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

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          Abstract

          Background

          The 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/designs

          A 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).

          Discussion

          It 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 registration

          Clinical Trials Registry CCTCTR CUHK_CCT00460. Date of trial registration: 02 July 2015.

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          Most cited references21

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          Nurse-staffing levels and the quality of care in hospitals.

          It is uncertain whether lower levels of staffing by nurses at hospitals are associated with an increased risk that patients will have complications or die. We used administrative data from 1997 for 799 hospitals in 11 states (covering 5,075,969 discharges of medical patients and 1,104,659 discharges of surgical patients) to examine the relation between the amount of care provided by nurses at the hospital and patients' outcomes. We conducted regression analyses in which we controlled for patients' risk of adverse outcomes, differences in the nursing care needed for each hospital's patients, and other variables. The mean number of hours of nursing care per patient-day was 11.4, of which 7.8 hours were provided by registered nurses, 1.2 hours by licensed practical nurses, and 2.4 hours by nurses' aides. Among medical patients, a higher proportion of hours of care per day provided by registered nurses and a greater absolute number of hours of care per day provided by registered nurses were associated with a shorter length of stay (P=0.01 and P<0.001, respectively) and lower rates of both urinary tract infections (P<0.001 and P=0.003, respectively) and upper gastrointestinal bleeding (P=0.03 and P=0.007, respectively). A higher proportion of hours of care provided by registered nurses was also associated with lower rates of pneumonia (P=0.001), shock or cardiac arrest (P=0.007), and "failure to rescue," which was defined as death from pneumonia, shock or cardiac arrest, upper gastrointestinal bleeding, sepsis, or deep venous thrombosis (P=0.05). Among surgical patients, a higher proportion of care provided by registered nurses was associated with lower rates of urinary tract infections (P=0.04), and a greater number of hours of care per day provided by registered nurses was associated with lower rates of "failure to rescue" (P=0.008). We found no associations between increased levels of staffing by registered nurses and the rate of in-hospital death or between increased staffing by licensed practical nurses or nurses' aides and the rate of adverse outcomes. A higher proportion of hours of nursing care provided by registered nurses and a greater number of hours of care by registered nurses per day are associated with better care for hospitalized patients.
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            The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis.

            To examine the association between registered nurse (RN) staffing and patient outcomes in acute care hospitals. Twenty-eight studies reported adjusted odds ratios of patient outcomes in categories of RN-to-patient ratio, and met inclusion criteria. Information was abstracted using a standardized protocol. Random effects models assessed heterogeneity and pooled data from individual studies. Increased RN staffing was associated with lower hospital related mortality in intensive care units (ICUs) [odds ratios (OR), 0.91; 95% confidence interval (CI), 0.86-0.96], in surgical (OR, 0.84; 95% CI, 0.80-0.89), and in medical patients (OR, 0.94; 95% CI, 0.94-0.95) per additional full time equivalent per patient day. An increase by 1 RN per patient day was associated with a decreased odds ratio of hospital acquired pneumonia (OR, 0.70; 95% CI, 0.56-0.88), unplanned extubation (OR, 0.49; 95% CI, 0.36-0.67), respiratory failure (OR, 0.40; 95% CI, 0.27-0.59), and cardiac arrest (OR, 0.72; 95% CI, 0.62-0.84) in ICUs, with a lower risk of failure to rescue (OR, 0.84; 95% CI, 0.79-0.90) in surgical patients. Length of stay was shorter by 24% in ICUs (OR, 0.76; 95% CI, 0.62-0.94) and by 31% in surgical patients (OR, 0.69; 95% CI, 0.55-0.86). Studies with different design show associations between increased RN staffing and lower odds of hospital related mortality and adverse patient events. Patient and hospital characteristics, including hospitals' commitment to quality of medical care, likely contribute to the actual causal pathway.
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              Educational levels of hospital nurses and surgical patient mortality.

              Growing evidence suggests that nurse staffing affects the quality of care in hospitals, but little is known about whether the educational composition of registered nurses (RNs) in hospitals is related to patient outcomes. To examine whether the proportion of hospital RNs educated at the baccalaureate level or higher is associated with risk-adjusted mortality and failure to rescue (deaths in surgical patients with serious complications). Cross-sectional analyses of outcomes data for 232 342 general, orthopedic, and vascular surgery patients discharged from 168 nonfederal adult general Pennsylvania hospitals between April 1, 1998, and November 30, 1999, linked to administrative and survey data providing information on educational composition, staffing, and other characteristics. Risk-adjusted patient mortality and failure to rescue within 30 days of admission associated with nurse educational level. The proportion of hospital RNs holding a bachelor's degree or higher ranged from 0% to 77% across the hospitals. After adjusting for patient characteristics and hospital structural characteristics (size, teaching status, level of technology), as well as for nurse staffing, nurse experience, and whether the patient's surgeon was board certified, a 10% increase in the proportion of nurses holding a bachelor's degree was associated with a 5% decrease in both the likelihood of patients dying within 30 days of admission and the odds of failure to rescue (odds ratio, 0.95; 95% confidence interval, 0.91-0.99 in both cases). In hospitals with higher proportions of nurses educated at the baccalaureate level or higher, surgical patients experienced lower mortality and failure-to-rescue rates.
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                Author and article information

                Contributors
                852 3943 6226 , janitachau@cuhk.edu.hk
                852 3943 4485 , suzannelo@cuhk.edu.hk
                852 3943 4095 , kchoi@cuhk.edu.hk
                852 3653 6748 , lschan@cihe.edu.hk
                215 746-0205 , mchughm@nursing.upenn.edu
                852 2990 2867 , tongwk2@ha.org.hk
                852 2632 6477 , kml539@ha.org.hk
                852 3943 6229 , ip2013@cuhk.edu.hk
                852 3943 6228 , fk95lee@cuhk.edu.hk
                852 3943 6227 , tzefanlee@cuhk.edu.hk
                Journal
                BMC Health Serv Res
                BMC Health Serv Res
                BMC Health Services Research
                BioMed Central (London )
                1472-6963
                4 December 2015
                4 December 2015
                2015
                : 15
                : 538
                Affiliations
                [ ]The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, 8/F, Esther Lee Building, Shatin, NT Hong Kong
                [ ]Department of Health Sciences, Caritas Bianchi College of Careers, Caritas Institute of Higher Education, 18 Chui Ling Road, Tseung Kwan O, NT Hong Kong
                [ ]School of Nursing; Center for Health Outcomes and Policy Research, University of Pennsylvania, Room 379, Fagin Hall, 418 Curie Blvd., Philadelphia, Pennsylvania 19104-4217 United States
                [ ]Infectious Disease Centre, Princess Margaret Hospital, Hospital Authority, Kowloon, Hong Kong
                [ ]Department of Medicine and Therapeutics, Prince of Wales Hospital, Hospital Authority, NT, Hong Kong
                Article
                1198
                10.1186/s12913-015-1198-0
                4670525
                26637190
                570ce6a8-682e-404c-91c7-71d076da9b49
                © Chau et al. 2015

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 17 August 2015
                : 25 November 2015
                Categories
                Study Protocol
                Custom metadata
                © The Author(s) 2015

                Health & Social care
                health facility environment,health manpower,nursing staff,hospital,nursing service,quality indicators

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