Licensed nurse staffing and adverse events in hospitals

OBJECTIVE: To examine the changes in licensed nursing staff in Pennsylvania hospitals from 1991 to 1997, and to assess the relationship of licensed nursing staff with patient adverse events in hospitals. DATA SOURCE: A convenience sample of all Pennsylvania, acute-care, hospitals, 1991 to 1997. STUDY DESIGN: The study first describes the percentage change of licensed nursing staff categories in Pennsylvania hospitals from 1991 to 1997. Second, random effects Poisson regressions are used to assess the association of the numbers and proportions of licensed nurses with yearly iatrogenic lung collapse, pressure sores, falls, pneumonia, posttreatment infections, and urinary tract infections. Controls are the yearly number of patients, hospital acuity, and other hospital characteristics. DATA COLLECTION: Secondary data containing patient- and hospital-level measures from three sources were recoded to establish the incidence of adverse events, aggregated to the hospital level, and merged to form one data set. PRINCIPAL FUNDING: Licensed nurses' acuity-adjusted patient load increased from 1991 to 1997. Licensed nurse/total nursing staff declined from 1994 to 1997. Greater incidence of nearly all adverse events occurred in hospitals with fewer licensed nurses. Greater incidence of decubitus ulcers and pneumonia occurred in hospitals with a lower proportion of licensed nurses. CONCLUSIONS: This study suggests that licensed nurses' patient load began increasing in the 1990s. Adequate licensed nurse staffing is important in minimizing the incidence of adverse events in hospitals. Ensuring adequate licensed nurse staffing should be an area of major concern to hospital management. Improved measures of nurse staffing and patient outcomes, and further studies are suggested.     

Nurse qualifications and perceptions of patient safety and quality of care in South Africa

A plethora of research links professional nurses' qualifications to patient outcomes. Also, research has shown that reports by nurses on the quality of care correspond with process or outcome measures of quality in a hospital. New to the debate is whether professional nurses' qualifications impact on their perceptions of patient safety and quality of care. This research aims to investigate professional nurses' perceptions of patient safety and quality of care in South Africa, and the relationship between these perceptions and professional nurses' qualifications. A cross‐sectional survey of 1117 professional nurses from medical and surgical units of 55 private and 7 public hospitals was conducted. Significant problems with regard to nurse‐perceived patient safety and quality of care were identified, while adverse incidents in patients and professional nurses were underreported. Qualifications had no correlation with perceptions of patient safety and quality of care, although perceptions may serve as a valid indicator of patient outcomes. Creating an organizational culture that is committed to patient safety and encourages the sharing of adverse incidents will contribute to patient safety and quality of care in hospitals.     

Nurse-patient ratios: a systematic review on the effects of nurse staffing on patient, nurse employee, and hospital outcomes

OBJECTIVE: To determine whether the peer-reviewed literature supports specific, minimum nurse-patient ratios for acute care hospitals and whether nurse staffing is associated with patient, nurse employee, or hospital outcomes. BACKGROUND: Hospital care may be compromised by forces that have increased patient acuity, reduced the ratio of caregivers to patients, and lowered the level of training of these caregivers. METHODS: We systematically reviewed studies of the effects of nurse staffing on patient, nurse employee, and hospital outcomes published between 1980 and 2003 to determine whether they could guide the setting of minimum licensed nurse-patient ratios in acute care hospitals. RESULTS: Of 2897 titles and abstracts of interest, 490 articles were retrieved, and 43 met the inclusion criteria. Although all adjusted for case mix and skill mix, only one recent study addressed minimum nurse staffing ratios. Patient outcomes were limited to in-hospital, adverse events. Evidence suggests that richer nurse staffing is associated with lower failure-to-rescue rates, lower inpatient mortality rates, and shorter hospital stays. CONCLUSION: The literature offers no support for specific, minimum nurse-patient ratios for acute care hospitals, especially in the absence of adjustments for skill and patient mix, although total nursing hours and skill mix do appear to affect some important patient outcomes.     

Effect of nurse staffing on patient outcomes: a review of the literature

Staff shortages present nurses with ever increasing levels of stress and working hours. This has resulted in a corresponding increase in talent flight away from the nursing profession. Responding to financial constraints imposed by the Bureau of National Health Insurance (NHI), Taiwan hospitals have reduced nursing staff numbers and recruited nurses at lower levels of competencies and experience. However, few studies have explored the impact of nurse staffing on patient outcomes in Taiwan. Accordingly, we review relevant literature on nurse classifications, the current status of Taiwan nursing manpower, Taiwan and other national regulations on nursing staffing, and the impact of nursing staffing on patient outcomes in an effort to facilitate future study. Our literature review demonstrated that insufficient nursing staffing relates significantly to rates of nosocomial infections, patient mortality, patient falls, pressure ulcers, and rates of patient and family satisfaction. Insufficient nurse staffing leads to increases in adverse patient events, prolonged average hospital stay lengths, and total healthcare expenditures. Evidence shows that nurse staffing is closely linked to patient outcomes.     

Charge nurse leadership development and evaluation

OBJECTIVE: To describe the development and evaluation of a permanent charge nurse role and report outcomes of this leadership model over 4 years. BACKGROUND: A permanent charge nurse role was developed to improve continuity of care and develop emerging nurse leaders. An evaluation model was constructed to measure program outcomes. Kouzes and Posner's Leadership Model served as the theoretical framework. METHODS: The permanent charge nurse role was developed, training planned, and the evaluation framework established. Measurements included two survey instruments, an investigator-developed End-of-Shift Report, and institutional patient satisfaction data. Survey instruments included Kouzes and Posner's Leadership Practice Inventory (LPI), concurrently measuring self (charge) and other (staff) perceptions of charge leadership. The McClosky Mueller Satisfaction Scale (MMSS) measured charge and staff nurse job satisfaction. Data were collected at baseline, post-implementation, and additional time periods. RESULTS: Charge RNs reported significantly more favorable perceptions of leadership abilities than staff. The Shift Report successfully tracked both system and charge management issues. Patient satisfaction data did not yield data due to vendor changes. Job satisfaction results showed charge nurses reported higher satisfaction with schedule, praise and recognition, control and responsibility, than staff nurses. CONCLUSIONS: Using data to evaluate charge nurse leadership guides continued program improvements.     

The multiple dimensions of staff nurse role conception

Role expectations among staff nurses in hospitals have been linked to turnover and attrition from the profession and may be associated with phenomena such as absenteeism and burnout. A study was conducted in eight Midwestern hospitals to obtain an empirically based model of staff nurse role conception. Seven major components of the construct were identified, which included 12 different dimensions. Data from the study provided helpful information for nurse administrators in understanding the dynamics of the hospital work environment for staff nurses. Potential sources of role conflict are discussed.     

Nursing staff numbers and their relationship to conflict and containment rates on psychiatric wards-a cross sectional time series poisson regression study

BackgroundThe link between positive outcomes and qualified nurse staffing levels is well established for general hospitals. Evidence on staffing levels and outcomes for mental health nursing is more sparse, contradictory and complicated by the day to day allocation of staff resources to wards with more seriously ill patients.ObjectiveTo assess whether rises in staffing numbers precede or follow levels of adverse incidents on the wards of psychiatric hospitals.DesignTime series analysis of the relationship between shift to shift changes over a six month period in total conflict incidents (aggression, self-harm, absconding, drug/alcohol use, medication refusal), total containment incidents (pro re nata medication, special observation, manual restraint, show of force, time out, seclusion, coerced intramuscular medication) and nurse staffing levels.Settings32 acute psychiatric wards in England.MethodsAt the end of every shift, nurses on the participating wards completed a checklist reporting the numbers of conflict and containment incidents, and the numbers of nursing staff on duty.ResultsRegular qualified nurse staffing levels in the preceding shifts were positively associated with raised conflict and containment levels. Conflict and containment levels in preceding shifts were not associated with nurse staffing levels.ConclusionsResults support the interpretation that raised qualified nurse staffing levels lead to small increases in risks of adverse incidents, whereas adverse incidents do not lead to consequent increases in staff. These results may be explicable in terms of the power held and exerted by psychiatric nurses in relation to patients.     

Development of the hospital nurse surveillance capacity profile

Better patient outcomes are often achieved through effective surveillance, a primary function of nurses. The purpose of this article is to define, operationalize, measure, and evaluate the nurse surveillance capacity of hospitals. Nurse surveillance capacity is defined as the organizational features that enhance or weaken nurse surveillance. It includes a set of registered nurse (staffing, education, expertise, experience) and nurse practice environment characteristics. Empirical referents were extracted from existing survey data from 9,232 nurses in 174 hospitals. Using a ranking methodology, a Hospital Nurse Surveillance Capacity Profile was created for each hospital. Greater nurse surveillance capacity was significantly associated with better quality of care and fewer adverse events. The profile may assist administrators to improve nurse surveillance and patient outcomes. © 2009 Wiley Periodicals, Inc. Res Nurs Health 32:217–228, 2009     

Quality assurance requirements for contract/agency nurses

According to the American Hospital Association, over half of its member hospitals used contract/agency nurses to fill vacant positions in 2000. It is imperative that companies that provide nurses be able to furnish, to employing hospitals, documentation that demonstrates each nurse's ability to practice safely and legally. The article specifies the areas where documentation is needed along with discussion of each area. The nurse executive needs to be aware of these issues to ensure that the facility in which he or she works is getting the appropriate information regarding supplemental staff in order to protect against licensure and litigation repercussions.     

Workplace violence against nurses,job satisfaction,burnout, and patient safety in Chinese hospitals

BackgroundMost nurses have experienced some form of workplace violence, which could lead to physical or psychological harm and reduced job performance. Previous studies have examined the effects of workplace violence on nurses' job satisfaction and patient safety, but there have been very few examinations of whether workplace violence affects patient safety through nurse job satisfaction and burnout.PurposeTo investigate the relationships among workplace violence, nurse outcomes and patient safety. To explore whether nurse burnout and job satisfaction play mediating roles in the association of workplace violence and patient safety.MethodsA cross-sectional survey was conducted in 23 hospitals in Guangdong province in China to collect data from 1502 nurses. A structural equation model design was tested with validated measurement instruments.FindingsNurse-reported workplace violence was found to be associated directly with higher incidences of burnout, less job satisfaction, lower patient safety and more adverse events. Nurse burnout was associated directly with lower patient safety and more adverse events. Higher nurse job satisfaction was associated directly with higher patient safety. Nurse burnout and job satisfaction played mediating roles in workplace violence and patient safety. The model explained 19.8% and 35.0% of nurse-reported patient safety and adverse events, respectively.DiscussionIt is important for administrators to consider how to protect nurses from workplace violence, to improve their wellbeing at work, and to deliver safe patient care. When nurses experience workplace violence, it is necessary to pay attention to their emotional reactions and job attitudes, and to provide them with support in order to avoid adverse impacts on patient safety. Further practices and research initiatives to support nurses' safety at work are recommended.     

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.     

The effects of nurse staffing on adverse events,morbidity, mortality,and medical costs

BACKGROUND: Nurse staffing levels are an important working condition issue for nurses and believed to be a determinant of the quality of nursing care and patient outcomes. OBJECTIVES: To examine the effects of nurse staffing on adverse events, morbidity, mortality, and medical costs. METHODS: Using two existing databases, the study sample included 232 acute care California hospitals and 124,204 patients in 20 surgical diagnosis-related groups. The adverse events included patient fall/injury, pressure ulcer, adverse drug event, pneumonia, urinary tract infection, wound infection, and sepsis. Multilevel analysis was employed to examine, simultaneously, the effects of nurse staffing and patient and hospital characteristics on patient outcomes. RESULTS: Three statistically significant relationships were found between nurse staffing and adverse events. An increase of 1 hour worked by registered nurses (RN) per patient day was associated with an 8.9% decrease in the odds of pneumonia. Similarly, a 10% increase in RN Proportion was associated with a 9.5% decrease in the odds of pneumonia. Providing a greater number of nursing hours per patient day was associated with a higher probability of pressure ulcers. The occurrence of each adverse event was associated with a significantly prolonged length of stay and increased medical costs. Patients who had pneumonia, wound infection or sepsis had a greater probability of death during hospitalization. CONCLUSION: Patients are experiencing adverse events during hospitalization. Care systems to reduce adverse events and their consequences are needed. Having appropriate nurse staffing is a significant consideration in some cases.     

Nurse Staffing Levels and Adverse Events Following Surgery in U.S. Hospitals

Purpose: To examine the relationship between nurse staffing and selected adverse events hypothesized to be sensitive to nursing care, while controlling for related hospital characteristics. Efforts in the United States to reduce hospital costs, resulting in strategies to use fewer nurses, have stimulated extensive debate but little evaluation.
Design: Survey using data from a 20% stratified probability sample to approximate U.S. community hospitals. The sample included 589 acute-care hospitals in 10 states.
Methods: Discharge data from 1993 for patients aged 18 years and over were used to create hospital-level adverse event indicators. These hospital-level data were matched to American Hospital Association data on community hospital characteristics, including nurse staffing, to examine the relationship between nurse staffing and adverse events.
Results: A large and significant inverse relationship was found between full-time-equivalent RNs per adjusted inpatient day (RNAPD) and urinary tract infections after major surgery (p<.0001) as well as pneumonia after major surgery (p<.001). A significant but less robust inverse relationship was found between RNAPD and thrombosis after major surgery (p<.01), as well as pulmonary compromise after major surgery (p<.05).
Conclusions: Inverse relationships between nurse staffing and these adverse events provide information for managers to use when redesigning and restructuring the clinical workforce employed in providing inpatient care.     

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.     

Impact of nursing overtime on nurse-sensitive patient outcomes in New York hospitals, 1995-2000

During the past several years, nurses and their advocates have expressed concern about heavy use of overtime in hospitals and claimed that it undermines the quality of nursing care. Using staffing and discharge data covering 1995 to 2000 from 161 acute general hospitals in New York State, this study uses multi variate regression to analyze the relationship between overtime and the rates of six nurse-sensitive patient outcomes and mortality. We find an association of overtime with lower rates of mortality in medical and surgical patients but do not consider these findings definitive. Because overtime use is episodic and unit specific, further study of these issues using data that examines the occurrence of adverse events by unit during periods of heavy nurse overtime is recommended.     

Situation,Background, Assessment,Recommendation: Competency Assessment for Agency Nurses in Radiology

Agency (daily registry) nurses play a crucial role in health care. Agencies provide supplemental staffing for health-care organizations on an as-needed basis. Health-care organizations are required to apply the same standards for competency assessment for agency nurses as they would for their own staff. Radiology is a highly specialized area that demands a high level of competency for all staff nurses, permanent or temporary. This article outlines the process one organization used to assess and develop competency assessment of agency nurses in radiology.