Query: perioperative nurse staffing

title: Communication, teamwork, and trust in an office based practice.
abstract: A s a certified registered nurse anesthetist (CRNA) I provide anesthesia services for plastic and endoscopy procedures in an office based setting. Office based practice has unique advantages and efficiencies that are similar to an outpatient surgery center while requiring the same vigilance and standard of care as any other perioperative practice setting. Advantages of officebased practice, when compared to an inpatient or other outpatient setting, include increased patient and provider convenience and satisfaction, scheduling flexibility, staffing consistency, efficiency, patient privacy, increased cost effectiveness, and decreased risk of infection. My experience as a member of small clinical teams, providing patient care for both brief and sometimes lengthy procedures, confirms the importance of teamwork, effective communication, and collaboration during all phases of patient care. Office based team members have multiple responsibilities that they complete collaboratively. These responsibilities include optimizing patient care, improving communication with the patient, and building and promoting a culture of safety. Additional responsibilities that affect the provision of care in the office based setting include participating in professional advocacy, participating in professional associations and leadership activities,

title: Hospital nurse staffing models and patient and staff related outcomes.
abstract: Nurses comprise the largest component of the health workforce worldwide and numerous models of workforce allocation and profile have been implemented. These include changes in skill mix, grade mix or qualification mix, staff allocation models, staffing levels, nursing shifts, or nurses' work patterns. This is the first update of our review published in 2011.  The purpose of this review was to explore the effect of hospital nurse staffing models on patient and staff related outcomes in the hospital setting, specifically to identify which staffing model(s) are associated with: 1) better outcomes for patients, 2) better staff related outcomes, and, 3) the impact of staffing model(s) on cost outcomes. SEARCH METHODS CENTRAL, MEDLINE, Embase, two other databases and two trials registers were searched on 22 March 2018 together with reference checking, citation searching and contact with study authors to identify additional studies.  We included randomised trials, non randomised trials, controlled before after studies and interrupted time series or repeated measures studies of interventions relating to hospital nurse staffing models. Participants were patients and nursing staff working in hospital settings. We included any objective reported measure of patient staff related, or economic outcome. The most important outcomes included in this review were: nursing staff turnover, patient mortality, patient readmissions, patient attendances at the emergency department (ED) length of stay, patients with pressure ulcers, and costs.  We worked independently in pairs to extract data from each potentially relevant study and to assess risk of bias and the certainty of the evidence.  We included 19 studies, 17 of which were included in the analysis and eight of which we identified for this update. We identified four types of interventions relating to hospital nurse staffing models: introduction of advanced or specialist nurses to the nursing workforce; introduction of nursing assistive personnel to the hospital workforce; primary nursing; and staffing models.The studies were conducted in the USA, the Netherlands, UK, Australia, and Canada and included patients with cancer, asthma, diabetes and chronic illness, on medical, acute care, intensive care and long stay psychiatric units. The risk of bias across studies was high, with limitations mainly related to blinding of patients and personnel, allocation concealment, sequence generation, and blinding of outcome assessment.The addition of advanced or specialist nurses to hospital nurse staffing may lead to little or no difference in patient mortality (3 studies, 1358 participants) It is uncertain whether this intervention reduces patient readmissions (7 studies, 2995 participants) patient attendances at the ED (6 studies, 2274 participants) length of stay (3 studies, 907 participants) number of patients with pressure ulcers (1 study, 753 participants) or costs (3 studies, 617 participants) as we assessed the evidence for these outcomes as being of very low certainty. It is uncertain whether adding nursing assistive personnel to the hospital workforce reduces costs (1 study, 6769 participants) as we assessed the evidence for this outcome to be of very low certainty. It is uncertain whether primary nursing (3 studies, 464 participants) or staffing models (1 study, 647 participants) reduces nursing staff turnover, or if primary nursing (2 studies, 138 participants) reduces costs, as we assessed the evidence for these outcomes to be of very low certainty.  The findings of this review should be treated with caution due to the limited amount and quality of the published research that was included. We have most confidence in our finding that the introduction of advanced or specialist nurses may lead to little or no difference in one patient outcome (i.e. mortality) with greater uncertainty about other patient outcomes (i.e. readmissions, ED attendance, length of stay and pressure ulcer rates) The evidence is of insufficient certainty to draw conclusions about the effectiveness of other types of interventions, including new nurse staffing models and introduction of nursing assistive personnel, on patient, staff and cost outcomes. Although it has been seven years since the original review was published, the certainty of the evidence about hospital nurse staffing still remains very low.

title: Association of Nurse Engagement and Nurse Staffing on Patient Safety
abstract: Supplemental Digital Content is Available in the Text.  Nurse engagement is a modifiable element of the work environment and has shown promise as a potential safety intervention.  Our study examined the relationship between the level of engagement, staffing, and assessments of patient safety among nurses working in hospital settings.  A secondary analysis of linked cross sectional data was conducted using survey data of 26 960 nurses across 599 hospitals in 4 states. Logistic regression models were used to examine the association between nurse engagement, staffing, and nurse assessments of patient safety.  Thirty two percent of nurses gave their hospital a poor or failing patient safety grade. In 25% of hospitals, nurses fell in the least or only somewhat engaged categories. A 1 unit increase in engagement lowered the odds of an unfavorable safety grade by 29% (P .001) Hospitals where nurses reported higher levels of engagement were 19% (P .001) less likely to report that mistakes were held against them. Nurses in poorly staffed hospitals were 6% more likely to report that important information about patients "fell through the cracks" when transferring patients across units (P .001)  Interventions to improve nurse engagement and adequate staffing serve as strategies to improve patient safety.

title: Association of nurse staffing and nursing workload with ventilator associated pneumonia and mortality: a prospective, single center cohort study.
abstract: Nurse understaffing and increased nursing workload have been associated with increased risk of adverse patient outcomes and even mortality.  To determine whether nurse staffing and nursing workload are associated with ventilator associated pneumonia and mortality.  This prospective, observational cohort study was conducted in a single tertiary level teaching hospital in Finland during 2014 2015. The association between nurse staffing, nursing workload and prognosis was determined using daily nurse to patient ratios, Therapeutic Intervention Scoring System and Intensive Care Nursing Scoring System scores, and Intensive Care Nursing Scoring System indices. Ventilator associated pneumonia was defined according to the Centers for Disease Control and Prevention criteria.  Evaluable data was available for 85 patients. The overall ventilator associated pneumonia and 28 day mortality rates were 23.5% and 35.3% respectively. Nurse staffing, measured as the daily lowest nurse to patient ratio (P 0.006) and median Intensive Care Nursing Scoring System index (P 0.046) were significantly lower in patients with ventilator associated pneumonia. In addition, nursing workload, measured as median scores obtained by the Therapeutic Intervention Scoring System (P 0.009) and Intensive Care Nursing Scoring System (P 0.03) was significantly higher in infected patients. The median (P 0.02) and daily highest (P 0.03) Intensive Care Nursing Scoring System scores were significantly higher in non survivors.  Lower nurse staffing and increased nursing workload are associated with ventilator associated pneumonia and mortality, demonstrating that adequate staffing is a prerequisite for the availability and quality of critical care services.

title: Nurse staffing level and quality of acute care services: Evidence from cross national panel data analysis in OECD countries
abstract: Most of previous studies aimed to estimate the effect of nurse staffing on quality of acute hospital care have used stochastic methods and their results are mixed.  To measure the magnitude of effect of nurse staffing level on increasing quality of acute care services in long run.  The number of practicing nurses' density per 1000 population as the proxy of nurse staffing level and three Health Care Quality Indicators (HCQI) included 30 day mortality per 100 patients based on acute myocardial infarction (MORTAMIO) hemorrhagic stroke (MORTHSTO) and ischemic stroke (MORTISTO) were collected as a part of ongoing project by OECD.org in panels of 26 OECD countries over 2005 2015 period.  Panel data analysis.  There were committed relationships from nurse staffing level to the enhancement of HCQI i.e. 1% increase in nurse staffing level would reduce the rates of patient mortality based on MORTAMIO, MORTHSTO and MORTISTO by 0.65% 0.60% and 0.80% respectively. Furthermore, the role of nurse staffing level in increasing overall HCQI were simulated at the highest level in Sweden 3.53) Denmark 3.31) Canada 2.59) Netherlands 2.33) Finland 2.09) Switzerland 1.72) Australia 1.64) and United States 1.53)  A higher proportion of nurses staffing level is associated with higher quality of acute care services in OECD countries. Also, the nursing characteristics of Sweden, Denmark, Canada, Netherlands, Finland, Switzerland, Australia and United States would be good patterns for other countries to maximize nursing outcomes in the care of patients with acute and life threatening conditions by reducing the risk of complication, mortality and adverse clinical outcomes.

title: Post operative mortality, missed care and nurse staffing in nine countries: A cross sectional study
abstract: Variation in post operative mortality rates has been associated with differences in registered nurse staffing levels. When nurse staffing levels are lower there is also a higher incidence of necessary but missed nursing care. Missed nursing care may be a significant predictor of patient mortality following surgery.  Examine if missed nursing care mediates the observed association between nurse staffing levels and mortality.  Data from the RN4CAST study (2009 2011) combined routinely collected data on 422,730 surgical patients from 300 general acute hospitals in 9 countries, with survey data from 26,516 registered nurses, to examine associations between nurses' staffing, missed care and 30 day in patient mortality. Staffing and missed care measures were derived from the nurse survey. A generalized estimation approach was used to examine the relationship between first staffing, and then missed care, on mortality. Bayesian methods were used to test for mediation.  Nurse staffing and missed nursing care were significantly associated with 30 day case mix adjusted mortality. An increase in a nurse's workload by one patient and a 10% increase in the percent of missed nursing care were associated with a 7% (OR 1.068, 95% CI 1.031 1.106) and 16% (OR 1.159 95% CI 1.039 1.294) increase in the odds of a patient dying within 30 days of admission respectively. Mediation analysis shows an association between nurse staffing and missed care and a subsequent association between missed care and mortality.  Missed nursing care, which is highly related to nurse staffing, is associated with increased odds of patients dying in hospital following common surgical procedures. The analyses support the hypothesis that missed nursing care mediates the relationship between registered nurse staffing and risk of patient mortality. Measuring missed care may provide an 'early warning' indicator of higher risk for poor patient outcomes.

title: The impact of nurse staffing levels and nurse's education on patient mortality in medical and surgical wards: an observational multicentre study
abstract: BackgroundGrowing evidence indicates that improved nurse staffing in acute hospitals is associated with lower hospital mortality. Current research is limited to studies using hospital level data or without proper adjustment for confounders which makes the translation to practice difficult.MethodIn this observational study we analysed retrospectively the control group of a stepped wedge randomised controlled trial concerning 14 medical and 14 surgical wards in seven Belgian hospitals. All patients admitted to these wards during the control period were included in this study. Pregnant patients or children below 17 years of age were excluded. In all patients, we collected age, crude ward mortality, unexpected death, cardiac arrest with Cardiopulmonary Resuscitation (CPR) and unplanned admission to the Intensive Care Unit (ICU) A composite mortality measure was constructed including unexpected death and death up to 72 h after cardiac arrest with CPR or unplanned ICU admission. Every 4 months we obtained, from 30 consecutive patient admissions across all wards, the Charlson comorbidity index. The amount of nursing hours per patient days (NHPPD) were calculated every day for 15 days, once every 4 months. Data were aggregated to the ward level resulting in 68 estimates across wards and time. Linear mixed models were used since they are most appropriate in case of clustered and repeated measures data.ResultsThe unexpected death rate was 1.80 per 1000 patients. Up to 0.76 per 1000 patients died after CPR and 0.62 per 1000 patients died after unplanned admission to the ICU. The mean composite mortality was 3.18 per 1000 patients. The mean NHPPD and proportion of nurse Bachelor hours were respectively 2.48 and 0.59. We found a negative association between the nursing hours per patient day and the composite mortality rate adjusted for possible confounders (B 2.771, p 0.002) The proportion of nurse Bachelor hours was negatively correlated with the composite mortality rate in the same analysis (B 8.845, p 0.023) Using the regression equation, we calculated theoretically optimal NHPPDs.ConclusionsThis study confirms the association between higher nurse staffing levels and lower patient mortality controlled for relevant confounders.

title: How many nurses do we need? A review and discussion of operational research techniques applied to nurse staffing.
abstract: Despite a long history of health services research that indicates that having sufficient nursing staff on hospital wards is critical for patient safety, and sustained interest in nurse staffing methods, there is a lack of agreement on how to determine safe staffing levels. For an alternative viewpoint, we look to a separate body of literature that makes use of operational research techniques for planning nurse staffing. Our goal is to provide examples of the use of operational research approaches applied to nurse staffing, and to discuss what they might add to traditional methods. The paper begins with a summary of traditional approaches to nurse staffing and their limitations. We explain some key operational research techniques and how they are relevant to different nurse staffing problems, based on examples from the operational research literature. We identify three key contributions of operational research techniques to these problems: "problem structuring" handling complexity and numerical experimentation. We conclude that decision making about nurse staffing could be enhanced if operational research techniques were brought in to mainstream nurse staffing research. There are also opportunities for further research on a range of nurse staff planning aspects: skill mix, nursing work other than direct patient care, quantifying risks and benefits of staffing below or above a target level, and validating staffing methods in a range of hospitals.

title: Hospital nurse staffing and staff patient interactions: an observational study
abstract: Existing evidence indicates that reducing nurse staffing and/or skill mix adversely affects care quality. Nursing shortages may lead managers to dilute nursing team skill mix, substituting assistant personnel for registered nurses (RNs) However, no previous studies have described the relationship between nurse staffing and staff patient interactions.  Six wards at two English National Health Service hospitals.  We observed 238 hours of care (n=270 patients) Staff patient interactions were rated using the Quality of Interactions Schedule. RN, healthcare assistant (HCA) and patient numbers were used to calculate patient to staff ratios. Multilevel regression models explored the association between staffing levels, skill mix and the chance of an interaction being rated as 'negative' quality, rate at which patients experienced interactions and total amount of time patients spent interacting with staff per observed hour. % of the 3076 observed interactions were rated as negative. The odds of a negative interaction increased significantly as the number of patients per RN increased (p=0.035, OR of 2.82 for =8 patients/RN compared with >6 to <8 patients/RN) A similar pattern was observed for HCA staffing but the relationship was not significant (p=0.056) When RN staffing was low, the odds of a negative interaction increased with higher HCA staffing. Rate of interactions per patient hour, but not total amount of interaction time, was related to RN and HCA staffing levels.  Low RN staffing levels are associated with changes in quality and quantity of staff patient interactions. When RN staffing is low, increases in assistant staff levels are not associated with improved quality of staff patient interactions. Beneficial effects from adding assistant staff are likely to be dependent on having sufficient RNs to supervise, limiting the scope for substitution.

title: Determining acute nurse staffing: a hermeneutic review of an evolving science
abstract: Calculating nurse staffing in the acute hospital has become a key issue but solutions appear distant. Community, mental health and areas such as learning disability nursing have attracted less attention and remain intractable. This review aims to examine current approaches to the issue across many disciplines.  The approach taken is iterative and in the form of a hermeneutic review. 769 pieces of evidence were reviewed from across disciplines such as nursing, medicine, engineering, statistics, population science, computer science and mathematics where hospital nurse staffing was the subject of the study.  A number of themes emerged. The first iteration showed the predominance of unit base approaches (eg, nurse numbers, ratios, activity and workload) and the second was the development of methodologies. Subsequent iterations examined issues such as demand, safety, nurse education, turnover, patient outcomes, patient or staff satisfaction, workload and activity. The majority of studies examined (n=767) demonstrated some association between staffing (units or type/skill) and various factors such as staff or patient satisfaction, working conditions, safety parameters, outcomes complexity of work achieved, work left undone or other factors. Many potential areas such as operational safety research were not utilised.  Although the relationship between staffing in acute care and factors such as units, safety or workload is complex, the evidence suggests an interdependent relationship which should only be dismissed with caution. The nature of these relationships should be further examined in order to determine nurse staffing. The body of knowledge appears substantial and complex yet appears to have little impact on policy.