Benchmarking nurse staffing levels: the development of a nationwide feedback tool

Title. Benchmarking nurse staffing levels: the development of a nationwide feedback tool. Aim. This paper is a report of a study to develop a methodology that corrects nurse staffing for nursing care intensity in a way that allows nationwide benchmarking of nurse staffing data. Background. Although nurse workload measurement systems are recognized to be informative in nurse staffing decisions, they are rarely used. When these systems are used, however, it is only possible to compare units within hospitals, because currently available instruments are not standardized for comparisons beyond hospital boundaries. The Belgian Nursing Minimum Dataset (B‐NMDS) contains uniformly measured data about the intensity of nursing care and nurse staffing levels for all hospitals in Belgium. Method. We conducted a retrospective multilevel analysis of the B‐NMDS for the year 2003. The sample included 690,258 inpatient days for 298,691 patients, recorded from 1637 acute care nursing units in 115 hospitals. We corrected the number of nursing staff by using different covariates available in the B‐NMDS: intensity of nursing care, type of day (week vs. weekend), service type (general vs. intensive) and hospital type (academic vs. general). Findings. The multilevel approach allowed us to explain about 70% of the variability in the number of nursing staff per nursing unit using hospital type (P = 0·0053); intensity of nursing care (P < 0·0001) and service type (P < 0·0001) as the only covariates. Conclusion. The feedback tool we developed can inform nurse managers and policymakers about nursing intensity‐adjusted nurse staffing levels according to different benchmarks. Our study demonstrates that investing in large nursing datasets is appropriate for the international nursing community.     

The Belgian Nursing Minimum Data Set II (B-NMDS II) and its transfer to German hospitals: results of the first investigation phase, the translation and adaption process of the instrument

The introduction of the DRG system in Germany showed again that there is a maintaining need in hospitals for a valid and reliable instrument that provides comparable data for necessary nursing care, costs, personnel requirements, and the quality of nursing care. The instrument should be suitable as well for nursing practice as for national health reports. It should provide founded statements for the different participants in the health system. The NMDS seems to be an instrument that could provide these complex data. Since 2006, a research project has been carried out to investigate the?transfer of the Belgian B-NMDS II to German hospitals. The project is divided into two phases. The first phase comprises the translation and adaptation process of the B-NMDS II. In the second phase the data collection in the hospitals and the data analysis will be performed. In this article the methodical procedure of the first investigation phase is specified. The translation and adaptation process of the B-NMDS II is executed in a multi-level procedure.     

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.     

Using the nursing minimum data set for the Netherlands (NMDSN) to illustrate differences in patient populations and variations in nursing activities

RATIONALE: A nursing minimum data set (NMDS) provides data that are useful to legitimate nurses' contribution to healthcare. In Belgium and the US, such NMDS are operational, other countries are developing it, among which is the Netherlands. OBJECTIVE: To evaluate whether the nursing minimum data set for the Netherlands (NMDSN) is suitable to describe the diversity of patient populations and the variability of nursing care. METHODOLOGY: Using the NMDSN data collection forms, patient data were collected from 15 different hospital wards. During one week, nurses manually completed the NMDSN list for every patient. The data analysis methodology from the Belgian MVG was used, including ridit analysis and graphs. RESULTS: The NMDSN includes items related to hospital, patient demographics, medical condition, nursing process, nursing phenomena, nursing interventions, outcomes of nursing care, and complexity of care. There were 686 individual patients in the study, while for the data analysis their 2090 patient days in the hospital were used. Frequencies of nursing phenomena, nursing activities and results of care were calculated, transformed into ridit scores, and presented graphically as 'fingerprints'. CONCLUSION: The set of NMDSN items allows illustrating the diversity of patient populations, and variation in nursing care by means of 'fingerprints'.     

Testing an inpatient nursing intensity billing model

There has been growing concern about the costs and intensity of inpatient nursing care, which consumes more than 40% of hospital direct costs and $165 billion each year. Allocating nursing labor as an average cost per patient and charged as room and board creates cost compression, distorts hospital payment, and hides the economic value of nurses. This article examines a method for adjusting daily room charges using nursing intensity weights assigned by the diagnosis related group. In a test using claims data from 286 hospitals in four states representing 1,856,256 patient discharges in 2002, the nursing intensity adjustment improved explained total cost variance by 8.5% for adult all payer patients (R2 = .4448 vs. .4825) and 9.4% for Medicare only patients (R2 = .4387 vs. .4798) compared to unadjusted days. This article discusses unbundling inpatient nursing care intensity and charges from room and board and recommends implementing this billing process at all U.S. hospitals.     

Exploring the nursing minimum data set for The Netherlands using multidimensional scaling techniques

RATIONALE: To fulfil the need for a systematic collection of nursing data that give insight in nursing care and its benefits and costs, a nursing minimum data set (NMDS) has been developed and validated for Dutch general hospitals. A NMDS provides data describing the diversity in patient populations and variability in nursing activities that can be analysed in various ways. AIM OF THE STUDY: To explore and compare the fundamental underlying dimensions describing patient problems and nursing interventions in Dutch general hospital wards. METHODS: Data of predominantly nominal and ordinal measurement level that were collected with the NMDS for The Netherlands on 15 Dutch hospital wards underwent two consecutive steps: first, they were transformed into metric data by means of RIDIT (relative to an identified distribution) analysis; secondly, they were analysed by means of multidimensional scaling. RESULTS: Multidimensional scaling techniques yielded a fairly good three-dimensional solution of the NMDS data. Hospital wards could be distinguished from each other on the basis of patient problems and nursing interventions most common on some wards but not on others. The core aspects underlying patient problems concerned dependency problems, life threatening problems and endogenous-exogenous problems, while discriminating nursing interventions were cure-care activities, internally-externally oriented activities and psychosocial-physical interventions. LIMITATIONS: Not all types of hospital wards were represented, which limits the representativeness of the results for Dutch general hospitals. Furthermore, the patient sample size over the 15 wards was relatively small. CONCLUSION: The constructs are consistent with NMDS findings in Belgium and findings from practice, which contributes to their content validity.     

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.     

Adjustment of inpatient care reimbursement for nursing intensity

The Centers for Medicare and Medicaid Services has begun an ambitious recalibration of the inpatient prospective payment system, the first since its introduction in 1983. Unfortunately, inpatient nursing care has been overlooked in the new payment system and continues to be treated as a fixed cost and billed at a set per-diem "room and board" fee despite the known variability of nursing intensity across different care settings and diagnoses. This article outlines the historical influences regarding costing, billing, and reimbursement of inpatient nursing care and provides contemporary evidence about the variability of nursing intensity and costs at acute care hospitals in the United States. A remedy is proposed to overcome the existing limitations of the Inpatient Prospective Payment System by creating a new nursing cost center and nursing intensity adjustment by DRG for each routine-and intensive-care day of stay to allow independent costing, billing, and reimbursement of inpatient nursing care.     

Test of the nursing minimum data set: availability of data and reliability

An initial study of the availability of the elements in the Nursing Minimum Data Set (NMDS) and intercoder reliability across four types of clinical settings is reported. These clinical settings included an acute care hospital, a nursing home, a home health care agency, and two ambulatory care clinics. The health records of 116 randomly selected subjects were reviewed to determine the availability of the NMDS elements. A randomly selected subset of 23 of these records provided data on intercoder agreement. All but four of the NMDS elements were available for 85% or more of the subjects. The average intercoder agreement across all NMDS elements was a satisfactory 91%. However, the intercoder agreement on some NMDS elements was much lower, suggesting a need to refine the definitions and procedures for collecting some of the NMDS elements. Where appropriate, coefficient Kappa and Pearson product moment correlation statistics for reliability are reported on individual NMDS elements.     

Pain assessment and intensity in hospitalized children in Canada

Numerous acute pediatric pain assessment measures exist; however, pain assessment is not consistently performed in hospitalized children. The objective of this study was to determine the nature and frequency of acute pain assessment in Canadian pediatric hospitals and factors influencing it. Pain assessment practices and pain intensity scores documented during a 24-hour period were collected from 3,822 children aged 0 to 18 years hospitalized on 32 inpatient units in 8 Canadian pediatric hospitals. Pain assessment was documented at least once within the 24 hours for 2,615/3,822 (68.4%) children; 1,097 (28.7%) with a pain measure alone, 1,006 (26.3%) using pain narratives alone, and 512 (13.4%) with both a measure and narrative. Twenty-eight percent of assessments were conducted with validated measures. The mean standardized pain intensity score was 2.6/10 (SD 2.8); however, 33% of the children had either moderate (4–6/10) or severe (7–10/10) pain intensity recorded. Children who were older, ventilated, or hospitalized in surgical units were more likely to have a pain assessment score documented. Considerable variability in the nature and frequency of documented pain assessment in Canadian pediatric hospitals was found. These inconsistent practices and significant pain intensity in one-third of children warrant further research and practice change.PerspectiveThis article presents current pediatric pain assessment practices and data on pain intensity in children in Canadian pediatric hospitals. These results highlight the variability in pain assessment practices and the prevalence of significant pain in hospitalized children, highlighting the need to effectively manage pain in this population.     

Acute kidney injury in the intensive care unit according to RIFLE

OBJECTIVES: To apply the RIFLE criteria "risk," "injury," and "failure" for severity of acute kidney injury to patients admitted to the intensive care unit and to evaluate the significance of other prognostic factors. DESIGN: Retrospective analysis of the Riyadh Intensive Care Program database. SETTING: Riyadh Intensive Care Unit Program database of 41,972 patients admitted to 22 intensive care units in the United Kingdom and Germany between 1989 and 1999. PATIENTS: Acute kidney injury as defined by the RIFLE classification occurred in 15,019 (35.8%) patients; 7,207 (17.2%) patients were at risk, 4,613 (11%) had injury, and 3,199 (7.6%) had failure. It was found that 797 (2.3%) patients had end-stage dialysis-dependent renal failure when admitted to an intensive care unit. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS:: Patients with risk, injury, and failure classifications had hospital mortality rates of 20.9%, 45.6%, and 56.8%, respectively, compared with 8.4% among patients without acute kidney injury. Independent risk factors for hospital mortality were age (odds ratio 1.02); Acute Physiology and Chronic Health Evaluation II score on admission to intensive care unit (odds ratio 1.10); presence of preexisting end-stage disease (odds ratio 1.17); mechanical ventilation (odds ratio 1.52); RIFLE categories risk (odds ratio 1.40), injury (odds ratio 1.96), and failure (odds ratio 1.59); maximum number of failed organs (odds ratio 2.13); admission after emergency surgery (odds ratio 3.08); and nonsurgical admission (odds ratio 3.92). Renal replacement therapy for acute kidney injury was not an independent risk factor for hospital mortality. CONCLUSIONS: The RIFLE classification was suitable for the definition of acute kidney injury in intensive care units. There was an association between acute kidney injury and hospital outcome, but associated organ failure, nonsurgical admission, and admission after emergency surgery had a greater impact on prognosis than severity of acute kidney injury.     

Development and validation of scales to measure organisational features of acute hospital wards

In order to make comparisons between wards and explain variations in outcomes of nursing care, there is a growing need in nursing research for reliable and valid measures of the organisational features of acute hospital wards. This research developed The Ward Organisational Features Scales (WOFS); each set of six scales comprising 14 subscales which measure discrete dimensions of acute hospital wards. A study of a nationally representative sample of 825 nurses working in 119 acute wards in 17 hospitals, drawn from seven Regional Health Authorities in England provides evidence for the structure, reliability and validity of this comprehensive set of measures related to: the physical environment of the ward, professional nursing practice, ward leadership, professional working relationships, nurses' influence and job satisfaction. Implications for further research are discussed.     

Do DRG reimbursement rates reflect nursing costs?

The assumption underlying diagnosis related group (DRG) reimbursement is that the prospective, diagnosis-determined rates reflect actual costs incurred during a hospital stay. The nursing component represents a significant percentage of the costs associated with a patient's hospital stay. However, a study of actual nursing labor costs for 240 acute care patients in five DRG categories showed that some DRGs vary in daily nursing labor costs up to 500% over the course of a patient's stay. For some DRGs, the patient's DRG classification is not an adequate measure for determining, assigning, or allocating nursing costs within the institution. Hospitals that do not track actual nursing costs risk unanticipated cost overruns for some diagnoses that may have a significant effect on hospital finances.     

Interhospital transfer of critically ill patients: demographic and outcomes comparison with nontransferred intensive care unit patients

PURPOSE: We examined the association between access to intensive care services and mortality in a cohort of critically ill patients. MATERIALS AND METHODS: We conducted an observational study involving 6298 consecutive admissions to the intensive care units (ICUs) of a tertiary care hospital. Data including demographics, admission source, and outcomes were collected on all patients. Admission source was classified as "transfer" for patients admitted to the ICU from other hospitals, "ER" for patients admitted from the emergency room, and "ward" for patients admitted from non-ICU inpatient wards. RESULTS: Transfer patients had higher crude ICU and hospital mortality rates compared with emergency room admissions (crude odds ratio [OR], 1.51; 95% confidence interval [CI], 1.32-1.75). After adjusting for age, sex, diagnosis, comorbidities, and acute physiology scores, the difference in ICU mortality remained significant (OR, 1.30; 95% CI, 1.09-1.56); however, hospital mortality did not (OR, 1.19; 95% CI, 1.00-1.41). Compared with ward patients, transfer from other hospitals was associated with lower hospital mortality after adjusting for severity of illness and other case-mix variables (OR, 0.81; 95% CI, 0.68-0.95). CONCLUSIONS: We found some evidence to suggest that differential access to intensive care services impacts mortality within this case mix of patients. These findings may have implications for current efforts to centralize and regionalize critical care services.     

Discharge destination after dysvascular lower-limb amputations

OBJECTIVE: To examine postacute care rehabilitation services use after dysvascular amputation. DESIGN: State-maintained hospital discharge data from the Maryland Health Services Cost Review Commission were analyzed. SETTING: Maryland statewide hospital discharge database. PARTICIPANTS: Persons discharged from nonfederal acute care hospitals from 1986 to 1997 with a procedure code for lower-limb amputation (ICD-9-CM code 84.12-.19), excluding toe amputations. Those persons with amputations due to trauma, bone malignancy, or congenital anomalies were excluded. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Postacute care service utilization. RESULTS: There were 16,759 discharges with an amputation procedure over this period. The average age was 69.3+/-14.3 years, and 51.9% were men. Black persons comprised 42.4% of the sample. Diabetes was present in 42.0%, and peripheral vascular disease was noted for 66.1% of amputees. Amputations were at the foot (19.4%), transtibial (38.1%), and transfemoral (42.4%) levels. The largest proportion (40.6%) of patients was discharged directly home after acute care, 37.4% went to a nursing home, 9.2% went home with home care, and 9.6% were discharged to an inpatient rehabilitation unit. From 1986 to 1997, there were downward trends in the rate of discharges directly home and corresponding upward trends in nursing home and inpatient rehabilitation dispositions. CONCLUSIONS: Inpatient rehabilitation use is infrequent after dysvascular amputation. Prospective studies are necessary to examine outcomes for persons receiving rehabilitation services in different care settings to define the optimal rehabilitation venue for functional restoration.     

State of the science: outcomes of acute inpatient psychiatric care

Identifying client outcomes related to nursing care is critical to establish empirical evidence that supports the effectiveness of psychiatric nursing. The purpose of this article is to conduct a methodological review of the literature that examines client outcomes after treatment in acute care inpatient psychiatric hospitals and psychiatric units of general hospitals. The databases Medline, CINAHL, HealthSTAR/Ovid HealthSTAR and psycINFO were searched for articles published between 1991and 2004. A review of literature was conducted of studies related to client outcomes after inpatient psychiatric treatment. Forty-seven studies were reviewed. There is a dearth of literature related to client outcomes after inpatient psychiatric treatment. The existing literature has conceptual and methodological limitations. The organization of psychiatric nursing care, in relation to outcomes is nonexistent in the literature. Outcomes that are sensitive to nursing care must be conceptualized theoretically and then examined empirically. The Quality Health Outcomes model is proposed to conceptualize outcomes of acute inpatient psychiatric treatment that are sensitive to nursing interventions and the organization of nursing care.