Are hospital nurse staffing practices associated with postoperative cardiac events and death? A systematic review

Abstract

IntroductionPostoperative cardiac events are frequent complications of surgery, and their occurrence could be associated with suboptimal nurse staffing practices, but the existing evidence remains scattered. We systematically reviewed studies linking nurse staffing practices to postoperative cardiac events and two related outcomes, all-cause mortality and failure-to-rescue.MethodsA systematic search of the English/French literature was undertaken in the CINAHL, PsychInfo, and Medline databases. Studies were included if they: a) were published between 1996 and 2018; b) used a quantitative design; c) examined the association between at least one of seven staffing practices of interest (i.e., staffing levels, skill mix, work environment characteristics, levels of education and experience of the registered nurses, and overtime or temporary staff use) and postoperative cardiac events, mortality or failure-to-rescue; and d) were conducted among surgical patients. Data extraction, analysis, and synthesis, along with study methodological quality appraisal, were performed by two authors. High methodological heterogeneity precluded a formal meta-analysis.ResultsAmong 3,375 retrieved articles, 44 studies were included (39 cross-sectional, 3 longitudinal, 1 case-control, 1 interrupted time series). Existing evidence shows that higher nurse staffing levels, a higher proportion of registered nurses with an education at the baccalaureate degree level, and more supportive work environments are related to lower rates of both 30-day mortality and failure-to-rescue. Other staffing practices were less often studied and showed inconsistent associations with mortality or failure-to-rescue. Similarly, few studies (n = 10) examined the associations between nurse staffing practices and postoperative cardiac events and showed inconsistent results.ConclusionHigher nurse staffing levels, higher registered nurse education (baccalaureate degree level) and more supportive work environments were cross-sectionally associated with lower 30-day mortality and failure-to-rescue rates among surgical patients, but longitudinal studies are required to corroborate these associations. The existing evidence regarding postoperative cardiac events is limited, which warrants further investigation.

Nurse Staffing Practices and Postoperative Atrial Fibrillation Among Cardiac Surgery Patients: A Multisite Cohort Study

“…We found that higher RN understaffing over the first 6 postoperative days was associated with higher odds of POAF occurrence, a finding consistent with that of a growing number of studies that linked RN staffing levels to several surgical outcomes. 18,27,46 Moreover, to the best of our knowledge, the present investigation is the first multisite longitudinal study to measure RN understaffing over the time window during which POAF is most likely to occur. This methodological characteristic, along with our finding of an association of the same magnitude in two administratively distinct UHCs, strengthens the belief that RN understaffing contributes to the incidence of POAF.…”

“…[12][13][14] Among these, an increasing number of studies have suggested that nurse staffing practices in the postoperative period (e.g., using adequate staffing levels, a richer registered nurse (RN) skill mix, higher numbers of RNs educated at the baccalaureate degree level, and more experienced teams of RNs), which are amenable to managerial intervention, are associated with lower rates of surgical mortality and fewer adverse events. [15][16][17][18] Similarly, several recent investigations pointed out that suboptimal nurse staffing practices (e.g., higher RN understaffing and a higher non-RN skill mix) are correlated with worse patient outcomes. [19][20][21] To explain these associations, it has been proposed that nurse staffing practices can improve or weaken nurse surveillance, one of the most important functions of RNs.…”

“…15,22,23 Adequate staffing levels and a richer RN skill mix are assumed to increase the effectiveness of nurse surveillance by allowing RNs to spend more time at the bedside, therefore increasing the rapidity with which they can detect any change in a patient's condition and intervene. 18,23,24 Higher education at the baccalaureate degree level and greater work experience are assumed to improve nurse surveillance by providing RNs with more knowledge, better patient surveillance skills, and a broader repertoire of interventions. 15,22,25 While there is growing international evidence suggesting that these four nurse staffing practices are linked to improved surgical outcomes, to our knowledge, no previous study has examined whether they are associated with POAF occurrence in cardiac surgery patients.…”

Assessment of Magnet status and Textbook Outcomes among medicare beneficiaries undergoing hepato‐pancreatic surgery for cancer

“…In particular, a higher nurse‐to‐bed ratio was associated with improved postoperative outcomes irrespective of hospital Magnet status. There is a well‐recognized body of literature on the relationship of structural measures such as nurse staffing and clinical outcomes 27,28 . In particular, data have demonstrated that higher nurse staffing ratios can directly improve clinical outcomes 21,29 .…”

Do We Get What We Pay For? Examining the Relationship Between Payments and Clinical Outcomes in High-Volume Elective Surgery in a Commercially-Insured Population

“…For example, hospital reputation, hospital incorporation into integrated delivery systems, and proportion of hospitals' reimbursements in a value-based payment arrangement likely influence provider-payer negotiations and are infrequently included in clinical quality studies. Additionally, there is a wealth of published literature on the correlation between nurse staffing and nurse education and quality outcomes [44][45][46] ; analyzes may benefit from adjustments for these factors.…”