The relationship between nurse staffing and patient outcomes

OBJECTIVES: To examine the association between in-hospital mortality and four nurse staffing variables-the ratio of total nursing staff to patients, the proportion of RNs to total nursing staff, the mean years of RN experience, and the percentage of nurses with bachelor of science in nursing degrees. BACKGROUND: Studies suggest that nurse staffing changes affect patient and organizational outcomes, but the impact of nurse staffing on patient outcomes has not been studied sufficiently and the results of the previous studies are equivocal. Additionally, the studies of the relationship between nurse staffing and patient outcomes or the impact of nurse staffing on patient outcomes had not been previously examined in Thailand. METHODS: A retrospective, cross-sectional, observational research design was employed to study the research questions. Data of 2531 patients admitted to seven medical units and 10 surgical units of a 2300-bed university hospital in Thailand was used. All data of patients admitted to this hospital with four common groups of principal diagnoses (diseases of the heart, malignant neoplasms [cancer of all forms], hypertension and cerebrovascular diseases, and pneumonia and other diseases of the lung) was extracted from patient charts and discharge summaries in the calendar year 1999. Nurse staffing variables for each nursing unit in 1999 came from nursing service department databases. Multivariate logistic regression was used to determine the relationship between nurse staffing variables and in-hospital mortality. RESULTS: The findings of this study revealed that the ratio of total nurse staffing to patients was significantly related to in-hospital mortality in both partial and marginal analyses, controlling for patient characteristics. In addition, the ratio of total nursing staff to patients was found to be the best predictor of in-hospital mortality among the four nurse staffing variables, controlling for patient characteristics. The study did not find any significant relationship between in-hospital mortality and three nurse staffing variables (the proportion of RNs to total nursing staff, the mean years of RN experience, and the percentage of bachelor degree prepared nurses) probably due to the low variation of these variables across nursing units or because they may have correlated with other variables. CONCLUSIONS: The findings of this study add to our understanding of the importance of nurse staffing and its relationship to the patient outcome of hospital mortality. Further, the findings also provide information for hospital and nursing administrators to use when restructuring the clinical workforce, revising hospital policies, or making contractual decisions on behalf of nursing and public beneficiaries.     

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 and nurse outcomes: A systematic review and meta-analysis

Background

A great number of studies have been conducted to examine the relationship between nurse staffing and patient outcomes. However, none of the reviews have rigorously assessed the evidence about the effect of nurse staffing on nurse outcomes through meta-analysis.

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.     

Nurse staffing and patient outcomes in inpatient rehabilitation settings.

In rehabilitation nursing, the patient classification systems or acuity models and nurse-staffing ratios are not supported by empirical evidence. Moreover there are no studies published characterizing nursing hours per patient day, proportion of RN staff and impact of agency nurses in inpatient rehabilitation settings. The purpose of this prospective observational study was to describe rehabilitation nurse staffing patterns, to validate the impact of rehabilitation nursing on patient outcomes, and to test whether existing patient measures on severity and outcomes in rehabilitation could be used as a proxy for burden of care to predict rehabilitation nurse staffing ceilings and daily nurse staffing requirements. A total of 54 rehabilitation facilities in the United States, stratified by geography, were randomly selected to participate in the study.     

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,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.     

Patient turnover and the relationship between nurse staffing and patient outcomes

High patient turnover (patient throughput generated by admissions, discharges, and transfers) contributes to increased demands and resources for care. We examined how the relationship between registered nurse (RN) staffing and failure-to-rescue (FTR) varied with patient turnover levels by analyzing quarterly data from the University HealthSystem Consortium. The data included 42 hospitals, representing 759 nursing units and about 1 million inpatients. Higher RN staffing was associated with lower FTR. When patient turnover increased from 48.6% to 60.7% on nonintensive units (non-ICUs), the beneficial effect of non-ICU RN staffing on FTR was reduced by 11.5%. RN staffing should be adjusted according to patient turnover because turnover increases patient care demand beyond that presented by patient count, and outcomes may be adversely affected.     

Nurse staffing and patient outcomes: evolution of an international study.

Industry-wide health sector reforms in the United States, Canada, and Europe have provided a unique opportunity to examine the effects of hospital restructuring on inpatient nursing care and patient outcomes across an array of settings. Seven interdisciplinary research teams--1 each in Alberta, British Columbia, England, Germany, Ontario, Scotland, and the United States--have formed an international consortium whose aim is to study the effects of such restructuring. Each site has enrolled large numbers of hospitals and nurses to explicate the role that organization of nursing care, a target of hospital restructuring, plays in differential patient outcomes. The study seeks to understand more fully the influence of both nurse staffing and the nursing practice environment on patient outcomes. Discussion of the theoretical foundation, study design, and process of developing the study instruments and measures illustrates the process to date, as well as the feasibility of and opportunities inherent in such an international endeavour.     

Nurse staffing and patient outcomes: a longitudinal study on trend and seasonality

Background

Time trends and seasonal patterns have been observed in nurse staffing and nursing-sensitive patient outcomes in recent years. It is unknown whether these changes were associated.

Methods

Quarterly unit-level nursing data in 2004–2012 were extracted from the National Database of Nursing Quality Indicators® (NDNQI®). Units were divided into groups based on patterns of missing data. All variables were aggregated across units within these groups and analyses were conducted at the group level. Patient outcomes included rates of inpatient falls and hospital-acquired pressure ulcers. Staffing variables included total nursing hours per patient days (HPPD) and percent of nursing hours provided by registered nurses (RN skill-mix). Weighted linear mixed models were used to examine the associations between nurse staffing and patient outcomes at trend and seasonal levels.

Results

At trend level, both staffing variables were inversely associated with all outcomes (p?<?0.001); at seasonal level, total HPPD was inversely associated (higher staffing related to lower event rate) with all outcomes (p?<?0.001) while RN skill-mix was positively associated (higher staffing related to higher event rate) with fall rate (p?<?0.001) and pressure ulcer rate (p?=?0.03). It was found that total HPPD tended to be lower and RN skill-mix tended to be higher in Quarter 1 (January-March) when falls and pressure ulcers were more likely to happen.

Conclusions

By aggregating data across units we were able to detect associations between nurse staffing and patient outcomes at both trend and seasonal levels. More rigorous research is needed to study the underlying mechanism of these associations.

     

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.