Implications of the California Nurse Staffing Mandate for Other States

Objectives. To determine whether nurse staffing in California hospitals, where state‐mandated minimum nurse‐to‐patient ratios are in effect, differs from two states without legislation and whether those differences are associated with nurse and patient outcomes. Data Sources. Primary survey data from 22,336 hospital staff nurses in California, Pennsylvania, and New Jersey in 2006 and state hospital discharge databases. Study Design. Nurse workloads are compared across the three states and we examine how nurse and patient outcomes, including patient mortality and failure‐to‐rescue, are affected by the differences in nurse workloads across the hospitals in these states. Principal Findings. California hospital nurses cared for one less patient on average than nurses in the other states and two fewer patients on medical and surgical units. Lower ratios are associated with significantly lower mortality. When nurses' workloads were in line with California‐mandated ratios in all three states, nurses' burnout and job dissatisfaction were lower, and nurses reported consistently better quality of care. Conclusions. Hospital nurse staffing ratios mandated in California are associated with lower mortality and nurse outcomes predictive of better nurse retention in California and in other states where they occur.     

Nurse Migration: A Canadian Case Study

Objective. To synthesize information about nurse migration in and out of Canada and analyze its role as a policy lever to address the Canadian nursing shortage.
Principal Findings. Canada is both a source and a destination country for international nurse migration with an estimated net loss of nurses. The United States is the major beneficiary of Canadian nurse emigration resulting from the reduction of full-time jobs for nurses in Canada due to health system reforms. Canada faces a significant projected shortage of nurses that is too large to be ameliorated by ethical international nurse recruitment and immigration.
Conclusions. The current and projected shortage of nurses in Canada is a product of health care cost containment policies that failed to take into account long-term consequences for nurse workforce adequacy. An aging nurse workforce, exacerbated by layoffs of younger nurses with less seniority, and increasing demand for nurses contribute to a projection of nurse shortage that is too great to be solved ethically through international nurse recruitment. National policies to increase domestic nurse production and retention are recommended in addition to international collaboration among developed countries to move toward greater national nurse workforce self sufficiency.     

Concurrent and Lagged Effects of Registered Nurse Turnover and Staffing on Unit‐Acquired Pressure Ulcers

Objective

We examined the concurrent and lagged effects of registered nurse (RN) turnover on unit-acquired pressure ulcer rates and whether RN staffing mediated the effects.

Data Sources/Setting

Quarterly unit-level data were obtained from the National Database of Nursing Quality Indicators for 2008 to 2010. A total of 10,935 unit-quarter observations (2,294 units, 465 hospitals) were analyzed.

Methods

This longitudinal study used multilevel regressions and tested time-lagged effects of study variables on outcomes.

Findings

The lagged effect of RN turnover on unit-acquired pressure ulcers was significant, while there was no concurrent effect. For every 10 percentage-point increase in RN turnover in a quarter, the odds of a patient having a pressure ulcer increased by 4 percent in the next quarter. Higher RN turnover in a quarter was associated with lower RN staffing in the current and subsequent quarters. Higher RN staffing was associated with lower pressure ulcer rates, but it did not mediate the relationship between turnover and pressure ulcers.

Conclusions

We suggest that RN turnover is an important factor that affects pressure ulcer rates and RN staffing needed for high-quality patient care. Given the high RN turnover rates, hospital and nursing administrators should prepare for its negative effect on patient outcomes.     

Nurse Staffing Levels and Medicaid Reimbursement Rates in Nursing Facilities

Objective. To examine the relationship between nursing staffing levels in U.S. nursing homes and state Medicaid reimbursement rates.
Data Sources. Facility staffing, characteristics, and case-mix data were from the federal On-Line Survey Certification and Reporting (OSCAR) system and other data were from public sources.
Study Design. Ordinary least squares and two-stage least squares regression analyses were used to separately examine the relationship between registered nurse (RN) and total nursing hours in all U.S. nursing homes in 2002, with two endogenous variables: Medicaid reimbursement rates and resident case mix.
Principal Findings. RN hours and total nursing hours were endogenous with Medicaid reimbursement rates and resident case mix. As expected, Medicaid nursing home reimbursement rates were positively related to both RN and total nursing hours. Resident case mix was a positive predictor of RN hours and a negative predictor of total nursing hours. Higher state minimum RN staffing standards was a positive predictor of RN and total nursing hours while for-profit facilities and the percent of Medicaid residents were negative predictors.
Conclusions. To increase staffing levels, average Medicaid reimbursement rates would need to be substantially increased while higher state minimum RN staffing standards is a stronger positive predictor of RN and total nursing hours.     

Lower Mortality for Abdominal Aortic Aneurysm Repair in High‐Volume Hospitals Is Contingent upon Nurse Staffing

Objective

To determine whether and to what extent the lower mortality rates for patients undergoing abdominal aortic aneurysm (AAA) repair in high-volume hospitals is explained by better nursing.

Data Sources

State hospital discharge data, Multi-State Nursing Care and Patient Safety Survey, and hospital characteristics from the AHA Annual Survey.

Study Design

Cross-sectional analysis of linked patient outcomes for individuals undergoing AAA repair in four states.

Data Collection

Secondary data sources.

Principal Findings

Favorable nursing practice environments and higher hospital volumes of AAA repair are associated with lower mortality and fewer failures-to-rescue in main-effects models. Furthermore, nurse staffing interacts with volume such that there is no mortality advantage observed in high-volume hospitals with poor nurse staffing. When hospitals have good nurse staffing, patients in low-volume hospitals are 3.4 times as likely to die and 2.6 times as likely to die from complications as patients in high-volume hospitals (p < .001).

Conclusions

Nursing is part of the explanation for lower mortality after AAA repair in high-volume hospitals. Importantly, lower mortality is not found in high-volume hospitals if nurse staffing is poor.     

Nursing Home Compare Star Rating and Daily Direct-Care Nurse Staffing During Hurricane Irma

ObjectivesNursing homes (NHs) are affected by major hurricanes and other natural disasters. To mitigate adverse effects of a major hurricane, NHs often increase their direct-care nurse staffing levels to meet the needs of their residents. However, the quality rating of the NH may affect the resources available to obtain and retain staff. This data brief provides estimates of direct-care nurse staffing levels by quality star rating during Hurricane Irma.DesignRetrospective cohort study from September 3, 2017, to September 10, 2017.Setting and Participants570 Florida NHs that sheltered in place during Hurricane Irma.MethodsWe stratified NHs by their NH Compare overall quality star rating and then measured change in direct-care nurse staffing levels for registered nurses, licensed practical nurses, and certified nursing assistants.ResultsWe found that the NH Compare overall star rating was positively associated with a greater staffing level response during Hurricane Irma among registered nurses, licensed practical nurses, and certified nursing assistants. This change was largest for 5-star facilities and smallest for 1-star facilities.Conclusions and ImplicationsHigher-quality NHs may be more responsive and have the resources to be more responsive, to increased needs during a natural disaster. Our findings may serve as a platform for ongoing discussion on the role of the federal, state, and local governments in ensuring minimum staffing standards during natural disasters.     

Associations Between Daily Nurse Staffing Levels and Daily Hospitalizations and ED Visits in Nursing Homes

ObjectivesAlthough many prior studies have shown that high average levels of nurse staffing in nursing homes are associated with fewer hospitalizations, some studies have not, suggesting that the average nursing level may mask a more complex relationship. This study examines this issue by investigating the associations of daily staffing patterns and daily hospitalizations and emergency department (ED) visits.DesignRetrospective analyses of national Payroll Based Journal (PBJ) staffing data merged with the Minimum Data Set.Setting and ParticipantsA total of 15,718 nursing homes nationally reporting PBJ data during 2017–2019, their staff, and residents.MethodsWe estimated facility-day-level models as conditional facility fixed-effect Poisson regressions with robust standard errors. The dependent variables were daily numbers of hospitalization and ED visits and the independent variables of interest were the number of registered nurse (RN), licensed practical nurse (LPN), and certified nurse assistant (CNA) hours on the same and prior days.ResultsThe daily number of hospital transfers averaged 0.28 (SD 0.21). Daily total direct-care staffing hours averaged 288.7 (SD 188.2), with RNs accounting for 35.0, LPNs for 68.7, and CNAs for 185.0. Higher staffing was associated with more hospitalizations on the concurrent day. Higher staffing on the day prior was associated with fewer hospitalizations. The effect size was larger for RNs and LPNs (same day = ～2%; prior day = approximately ?0.7% to ?0.9%) than for CNAs (same day <1%; prior day < ?0.5%). ED visits not leading to hospitalizations, and analyses for subsamples exhibited similar findings.Conclusions and ImplicationsOur findings suggest that staff can address developing problems and prevent admissions the next day and identify emergent problems and hospitalize the same day. They also underscore the complex array of nursing home factors involved in hospitalization and ED visits, including the influence of daily staffing variation, suggesting the need for further research to better understand the associations between staffing and appropriate resident transfers to the hospital or the ED, and the potential implications for quality metrics in these domains.     

Safe nurse staffing policies for hospitals in England,Ireland, California,Victoria and Queensland: A discussion paper

ObjectiveThe association between higher registered nurses (RN) staffing (educational level and number) and better patient and nurse outcomes is well-documented. This discussion paper aims to provide an overview of safe staffing policies in various high-income countries to identify reform trends in response to recurring nurse workforce challenges.MethodsBased on a scan of the literature five cases were selected: England (UK), Ireland, California (USA), Victoria and Queensland (Australia). Information was gathered via a review of the grey and peer-reviewed literature. Country experts were consulted for additional information and to review country reports.ResultsThe focus of safe staffing policies varies: increasing transparency about staffing decisions (England), matching actual and required staffing levels based on patient acuity measurement (Ireland), mandated patient-to-nurse ratios at the level of the nurse (California) or the ward (Victoria, Queensland). Calibration of the number of patients by the number of nurses varies across cases. Nevertheless, positive effects on the nursing workforce (increased bedside staffing) and staff well-being (increased job satisfaction) have been consistently documented. The impact on patient outcomes is promising but less well evidenced.ConclusionCountries will have to set safe staffing policies to tackle challenges such as the ageing population and workforce shortages. Various approaches may prove effective, but need to be accompanied by a comprehensive policy that enhances bedside nurse staffing in an evidence-based, objective and transparent way.     

A Review of Staffing in Childcare Centres in Six Countries

A review of the international literature on staffing in childcare centres in five English language countries and Denmark reveals both remarkable similarities and interesting differences in the childcare workforce. The paper compares characteristics of the workforce; their training and professional membership. It also compares conditions of work in each country, including salaries, staff benefits, and features of the working environment such as job satisfaction and staff turnover. Findings indicate that childcare workers tend to be young and female; that a relatively high proportion of untrained staff work in childcare centres; that, except in Denmark, the level of extrinsic benefits is startlingly low. Workers are paid relatively little compared to the average pay for women in their countries but the workforce does not benefit from enhanced conditions of work to compensate for low pay. However, the level of intrinsic satisfaction with the work is high. Caring for children is a satisfying form of employment, even if it offers a limited career structure.     

美国医院员工的工作效率:JCAHO的新标准与护理人力资源

介绍了美国健康保健组织鉴定委员会(JCAHO)于2002年7月1日提出的一项新标准：这项标准是被用来帮助医疗机构配置适宜比例的医务人员，以进一步提高员工的工作效率，提供更为良好的医疗服务：探讨了JCAHO关于缓解美国医院护理人力资源短缺的建议。认为：根据各项研究的结果和美国权威机构的报告，改善员工工作实效不但有助于提高医疗行为的安全性、改善临床治疗效果，同时还有助于留住员工，节省医院大量的人力、财力和物力。     

Effects of Nurse Staffing on Resident Outcomes in Nursing Homes: A Systematic Review

ObjectivesTo evaluate the evidence on effects of nurse staffing in nursing homes on resident outcomes.DesignSystematic review.Setting and ParticipantsStudies evaluating the effects of nurse staffing levels, total staffing, or skill mix on pressure ulcers, nursing home associated infections, and pain outcomes for adult residents in US nursing homes.MethodsWe searched MEDLINE, Embase, CINAHL, and the Cochrane Database for English-language articles published between January 2000 and May 2021. We also searched for gray literature and sought expert referrals. Two reviewers participated in determination of eligibility, assessment of methodological quality, and abstraction of data. Abstracted data included study design; setting and population characteristics; and resident outcomes. We rated overall certainty of evidence (very low, low, moderate, and high) for each outcome using GRADE.ResultsOf 9152 unique citations, 378 articles underwent full-text review. We identified 22 eligible studies that addressed pressure ulcers (k = 15), COVID-19 cases and/or mortality (k = 4), other infections (k = 8), and moderate-severe pain among residents (k = 7); some examined multiple outcomes. Most studies (k = 17) were rated moderate or high quality. All studies were observational. Overall, registered nurse (RN) staffing was probably associated with fewer pressure ulcers (moderate certainty) and possibly fewer COVID-19 infections/mortality (low certainty), other infections (low certainty) and lower rates of moderate-severe pain (low certainty). Higher skill mix was probably associated with fewer pressure ulcers, higher resident COVID-19 infections, fewer other infections, and lower rates of moderate-severe pain (low certainty for all outcomes).Conclusions and ImplicationsHigher RN staffing and skill mix may be associated with better nursing home resident outcomes, while results were mixed for total staffing. Increasing RN staffing levels and skill mix are one of a variety of approaches to improve nursing home care.     

护士组织承诺的研究进展

本文综述护士组织承诺的研究进展,介绍了组织承诺的概念和发展阶段、有关护士组织承诺的前因变量和后果变量,并就护理管理者提高护士的组织承诺提出建议.     

对公立医院“取消编制”政策构建的辩证思考

通过分析公立医院编制人事管理的现况,对取消编制涉及的不同职能医院、区域卫生规划、医院的公益本质属性、医疗人才的培养、配套的养老政策和财政投入作深入思考,认识到受多方面因素影响,在编制改革前期公立医院和政府还需要完善内、外部条件才能推进编制改革顺利进行。     

Nurse Value-Added and Patient Outcomes in Acute Care

ObjectiveThe aims of the study were to (1) estimate the relative nurse effectiveness, or individual nurse value-added (NVA), to patients’ clinical condition change during hospitalization; (2) examine nurse characteristics contributing to NVA; and (3) estimate the contribution of value-added nursing care to patient outcomes.ConclusionsNurses differ in their value-added to patient outcomes. The ability to measure individual nurse relative value-added opens the possibility for development of performance metrics, performance-based rankings, and merit-based salary schemes to improve patient outcomes and reduce costs.     

宁夏各级医院人力资源编制现状研究

1978年颁布的医院人力资源编制标准中医院床位数量是根据医疗服务需求设置的,而且工作量多少与床位数量有直接的关系。但随着医学科学技术的不断发展,医疗服务需求发生重大变化,目前的人力资源编制标准已经远远不能适应现代医院发展的需要,而且出现种种弊端。研究通过调查宁夏各级医院人力资源编制和资源配置现状,分析现有编制标准中存在的问题,为医院人力资源编制标准的改革提供理论依据。