Nurse staffing, care delivery model, and patient care quality

Little research has been conducted examining the linkages between nurse staffing and care delivery models in relation to patient care quality. Nurses in this study perceive that an all-RN staffing model is associated with better quality outcomes for patients, and that staffing models that include professional and unregulated staff may pose a challenge for unit-based communication and the coordination of care. Patient care delivery models were also important predictors of the quality outcomes studied.     

Nurse staffing and patient safety

Safe, effective and ethical nurse staffing requires that there is a sufficient number and appropriate use and mix of competent nurses available to care for patients. Because of its close connections with patient safety, nurse staffing has become an important concern for governments, health-care providers and the public. This article provides highlights from the Canadian Health Services Research Foundation research report Evaluation of Patient Safety and Nurse Staffing (2005), which focused on the connections between nurse staffing and patient safety. The report findings were discussed at a roundtable of decision-makers and experts, and these deliberations and the literature evidence were used to create the final synthesis. The authors present one of the key recommendations for nurse staffing that arose from the synthesis.     

Nurse staffing and patient falls on acute care hospital units

Changes in health care financing, beginning in the 1980's, resulted in reduced nurse staffing and skill levels in acute care hospitals. Research has shown that reduced nurse staffing has endangered some aspects of patient safety. This study estimated the relationship between three aspects of nurse staffing and the patient fall rate for four types of acute care units. The association was estimated using a generalized linear mixed model with data for 2002 from 1751 hospital units in the National Database of Nursing Quality Indicators. Higher fall rates were associated with fewer nursing hours per patient day and a lower percentage of registered nurses, although the relationship varied by unit type. Smaller hospitals also had higher fall rates. Information on unit type and different aspects of nurse staffing, with advanced statistical modeling, resulted in a more precise understanding of the relationship between nurse staffing and falls.     

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.     

Nurse perceptions of the impact of nursing care on patient outcomes: an exploratory study

The aim of this research was to explore registered nurses' perceptions of the relationship between nursing care and clinical outcomes. We conducted an exploratory survey using a convenience sample of nurses attending a 3 day nursing practice conference. Nurses with postgraduate degrees and those with a clinical main work role had higher mean scores for the impact of nursing care on patient outcomes. Nurses reported that pressure ulcers and surgical wound infection were most affected by nursing care. Falls, medication errors, pain management, and patient education were some of the clinical indicators suggested as additional appropriate measures of nursing care. Our results suggest that nurses' educational background and work role may influence their perception of the impact of nursing care on patient outcomes.     

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.     

Nurse staffing levels and quality of care in Northeastern Pennsylvania nursing homes.

This study evaluated current nurse staffing levels in 90 licensed nursing homes in Northeastern Pennsylvania to determine whether they are significantly different from state and national averages. It further examined the association between nurse staffing and quality of patient care provided to nursing home residents. Findings indicate that although nurse staffing levels appear to be comparable with state and national averages, quality of care might be negatively affected when nurse staffing levels are reduced. Practical recommendations for solutions to the current nurse recruitment and retention crises are presented to ensure adequate nurse staffing and quality of care to elderly citizens.     

Nurse staffing in long-term care facilities

This qualitative study provides insight into how nurse administrators in long-term care facilities make staffing decisions and the factors they consider when making those decisions. The provides an evidenced-based framework for nurse administrators on how they can organize a comprehensive staffing program for their facility.     

Nurse staffing models as predictors of patient outcomes

BACKGROUND: Little research has been conducted that examined the intended effects of nursing care on clinical outcomes. OBJECTIVE: The objective of this study was to evaluate the impact of different nurse staffing models on the patient outcomes of functional status, pain control, and patient satisfaction with nursing care. RESEARCH DESIGN: A repeated-measures study was conducted in all 19 teaching hospitals in Ontario, Canada. SUBJECTS: The sample comprised hospitals and adult medical-surgical and obstetric inpatients within those hospitals. MEASURES: The patient's functional health outcomes were assessed with the Functional Independence Measure (FIM) and the Medical Outcome Study SF-36. Pain was assessed with the Brief Pain Inventory and patient perceptions of nursing care were measured with the nursing care quality subscale of the Patient Judgment of Hospital Quality Questionnaire. RESULTS: The proportion of regulated nursing staff on the unit was associated with better FIM scores and better social function scores at hospital discharge. In addition, a mix of staff that included RNs and unregulated workers was associated with better pain outcomes at discharge than a mix that involved RNs/RPNs and unregulated workers. Finally, patients were more satisfied with their obstetric nursing care on units where there was a higher proportion of regulated staff. CONCLUSIONS: The results of this study suggest that a higher proportion of RNs/RPNs on inpatient units in Ontario teaching hospitals is associated with better clinical outcomes at the time of hospital discharge.     

Nurse staffing, nursing intensity, staff mix, and direct nursing care costs across Massachusetts hospitals

OBJECTIVE: This study describes the distribution of patient-to-registered nurse (RN) ratios, RN intensity of care, total staff intensity of care, RN to total staff skill mix percent, and RN costs per patient day in 65 acute community hospitals and 9 academic medical centers in Massachusetts. METHODS: We conducted a retrospective secondary analysis of the Patients First database published by the Massachusetts Hospital Association for planned nurse staffing in 601 inpatient nursing units in the state for 2005 using a multivariate linear statistical model controlling for hospital type and unit type. Nursing unit types were identified as adult and pediatric medical/surgical, step down, critical care, neonatal level II, and neonatal level III/IV nurseries. RESULTS: Medical centers had significantly higher case-mix index (1.72 vs 1.20, P < .001), longer lengths of stay (5.18 vs 4.19, P < .001), more beds (574 vs 147, P < .001), discharges (31,597 vs 7,248, P < .001), and patient days (161,440 vs 31,020, P < .001) compared with to community hospitals. Medical centers had significantly lower patient-to-RN ratios (3.22 vs 4.64, P < .001), higher nursing intensity and total nursing staff intensity (9.62 vs 7.43/11.75 vs 9.87, both P < .001), higher percent of RN to all staff mix (79% vs 71%, P < .001), and higher RN costs per patient day ($385 vs $297, P < .001) compared with to community hospitals. There were significant differences in adult med/surg units between community hospitals and medical centers for patient-to-RN staffing ratios (5.25 vs 4.08), nursing intensity (5.1 vs 6.2 hours daily), skill mix (67% vs 73% RN), and RN costs per patient day ($203 vs $248, all P < .001). There were no significant differences between the adult step-down units. CONCLUSION: The significant differences between community hospitals and medical centers, unit type, as well as the high degree of variability in patient-to-RN ratios, nursing intensity, skill mix, and RN costs per patient day suggest that nursing resource expenditure at Massachusetts hospitals is complex and affected by case mix, unit size, and complexity of care.     

Nurse strategies for optimising patient participation in nursing care

The study’s rationale: Patient participation is an essential factor in nursing care and medical treatment and a legal right in many countries. Despite this, patients have experienced insufficient participation, inattention and neglect regarding their problems and may respond with dependence, passivity or taciturnity. Accordingly, nurses strategies for optimising patient participation in nursing care is an important question for the nursing profession. Aim and objective: The aim was to explore Registered Nurses’ strategies to stimulate and optimise patient participation in nursing care. The objective was to identify ward nurses’ supporting practices. Methodological design and justification: A qualitative research approach was applied. Three focus groups with experienced Registered Nurses providing inpatient somatic care (n = 16) were carried out. These nurses were recruited from three hospitals in West Sweden. The data were analysed using content analysis technique. Ethical issues and approval: The ethics of scientific work was adhered to. According to national Swedish legislation, no formal permit from an ethics committee was required. The participants gave informed consent after verbal and written information. Results: Nurse strategies for optimising patient participation in nursing care were identified as three categories: ‘Building close co‐operation’, ‘Getting to know the person’ and ‘Reinforcing self‐care capacity’ and their 10 subcategories. Conclusions: The strategies point to a process of emancipation of the patient’s potential by finding his/her own inherent knowledge, values, motivation and goals and linking these to actions. Nurses need to strive for guiding the patient towards attaining meaningful experiences, discoveries, learning and development. The strategies are important and useful to balance the asymmetry in the nurse–patient relationship in daily nursing practice and also in quality assurance to evaluate and improve patient participation and in education. However, further verification of the findings is recommended by means of replication or other studies in different clinical settings.     

Nurse staffing and patient outcomes in Veterans Affairs hospitals

OBJECTIVE: To assess characteristics and perceptions of nurses working in the Veterans Health Administration (VHA), comparing types of nursing personnel, to benchmark to prior studies across healthcare systems. BACKGROUND: Prior studies have shown relationships between positive registered nurse (RN) perceptions of the practice environment and patient outcomes. To date, no study has reported the comparison of RN perceptions of the practice environment in hospital nursing with those of non-RN nursing personnel. This study is the first to offer a more comprehensive look at perceptions of practice environment from the full range of the nursing work force and may shed light on issues such as the relationship of skill mix to nurse and patient outcomes. METHODS: Cross-sectional observational study with a mailed survey administered to all nursing personnel in 125 VA Medical Centers between February and June 2003. RESULTS: Compared with other types of nursing personnel in the VHA, RNs are generally less positive about their practice environments. However, compared with RNs in other countries and particularly with other RNs in the United States (Pennsylvania), VHA RNs are generally more positive about their practice environment and express more job satisfaction. CONCLUSIONS: The nursing work force of the VHA has some unique characteristics. The practice environment for nurses in the VHA is relatively positive, and may indicate that the VHA, as a system, provides an environment that is more like magnet hospitals. This is significant for a public sector hospital system.     

Computerization of patient acuity and nursing care planning. New approach to improved patient care and cost-effective staffing

Patient classification systems are essential for nurse administrators to justify nursing staff and to project budget. To answer these needs effectively, a computerized patient classification system must be customized to existing physical and human resources within each health care facility. Nursing administrators at Riverside Medical Center met this need by developing a computerized patient classification system that integrates patient acuity with patient care plans and nursing diagnoses. Direct cost accounting of nursing care according to patient needs and outcomes can be justified by correlating this management and practice data.