Post-operative mortality,missed care and nurse staffing in nine countries: A cross-sectional study

BackgroundVariation in post-operative mortality rates has been associated with differences in registered nurse staffing levels. When nurse staffing levels are lower there is also a higher incidence of necessary but missed nursing care. Missed nursing care may be a significant predictor of patient mortality following surgery.AimExamine if missed nursing care mediates the observed association between nurse staffing levels and mortality.MethodData from the RN4CAST study (2009–2011) combined routinely collected data on 422,730 surgical patients from 300 general acute hospitals in 9 countries, with survey data from 26,516 registered nurses, to examine associations between nurses’ staffing, missed care and 30-day in-patient mortality. Staffing and missed care measures were derived from the nurse survey. A generalized estimation approach was used to examine the relationship between first staffing, and then missed care, on mortality. Bayesian methods were used to test for mediation.ResultsNurse staffing and missed nursing care were significantly associated with 30-day case-mix adjusted mortality. An increase in a nurse’s workload by one patient and a 10% increase in the percent of missed nursing care were associated with a 7% (OR 1.068, 95% CI 1.031–1.106) and 16% (OR 1.159 95% CI 1.039–1.294) increase in the odds of a patient dying within 30 days of admission respectively. Mediation analysis shows an association between nurse staffing and missed care and a subsequent association between missed care and mortality.ConclusionMissed nursing care, which is highly related to nurse staffing, is associated with increased odds of patients dying in hospital following common surgical procedures. The analyses support the hypothesis that missed nursing care mediates the relationship between registered nurse staffing and risk of patient mortality. Measuring missed care may provide an ‘early warning’ indicator of higher risk for poor patient outcomes.     

How do nurses manage their work under time pressure? Occurrence of implicit rationing of nursing care in the intensive care unit: A qualitative study

ObjectivesThe aim of this study was to explore the experience of intensive care unit nurses under time pressure and the occurrence of implicit rationing under time pressure.MethodsIn-depth audio-recorded interviews were conducted with 18 intensive care unit nurses. Colaizzi seven-step analysis of phenomenological data was used.FindingsThree themes emerged from the analysis: the influence of internal and external environments, perceived differences in time pressure, and broad coping styles.ConclusionsUnder the influence of various factors, including continuous or intermittent time pressure, nurses employ strategies to deal with the pressure. Sometimes, these strategies allow them to complete all their necessary work. However, with the increase in time pressure, sometimes some work that must be done is changed into work that should be done in the consciousness of nurses. In such cases, nurses choose the strategy of implicit rationing to deal with time pressure.     

‘Failure to Maintain’: A theoretical proposition for a new quality indicator of nurse care rationing for complex older people in hospital

Complex older patients represent about half of all acute public hospital admissions in Australia. People with dementia are a classic example of complex older patients, and have been identified to have higher rates of hospital-acquired complications. Complications contribute to poorer patient outcomes, and increase length of stay and cost to hospitals. The care for older people with dementia is complex, and this has been attributed to: their cognitive response to being hospitalised; their limited ability to self-care; and lack of nursing engagement with the family caregiver. Registered nurses can offer simultaneous assessment and intervention to prevent or mitigate hospital-acquired complications. However, it is known that when demand for nursing care exceeds supply, care is prioritised according to acute medical need. Consequently some basic but essential nursing care activities such as patient mobility, communication, skin care, hydration and nutrition are implicitly rationed.This paper offers a theoretical proposition of ‘Failure to Maintain’ as a conceptual framework to indicate implicit care rationing by nurses. Care rationing contributes to functional and cognitive decline of complex older patients, which then contributes to higher rates of hospital acquired complications. Four key hospital acquired complications: pressure injuries, pneumonia, urinary tract infections and delirium are proposed as measurable indicators of ‘Failure to Maintain’.Hospital focus on throughput constrains nurses to privilege predictable, solvable and medically-related procedures and processes that will lead to efficient discharge over patient mobility, communication, skin care, hydration and nutrition. This privileging, also known as implicit rationing, is theoretically and physiologically associated with a rise in the incidence of complications such as pressure injuries, pneumonia, urinary tract infection, and delirium. Complex older patients, including those with dementia, are at higher risk of the complications, therefore should have higher delivery of prophylactic intervention (ie have higher care needs). ‘Failure to Maintain’ offers a conceptual framework that is inclusive of, and sensitive to, this vulnerable population.Implicit rationing is occurring and it likely contributes to functional and cognitive decline in complex older patients and hospital-acquired complications. However, the lack of patient functional ability data at admission and discharge for hospitalised patients, and lack of usable ward and hospital level nurse staffing and workload data makes it difficult to monitor, understand and improve quality of care. Current research in the fields of acute geriatrics and nursing work environments show promise through enabling multidisciplinary team communication, and facilitating clinical autonomy to provide patient focussed care, and avoid ‘Failing to Maintain’.The research field of acute geriatrics can understand and act on the risk modification role of nurses, including controlling for nurse staffing and work environment variables in intervention studies. The research field of nurse sensitive outcomes should incorporate the different profile of complex older patients, by including age brackets and functional ability as variables in their studies. Clinically, nursing work environments can be designed to recognise the different profile of complex older patients by adapting practices to privilege mobility, hydration, nutrition, skin care and communication in the midst of acute care interventions.     

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.     

The characteristics and factors associated with omitted nursing care in the intensive care unit: A cross-sectional study

IntroductionPrior research showed that work environment features in acute care settings influence nurses’ capacity to provide care and impacts patient outcomes (e.g., falls). However, little is known about this phenomenon in the intensive care unit. The objectives of this study were to describe the characteristics of omitted nursing care, and to examine the associations between work environment features, omitted nursing care and nurse-reported outcomes in the intensive care unit.MethodsAn electronic cross-sectional correlational study was conducted in the province of Quebec, Canada. Over September 2021, nurses were asked to complete the Healthy Work Environment Assessment Tool (HWEAT), the Intensive Care Unit Omitted Nursing Care instrument (ICU-ONC) and to report their perceptions of nurse-reported outcomes (e.g., quality of care). The associations between these variables were estimated using multivariable cluster-robust regression models, adjusted for nurse and hospital characteristics.ResultsA total of 493 nurses from 42 distinct hospitals participated to this study. On average, nurses felt that their work environment was acceptable, and that the quality and safety of patient care was good. Basic care activities (e.g., mobilisation) were most frequently reported as omitted as opposed to those related to surveillance and medical interventions. In multivariable analyses, higher work environment scores were associated with reduced omitted nursing care scores (p < 0.001) and better ratings for nurse-reported outcomes (p < 0.001). Also, higher omitted nursing care scores were associated with more negative perceptions about the quality and safety of care (p < 0.001).ConclusionOur study portrays the characteristics and some factors associated with omitted nursing care in the intensive care unit. Further research should determine whether intensive care nurses’ reports of organisational features and omitted nursing care are associated with objectively captured patient outcomes.     

Missed nursing care in the critical care unit,before and during the COVID-19 pandemic: A comparative cross-sectional study

ObjectivesTo describe and evaluate reported missed nursing care in the critical care context during different phases of the COVID-19 pandemic in Sweden.Research methodologyA comparative cross-sectional design was used, comparing missed nursing care in three samples: before the COVID-19 pandemic in 2019, during the second wave of the pandemic in spring 2020, and during the third wave of the pandemic in fall 2021.SettingThe study was conducted at critical care units at a university hospital, Sweden.Main outcome measuresThe MISSCARE Survey-Swedish version was used to collect data along with two study-specific questions concerning perception of patient safety and quality of care.ResultsSignificantly more overtime hours and number of days absent due to illness were reported during the pandemic. The nurse/patient ratio was above the recommended level at all data collection time points. Most missed nursing care was reported in items concerning basic care. The most reported reasons for missed nursing care in all samples concerned inadequate staffing, urgent situations, and a rise in patient volume. Most nurses in all samples perceived the level of patient safety and quality of care as good, and the majority had no intention to leave their current position.ConclusionThe pandemic had a great impact on the critical care workforce but few elements of missed nursing care were affected. To measure and use missed nursing care as a quality indicator could be valuable for nursing managers, to inform them and improve their ability to meet changes in patient needs with different workforce approaches in critical care settings.     

The association between nurse staffing and omissions in nursing care: A systematic review

Aims

To identify nursing care most frequently missed in acute adult inpatient wards and to determine evidence for the association of missed care with nurse staffing.

Background

Research has established associations between nurse staffing levels and adverse patient outcomes including in‐hospital mortality. However, the causal nature of this relationship is uncertain and omissions of nursing care (referred as missed care, care left undone or rationed care) have been proposed as a factor which may provide a more direct indicator of nurse staffing adequacy.

Design

Systematic review.

Data Sources

We searched the Cochrane Library, CINAHL, Embase and Medline for quantitative studies of associations between staffing and missed care. We searched key journals, personal libraries and reference lists of articles.

Review Methods

Two reviewers independently selected studies. Quality appraisal was based on the National Institute for Health and Care Excellence quality appraisal checklist for studies reporting correlations and associations. Data were abstracted on study design, missed care prevalence and measures of association. Synthesis was narrative.

Results

Eighteen studies gave subjective reports of missed care. Seventy‐five per cent or more nurses reported omitting some care. Fourteen studies found low nurse staffing levels were significantly associated with higher reports of missed care. There was little evidence that adding support workers to the team reduced missed care.

Conclusions

Low Registered Nurse staffing is associated with reports of missed nursing care in hospitals. Missed care is a promising indicator of nurse staffing adequacy. The extent to which the relationships observed represent actual failures, is yet to be investigated.     

Association between nurse staffing levels and rotavirus infection in neonatal intensive care units: A retrospective observational study

ObjectivesTo explore the relationship between nurse staffing levels and rotavirus infection in neonatal intensive care units.Research MethodologyThis study adopted a retrospective observational design with data from the Health Insurance Review and Assessment Service (2018) database in South Korea. Participants were 35,308 infants in neonatal intensive care units. Multiple logistic regression analyses were employed to examine the association between nurse staffing levels and rotavirus infection in neonatal intensive care units after adjusting for confounding variables such as patient and hospital-related characteristics.ResultsA total of 1,514 (4.3%) infants developed rotavirus infection. Among the confounding variables, infectious disease, and being admitted from January to March and in December significantly increased the risk of rotavirus infection, whereas low birth weight, cardiovascular disorders, neonatal jaundice, receiving breastmilk, central line insertion, and ventilator usage significantly decreased the risk. Neonatal intensive care units with a grade 5 nurse staffing level (compared with grades 1–4) had a higher risk of rotavirus infection.ConclusionsThe results suggest that neonatal intensive care units with higher (vs lower) nurse staffing levels are associated with lower rotavirus infection rates among infants. High-risk infants are extremely susceptible to hospital-acquired infections, and more intensive nursing care that differs from that provided to adult or paediatric patients is required. Therefore, nurse staffing levels with less than a 2:1 patient-to-nurse ratio are needed to control and prevent rotavirus infection in neonatal intensive care units.     

The impact of general practice nursing care on patient satisfaction and enablement in Australia: A mixed methods study

BackgroundThe numbers of nurses in general practice in Australia tripled between 2004 and 2012. However, evidence on whether nursing care in general practice improves patient outcomes is scarce. Although patient satisfaction and enablement have been examined extensively as outcomes of general practitioner care, there is little research into these outcomes from nursing care in general practice. The aim of this study was to examine the relationships between specific general practice characteristics and nurse consultation characteristics, and patient satisfaction and enablementMethodsA mixed methods study examined a cross-section of patients from 21 general practices in the Australian Capital Territory. The Patient Enablement and Satisfaction Survey was distributed to 1665 patients who received nursing care between September 2013 and March 2014. Grounded theory methods were used to analyse interviews with staff and patients from these same practices. An integrated analysis of data from both components was conducted using multilevel mixed effect models.ResultsData from 678 completed patient surveys (response rate = 42%) and 48 interviews with 16 nurses, 23 patients and 9 practice managers were analysed. Patients who had longer nurse consultations were more satisfied (OR = 2.50, 95% CI: 1.43–4.35) and more enabled (OR = 2.55, 95% CI: 1.45–4.50) than those who had shorter consultations. Patients who had continuity of care with the same general practice nurse were more satisfied (OR = 2.31, 95% CI: 1.33–4.00) than those who consulted with a nurse they had never met before. Patients who attended practices where nurses worked with broad scopes of practice and high levels of autonomy were more satisfied (OR = 1.76, 95% CI: 1.09–2.82) and more enabled (OR = 2.56, 95% CI: 1.40–4.68) than patients who attended practices where nurses worked with narrow scopes of practice and low levels of autonomy. Patients who received nursing care for the management of chronic conditions (OR = 2.64, 95% CI: 1.32–5.30) were more enabled than those receiving preventive health care.ConclusionsThis study provides the first evidence of the importance of continuity of general practice nurse care, adequate time in general practice nurse consultations, and broad scopes of nursing practice and autonomy for patient satisfaction and enablement. The findings of this study provide evidence of the true value of enhanced nursing roles in general practice. They demonstrate that when the vision for improved coordination and multidisciplinary primary health care, including expanded roles of nurses, is implemented, high quality patient outcomes can be achieved.     

Relationship between nurse staffing level and adult nursing-sensitive outcomes in tertiary hospitals of Korea: Retrospective observational study

BackgroundNurse staffing level is an important factor on nursing sensitive outcome. The relationships of nurse staffing level with nursing sensitive outcomes such as mortality, upper gastrointestinal bleeding and pressure ulcer have been explored in the United States, Canada, Australia, and New Zealand. Lower level of hospital nurse staffing seems associated with more adverse outcomes, especially mortality. However, there is insufficient evidence of the nurse staffing level-outcome relationship in other indicators.ObjectivesThis study was conducted to describe the status and prove the relationships of nurse staffing level with nursing sensitive outcome indicators for adult medical and surgical inpatients in Korea. Patient and hospital characteristics as covariates on nurse sensitive outcome were also explored.DesignThis was a retrospective observational study.SettingThe study setting was all 46 tertiary hospitals in Korea.ParticipantsWe selected all anonymized patients aged 19 years or older and admitted at tertiary hospitals for two years (2013–2014) using electronic reimbursement claims data.MethodMultiple logistic regression was used to examine relationships of nurse staffing level (accounted for full-time registered nurses in general ward only) with Nursing-sensitive outcomes (NSOs) adjusted for patient and hospital characteristics. NSOs included urinary tract infection, upper gastrointestinal tract bleeding, deep vein thrombosis, hospital-acquired pneumonia, pressure ulcer, sepsis, shock/cardiac arrest, CNS complication, in-hospital death, wound infection, physiologic/metabolic derangement and pulmonary failure.ResultsThe total number of patients in 46 tertiary hospitals in Korea for two years was 3,665,307. Among these, number of patients who had at least one nursing-sensitive outcome was 338,369 (9.23%). The significant relationships of nurse staffing level with six nursing-sensitive outcome rates (urinary tract infection, upper gastrointestinal tract bleeding, hospital-acquired pneumonia, shock/cardiac arrest, in-hospital death, and wound infection) were shown. These six nursing-sensitive outcomes showed an increasing trend as nurse staffing level degraded even after adjusting for patient and hospital characteristics. When the nursing-sensitive outcomes between those of group 1 (bed-to-nurse ratio < 2:1) and group 3 (between 2.5:1 and 3:1) were compared, the adjusted incidence rate of shock/cardiac arrest showed the highest difference (1.06%).ConclusionWe demonstrated strong evidence for the relationships of nurse staffing level with six nursing-sensitive outcomes. We can use this study to improve nursing quality and to inform patients of the nursing quality of hospitals so they can choose hospitals with better nursing quality. The nurse staffing level should be optimized for better outcomes.     

Missed nursing care in Australia: Exploring the contributing factors

BackgroundNurses are increasingly ending their shifts with outstanding tasks and missing vital aspects of patient care. Research has indicated that this could have a detrimental effect on both nurse and patient outcomes. The connection between inadequate staffing levels and missed nursing care is well documented in the research. However, other contributing factors leading to missed nursing care remain uncertain. This scoping review seeks to identify the contributing factors to missed nursing care in an Australian context.AimTo determine the contributing factors to missed nursing care by registered nurses in Australian hospitals.MethodsMEDLINE, CINAHL, and PubMed were searched for primary and secondary research articles. A scoping review was conducted using the Joanna Briggs Institute methodology for scoping reviews. Data from the studies was analysed by two independent reviewers and presented with a narrative synthesis of the findings.FindingsSeventeen studies were conducted in Australia. The main contributing factors to missed nursing care were: Inadequate staffing, environmental factors, and urgent situations. Nurses’ poor insight into personal and professional accountability was also found to contribute to missed nursing care.DiscussionThis review adds an important perspective to the impact of staffing on missed nursing care due to the mandated nurse-to-patient ratios in Australia, which has not been investigated in other countries. It found that mandated nurse-to-patient ratios can lead to a reduction in missed nursing care.ConclusionFurther research is required into mandated nurse-to-patient ratios and a nurse's personal and professional accountability and missed nursing care.     

Understanding the complexity of working under time pressure in oncology nursing: A grounded theory study

BackgroundThe international nursing shortage has implications for the quality and safety of patient care. Various studies report that nurses do not have time to complete all necessary nursing care tasks, potentially resulting in nurse-perceived time pressure. Providing good care in the current nursing environment often poses a real ethical challenge for nurses. How nurses experience caring for cancer patients under time pressure and how they deal with the limited time available in achieving an ethical nursing practice remains unclear.ObjectivesTo report qualitative research grounded in oncology nurses’ experiences with time pressure, its perceived impact on nursing care and the ways in which they deal with it.DesignA qualitative study design with a grounded theory approach was conducted to explore and explain oncology nurses’ experiences with time pressure and its underlying dynamics.Setting and participantsPurposive and theoretical sampling led to the inclusion of 14 nurses with diverse characteristics from five inpatient oncology nursing wards in one academic hospital.MethodsIndividual, semi-structured, in-depth interviews were conducted over a six-month period in 2015 and 2016. Data collection and analysis occurred simultaneously. The interview data was analysed using the Qualitative Analysis Guide of Leuven and NVivo software.ResultsThe conceptualised phenomenon of time pressure, grounded in empirical data, illuminated its complexity and helped us to explicate and describe what nurses felt when working under time pressure. The interviewed nurses described time pressure as a shared yet nuanced reality. We uncovered that nurses dealt with time pressure in varied ways, with a broad range of proactive and ‘ad hoc’ strategies. According to our interviewees, time pressure was a significant barrier in providing good nursing care. They illustrated how time pressure particularly affected the interactional aspects of care, which most nurses considered as essential in an oncology setting. Underlying personal, cultural and context-related factors seemed to play a key role in nurses’ individual experiences with time pressure.ConclusionTime pressure is a widely recognised and experienced phenomenon among nurses which has substantial negative implications for the quality and safety of patient care. Our findings reinforce the need to establish better support for nurses and to reduce the circumstances in which nurses are ethically challenged to provide good care due to time pressure. Based on our findings, we recommend investing more in the nursing culture and nurses’ personal development, in addition to optimising nurse staffing levels.     

The experience of new nurses’ early working life: Learning in a hospital care context – An interview study

AimTo explore how nurses during their early working life learn to provide high-quality care in relation to organisational prerequisites in a hospital setting.BackgroundWhen nurses enter employment in contemporary hospital settings, they face multiple learning challenges. Organisational prerequisites that have been identified to affect their ability to learn to provide high-quality care are related to staffing turnovers, large patient groups and a lack of experienced staff to support their learning.DesignQualitative.MethodsThe study was conducted between 2018 and 2019 at a medium-sized hospital in Sweden. Data from interviews with 10 nurses with fewer than two years’ work experience were subjected to qualitative content analysis.ResultsThe results describe the nurses’ learning during their early working life in two categories: Performing tasks in relation to organisational prerequisites and Making use of clinical experiences to grasp the complexity of nursing care. The first theme reflected a learning process that was initially characterised by seeking confirmation and instructions from colleagues of how to act safely and by balancing the demands of time efficiency and sustaining patient safety. The second theme reflected that, after addressing organisational prerequisites, the nurses tried to understand and make use of clinical experiences to grasp the complexity of nursing care by encountering and processing clinical patient situations.ConclusionsThe results of this study revealed that nurses’ learning during early working life seemed to be primarily directed towards handling tasks, with sometimes limited opportunities to grasp the complexity of nursing care. Their learning depended largely on their own initiative and motivation and was strongly influenced by organisational prerequisites. The limited availability of experienced nurse colleagues and lack of time devoted for reflection needs to be dealt with to support nurses’ learning.     

整体护理实际效果分析与探讨

整体护理是以病人为中心的一种先进的护理模式,摒弃了功能制护理只注重治病,而不注重身心护理的弊端。但在实施整体护理工作中仍有一些影响实际效果的因素存在,如：制定的护理计划难以付诸实践;工作方法还停留在功能制护理的模式上;护理人员的自身素质还不能完全适应整体护理的需要。结合我院的实际情况对此进行分析,并提出相应改进措施：(1)以病人为中心,制定新的护理表格;(2)制定新的工作程序和有效的质量评估标准;(3)提高护理人员多方面素质,以提高整体护理的实际效果。     

Hospital staffing,organization, and quality of care: Cross-national findings

OBJECTIVE: To examine the effects of nurse staffing and organizational support for nursing care on nurses' dissatisfaction with their jobs, nurse burnout, and nurse reports of quality of patient care in an international sample of hospitals. DESIGN: Multisite cross-sectional survey SETTING: Adult acute-care hospitals in the U.S. (Pennsylvania), Canada (Ontario and British Columbia), England and Scotland. Study Participants: 10319 nurses working on medical and surgical units in 303 hospitals across the five jurisdictions. INTERVENTIONS: None Main outcome measures: Nurse job dissatisfaction, burnout, and nurse-rated quality of care. RESULTS: Dissatisfaction, burnout and concerns about quality of care were common among hospital nurses in all five sites. Organizational/managerial support for nursing had a pronounced effect on nurse dissatisfaction and burnout, and both organizational support for nursing and nurse staffing were directly, and independently, related to nurse-assessed quality of care. Multivariate results imply that nurse reports of low quality care were three times as likely in hospitals with low staffing and support for nurses as in hospitals with high staffing and support. CONCLUSION: Adequate nurse staffing and organizational/managerial support for nursing are key to improving the quality of patient care, to diminishing nurse job dissatisfaction and burnout and, ultimately, to improving the nurse retention problem in hospital settings.     

Differences in nursing practice environment among US acute care unit types: A descriptive study

BackgroundThe hospital nursing practice environment has been found to be crucial for better nurse and patient outcomes. Yet little is known about the professional nursing practice environment at the unit level where nurses provide 24-hour bedside care to patients.ObjectivesTo examine differences in nursing practice environments among 11 unit types (critical care, step-down, medical, surgical, combined medical–surgical, obstetric, neonatal, pediatric, psychiatric, perioperative, and emergency) and by Magnet status overall, as well as four specific aspects of the practice environment.DesignCross-sectional study.Settings5322 nursing units in 519 US acute care hospitals.MethodsThe nursing practice environment was measured by the Practice Environment Scale of the Nursing Work Index. The Practice Environment Scale of the Nursing Work Index mean composite and four subscale scores were computed at the unit level. Two statistical approaches (one-way analysis of covariance and multivariate analysis of covariance analysis) were employed with a Tukey-Kramer post hoc test.ResultsIn general, the nursing practice environment was favorable in all unit types. There were significant differences in the nursing practice environment among the 11 unit types and by Magnet status. Pediatric units had the most favorable practice environment and medical–surgical units had the least favorable. A consistent finding across all unit types except neonatal units was that the staffing and resource adequacy subscale scored the lowest compared with all other Practice Environment Scale of the Nursing Work Index subscales (nursing foundations for quality of care, nurse manager ability, leadership, and support, and nurse–physician relations). Unit nursing practice environments were more favorable in Magnet than non-Magnet hospitals.ConclusionsFindings indicate that there are significant variations in unit nursing practice environments among 11 unit types and by hospital Magnet status. Both hospital-level and unit-specific strategies should be considered to achieve an excellent nursing practice environment in all hospital units.     

The training needs of Korean intensive care unit nurses regarding delirium

ObjectivesThe aim of this study was to investigate high-priority training needs by analysing the perceived importance and self-reported performance of nurses’ delirium care competency.DesignA cross-sectional survey with a convenience sample of 255 Korean intensive care units nurses.SettingIntensive care units in the Republic of Korea.Main outcome measuresIntensive care unit nurses’ delirium care competency.ResultsExploratory factor analysis of the Nurse Delirium Care Competency Scale showed a six-factor structure, which accounted for 67.51% of the variance in nurses’ delirium care competency: management algorithm, prevention, communication, nursing management, assessment, and collaboration. The self-reported performance scores of all six factors were significantly lower than their perceived importance scores. The delirium assessment factor was identified as a high training priority on the importance-performance matrix for new graduate nurses.ConclusionTraining programmes should be developed considering the six delirium care competency factors identified in this study. Further, nurse educators must adopt active educational modalities such as case-based small group learning and simulation-based learning to improve nurse competency in recognising and managing delirium.     

Critical care nurses’ lived experiences of interhospital intensive care unit-to-unit transfers: A phenomenological hermeneutical study

ObjectiveTo explore critical care nurses’ lived experiences of transferring intensive care patients between hospitals.MethodsA phenomenological hermeneutic approach using data generated through individual interviews with 11 critical care registered nurses.SettingTwo general intensive care units in Sweden.FindingsFive themes were identified: it depends on me; your care makes a difference; being exposed; depending on interprofessional relationships; and sensing professional growth. These themes were synthesised into a comprehensive understanding showing how transferring intensive care patients between hospitals meant being on an ambivalent journey together with the patient but also on a journey within yourself in your own development and growth, where you, as a nurse, constantly are torn between contradictory feelings and experiences.ConclusionInterhospital intensive care unit-to-unit transfers can be a challenging task for critical care nurses but also an important opportunity for professional growth. During the transfer, nurses become responsible for the patient, their colleagues and the entire transfer process. In a time of an increasing number of interhospital intensive care unit-to-unit transfers, this study illuminates the risk for missed nursing care, showing that the critical care nurse has an important role in protecting the patient from harm and safeguarding dignified care.     

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.