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Staffing Levels and Patient Outcomes
By: Amy Reames, Temple Robinson, Nacole Shafer,
Stacey Swartzendruber, Lisa Watson
Supporting Evidence for Research
Hospitalized patients depend on nurses
Low nurse-to-patient ratios have higher rate of hospital-related complications
Higher nurse-to-patient ratios have more favorable outcomes
Setting standardized nurse-patient ratio to benefit patients
PICO QUESTION
Is there a relationship between nurse-to-patient ratios and favorable outcomes for patients in the hospital setting?
Literature Review
Each member submitted articles 27 articles total submitted 16 were found to be from acceptable
sources 10 of those were found to be relevant 4 agreed upon by all members of
group Following is an example of how
articles we critiqued
1 2 3 4 5 6 7 8 9
Level 1: Systematic Review/Meta-Analysis
x x x x
Level II: Randomized controlled trial
Level III: Controlled trial without randomization
Level IV: Case-control or cohort study
x x x x
Level V: Systematic review of qualitative/descriptive study
Level VI: Qualitative/descriptive study
Level VII: Expert opinion/ consensus
x
Article numerical reference1 = Kane, et al (2007); 2= Donaldson & Shapiro (2010); 3= AHRQ (2007); 4= Lake & Cheung (2006); 5= Aiken, et al (2002); 6= Burnes, et al (2007); 7= Needleman, et al (2002); 8= Frith, et al (2010; 9= Stanton (2004).
Table adapted from Fineout-Overholt, et al (2010).
ANALYSIS OF THE EVIDENCE
IMPACT OF CALIFORNIA MANDATED ACUTE CARE HOSPITAL NURSE STAFFING RATIOSA LITERATURE SYNTHESIS
N. Donaldson & S. Shapiro
Donaldson & Shaprio, 2010
Impact of California Mandated Acute Care Hospital Nurse Staffing RatiosA Literature Review
Shows how California’s nurse-to-patient ratios has affected patient care cost, quality, and outcomes in acute care hospitals
This article looks at 12 studies that examine this new mandate for California nurse-to-patient ratio
The literature search was performed by librarians specializing in the health sciences (Donaldson, 2010).
To help narrow the choices for review, the authors looked for articles that had been cited in other articles the most
Donaldson & Shaprio, 2010
Impact of California Mandated Acute Care Hospital Nurse Staffing RatiosA Literature Review
Most of the articles examined revealed that Registered Nurses provided more direct care with this new nurse-to-patient ratio
Articles showed that nurses were happier with their workplace with the mandated nurse-to-patient ratio
Under the new law the emergency department has more patients being “held” (Donaldson, 2010)
Believed patients were “held” due to waiting for more nurses to arrive to be able to admit these patients to the medical-surgical floor
Donaldson & Shaprio, 2010
Impact of California Mandated Acute Care Hospital Nurse Staffing RatiosA Literature Review
The study showed that RN’s were not available to do higher level work because there was less unlicensed staff to help with the work load
This article also states that lower nurse-to-patient ratios would decrease the stay of a patient was found not to be true
According to Donaldson et al. there is no supporting evidence regarding decreased patient outcomes with higher nurse-to-patient ratios
EFFECTS OF NURSE STAFFING ON HOSPITAL-ACQUIRED CONDITIONS AND LENGTH OF STAY IN COMMUNITY HOSPITALS.
K. Frith, F. Anderson, B. Caspers, K. Sanford, N. Hoyt, & K. Moore.
Frith et al. (2010)
Effects of Nurse Staffing on Hospital Acquired Conditions and Length of Stay in Community
Hospitals
The effects of nurse staffing on length of stay (LOS) and hospital acquired conditions in community hospitals were examined
Research group included eleven medical-surgical units, excluding those where intravenous vasoactive drips were administered, from four hospitals in three states
Two hospitals were located in rural areas and two from urban areas
Nurse staffing is defined as “the process of allocating the appropriate number and mix of licensed and unlicensed staff on a medical-surgical unit to meet the needs of patients” (Frith et al., 2010, pg 149)
Frith et al. (2010)
Effects of Nurse Staffing on Hospital Acquired Conditions and Length of Stay in Community
Hospitals
The study showed when there was a 1% increase in Registered Nurse (RN) staffing, the number of adverse events was reduced by 3.4%
For every one hour increase in RN hours the LOS was expected to decrease by 16.54% for patients at the median complication index
“For every additional patient in a nurse’s assignment, there was a 7% increase in likelihood of dying” (Frith et al., 2010, pg 148)
This study is limited in the fact that the only patients involved were from a medical/surgical unit
Frith et al, (2010), pg 147
Effects of Nurse Staffing on Hospital Acquired Conditions and Length of Stay in Community
Hospitals
Frith et al. states “the nurse is the last barrier between a patient and an error”
Continues with “sufficient numbers and the right mix of nurses are needed to provide vigilant surveillance of patients”
Concludes with “anticipating problems, observing for clinical cues, and implementing measures to reduce the probability of an adverse event”
THE ASSOCIATION OF REGISTERED NURSE STAFFING LEVELS AND PATIENT OUTCOMESSYSTEMATIC AND META-ANALYSIS
R. Kane, T. Shamliyan, C. Mueller, S. Duval, & T. Wilt.
Kane et al. (2007)
The Association of Registered Nurse Staffing Levels and Patient outcomes
Systematic Review and Meta-Analysis
Questions if registered nurse-to-patient levels affect patient outcomes.
The research was based on previous studies conducted in the Intensive Care Unit (ICU), the surgical unit, and the medical unit.
The study looked at “nurse sensitive patient outcomes”
Nurse Sensitive Patient outcomes “included hospital –related mortality, failure to rescue, cardiac arrest, shock, unplanned extubation, respiratory failure, deep venous thrombosis, upper gastrointestinal bleeding, surgical bleeding, patient falls, pressure ulcers, nosocomial infection, urinary tract infection, hospital acquired pneumonia, and nosocomial bloodstream infection “(Kane, et al., 2007, p. 1196).
Kane et al. (2007)
The Association of Registered Nurse Staffing Levels and Patient outcomes
Systematic Review and Meta-Analysis
Study looked at ICU’s, surgical and medical units separately
Accounted for the number of nurses per patient and also the ratio of “full time equivalents” (FTE).
FTE was determined by “assuming a 37.5-hour work week on average; 48 working wk/yr, and 8 hour shifts” (Kane et al., 2007, p. 1196).
It was found that a number of the “nurse sensitive patient outcomes” would have been higher had the registered nurse-to-patient ratio been higher.
The study states that “an increase by 1 RN FTE per patient day would save 5 lives per 1000 hospitalized patients in ICU, 5 lives per 1000 in medical patients, and 6 lives per 1000 surgical patients” (Kane et al., 2007, p. 1197).
Kane et al. (2007)
The Association of Registered Nurse Staffing Levels and Patient outcomes
Systematic Review and Meta-Analysis
The data in this study supports that an increase in registered nursing staff in hospitals directly affects to outcomes of patients.
The study concludes by stating there is supporting evidence to increase registered nurse to patient ratios will reduce the risk for negative “nurse sensitive patient outcomes”.
It continues that the managements support and skill level, education, experience are also important factors that play in positive patient outcomes.
ARE PATIENT FALLS AND PRESSURE ULCERS SENSITIVE TO NURSE STAFFING?
E. Lake & R. Cheung
Lake & Cheung, 2006
Are Patient Falls and Pressure Ulcers Sensitive to Nurse Staffing?
Systematic review of 11 articles pertaining to nurse staffing and the incidence of falls and pressure ulcers
Viewed by the American Nurses Association that both falls and pressure ulcers are incidents that occur due to nursing care
This article looked at different theoretical frameworks that focused on nursing’s affect on patient outcomes
quality health outcomes model the nursing role effectiveness model
Lake & Cheung, 2006
Are Patient Falls and Pressure Ulcers Sensitive to Nurse Staffing?
The quality health outcomes model states that, “system characteristics, interventions, client characteristics, and outcomes have a reciprocal relationship” (Lake & Cheung, 2006, p. 656)
The nursing role effectiveness model states that the nursing staff- mix (RN, LPN) and workload are variables that affect patient outcomes
These nursing theory frameworks support the need for further studies regarding patient outcomes and nursing staff
supporting the articles purpose in investigating the correlation between nursing care and pressure ulcers and falls
Lake, E., Cheung, R. (2006)
Are Patient Falls and Pressure Ulcers Sensitive to Nurse Staffing?
The study discusses limitations to the way that these variables were able to be compared
Some of the variables were obtained in different ways
Incident reports for falls were used in some studies
Other studies relied on diagnoses or event codes from data sets from the hospitals involved
Lake & Cheung, 2006
Are Patient Falls and Pressure Ulcers Sensitive to Nurse Staffing?
Studies on pressure ulcers also had variable sources of where data was obtained
The studies that were done on the hospital level used secondary diagnoses to gather their data
Studies that were done on the unit level were done by chart review or by observation
nurse staffing effects on both falls and pressure ulcers were shown to be controversial
Lake & Cheung, 2006
Are Patient Falls and Pressure Ulcers Sensitive to Nurse Staffing?
Nurse staffing effects on both falls and pressure ulcers were shown to be controversial
The eight studies regarding falls, “results were significant in two, mixed in three, and not significant in three” (Lake & Cheung, 2006, p 659)
The seven studies related to pressure ulcers, “results were significant in two, mixed in three, and not significant in two” (Lake & Cheung, 2006, p 659)
APPLICATION OF EVIDENCE
Donaldson & Shapiro, 2010
Application of Evidence After reviewing all four articles, research regarding
nursing ratios as a way of improving patient care seems to be inconclusive
Besides the lack of conclusive evidence, barriers to implementation of a mandatory nurse-patient ratio also exist
Several studies reviewed by Donaldson & Shapiro (2010) suggest that the implementation of mandatory nurse-patient ratios not only fail to produce a significant change in patient outcomes, but may actually cause problems in other areas of hospital management
increasing the number of registered nurses, decreases in ancillary staff may be see, which in turn, may increase the workload of the nurse
Kane, et al, 2007
Application of Evidence Kane’s conclusion that raising RN staff actually lowered
the number of adverse effects and LOS Cost-effectiveness of implementing a mandatory ratio still
needs to be taken into consideration Suggested that the possibility of support services needing
to be eliminated or other quality improvement projects abandoned in order to offset the costs incurred from implementing the ratio could occur
Other aspects of nursing besides a nurse-patient ratio play a role in the care of patients and affect patient care
the nurses’ experience educational level leadership styles Unit environment
SUMMARY
Summary
While some of the literature finds that higher nurse-patientratios lower adverse effects to patients, it is apparent to ourgroup that further research regarding the implementation of nurse-patient ratios needs to be carried out, both in regardsto its effect on patient outcomes as well as its effect on theentire healthcare organization. At this time, the group’sdecision is that there is not enough conclusive evidence tosupport our hypothesis that mandating a set nurse-patientratio will improve patient outcomes. We certainly need toresearch variables other than patient outcomes, andreceive consistent results in order to fully support theimplementation of this idea.
ReferencesDonaldson, N., Shapiro, S. (2010). Impact of California mandated acute care hospital nurse staffing ratios: A literature synthesis. Policy politics nursing practice, 11 (3), 184-201. doi: 10.1177/1527154410392240
Fineout-Overholt, E., Melnyk, B., Stillwell, S., Williamson, K. (2010). Critical appraisal of the evidence: Part III. American journal of nursing,
110(11), 43-51.
Frith, K., Anderson, F., Caspers, B., Sanford, K., Hoyt, N., & Moore, K. (2010). Effects of nurse staffing on hospital-acquired conditions and length of stay in community hospitals. Quality management in health care, 19(2), 147-155.
Kane, R., Shamliyan, T., Mueller, C., Duval, S., & Wilt, T. (2007). The association of registered nurse staffing levels and patient outcomes. Medical care, 45(12), 1195-1204.
ReferencesLake, E., Cheung, R. (2006). Are patient falls and pressure ulcers sensitive to nurse staffing? Western journal of nursing research, 28(6), 654-677. doi: 10.1177/0193945906290323