By: Amy Reames, Temple Robinson, Nacole Shafer, Stacey Swartzendruber, Lisa Watson

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



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



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)


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


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)



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 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


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)


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


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


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

Documents

By: Amy Reames, Temple Robinson, Nacole Shafer, Stacey Swartzendruber, Lisa Watson