Staffing Levels and Patient Outcomes

1. Staffing Levels and Patient Outcomes By: Amy Reames, Temple Robinson, Nacole Shafer, Stacey Swartzendruber, Lisa Watson

2. 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

3. PICoQuestion Is there a relationship between nurse-to-patient ratios and favorable outcomes for patients in the hospital setting?

4. 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

5. Article numerical reference 1 = 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).

6. Analysis of the evidence

7. Impact of California mandated acute care hospital nurse staffing ratiosA literature synthesis N. Donaldson & S. Shapiro

8. 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

9. 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

10. 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 Donaldson & Shaprio, 2010

11. 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.

12. 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)

13. 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)

14. 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” Frith et al, (2010), pg 147

15. The association of registered nurse staffing levels and patient outcomesSystematic and meta-analysis R. Kane, T. Shamliyan, C. Mueller, S. Duval, & T. Wilt.

16. The Association of Registered Nurse Staffing Levels and Patient outcomesSystematic 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)

17. The Association of Registered Nurse Staffing Levels and Patient outcomesSystematic 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)

18. The Association of Registered Nurse Staffing Levels and Patient outcomesSystematic 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. Kane et al. (2007)

19. Are patient falls and pressure ulcers sensitive to nurse staffing? E. Lake & R. Cheung

20. 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

21. 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 & Cheung, 2006

22. 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, E., Cheung, R. (2006)

23. 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

24. 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) Lake & Cheung, 2006

25. Application of Evidence

26. 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 Donaldson & Shapiro, 2010

27. 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 Kane, et al, 2007

28. Summary

29. Summary While some of the literature finds that higher nurse-patient ratios lower adverse effects to patients, it is apparent to our group that further research regarding the implementation of nurse-patient ratios needs to be carried out, both in regards to its effect on patient outcomes as well as its effect on the entire healthcare organization. At this time, the group’s decision is that there is not enough conclusive evidence to support our hypothesis that mandating a set nurse-patient ratio will improve patient outcomes. We certainly need to research variables other than patient outcomes, and receive consistent results in order to fully support the implementation of this idea.  

30. References Donaldson, 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.

31. References Lake, 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