Demanding safe staffing levels to ensure quality nursing care

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Explaining differences in English hospital death rates using routinely collected data
Objectives To ascertain hospital inpatient mortality in England and to determine which factors best explain variation in standardised hospital death ratios. Design Weighted linear regression analysis of routinely collected data over four years, with hospital standardised mortality ratios as the dependent variable. Setting England. Subjects Eight million discharges from NHS hospitals when the primary diagnosis was one of the diagnoses accounting for 80% of inpatient deaths. Main outcome measures Hospital standardised mortality ratios and predictors of variations in these ratios.

Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States
Objective To determine whether hospitals with a good organisation of care (such as improved nurse staffing and work environments) can affect patient care and nurse workforce stability in European countries. Design Cross sectional surveys of patients and nurses. Setting Nurses were surveyed in general acute care hospitals (488 in 12 European countries; 617 in the United States); patients were surveyed in 210 European hospitals and 430 US hospitals. Participants 33 659 nurses and 11 318 patients in Europe; 27 509 nurses and more than 120 000 patients in the US. Main outcome measures Nurse outcomes (hospital staffing, work environments, burnout, dissatisfaction, intention to leave job in the next year, patient safety, quality of care), patient outcomes (satisfaction overall and with nursing care, willingness to recommend hospitals).

Nurse Staffing and Healthcare Outcomes A Systematic Review of the International Research Evidence
The relationship between quality of care and the cost of the nursingworkforce is of concern to policymakers. This study assesses the evidence for a relationship between the nursing workforce and patient outcomes in the acute sector through a systematic review of international research produced since 1990 involving acute hospitals and adjusting for case mix. Twentytwo large studies of variable quality were included. They strongly suggest that higher nurse staffing and richer skill mix (especially of registered nurses) are associated with improved patient outcomes, although the effect size cannot be estimated reliably. The association appears to show diminishing marginal returns.

The Association of Registered Nurse Staffing Levels and Patient Outcomes
Objective : To examine the association between registered nurse (RN) staffing and patient outcomes in acute care hospitals. Study Selection : 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.

Nurse, care assistant and medical staffing: the relationship with mortality in English Acute Hospitals (Abstract)
Background : Higher levels of registered nurse (RN) staffing is associated with lower mortality and better quality of care in many studies. This research has rarely considered staffing by other groups including doctors. Workforce policy in the UK implies a reconfiguration of the care workforce with fewer registered nurses and a larger number of assistant practitioners and health care assistants (HCA). Therefore this study examines the association between medical, nursing, HCA staffing and standardised mortality rates.

'Care left undone' by nurses in English National Health Service (NHS) hospitals; the association with staffing levels, perceived quality and safety of nursing care (Abstract)
Aim : To examine the nature and prevalence of 'care left undone' by nurses in English National Health Service (NHS) hospitals and to assess whether the number of missed care episodes is associated with nurse staffing levels and nurse ratings of the quality of nursing care and patient safety environment. Background : There is strong evidence to show that lower nurse staffing levels in hospitals are associated with worse patient outcomes. However, little is known about how variations in staffing impact on patients. One hypothesised mechanism is the omission of necessary nursing care caused by time pressure - "missed care". Methods : Cross-sectional survey of 2,917 registered nurses (RN) working in 401 general medical/surgical wards in 46 general acute NHS hospitals in England.

RN4CAST Nurse Survey in England
The RN4CAST study aims to develop innovative forecasting methods of future nursing requirements by considering not only volumes, but quality of patient care. England is one of the 15 countries making up the RN4Cast consortium1. The National Nursing Research Unit (NNRU) has led the study in England and also led the development of an agreed protocol for collecting health outcome data across the nations of the consortium and dissemination strategy.

Is it time to set minimum nurse staffing levels in English hospitals?
Increasing economic pressures on healthcare systems raise concerns about how workforce cuts and reconfigurations may affect quality [1]. Currently there are no centrally set minimum staffing levels for National Health Service organisations; providers are responsible for determining staffing requirements locally. In this Policy+ we look at the impact mandated minimum Registered Nurse (RN) staffing levels have had in other countries and consider current guidelines and recommendations.

Patient Turnover and the Relationship Between Nurse Staffing and Patient Outcomes
Abstract : High patient turnover (patient throughput generated by admissions, discharges, and transfers) contributes to increased demands and resources for care. We examined how the relationship between registered nurse (RN) staffing and failure-to-rescue (FTR) varied with patient turnover levels by analyzing quarterly data from the University HealthSystem Consortium. The data included 42 hospitals, representing 759 nursing units and about 1 million inpatients. Higher RN staffing was associated with lower FTR. When patient turnover increased from 48.6% to 60.7% on nonintensive units (non-ICUs), the beneficial effect of non-ICU RN staffing on FTR was reduced by 11.5%. RN staffing should be adjusted according to patient turnover because turnover increases patient care demand beyond that presented by patient count, and outcomes may be adversely affected.

Benchmarking nurse staffing levels: the development of a nationwide feedback tool
Aim . This paper is a report of a study to develop a methodology that corrects nurse staffing for nursing care intensity in a way that allows nationwide benchmarking of nurse staffing data. Background . Although nurse workload measurement systems are recognized to be informative in nurse staffing decisions, they are rarely used. When these systems are used, however, it is only possible to compare units within hospitals, because currently available instruments are not standardized for comparisons beyond hospital boundaries. The Belgian Nursing Minimum Dataset (B-NMDS) contains uniformly measured data about the intensity of nursing care and nurse staffing levels for all hospitals in Belgium.

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