Staffing in acute hospital wards: part 2. Relationships between grade mix,staff stability and features of ward organizational environment

This paper explores relationships between grade mix, staff stability, care organization and nursing practice. The data were collected in the mid-1990s from a nationally representative sample of 100 acute hospital wards and 825 nurses. Analyses provides important insights for managers seeking to achieve the strategic aims set out in consecutive National Health Service (NHS) human resource management policies. Hypotheses about ward clinical grade mix were not well supported. Where there was rich grade mix, nurses reported better collaborative working with other disciplines and greater influence. However, it was expected that wards practising 'devolved' nursing would have a richer grade mix and that the latter would lead to more innovative practice and nurses experiencing greater job satisfaction. No evidence to support any of these hypotheses was found although the opposite scenario - a link between poor grade mix, unprogressive practice and perceived lower standards of care - was supported. Wards practising the 'devolved' system rely on adequate numbers of nurses rather than a rich grade mix, and do not necessarily provide a more stable, retentive work environment for nurses. By contrast, findings about staff stability were largely as expected. A strong link between staff stability and standards of professional nursing practice was found, indicating that staff stability is more important than a rich grade mix for achieving innovative, research-based practice. However, staff instability undermined cohesion with nurse colleagues, collaborative working with doctors, and nurses' ability to cope with the workload. Overall, both the papers demonstrate that staffing resources and prevailing ethos of care are more important predictors of care processes and job satisfaction than organizational systems. They identify the detrimental effects on nurses and their work of having few staff and a weak grade mix, and the importance of staff stability. Higher standards of nursing practice are achieved where stability is high, independently of staffing characteristics.     

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.     

Nurse experience and education: effect on quality of care

OBJECTIVE: To describe the relationships between the quality of patient care and the education and experience of the nurses providing that care. BACKGROUND: There is a call for more nurses with baccalaureate degrees and more experienced nurses to work in hospitals. Previous research studies have examined the characteristics, abilities, and work assignments of nurses with and without baccalaureate degrees but have not examined the quality of the patient care delivered. It is generally believed that more experienced nurses provide higher-quality care, but again few studies have actually examined this issue. METHODS: A secondary analysis of data, collected in two previous studies of the relationship between nurse staffing (hours of care, staff mix) and the quality of patient care, was used to determine the relationship between nurses' education and experience and the quality of care provided. The data were collected at the patient care unit level (42 units in study 1 and 39 units in study 2). Quality of care was indicated by lower unit rates of medication errors and patient falls. RESULTS: Controlling for patient acuity, hours of nursing care, and staff mix, units with more experienced nurses had lower medication errors and lower patient fall rates. These adverse occurrence rates on units with more baccalaureate-prepared nurses were not significantly better.     

Work related predictors for "satisfaction with dementia care" among nurses working in nursing homes

In German nursing homes dementia care is gaining increasing relevance. Dementia care is known to bear the high risk of a substantial occupational burden among nursing staff. Within this context, the "nurses' satisfaction with the care for residents with dementia" is investigated. Secondary data of the German 3q-study is used to assess degrees of nurses' satisfaction with the care for residents with dementia and potential work related predictors. Data from 813 nurses and nursing aides working in 53 nursing homes were included. 42% of all nursing staff was dissatisfied with the care for residents with dementia in their institution, however, pronounced differences were found between the institutions. Registered nurses and nurses in leading positions were more dissatisfied. A multiple regression analysis indicates that high "quantitative demands", low "leadership quality" and "social interaction with other professions" are strong predictors for nurses' satisfaction with the care for residents with dementia. No association was found for "emotional demands" and "possibilities for development". The results indicate that the "nurses" satisfaction with the care for residents with dementia" may be a highly relevant work factor for nursing staff in nursing homes which deserves additional attention in practice and research. The high predictive power of several work organisational factors implies that preventive action should also include work organisational factors.     

Staffing adequacy, supervisory support and quality of care in long-term care settings: staff perceptions

Title. Staffing adequacy, supervisory support and quality of care in long‐term care settings: staff perceptions Aim. This paper is a report of a study to explore relationships between perceived care quality, self‐assessed professional skills, and the perceptions of the quality‐related factors. Background. The work in long‐term care is more demanding than in the past. The quality of care is strongly related to the well‐being and job satisfaction of staff. Those emerge in part through a perception of resources allocated to caring and also through a perception of the quality achieved. Method. Data were collected in Finland in 2002 using a questionnaire sent to the nursing staff working in 112 wards in 40 long‐term care institutions monitoring their care with the Resident Assessment Instrument System. Institutions were invited to participate the survey. The response rate was 70·2% (n = 1262). The respondents represented 3·8% of nursing personnel working in long‐term care institutions. Findings. Staff members who perceived staffing levels as inadequate and supervisory support as insufficient had lower perceptions of their own professional skills and the quality of care. Perceptions of empowering support behaviour were more strongly associated to self‐assessed skills and to perceived care quality than perceptions of skills‐oriented support activities. Staff members with short professional training, older staff members and staff members with long work experience in the unit had lower perceptions of their professional skills than other groups. Conclusion. The perception of adequate staffing and of sufficient supervisory support, especially empowering support increases the probability of perceiving the care quality as good. If supervisors concern themselves with staff members’ perceptions, they can better identify the staffing needs and also the support needs of personnel.     

An exploration of nursing home organizational processes

The purpose of this study is to explore the relationship between nursing home staffs' perceptions of organizational processes (communication, teamwork, and leadership) with characteristics (turnover, tenure, and educational preparation) of the nursing home administrator (NHA) and director of nursing (DON). NHAs and DONs rate communication, teamwork, and leadership significantly higher than direct care staff do (registered nurses, licensed practical nurses, certified nurse aides [CNAs]). CNAs have the lowest ratings of communication and teamwork. Turnover of the NHA and DON is significantly and negatively associated with communication and teamwork. Two thirds of DONs surveyed hold less than a baccalaureate degree; this does not influence staffs' ratings of communication, teamwork, and leadership. Findings from this study highlight the need to explore differences in perceptions between administrative and direct care staff and how these may or may not influence staff development and quality improvement activities in nursing homes.     

Are nursing homes adequately staffed? The silent epidemic of malnutrition and dehydration in nursing home residents. Until mandatory staffing standards are created and enforced, residents are at risk

Providing care to produce positive resident outcomes is an ethical duty of nursing home staff. Research has shown that inadequate staffing levels present an increased health risk to nursing home residents. Nursing home residents may experience dehydration and malnutrition caused by inadequate staffing. Continued research in the area of nutrition and dehydration in nursing home residents may positively influence changes in staffing levels at nursing homes. Currently, residents living in understaffed nursing homes and not receiving proper care are the victims. It is time for nurses to forcefully lobby for national mandatory nurse staffing standards.     

Acuity and staffing under prospective payment

Nursing administrators are debating the desirable mix of professional (RN) and paraprofessional (LPN) nursing staff under the prospective payment system (DRGs). The staffing mix reflects the cost and quality of nursing care provided by an acute care hospital. Based on a reliable and valid acuity/care plan system, standards of care and nursing diagnoses, several DRGs were analyzed on an eight-bed medical/surgical intensive care unit with regard to intensity of care and staffing mix. This study showed nursing administrators that the staffing mix on an intensive care unit varies according to the acuity/care plan rather than DRGs or nursing diagnoses.     

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.     

Teamwork,clinical leadership skills and environmental factors that influence missed nursing care – A qualitative study on hospital wards

AimTo explore how nursing teams in clinical inpatient nursing hospital wards perform teamwork to prevent or reduce missed nursing care and how teamwork is influenced by clinical leadership skills and environmental factors.BackgroundEarlier studies on missed nursing care identified teamwork and leadership skills as promising factors in inpatient care that can positively influence quality of care and reduce missed nursing care. The effective use of teamwork in hospitals requires understanding what it is, how it is performed by nursing teams and how it is influenced by clinical leadership skills and environmental factors.DesignA qualitative exploratory study was undertaken between January and March 2021.MethodsA total of 16 registered nurses who worked on various hospital wards, participated in three online focus groups. Data were analyzed with thematic analysis according to Braun and Clarke.ResultsThematic analysis revealed four themes. First, nurses perform teamwork and clinical leadership skills in various ways. Some nurses work in pairs and have common goals, while other nurses work individually. This influences teamwork. Second, nurses are informal teachers, visible in teaching and learning from each other, contributing in constructive teamwork. Third, senior nurses are seen as informal leaders, forming connection between nursing wards and formal leaders, resulting in awareness of each other and the progress of patientcare. Finally, environmental factors influence the performance of teamwork.ConclusionsResults of this study show how knowledge regarding missed nursing care can be increased. Results can be used for developing training programs and embedding education in practice aimed at constructive teamwork, clinical leadership skills and missed nursing care.     

关于医院对在职护士开设《人际交流》课程的构思

目的 为了提高医院在职护士人际交流的能力,更好地为病人服务。 方法 对医院在职护士有计划地进行《人际交流》课程的设置,将《人际交流》课程改为十章节,总学时数为40学时。结果 通过系统、有目标地对护士进行人际交流知识的追加、补充教育,提高了护士在护理工作中运用人际交流的技巧。结论 护士通过学习掌握了人际交流知识与技巧,充分地运用于临床护理工作中,并与病人进行交流、沟通,获得较好的效果,也大大减少了临床工作医疗护理纠纷的发生。     

Implementation and Evaluation of LVN LEAD. A leadership and supervisory training program for nursing home charge nurses

Licensed practical/vocational nurses (LVNs) play an important role in U.S. nursing homes, with primary responsibility for supervising unlicensed nursing home staff. Research has shown that the relationship between charge nurses and certified nursing assistants (CNAs) has a significant impact on CNA job satisfaction and turnover as well as quality of care, yet nurses rarely receive supervisory training. The purpose of this project was to develop, pilot, and evaluate a leadership/supervisory training program for LVNs. Upon completion of the training program, many LVNs expressed and demonstrated a new understanding of their supervisory leadership and supervisory responsibilities. Directors of staff development are a potential vehicle for supporting LVNs' development as supervisors.     

A strategy for improving nurse retention and recruitment levels

A nursing shortage in one trust prompted a full investigation into the retention and recruitment of nurses. Workload, staffing levels, skill mix and working conditions were all problem areas for staff. The project highlighted the need to support the development of strong nurse leadership within each of the trust's directorates and to create more educational opportunities for staff.     

The relationship between nursing leadership and nurses' job satisfaction in Canadian oncology work environments

Background  Current Canadian oncology work environments are challenged by the same workforce statistics as other nursing specialties: nurses are among the most overworked, stressed and sick workers, and more than 8% of the nursing workforce is absent each week due to illness.
Aim  To develop and estimate a theoretical model of work environment factors affecting oncology nurses' job satisfaction.
Methods  The sample consisted of 515 registered nurses working in oncology settings across Canada. The theoretical model was tested as a structural equation model using LISREL 8.54.
Results  The final model fitted the data acceptably ( χ ² = 58.0, d.f. = 44, P  =   0.08). Relational leadership and physician/nurse relationships significantly influenced opportunities for staff development, RN staffing adequacy, nurse autonomy, participation in policy decisions, support for innovative ideas and supervisor support in managing conflict, which in turn increased nurses' job satisfaction.
Conclusions  These findings suggest that relational leadership and positive relationships among nurses, managers and physicians play an important role in quality oncology nursing environments and nurses' job satisfaction.
Implications for nursing management  Oncology nursing work environments can be improved by focusing on modifiable factors such as leadership, staff development and staffing resources, leading to better job satisfaction and hopefully retention of nurses.     

基层医院在职护士继续教育对护士护理技能的影响

目的 探讨基层医院在职护士继续教育对护士护理技能的影响.方法 选取2018年4月至2018年6月我院的210名在职护士作为对照组,选取2019年7月至2019年9月我院的340名在职护士作为观察组.对照组未参与继续教育,观察组参与规范化在职护士继续教育.比较两组在职护士的护理质量评分;分析在职护士继续教育效果与护士专业...     

A staff development programme to support the incorporation of the McGill model of nursing into an out-patient clinic department

In order to adopt a nursing model as a framework for professional practice in an out-patient department of a paediatric tertiary care hospital, a staff development programme was instituted The nursing model chosen was the McGill model of nursing, which emphasizes the complementary role of nursing and focuses on people's health, strengths and potentials Staff development initially consisted of a journal club and clinic nurses were exposed to such concepts as family, coping, and health As the nurses acquired theoretical knowledge, the staff development programme was concerned with applying this knowledge to clinical situations As well as the nursing in-service training, clinical supervision with small groups of nurses was instituted A study showed that staff development helped nurses to build a larger repetoire of family nursing skills The nursing role in the department evolved Nurses developed a more professional practice and provided health services which were complementary to those offered by other health professionals     

Do organizational factors explain the quality of care?

This study investigated the perceptions of patients, nurses, physicians, and managers of the quality of care. While they all evaluated the quality of care to be good, the evaluations of patients and staff were different from each other's. Organizational factors such as values and work explained the quality of care evaluated by nursing staff and physicians compared to work and leadership by managers. No obvious relationship between quality and leadership could be found.     

各国护理人力资源配置政策比较研究的范围综述

目的 对国内外护理人力资源配置政策进行范围审查,为优化国内护理人力资源配置提供参考。 方法 系统检索各国政府网站、法令政策网站、国际组织网站,以及PubMed、Web of Science、中国知网、万方数据库中的相关研究。检索时限为建库至2021年9月。 结果 共纳入8个国家/地区的15篇政策文献。在配置参考指标上,中国与英国北爱尔兰均采用床护比,其他国家/地区采用护患比。在护理人员结构上主要包括注册护士和非注册护士两类,不同国家/地区的护理人员结构比例不同。3个国家/地区规定了急诊科护理人力资源配置,国内急诊科的配置按照床护比制订了通用标准,美国加州和澳大利亚维多利亚参考护患比,并根据工作区域或班次进一步细化了急诊科护理人力资源配置。5个国家/地区规定了重症监护室护理人力资源配置,配置参考依据不同,其中国内重症监护室的护患比最高。 结论 需进一步健全国内护理人力资源配置政策,丰富护理人员结构并充分发挥应用价值,继续完善急危重症科室的配置方案,推进护理人力资源配置政策的落实。