursing sensitive outcomes by retrospectively extending the timeframe during which relevant patient disease information may be identified. The research also explored whether patient demographics and/or the characteristics of their hospitalisations were associated with nursing sensitive outcomes.

Results

During the 5 year study period there were 356,948 hospitalisation episodes involving 189,240 patients for a total of 2,493,654 inpatient days at the three tertiary metropolitan hospitals. There was a reduction in estimated rates for all nursing sensitive outcomes when a look-back period was applied to identify relevant health information from earlier hospitalisations within the preceding 2 years. Survival analysis demonstrates that the majority of relevant patient disease information is identified within approximately 2 years of the baseline nursing sensitive outcomes hospitalisation. Compared to patients without, patients with nursing sensitive outcomes were significantly more likely to be older (70 versus 58 years), female, have Charleson comorbidities, be direct transfers from another hospital, have a longer inpatient stay and spend time in intensive care units (p ≤ 0.001).

Conclusions

The results of this research suggest that nursing sensitive outcome rates may be over-estimated using current detection methods. Linked hospitalisation data enables the use of look-back periods to identify clinically relevant diagnosis codes recorded prior to the hospitalisation in which a nursing sensitive outcome is detected. Using linked hospitalisation data to incorporate look-back periods offers an opportunity to increase the accuracy of nursing sensitive outcome detection when using administrative data sources.     

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

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