Having a greater proportion of registered nurses in a respiratory care centre is associated with fewer urinary infections and increased successful ventilator weaning

This study explored the impact of skill mix model changes on patient outcomes in a critical care environment, specifically, a respiratory care centre based in a southern Taiwan medical centre. It identified that the cost of ventilator-dependent patients in Taiwan in 1999 was 3.5 billion New Taiwan dollars, equivalent to US$ 121 million. In this context, controlling the costs of healthcare while maintaining quality care became critical. This research examined two skill mix staffing models, a mixed registered nurse (RN) and nursing aid model and a 100% RN model, and their impact on patient outcomes. Patient outcomes were pressure ulcers, respiratory and urinary tract infections, blood stream infections, days of hospitalisation and ventilator weaning

Clinically practising nurses\u27 perceptions of professionalism

This study describes clinically practising nurses’ perceptions of professionalism and compares these with reports of nurses’ perceptions of professionalism in the published literature. A phenomenological approach was chosen to identify and interpret the phenomena (professionalism). Ten Registered Nurses representing a range of clinical nursing positions were interviewed on the subject. Data were analysed using an interpretive methodology which identified themes and meanings. Credibility of results was established through participant validation of the identified themes and meanings and by researcher and data triangulation. The study identified six themes common to all participants’ descriptions: expertise based upon a sound education, continued learning, and clinical skill; caring which involved communication skills, mutual trust and respect, and holistic nondiscriminatory care; an image which portrayed a professional persona, expertise and commitment; recognition of expertise by the public and other health workers; unity promoted through professional organisations; and finally autonomy. These themes were in agreement with the concept of professionalism as published in the literature

Nurse staffing and workload drivers in small rural hospitals: An imperative for evidence

Purpose: The aim of this study was to explore staffing issues and the workload drivers influencing nursing activities in designated small rural hospitals of Western Australia. A problem for small rural hospitals is an imbalance between nurse staffing resources and work activity. Sample: A purposive sample of 17 nurse leaders employed at designated small rural hospitals in Western Australia. Method: A qualitative research design was used. Data were collected by focus group and semi-structured interviews and review of Western Australian Country Health Service records. Thematic analysis was used to interpret data. Findings: A minimum nurse staffing model is in use. Staff workload is generated from multiple activities involving 24-hour emergency services, inpatient care, and other duties associated with a lack of clinical and administrative services. These factors together impact on nursing staff resources and the skill mix required to ensure the safety and quality of patient care. Conclusion: Nurse staffing for small rural hospitals needs site-specific recording techniques for workload measurement, staff utilisation and patient outcomes. It is imperative that evidence guide nurse staffing decisions and that the workload driving nursing activity is reviewed

The impact of nurse staffing methodologies on nurse and patient outcomes: A systematic review

Aim Aim of this study is to systematically review and synthesize available evidence to identify the association between nurse staffing methodologies and nurse and patient outcomes. Design Systematic review and narrative synthesis. Data sources A search of MEDLINE (EBSCO), CINAHL (EBSCO) and Web of Science was conducted for studies published in English between January 2000 and January 2020. Review methods The reporting of this review and narrative synthesis was guided by the preferred reporting items for systematic and meta-analysis guidelines (PRISMA) statement and data synthesis guided by the Synthesis Without Meta-analysis (SWiM) guideline. The quality of each article was assessed using the Mixed Methods Appraisal Tool. Results Twenty-two studies met the inclusion criteria. Twenty-one used the mandated minimum nurse-to-patient ratio methodology and one study assessed the number of nurse hours per patient day staffing methodology. Both methodologies were mandated. All studies that reported on nurse outcomes demonstrated an improvement associated with the implementation of mandated minimum nurse-to-patient ratio, but findings related to patient outcomes were inconclusive. Conclusions Evidence on the impact of specific nurse staffing methodologies and patient and nurse outcomes remains highly limited. Future studies that examine the impact of specific staffing methodologies on outcomes are required to inform this fundamental area of management and practice

The economic benefits of increased levels of nursing care in the hospital setting

Aim: To assess the economic impact of increased nursing hours of care on health outcomes in adult teaching hospitals in Perth, Western Australia. Background: Advancing technology and increased availability of treatment interventions are increasing demand for health care while the downturn in world economies has increased demand for greater efficiency. Nurse managers must balance nurse staffing to optimize care and provide efficiencies. Design: This longitudinal study involved the retrospective analysis of a cohort of multi-day stay patients admitted to adult teaching hospitals. Methods: Hospital morbidity and staffing data from September 2000 until June 2004, obtained in 2010 from a previous study, were used to analyse nursing-sensitive outcomes pre- and post-implementation of the Nurse Hours per Patient Day staffing method, which remains in place today. The cost of the intervention comprised increased nursing hours following implementation of the staffing method. Results: The number of nursing-sensitive outcomes was 1357 less than expected post-implementation and included 155 fewer \u27failure to rescue\u27 events. The 1202 other nursing-sensitive outcomes prevented were \u27surgical wound infection\u27, \u27pulmonary failure\u27, \u27ulcer, gastritis\u27, \u27upper gastrointestinal bleed\u27, and \u27cardiac arrest\u27. One outcome, pneumonia, showed an increase of 493. Analysis of life years gained was based on the failure to rescue events prevented and the total life years gained was 1088. The cost per life year gained was AUD$8907. Conclusion: The implementation of the Nurse Hours per Patient Day staffing method was cost-effective when compared with thresholds of interventions commonly accepted in Australia

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 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. ã 2016 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)

The development of the Western Australian Haemodialysis Vascular Access Complexity Instrument

Background The Western Australian Haemodialysis Vascular Access Classification instrument was developed to classify the cannulation complexity of the arteriovenous fistula or arteriovenous graft as simple, challenging, or complex. Although the instrument was developed by experts in haemodialysis nursing, the instrument had not undergone formal validity or reliability testing. Objectives Evaluate the Western Australian Haemodialysis Vascular Access Classification instrument for content validity, interrater and test–retest reliability. Design Prospective cohort study. Participants Content validity was assessed by haemodialysis nursing experts (n = 8). The reliability testing occurred in one in-centre and one satellite haemodialysis unit in Western Australia from September to November 2019. Reliability testing was performed by 38 haemodialysis nurses in 67 patients receiving haemodialysis and 247 episodes of cannulation. Measurements Interrater and test–retest reliability assessment was conducted using κ, adjusted κ, Bland–Altman plots, intraclass correlation coefficient and Pearson\u27s correlation coefficient. Results The final version of the instrument (n = 20 items) had individual item-level content validity indices ranging from 0.625 to 1.00 with a scale-level content validity index of 0.89. For both interrater (n = 172 pairs) and test–retest (n = 101 pairs), most individual variables had excellent adjusted κ (n = 33 variables), some fair to good agreement (n = 6 variables) and one variable with poor agreement. The classification of simple, challenging and complex demonstrated adjusted κ of fair to good, to excellent agreement for interrater reliability with lower levels of agreement for test–retest reliability. Conclusions This instrument may be used to match a competency-assessed nurse to perform the cannulation thereby minimising the risk of missed cannulation and trauma

Variables associated with successful vascular access cannulation in hemodialysis patients: A prospective cohort study

BACKGROUND: Successful vascular access (VA) cannulation is integral to the delivery of adequate dialysis, highlighting the importance of ensuring the viability of arteriovenous access in hemodialysis (HD) patients. Missed VA cannulation can lead to infection, infiltration, hematoma or aneurysm formation resulting in the need for access revision, central venous catheter (CVC) placement, or permanent loss of VA. Cannulation-related complications can also negatively impact on a patient\u27s dialysis experience and quality of life. This study aimed to identify patient, VA and nurse factors associated with unsuccessful VA cannulations. METHODS: A prospective cohort study was conducted in HD patients with a permanent VA from three HD units. Data on patient, VA and nurse characteristics, plus, cannulation technique were collected for each episode of cannulation. General Estimating Equation was used to fit a repeated measures logistic regression to determine the odds of cannulation success. RESULTS: We collected data on 1946 episodes of cannulation (83.9% fistula) in 149 patients by 63 nurses. Cannulation included use of tourniquet (62.9%), ultrasound (4.1%) and was by rope ladder (73.8%) or area (24.7%) technique. The miscannulation rate was 4.4% (n = 85) with a third of patients (n = 47) having at least one episode of miscannulation. Extravasation (n = 17, 0.9%) and use of an existing CVC (n = 6, 0.6%) were rare. Multivariable characteristics of successful cannulation included fistula compared with graft [OR 4.38; 95%CI, 1.89-10.1]; older access [OR 1.68; 95%CI, 1.32-2.14]; absence of stent [OR 3.37; 95%CI, 1.39-8.19]; no ultrasound [OR 13.7; 95%CI, 6.52-28.6]; no tourniquet [OR 2.32; 95%CI, 1.15-4.66]; and lack of post graduate certificate in renal nursing [OR 2.27; 95%CI, 1.31-3.93]. CONCLUSION: This study demonstrated a low rate of miscannulation. Further research is required on ultrasound-guided cannulation. Identifying variables associated with successful cannulation may be used to develop a VA cannulation complexity instrument that could be utilised to match to the cannulation skill of a competency-assessed nurse, thereby minimising the risk of missed cannulation and trauma