Turnover Rates and Factors Influencing Turnover of Korean Acute Care Hospital Nurses: A Retrospective Study Based on Survival Analysis

Background and aimNurse staffing levels are associated with patient mortality, but little is known regarding the association between nurse turnover rate and patient mortality. This study investigated the combined effect of the bed-to-nurse ratio and the nurse turnover rate on in-hospital mortality in patients admitted to Korean acute care hospitals using national administrative data.MethodsThis study analyzed data from the National Health Insurance Service (NHIS) on 459,113 admitted patients and 111,342 employed nurses in 403 hospitals in South Korea from January to December 2016. Differences in in-hospital mortality and nurse turnover among hospital characteristics, including the bed-to-nurse ratio, were explored using the chi-square test. Multilevel, multivariate GEE logistic regression analyses were used to examine the combined effect of the bed-to-nurse ratio and the nurse turnover rate on in-hospital mortality.ResultsDuring the study period, 13,675 (3.0%) patients died during hospitalization, and 13,349 (12.0%) nurses left their jobs. The risk of death among patients admitted to hospitals with a bed-to-nurse ratio of < 2.5 and a nurse turnover rate of ≥ 12% was lower than among patients admitted to hospitals with a bed-to-nurse ratio of ≥ 4.5 and a nurse turnover rate of ≥ 12% (odds ratio [OR] = 0.63; 95% confidence interval [CI], 0.48–0.82). The risk of in-hospital mortality decreased further when the nurse turnover rate was < 12% (OR = 0.59; 95% CI, 0.44–0.79).ConclusionThe bed-to-nurse ratio and nurse turnover rate were jointly associated with patient mortality. When hospitals with a low bed-to-nurse ratio also experienced high nurse turnover, the risk of in-hospital mortality was even greater. The finding of this study will help health policy makers to better understand the importance of both nursing staffing levels and nurse turnover rates. It is necessary to create a comprehensive improvement plan that integrates policies aiming to improve nurse staffing levels and reduce turnover rates into a single strategy.

While debates persist regarding the benefits and drawbacks of steroid use in treating vestibular neuritis (VN), few studies have analyzed real-world prescription patterns and clinical outcomes. This study aimed to fill this gap by leveraging South Korea's Health Insurance Review and Assessment (HIRA) big data to explore the actual use of steroids in clinical practice and their associated patient characteristics. Using HIRA data from 2007 to 2022, 237,673 VN patients were retrospectively analyzed and categorized into steroid (n = 23,235) and non-steroid groups (n = 214,438). Demographic, clinical, and economic variables, including age, sex, hospital type, medication use, and costs, were statistically compared using chi-square and t-tests. Steroid prescriptions accounted for 9.8% of VN cases, predominantly in females (63.2%) and younger patients (2.7% in the 20-24 age group vs. 1.6% in the non-steroid group). Prescription rates declined significantly in patients aged 55 years and older. Outpatients (87.2%) and those treated in clinics (65.1% for males, 75.3% for females) were more likely to receive steroids. Steroid prescriptions were also associated with lower hospital costs and insurance payments compared to the non-steroid group. This study is the first to analyze real-world steroid usage for VN through big data in Korea, offering valuable insights into clinical practices and prescription trends. Clinicians, especially in primary and outpatient clinic, are more likely to favor steroid treatment and avoid further testing or treatment when they are confident of diagnosing VN. However, the high rate of VN diagnosis in women suggests that vestibular migraine may be underdiagnosed and steroids may be misused. By identifying demographic and economic factors associated with steroid use, the findings highlight the importance of establishing evidence-based guidelines to optimize VN management in clinical settings.

This study evaluated the effect of sodium-glucose cotransporter-2 inhibitors (SGLT2i) on cancer development, particularly in hepatocellular carcinoma (HCC), in individuals with concomitant fatty liver disease (FLD) and type 2 diabetes mellitus (T2DM). Using data from Korea's Health Insurance Review and Assessment Service, we performed Kaplan-Meier and Cox regression analyses in patients with non-alcoholic fatty liver disease (NAFLD) and T2DM (NAFLD-T2DM cohort) and those with chronic viral hepatitis (CVH) alongside FLD and T2DM (FLD-T2DM-CVH cohort). In the propensity score (PS) matched NAFLD-T2DM cohort (N = 107,972), SGLT2i use was not associated with the occurrence of overall cancer, including HCC. However, old age, male sex, liver cirrhosis, and hypothyroidism were identified as independent risk factors for HCC occurrence, whereas statin and fibrate usage were associated with reduced HCC risk in this cohort in multivariate Cox analysis. In the PS-matched FLD-T2DM-CVH cohort (N = 2798), a significant decrease in HCC occurrence was observed among SGLT2i users (P = 0.03). This finding remained consistent in the multivariate Cox regression analysis (Hazard ratio = 2.21, 95% confidence interval = 1.01-4.85, P = 0.048). In conclusion, SGLT2i may be a beneficial option for diabetes management in patients with concomitant T2DM, FLD, and CVH while affirming the overall safety of SGLT2i in other types of cancer.

ObjectiveTo investigate the association between monthly turnover rates of hospital nurses and senior doctors and patient health outcomes (mortality and unplanned hospital readmissions).DesignRetrospective longitudinal study.SettingAll 148 NHS acute trusts in...

Objectives This study aimed to systematically review primary studies on the relationship between nurse staffing and hospital readmission. Methods This study was conducted based on a systematic review of related nursing literature and meta-analysis. The CINAHL, Cochrane Library, DBpia, PubMed, PsycINFO, and RISS databases were searched for either English or Korean language studies published between January 2000 and August 2018 that examined the association between nurse staffing and patient outcomes. Results Four studies examined the relationship between nurse staffing levels and readmission and all found negative relationships. Current evidence reveals that consistently higher nurse staffing is associated with better patient outcomes. The meta-analysis of 3 studies based on the random effect model showed that the higher nurse staffing level was effective in lowering readmission (odds ratio: 1.06; 95% confidence interval: 1.04-1.08). The meta-analyses revealed a significant increase in readmission in low nurse staffing levels. Conclusions The findings of this study suggest that sufficient nurse staffing is a strong indicator of the provision of nursing care quality. Continuous effort is recommended to set an optimal patient-to-nurse ratio to formulate guidelines regarding nurse staffing strategies. Key words: Nurse, Workforce, Readmission, Systematic review

The purpose of this study was to describe the (a) number and types of employed WOC certified nurses in acute care hospitals, (b) rates of hospital-acquired pressure injury (HAPI) and catheter-associated urinary tract infection (CAUTI), and (c) effectiveness of WOC certified nurses with respect to lowering HAPI and CAUTI occurrences. Retrospective analysis of data from National Database of Nursing Quality Indicators. The sample comprised 928 National Database of Nursing Quality Indicators (NDNQI) hospitals that participated in the 2012 NDNQI RN Survey (source of specialty certification data) and collected HAPI, CAUTI, and nurse staffing data during the years 2012 to 2013. We analyzed years 2012 to 2013 data from the NDNQI. Descriptive statistics summarized the number and types of employed WOC certified nurses, the rate of HAPI and CAUTI, and HAPI risk assessment and prevention intervention rates. Chi-square analyses were used to compare the characteristics of hospitals that do and do not employ WOC certified nurses. Analysis-of-covariance models were used to test the association between WOC certified nurses and HAPI and CAUTI occurrences. Just more than one-third of the study hospitals (36.6%) employed WOC certified nurses. Certified continence care nurses (CCCNs) were employed in fewest number. Hospitals employing wound care specialty certified nurses (CWOCN, CWCN, and CWON) had lower HAPI rates and better pressure injury risk assessment and prevention practices. Stage 3 and 4 HAPI occurrences among hospitals employing CWOCNs, CWCNs, and CWONs (0.27%) were nearly half the rate of hospitals not employing these nurses (0.51%). There were no significant relationships between nurses with specialty certification in continence care (CWOCN, CCCN) or ostomy care (CWOCN, COCN) and CAUTI rates. CWOCNs, CWCNs, and CWONs are an important factor in achieving better HAPI outcomes in acute care settings. The role of CWOCNs, CCCNs, and COCNs in CAUTI prevention warrants further investigation.

The aim of this study was to identify the patient and hospital characteristics related to nursing needs and nursing hours in acute hospital settings. To determine appropriate staffing levels, accumulating empirical data through direct observation and surveys reflecting the actual situation is necessary. In this cross-sectional study, we conducted direct observations of nurses in acute care hospitals from 1 May to 31 August 2020. Twenty-six hospitals in five cities participated, and 747 nursing personnel collected 1,681 patients' data while performing nursing activities. The data of 1,605 nurses were analysed using descriptive statistics, t tests, analysis of variance and linear regression. Hospital size, admission day, patients' dependence level, high fall risk and disease diagnoses were variables associated with nursing needs (F = 73.49, P < .001) and nursing hours (F = 57.7, P < .001). Comparing the correlates of nursing needs and nursing hours revealed that, unlike nursing needs, nursing hours were not significantly associated with surgery and certain diagnoses. This study confirmed the variables associated with nursing needs and nursing hours in acute hospitals; based on this, determining appropriate staffing levels, which is an important step in improving inpatients' health outcomes, is necessary. In acute hospitals, an increased number of nurse staffing should be employed based on the number of newly hospitalized patients, patients with high dependence levels and specific diagnoses, and those at high risk of falling.

FOREWORD 1 -- SYNTHESIS 2 -- 1. BACKGROUND 4 -- 1.1. THE BELGIAN NURSING WORKFORCE: A CONTEXT DESCRIPTION 5 -- 1.1.1. Two main educational pathways to enter the nursing profession 5 -- 1.1.2. The nursing workforce: facts and figures 5 -- 1.1.3. Nurse staffing levels in acute hospitals: licensing standards and hospital payment system 6 -- 1.2. THE IMPORTANCE OF ADEQUATE STAFFING LEVELS AND A GOOD NURSING WORK ENVIRONMENT 7 -- 1.2.1. Nurse staffing and outcomes are clearly associated but the relationship is complex 7 -- 1.2.2. Bedside nurse staffing levels in Belgian hospitals are known to be low in a European context 8 -- 1.3. A HOSPITAL LANDSCAPE IN EVOLUTION AND POTENTIAL IMPACT ON NURSING CARE 8 -- 1.4. STUDY OBJECTIVES – SCOPE AND APPROACH 9 -- 2. EVOLUTION IN THE INTENSITY OF NURSING CARE AND NURSE STAFFING LEVELS IN BELGIAN HOSPITALS 13 -- 2.1. EVOLUTION IN INTENSITY OF NURSING CARE AND NURSE STAFFING LEVELS 14 -- 2.1.1. Intensity of nursing care 14 -- 2.1.2. Nurse staffing levels 17 -- 2.1.3. Are nurse staffing levels adequate? 17 -- 2.1.4. Supporting staff 19 -- 2.2. RELATIONSHIP BETWEEN NURSE STAFFING LEVELS AND THE HOSPITAL BUDGET 19 -- 3. NURSE STAFFING LEVELS AND NURSING WORK ENVIRONMENT IN BELGIAN HOSPITALS 20 -- 3.1. NURSING WORK ENVIRONMENT 20 -- 3.2. NURSE STAFFING LEVELS 23 -- 3.2.1. Patient-to-nurse ratios 23 -- 3.2.2. Proportion of Bachelor-prepared nurses 24 -- 3.3. NURSING ACTIVITIES 24 -- 3.3.1. Care left undone as reported by nurses 24 -- 3.3.2. Non-nursing tasks 26 -- 3.4. NURSE OUTCOMES 26 -- 3.4.1. Risk of burnout 26 -- 3.4.2. Job dissatisfaction and intention to leave 28 -- 3.5. NURSE-PERCEIVED QUALITY OF CARE 28 -- 3.6. THE IMPACT OF FACTORS OF THE NURSING WORK ENVIRONMENT AND STAFFING ON (NURSE) OUTCOMES 28 -- 4. INTERNATIONAL SAFE STAFFING POLICIES 29 -- 4.1. BACKGROUND 29 -- 4.2. NURSING EDUCATION AND SKILL MIX 30 -- 4.3. WHY WERE ‘SAFE STAFFING POLICIES’ DEVELOPED? 30 -- 4.4. POLICY OPTIONS VARY FROM FLEXIBLE TO RIGID AND FROM LIMITED IN SCOPE TO VERY COMPREHENSIVE 31 -- 4.5. COMMON ELEMENTS AND OBJECTIVES OBSERVED IN SAFE STAFFING POLICIES 34 -- 4.6. IMPACT OF SAFE STAFFING POLICIES 35 -- 5. TOWARDS A SAFE STAFFING POLICY IN BELGIAN ACUTE HOSPITALS 37 -- 5.1. IMPROVE PATIENT-TO-NURSE RATIOS IN ACUTE HOSPITALS 37 -- 5.1.1. Use the nursing expertise for nursing care 45 -- 5.1.2. Simplify the hospital payment system and ensure a fair allocation system of (additional) resources for nurse staffing 45 -- 5.1.3. Nurse staffing levels on geriatric wards require specific attention 46 -- 5.2. A SAFE STAFFING POLICY AT THE MACRO-LEVEL 47 -- 5.2.1. Data-information system to inform and monitor a safe-staffing policy 47 -- 5.2.2. Evaluate the impact in a pro-active and systematic way 49 -- 5.3. STAFFING MATTERS FROM BOARD TO BEDSIDE 50 -- 5.3.1. Building a good environment for nurses with attention for staffing levels from board to bedside 50 -- 6. CONCLUSION 52 -- REFERENCES 53 -- RECOMMENDATIONS 59

Nursing turnover is a leading cause of inefficiency in health care delivery. Few studies have examined turnover among nurses who work in rural areas. We accessed human resources data that tracked hiring and terminations from a large health system operating in South Dakota, North Dakota, and Minnesota between January 2016 and December 2017. Our study sample included 7,634 registered nurses, 1,765 of whom worked in a rural community. Within the health system, there were 27 affiliated hospitals, 17 of which were designated critical access hospitals. We estimated nursing turnover rates overall and stratified turnover rates by available demographic and occupational characteristics, including whether the nurse worked in a community with an affiliated acute care hospital or critical access hospital. Overall, 19% of nurses left their position between January 2016 and December 2017. Turnover rates were associated with state, nurse gender and age, and occupational tenure, but were similar in urban and rural areas. Of note, turnover rates were significantly higher in communities without an affiliated acute care hospital or critical access hospital. Between 2016 and 2017, nearly 1 in 5 nurses working in this health system left their position. Turnover rates differed based on nurse demographics and selected occupational characteristics, including tenure. We also found higher turnover rates among nurses who worked in communities without an affiliated hospital, which points to a potential but unexplored benefit of hospitals in rural areas.

Acute care hospital nurse turnover is an important problem that affects patient care, operational efficiency and the overall healthcare outcome. Factors like work engagement and occupational stress can often cause high turnover rates. Previous research in the western context has shown that work engagement is negatively associated with turnover intention and occupational stress is positively related to it, but research in developing countries is scant. Work engagement and occupational stress are investigated as antecedents of turnover intention among nurses in acute care hospitals in Pakistan. Data were collected from 100 nurses using a quantitative approach via a structured survey. Here we analyse the results using Partial Least Squares Structural Equation Modelling (PLS-SEM), and find that work engagement significantly decreases turnover intention and occupational stress significantly increases it. These findings are relevant to the importance of creating a work engaged environment and management of occupational stress in order to increase nurse retention. The results are also useful for healthcare administrators developing retention strategies that will create a supportive work environment that will increase engagement and reduce stress.

This study aimed to assess the risk of secondary bladder and colorectal cancers following radiotherapy for prostate cancer using a nationwide nested case-control design based on Korea's Health Insurance Review and Assessment database. We conducted a nationwide nested case-control study using database, including men newly diagnosed with prostate cancer between 2011 and 2020. Patients were classified into radiotherapy and non-radiotherapy groups and matched 1:1 based on age, comorbidity index, and follow-up duration. Conditional logistic regression was used to assess the association between radiotherapy and secondary bladder and colorectal cancer incidences. In the crude cohort, radiotherapy was not significantly associated with secondary bladder or colorectal cancer. Kaplan-Meier analysis showed no significant differences in the cumulative incidence between radiotherapy and non-radiotherapy groups. However, nested case-control analysis revealed a significantly increased risk of secondary bladder cancer in the radiotherapy group (adjusted hazard ratio, 1.38; 95% confidence interval, 1.02 to 1.86), while no association was found for colorectal cancer (adjusted hazard ratio, 0.96; 95% confidence interval, 0.72 to 1.27). Radiotherapy was linked to an increased bladder cancer risk but not colorectal cancer risk, underscoring the need for targeted long-term surveillance.

Nurse staffing and patient outcomes: Strengths and limitations of the evidence to inform policy and practice. A review and discussion paper based on evidence reviewed for the National Institute for Health and Care Excellence Safe Staffing guideline development

Practice Problem: Nurse turnover rate and lack of retention are issues that have an impact on safe patient care, patient mortality, quality outcomes, and patient experiences in the acute care units at the identified project setting. Turnover leads to excess labor utilization of overtime and increased hospital costs. PICOT: The PICOT question that guided this project was (P) In acute care hospital nurses, how do (I) nurse retention strategies (C) compared with no nurse retention strategies (O) reduce nurses’ intention to leave and increase job satisfaction over (T) eight weeks? Evidence: Twenty-one articles were reviewed that identified autonomy, recognition, acknowledgement, communication, and transformational leadership as nurse retention strategies, which contributed to a positive workplace environment and led to improved job satisfaction and nurse retention. Intervention: The intervention consisted of focused communication that included staff recognition and acknowledgement by the nurse leaders of each unit, which had a positive effect on the workplace environment and job satisfaction. Outcome: The results indicated a statistically insignificant change in job satisfaction and intent to stay yet did show a clinical significance. Conclusion: The benefit of the project was that there was a clinically significant change in behaviors including: verbal expressions of increased job satisfaction, notable positive attitudes and hopefulness, as well as staff resilience. Consistent leadership and a larger sample size may produce statistical significance in a future study.

Sophisticated anti-fraud systems for the healthcare sector have been built based on several statistical methods. Although existing methods have been developed to detect fraud in the healthcare sector, these algorithms consume considerable time and cost, and lack a theoretical basis to handle large-scale data. Based on mathematical theory, this study proposes a new approach to using Benford's Law in that we closely examined the individual-level data to identify specific fees for in-depth analysis. We extended the mathematical theory to demonstrate the manner in which large-scale data conform to Benford's Law. Then, we empirically tested its applicability using actual large-scale healthcare data from Korea's Health Insurance Review and Assessment (HIRA) National Patient Sample (NPS). For Benford's Law, we considered the mean absolute deviation (MAD) formula to test the large-scale data. We conducted our study on 32 diseases, comprising 25 representative diseases and 7 DRG-regulated diseases. We performed an empirical test on 25 diseases, showing the applicability of Benford's Law to large-scale data in the healthcare industry. For the seven DRG-regulated diseases, we examined the individual-level data to identify specific fees to carry out an in-depth analysis. Among the eight categories of medical costs, we considered the strength of certain irregularities based on the details of each DRG-regulated disease. Using the degree of abnormality, we propose priority action to be taken by government health departments and private insurance institutions to bring unnecessary medical expenses under control. However, when we detect deviations from Benford's Law, relatively high contamination ratios are required at conventional significance levels.

First-year treatment adherence among outpatients initiating antihypertensive medication in Korea: Results of a retrospective claims review