A longitudinal examination of the association between nurse staffing levels, the practice environment and nurse-sensitive patient outcomes in hospitals

Abstract

BackgroundThe level of patient safety and outcomes accomplished depends on the quality of care provided. Previous studies found that nurse-to-patient ratio, practice environment, and nursing education were significant predictors of patient outcomes. However, the outcomes measured in previous studies were mainly inpatient mortality and failure-to-rescue rates. Few nurse-sensitive patient outcomes have been measured that quantify nurses’ contribution to patient care. Selecting appropriate outcomes that reflect the clinically relevant effect of nursing care is important. Moreover previous studies were largely cross-sectional and retrospective. These research designs are limited in their ability to explain the casual links between the variables examined. This study is aimed at determining the associations among staffing levels, skill mix of baccalaureate-prepared registered nurses, and practice environment on nurse-sensitive outcomes for medical and surgical patients in public hospitals in Hong Kong.Method/designsA multi-method research design will be adopted. The sample includes all medical and surgical wards of four major public hospitals that offer 24-h accident and emergency services. Multiple responses from registered nurses who work in the study wards will be collected over 12 months to examine their individual characteristics and perceptions of the practice environment. A 12-month prospective observational study will be performed to determine the association between nurse staffing levels, the practice environment, and nurse-sensitive patient outcomes including pressure ulcers, falls and restraint prevalence, urinary catheter-associated urinary tract infections, and central line catheter-associated bloodstream infections. Multilevel Cox proportional hazards models will be employed to examine the association between these patient outcomes and the explanatory nursing factors of primary interest (nurse staffing levels, education composition, and practice environment), with adjustment for all patient-, ward- and hospital-level potential confounders (age, sex, diagnosis, comorbidities, level of surgical invasiveness, mortality, length of stay, and type of admission).DiscussionIt is anticipated that knowledge of the association between nurse staffing levels, the practice environment, and nurse-sensitive outcomes will inform the provision of quality and timely patient care. This study will provide a landmark report that is of relevance and importance to patients and to hospital stakeholders and managers, health policy makers, nurses, and educators who advocate patient benefits.Trial registrationClinical Trials Registry CCTCTR CUHK_CCT00460. Date of trial registration: 02 July 2015.

The association between nurse staffing levels and paediatric nursing-sensitive outcomes in tertiary hospitals

“…The incidence rate of pressure ulcer and failure to rescue was the lowest in grade 3 nurse staffing hospitals. These results conflict with previous studies showing that lower rates of NSOs and nurse staffing levels are associated with the adult population (Chau et al., ; Schreuders et al., ; Stalpers et al., ). This may be affected by other nursing work factors in addition to the nurse staffing level, which is defined by nurse/patient ratios, due to the unique health needs of paediatric patients.…”

“…Although the incidence calculation methods of the two studies are different, in Wilson et al's (2013) study, the incidence rate of both medical and surgical nursing NSOs was high, whereas the incidence rate of nursing NSOs related to medical infection were high in this study. Because NSOs are affected by hospital factors, patient factors, nurse staffing levels, and work environment (Chau et al, 2015;Schreuders et al, 2014;Stalpers et al, 2015), the order of NSO occurrences is believed to be different according to the medical characteristics of respective countries. There was a lower incidence rate of LRTI, GI infection, pneumonia, and sepsis in grade 1 nurse staffing hospitals than in lower grade hospitals.…”

“…Nurses should be deployed at an appropriate level for the patients’ health and safety (Kane et al., ). Previous studies (Chau et al., ; Schreuders et al., ; Stalpers et al., ) have identified the relationship between nurse staffing levels and NSOs to provide evidence for the necessity of adequate nurse staffing. However, most studies have been conducted on adult patients, and there were no studies on paediatric patients.…”

“…The association between nurse staffing levels and paediatric nursing-sensitive outcomes in tertiary hospitals 2 | BACKG ROU N D In 2007, the Agency for Healthcare Research and Quality metaanalysed 94 studies and presented a conclusion that higher nurse staffing levels and adverse patient outcomes were significantly associated (Kane, Shamliyan, Mueller, Duval, & Wilt, 2007). Several international studies have continued to analyse the relationships between nurse staffing and NSOs by controlling hospital and patient characteristics or using various data sources for the establishment of evidence that quantitative nurse staffing needs to be fulfilled in order to provide high-quality health care to patients (Chau et al, 2015;;Schreuders, Bremner, Geelhoed, & Finn, 2014;Stalpers, Brouwer, Kaljouw, & Schuurmans, 2015). It is currently difficult to conclude that a certain level of nurse staffing has an exact relationship with NSOs because different studies use different methodologies and standard NSOs are not measured.…”

The importance of being meticulous in evaluating the evidence and risks with everyday care

“…Sufficient staffing as nurse/patient ratio, as well as levels of bedside competency, is most likely a major determinant of efficacy in any intensive care medicine unit. Optimal staffing is definitely a controversial area, given health care financing challenges and rising costs in general, and the goal of improving patient outcomes. The type of cost – benefit analyses (primarily in terms of medical costs and benefits) from different procedures as described above, may actually also be very helpful when trying to define optimal nurse staffing also from an economic and quality perspective.…”