Diane E Twigg

The Impact of Nurses on Patient Morbidity and Mortality - the Need for a Policy Change in Response to the Nursing Shortage

CONTEXT Workforce projections indicate that by 2012 there will be a shortfall of 61,000 registered nurses in Australia. There is a growing body of evidence that links registered nurse staffing to better patient outcomes. PURPOSE This article provides a comprehensive review of the research linking nurse staffing to patient outcomes at a time of growing shortages, highlighting that a policy response based on substituting registered nurses with lower skilled workers may have adverse effects on patient outcomes. METHOD An electronic search of articles published in English using the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Journals @ OVID and Medline was undertaken. FINDINGS Robust evidence exists nationally and internationally that links nurse staffing to patient outcomes. Recent meta-analyses have found that there was a 3-12% reduction in adverse outcomes and a 16% reduction in the risk of mortality in surgical patients with higher registered nurse staffing. Evidence confirms that improvements in nurse staffing is a cost-effective investment for the health system but this is not fully appreciated by health policy advisors. CONCLUSIONS An appropriate policy response demands that the evidence that patient safety is linked to nurse staffing be recognised. Policy makers must ensure there are sufficient registered nurses to guarantee patient safety.

Impact of skill mix variations on patient outcomes following implementation of nursing hours per patient day staffing: A retrospective study

AIMS This article is a report of a study of the association between skill mix and 14 nursing-sensitive outcomes following implementation of the nursing hours per patient day staffing method in Western Australian public hospitals in 2002, which determined nursing hours by ward category but not skill mix. BACKGROUND Findings from previous studies indicate that higher nurse staffing levels and a richer skill mix are associated with improved patient outcomes. Measuring skill mix at a hospital level for specific staffing methods and associated nursing-sensitive patient outcomes are important in providing staffing for optimal patient care. DESIGN The research design for the larger study was retrospectively analysing patient and staffing administrative data from three adult tertiary hospitals in metropolitan Perth over 4 years. METHODS A subset of data was used to determine the impact of skill mix on nursing-sensitive outcomes following implementation of the staffing method. All patient records (N=103,330) and nurse staffing records (N=73,770) from nursing hours per patient day wards from October 2002-June 2004 following implementation were included. RESULTS Increases in Registered Nurse hours were associated with important decreases in eight nursing-sensitive outcomes at hospital level and increases in three nursing-sensitive outcomes. The lowest skill mix saw the greatest reduction in nursing-sensitive outcome rates. CONCLUSIONS The skill mix of nurses providing care could impact patient outcomes and is an important consideration in strategies to improve nurse staffing. Levels of hospital nurse staffing and skill mix are important organizational characteristics when predicting patient outcomes.

Policies to sustain the nursing workforce: an international perspective

AIM Examine metrics and policies regarding nurse workforce across four countries. BACKGROUND International comparisons inform health policy makers. METHODS Data from the OECD were used to compare expenditure, workforce and health in: Australia, Portugal, the United Kingdom (UK) and the United States (US). Workforce policy context was explored. RESULTS Public spending varied from less than 50% of gross domestic product in the US to over 80% in the UK. Australia had the highest life expectancy. Portugal has fewer nurses and more physicians. The Australian national health workforce planning agency has increased the scope for co-ordinated policy intervention. Portugal risks losing nurses through migration. In the UK, the economic crisis resulted in frozen pay, reduced employment, and reduced student nurses. In the US, there has been limited scope to develop a significant national nursing workforce policy approach, with a continuation of State based regulation adding to the complexity of the policy landscape. The US is the most developed in the use of nurses in advanced practice roles. Ageing of the workforce is likely to drive projected shortages in all countries. LIMITATIONS There are differences as well as variation in the overall impact of the global financial crisis in these countries. CONCLUSION Future supply of nurses in all four countries is vulnerable. IMPLICATIONS FOR NURSING AND HEALTH POLICY Work force planning is absent or restricted in three of the countries. Scope for improved productivity through use of advanced nurse roles exists in all countries.

Is there an economic case for investing in nursing care - what does the literature tell us?

Aim To determine the cost effectiveness of increasing nurse staffing or changing the nursing skill mix in adult medical and/or surgical patients? Background Research has demonstrated that nurse staffing levels and skill mix are associated with patient outcomes in acute care settings. If increased nurse staffing levels or richer skill mix can be shown to be cost-effective hospitals may be more likely to consider these aspects when making staffing decisions. Design A systematic review of the literature on economic evaluations of nurse staffing and patient outcomes was conducted to see whether there is consensus that increasing nursing hours/skill mix is a cost-effective way of improving patient outcomes. We used the Cochrane Collaboration systematic review method incorporating economic evidence. Data sources The MEDLINE, CINAHL, SPORTDiscus and PsychINFO databases were searched in 2013 for published and unpublished studies in English with no date limits. Review methods The review focused on full economic evaluations where costs of increasing nursing hours or changing the skill mix were included and where consequences included nursing sensitive outcomes. Results Four-cost benefit and five-cost effectiveness analyses were identified. There were no cost-minimization or cost-utility studies identified in the review. A variety of methods to conceptualize and measure costs and consequences were used across the studies making it difficult to compare results. Conclusion This review was unable to determine conclusively whether or not changes in nurse staffing levels and/or skill mix is a cost-effective intervention for improving patient outcomes due to the small number of studies, the mixed results and the inability to compare results across studies.

The impact of understaffed shifts on nurse‐sensitive outcomes

AIM To explore the relationship between exposure to understaffed shifts and nurse-sensitive outcomes at the patient level. BACKGROUND Nurse-sensitive outcomes are adverse patient outcomes that can be used as indicators of the quality of nursing care. DESIGN This study was conducted in 2014 and was a secondary analysis of administrative data from a large acute care hospital in Western Australia. The sample included 36,529 patient admissions over a two-year period from October 2004-November 2006. METHODS An understaffed indicator variable was created from nurse staffing data and used to examine patient data to create a variable indicating the total number of understaffed shifts each patient had been exposed to during their hospital stay. Logistic regression was used to determine the odds of acquiring a nurse-sensitive outcome for those exposed to understaffed shifts. RESULTS The prevalence ratio showed that for each of the nurse-sensitive outcomes there was an increase in prevalence for those who were exposed to an understaffed shift, with all ratios being greater than one. After adjusting for patient characteristics, nurse-sensitive outcomes found to have the understaffed variable significant in the logistic regression model were surgical wound infection, urinary tract infection, pressure injury, pneumonia, deep vein thrombosis, upper gastrointestinal bleed, sepsis and physiological metabolic derangement. All odds ratios were small effects. CONCLUSION Preventing understaffing is a consideration for improving the quality of care for patients. Attributing the understaffing variable at the patient level enables exposure to be captured across ward changes increasing the sensitivity with which this variable can be measured.

The critical role of nurses to the successful implementation of the National Safety and Quality Health Service Standards

The National Safety and Quality Health Service Standards requires health service compliance by 2013 and covers several areas including governance arrangements, partnerships with consumers and eight key clinical processes. Nurses in Australia comprise 62% of the hospital workforce, are the largest component and hence play a critical role in meeting these standards and improving the quality of patient care. Several of the standards are influenced by nursing interventions, which incorporate any direct-care treatment that the nurse performs for a patient that may be nurse or physician initiated. The ability for nurses to undertake these interventions is influenced by the hours of care available, the skill mix of the nursing workforce and the environment in which they practice. Taking into consideration the predicted nursing shortages, the challenge to successfully implement the National Safety and Quality Health Service Standards will be great. This paper examines the role of nursing in the delivery of the National Standards, analyses the evidence with regard to nursing-sensitive outcomes and discusses the implications for health service decision makers and policy.

The impact of adding assistants in nursing to acute care hospital ward nurse staffing on adverse patient outcomes: An analysis of administrative health data

OBJECTIVES The aim of this study was to assess the impact of adding assistants in nursing to acute care hospital ward nurse staffing on adverse patient outcomes using administrative health data. DESIGN Logistic regression modelling was used with linked administrative health data to examine the association between seven adverse patient outcomes and use of assistants in nursing utilising a pre-test/post-test design. Outcomes included were in-hospital 30-day mortality, failure to rescue, urinary tract infection, pressure injury, pneumonia, sepsis and falls with injury. SETTING Eleven acute care metropolitan hospitals in Western Australia. SAMPLE Patients were retained in the dataset if they spent any time on a medical, surgical or rehabilitation ward during their admission and excluded if they only spent time on other ward types, as the outcomes used in this study are only validated for these patient populations. There were 256,302 patient records in the total sample with 125,762 in the pre-test period (2006-2007) and 130,540 in the post-test period (2009-2010). RESULTS The results showed three significant increases in observed to expected adverse outcomes on the assistant in nursing wards (failure to rescue, urinary tract infection, falls with injury), with one significant decrease (mortality). On the non-assistant in nursing wards there was one significant decrease (pneumonia) in the observed to expected adverse outcomes and one significant increase (falls with injury). Post-test analysis showed that spending time on assistant in nursing wards was a significant predictor for urinary tract infection and pneumonia. For every 10% of extra time patients spent on assistant in nursing wards they had a 1% increase in the odds of developing a urinary tract infection and a 2% increase in the odds of developing pneumonia. CONCLUSION The results suggest that the introduction of assistants in nursing into ward staffing in an additive role should be done under a protocol which clearly defines their role, scope of practice, and working relationship with registered nurses, and the impact on patient care should be monitored.

Telehealth for paediatric burn patients in rural areas: a retrospective audit of activity and cost savings

INTRODUCTION Since 2005, the Western Australian paediatric burn unit has provided a state-wide clinical consultancy and support service for the assessment and management of acute and rehabilitative burn patients via its telehealth service. Since then, the use of this telehealth service has steadily increased as it has become imbedded in the model of care for paediatric burn patients. Primarily, the service involves acute and long term patient reviews conducted by the metropolitan-located burn unit in contact with health practitioners, advising patients and their families who reside outside the metropolitan area thereby avoiding unnecessary transfers and inpatient bed days. A further benefit of the paediatric burn service using telehealth is more efficient use of tertiary level burn unit beds, with only those patients meeting clinical criteria for admission being transferred. AIM To conduct a retrospective audit of avoided transfers and bed days in 2005/06-2012/13 as a result of the use of the paediatric Burns Telehealth Service and estimate their cost savings in 2012/13. METHOD A retrospective chart audit identified activity, avoided unnecessary acute and scar review patient transfers, inpatient bed days and their associated avoided costs to the tertiary burn unit and patient travel funding. RESULTS Over the period 2005/06-2012/13 the audit identified 4,905 avoided inpatient bed days, 364 avoided acute patient transfers and 1,763 avoided follow up review transfers for a total of 1,312 paediatric burn patients as a result of this telehealth service. This paper presents the derivation of these outcomes and an estimation of their cost savings in 2012/13 of AUD 1.89million. CONCLUSION This study demonstrates avoided patient transfers, inpatient bed days and associated costs as the result of an integrated burns telehealth service.

A comparison of nursing tasks undertaken by regulated nurses and nursing support workers: a work sampling study

AIMS The aim of this study was to determine which tasks unregulated nursing support staff spend their work time undertaking and to determine differences between the work undertaken by licensed/regulated nurses on units which have nursing support workers and those on units which do not. BACKGROUND Acute hospital nursing teams often include nursing support staff; little is known about what kinds of tasks these unregulated support workers do and how it affects the work tasks of their licensed/regulated team members. DESIGN Cross-sectional analysis of nurse work sampling data. METHODS Data collection took place between March-October 2013. The proportion of time spent on 25 work activities by nursing support staff and licensed/regulated nursing staff was compared. Logistic regression models estimated whether nursing support staff or licensed/regulated nurses were more likely to conduct direct and indirect patient care tasks and whether licensed/regulated nurses on units with nursing support staff were more likely to conduct direct or indirect tasks compared with those on units without nursing support workers. RESULTS Nursing support staff spent the majority of their time engaged in direct care tasks, e.g. admission and assessment, hygiene and mobility. Although licensed/regulated nurses were less likely to undertake direct care tasks compared with support workers, those who worked on units with support workers undertook more direct care compared with those who worked on units without support workers. CONCLUSIONS Nursing support workers were given tasks that required substantial amounts of patient interaction. These staff may be associated with an increase in direct care tasks for licensed/regulated nurses, who may duplicate the direct care done by nursing support workers.

Issues impacting on enrolled nurse education for Aboriginal and Torres Strait Islander students: a discussion

Background: Achieving increased participation of Aboriginal and Torres Strait Islander peoples in Australia’s health workforce, particularly nursing, is federal government policy imperative. However, the uptake of Aboriginal and Torres Strait Islander students into nursing has stalled and their attrition from tertiary nursing courses is considerably higher than for other students. Aim: To alert the profession to issues impacting enrolled nursing education for Aboriginal and Torres Strait Islander students. Design: Discussion paper. Results: Studies of Aboriginal and Torres Strait Islander students mainly focus on tertiary education for registered nurses whereas vocational education and training (VET) for enrolled nurses is usually overlooked. It is generally assumed that the issues influencing the recruitment, attrition, and retention of Aboriginal and Torres Strait Islander students in higher education universities and other institutions similarly impact enrolled nursing students in the VET sector. Conclusion: Research that contributes robust evidence-based knowledge specifically on strategies addressing issues in enrolled nursing education for Aboriginal and Torres Strait Islander students and their employment uptake is required.