Nursing Skill Mix Research Articles

Informing policy with health labour market analysis to improve availability of family doctors in Tajikistan

BackgroundTajikistan has embarked on health reforms to orient the health system towards primary health care (PHC). The health labour market analysis (HLMA) was initiated by the Ministry of Health with the World Health Organization (WHO) on policy questions related to the PHC workforce team. This article presents the results with focus on family doctors as a critical part of the PHC team, providing lessons for strengthening family medicine and PHC in the European Region and central Asia.MethodsThe HLMA framework was used to guide the analysis. The data for analysis were provided by the Ministry of Health and Social Protection of the Population of the Republic of Tajikistan. Descriptive means were used to analyse the data. A Technical Working Group guided the process.ResultsThere has been an increase in the number of health workers in the country over the last 7 years. However, there is a huge shortage of family doctors when compared with norms, with decreasing family doctor densities over the last 7 years. Family doctors have the highest vacancy rates among specialists and also constitute the highest proportion of specialists who migrate. There is inequitable distribution of doctors across the regions. Overall number of enrolments and graduates in family medicine are declining. Although salaries in PHC are higher than in hospitals, the overall health workforce salaries are lower than the national average. While there have been efforts to retain and attract doctors to PHC in rural and remote regions, challenges exist. The attraction of doctors to narrow specialties may be leading to undermining PHC and family medicine. While the optimal skill-mix and availability of nurses provide an opportunity to strengthen multi-disciplinary teams at the PHC level, shortages and unequal distribution of doctors are affecting health services coverage and health indicators.ConclusionsApplication of the HLMA framework has helped identify the bottlenecks in the health labour market flows and the possible explanations for them. The policy considerations emerging out of the HLMA have contributed to improving evidence-based planning for retention and recruitment of the PHC workforce, improvements in medical and nursing education, and higher investments in the PHC workforce and particularly in family doctors. Implementation of the Action Plan will require political commitment, financial resources, strong inter-sectoral collaboration, stakeholder management, and cross-country learning of best practices. Through this process, Tajikistan has shown the way forward in implementing the Central Roadmap for health and well-being in Central Asia and the Framework for Action on the Health and Care Workforce in the WHO European Region.

Evaluating associations between patient-to-nurse ratios and mortality, process of care events and vital sign documentation on paediatric wards: a secondary analysis of data from the EPOCH cluster-randomised trial

ObjectiveTo describe the associations between patient-to-nurse staffing ratios and rates of mortality, process of care events and vital sign documentation.DesignSecondary analysis of data from the evaluating processes of care and...

Patient dependency in the Oncology Emergency Room. Reliability and validity of the Jones Dependency Tool

BackgroundPatients’ dependency has significant nursing implications. Nurse skill mix and staffing levels may be addressed more successfully when dependency can be measured. In the oncology emergency room, a valid and reliable tool that measures patients’ dependency on nursing care is necessary. AimThis study aimed to evaluate the psychometric properties of the Jones Dependency Tool in Adult Oncology Emergency Setting at a Cancer Center in Jordan. MethodsA prospective cross-sectional design was used to test the Reliability and Validity of the Jones Dependency Tool among patients with cancer visiting the ED. A sample of 79 patients were assessed using the JDT and Conner’s tool. ResultsJones Dependency Tool showed a high level of validity and reliability. In terms of reliability, which was tested by test-re-test, Intra-class correlation (ICC) = 0.902 which indicates good to excellent. The tool demonstrates a high validity evidenced by its correlation with a criterion (p < 0.001). ConclusionThe study demonstrated that the JDT tool is a valid and reliable tool that can be used to quantify a patient's dependency level and the level of nursing care they need, assisting in the selection of the ideal staffing level in terms of quantity and skill mix.

Relationships among Nursing Skill Mix, Missed Nursing Care, and Adverse Events in Small and Medium-Sized Hospital Comprehensive Nursing Care Wards

Relationships among Nursing Skill Mix, Missed Nursing Care, and Adverse Events in Small and Medium-Sized Hospital Comprehensive Nursing Care Wards

CONTRACT NURSE STAFFING AND NURSING HOMES: ANTECEDENTS AND CONSEQUENCES

Abstract Nursing home (NH) quality has been a matter of long-standing policy interest at the federal and state level, as it concerns the health and well-being of one of our most vulnerable populations. Nurse staffing intensity and skill mix have a consequential impact on NH care quality. Unfortunately, NH staffing has been marked by multitudes of challenges including high levels of turnover and absenteeism. In recent years, the utilization of agency or contract nurse staffing has increased as facilities face persistent staffing shortages exacerbated by COVID-19 which has had a disproportionate and devastating impact on NHs. The literature suggests that agency staffing negatively influences the performance of healthcare organizations due to multiple reasons including unfamiliarity with organizational culture, decline in teamwork, and the attendant high costs attached to contract staffing. However, contract nurse utilization practices and its impact on NH care has not been studied adequately, and much of the limited literature relies on datasets with limited understanding of agency staffing. The overarching goal of this symposium is to explore the antecedents and consequences of the increased utilization of contract nurse staffing. As part of the symposium, we include studies examining NH nursing skill mix and intensity, the organizational and market level factors associated with higher levels of contract staffing, and the impact of nurse contract staffing on NH staff turnover, quality, and financial performance. We believe that this series of studies would have important managerial and policy implications. This is a Research in Quality of Care Interest Group Sponsored Symposium.

Evaluating trends in private equity ownership and impacts on health outcomes, costs, and quality: systematic review

ObjectiveTo review the evidence on trends and impacts of private equity (PE) ownership of healthcare operators.DesignSystematic review.Data sourcesPubMed, Web of Science, Embase, Scopus, and SSRN.Eligibility criteria for study selectionEmpirical research...

Nursing Research Priorities based on the Nurse-sensitive Indicators: Scoping Review

Background: Patient-centeredness, safety, and quality of care are major healthcare concerns worldwide. Clinical indicators are essential for monitoring and evaluating safety and quality of care within the health care system. Therefore, research on clinical indicators can improve the quality of care, promote good practices, clarify key concepts, and identify gaps vital to nursing care. Objective: The study aims to explore nurse-sensitive indicators to find significant research areas and prioritize them. Design: The study design is exploratory research conducted through scoping review, followed by Delphi consultation to identify nurse-sensitive indicators applicable in the Saudi Arabia health care system and prioritize these indicators as research areas. Results: The most frequently cited indicators are patient fall, medication error, patient satisfaction, catheter-associated infection, pain, pressure ulcer, the incidence of deep vein thrombosis or pulmonary embolism, appropriate levels of nursing skill mix, and nursing initial and need assessment. The result shows that (33) NSIs are essential to the quality of nursing care and patient safety in Saudi Arabia. Conclusion: Patient-centeredness, patient safety, a healthy work environment, and a nursing informatics system are significant research dimensions. We found that nurse satisfaction, patient satisfaction, pressure ulcers, patient falls, nurse-patient communication, patient engagement, and pain management are research priorities. Recommendations: Further studies must be conducted on NSIs that address patient-centeredness, safety, a healthy work environment, and a nursing informatics system. It can be observed that most of the studies focused on outcome indicators, and there is a need to study patient-reported indicators as a significant patient-centered concept.

The relationship between nursing skill mix and severity of illness of patients admitted in Australian and New Zealand intensive care units

BackgroundCritically ill patients in the intensive care environment require an appropriate nursing workforce to improve quality of care and patient outcomes. However, limited information exists as to the relationship between severity of illness and nursing skill mix in the intensive care. ObjectiveThe aim of this study was to describe the variation in nursing skill mix across different hospital types and to determine if this was associated with severity of illness of critically ill patients admitted to adult intensive care units (ICUs) in Australia and New Zealand. Design & SettingA retrospective cohort study using the Australia and New Zealand Intensive Care Society Adult Patient Database (to provide information on patient demographics, severity of illness, and outcome) and the Critical Care Resources Registry (to provide information on annual nursing staffing levels and hospital type) from July 2014 to June 2020. Four hospital types (metropolitan, private, rural/regional, and tertiary) and three patient groups (elective surgical, emergency surgical, and medical) were examined. Main outcome measureThe main outcome measure was the proportion of critical care specialist registered nurses (RNs) expressed as a percentage of the full-time equivalent (FTE) of total RNs working within each ICU each year, as reported annually to the Critical Care Resources Registry. ResultsData were examined for 184 ICUs in Australia and New Zealand. During the 6-year study period, 770 747 patients were admitted to these ICUs. Across Australia and New Zealand, the median percentage of registered nursing FTE with a critical care qualification for each ICU (n = 184) was 59.1% (interquartile range [IQR] = 48.9–71.6). The percentage FTE of critical care specialist RNs was highest in private [63.7% (IQR = 52.6–78.2)] and tertiary ICUs [58.1% (IQR = 51.2–70.2)], followed by metropolitan ICUs [56.0% (IQR = 44.5–68.9)] with the lowest in rural/regional hospitals [55.9% (IQR = 44.9–70.0)]. In ICUs with higher percentage FTE of critical care specialist RNs, patients had higher severity of illness, most notably in tertiary and private ICUs. This relationship was persistent across all hospital types when examining subgroups of emergency surgical and medical patients and in multivariable analysis after adjusting for the type of hospital and relative percentage of each diagnostic group. ConclusionsIn Australian and New Zealand ICUs, the highest acuity patients are cared for by nursing teams with the highest percentage FTE of critical care specialist RNs. The Australian and New Zealand healthcare system has a critical care nursing workforce which scales to meet the acuity of ICU patients across Australia and New Zealand.

Skilled Nursing Facility Participation in Bundled Payments Was Related to Small Increases in Nurse Staffing Levels.

Medicare implemented Bundled Payments for Care Improvement (BPCI) Model 3 in 2013, in which participating skilled nursing facilities (SNFs) were accountable for episode costs. We performed comparative interrupted time series analyses to evaluate associations between SNF BPCI participation and nurse staffing levels, using Medicare claims, resident assessments, and facility-level and market-level files of 2010-2017. For persistent-participating SNFs, BPCI was associated with improved certified nursing assistant (CNA) staffing levels (differential change = .03hours, p = .025). However, BPCI was not related to changes in registered nurse (RN) and all licensed nurse hours, and nurse skill mix. Among drop-out SNFs, BPCI was associated with increased RN staffing levels (differential change = .02hours, p = .009), leading to a higher nurse skill ratio (0.51 percentage points, p = .016) than control SNFs. Bundled payments for care improvement had no impact on CNA and all licensed nurse staffing levels. In conclusion, BPCI was associated with statistically significant but small increases in nurse staffing levels.

Identifying gaps in global evidence for nurse staffing and patient care outcomes research in low/middle-income countries: an umbrella review

ObjectiveTo identify nurse staffing and patient care outcome literature in published systematic reviews and map out the evidence gaps for low/middle-income countries (LMICs).MethodsWe included quantitative systematic reviews on nurse staffing...

CN67 Scattered ward care: The importance of appropriate nursing skill mix in managing oncology inpatients

Patients with cancer may require inpatient care at times during their care. Most hospitals have specialised cancer wards, though often with limited bed capacity. Most of these wards are focused on the provision of systemic therapy, acute symptom control or a combination of these interventions. The remainder of the oncology inpatients are often cared for in the same hospital but scattered around various wards where the skill mix of the nursing staff may not be focused on the management of patients with cancer. This assessment aims to evaluate the distribution of care for patients with cancer within an ESMO designated centre for integrated oncology and palliative care. Patients with cancer admitted under the medical oncology service between 3-4/22 were included in the analysis. Data was collected regarding the bed utilisations per ward where the patient was cared for, their underlying diagnosis, the reason for the admission, and the core function of the patients' ward. During the period of 1/3/22 to 26/4/22 there were 1696 bed days used across 28 wards for 167 admitted patients. Patient care was delivered via the core inpatient chemotherapy unit in 40% of bed days assessed, with 1 other ward (Hamilton ward) providing care for 15% of bed days assessed. The remaining 26 wards each provided care for 0.05 to 6% of the clinical admission. Surgical wards were involved in 11% of the care. ICU represented only 1% of bed days. 66% of admissions related to cancer-related symptoms; 10% related to the provision of chemotherapy, 7% related to treatment toxicity and 17% to other reasons. The most common cancers were Lung (20%); CNS lymphoma (11%); Colorectal (10%); Prostate (9%); Hepatobiliary (8%); Breast (7%). Inpatient cancer care within Hospitals is often provided across many different wards focussed on varied diseases. This places certain challenges in terms of skill mix amongst the nursing staff in care of these patients with cancer, either on active therapy or in the final phases of their disease. It is important therefore to have targeted enhancement of the required skill mix for non-cancer trained nurses involved in the care of patients with cancer or to centralise their care to selected wards where the needs of these patients can be delivered.

The Association between Nursing Skill Mix and Patient Outcomes in a Mental Health Setting: Protocol for an Observational Feasibility Study.

International research on nursing skill mix has focused primarily on medical and surgical patient populations. The association between nursing skill mix and clinical outcomes for psychiatric inpatients has not been explored. The aim of this study is to establish the feasibility of extracting and linking nurse and inpatient data from hospital administrative data sources. This is an observational study. Data will be extracted from hospital administrative sources and linked together. Patient information will include duration and number of psychiatric hospital admissions. We will extract information on the educational preparation of nurses working in the participating hospitals to enable us to calculate estimates of the nursing skill mix. The study will be conducted in two psychiatric inpatient services in Australia. Our study will test the feasibility of extracting and linking nursing skill mix and patient data in a mental health setting and will inform the methodological development of an appropriately powered observational study. Australian and New Zealand clinical trial registry: ACTRN12619001337167p.

Nurse staffing and patient-perceived quality of nursing care: a cross-sectional analysis of survey and administrative data in German hospitals

ObjectiveTo examine the impact of nurse staffing on patient-perceived quality of nursing care. We differentiate nurse staffing levels and nursing skill mix as two facets of nurse staffing and use...

Implementing a Medical Emergency and Rapid Intervention Team

<h3>Background Information</h3> Failure to rescue accounts for approximately 60,000 deaths each year in Medicare patients under the age of 75. In a large outpatient oncology facility that encompasses an infusion center, multimodality procedure unit, radiation treatment center & multidisciplinary clinic, the need to implement a rapid rescue team was identified to mitigate the risk of failure to rescue. <h3>Objectives of Project</h3> The goal of this initiative was to implement a Medical Emergency and Rapid Intervention Team (MERIT) service to care for patients undergoing chemotherapy, blood transfusions, procedures, radiation and other oncology treatments. A standardized process was developed for MERIT activation by healthcare providers within the facility. In-Service all employees in the facility and empower them to activate MERIT for identified patients. <h3>Process of Implementation</h3> The current MERIT policy for inpatients was reviewed and collaboration was formed with institutional leaders to revise it for an ambulatory center. A needs assessment was conducted and knowledge deficits were identified. The skill mix of PACU nurses was reviewed to identify those with a high acuity background to be a core member of the MERIT team. An orientation and competency check-off was developed, which included requiring members to have Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS) and High Acuity Training. A post-implementation survey was conducted to assess needs and knowledge gaps. <h3>Statement of Successful Practice</h3> The assessment survey indicated 83% of staff were able to identify all the correct situations to call MERIT, 9% of staff were not sure what situations require MERIT and 25% of staff did not know the correct extension to request MERIT. Post implementation of MERIT service, the building team members indicated 84.4% of the staff were able to identify correct situations to call MERIT, and 98% of the staff knew the correct extension to request MERIT. Post education survey was done 2 weeks after go live and showed improvement in knowledge and comfort level in calling MERIT. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> Providing a MERIT service in an outpatient facility could mitigate the risk of failure to rescue, and improve patient outcomes.

The role of nurse staffing in the performance of function-preserving processes during acute hospitalization: A cross-sectional study

BackgroundPerformance of function-preserving hospitalization processes related to patient mobility, use of continence aids and food intake is significantly associated with outcomes in older adults. Nurses are the front-line personnel responsible for promoting performance of such processes. The degree to which nurse staffing is related to this performance is unclear. ObjectiveTo identify nurse-staffing characteristics and nursing-related care needs associated with older patients’ mobility, continence care and food intake during acute hospitalization. DesignCross-sectional study using survey data from the Hospitalization Process Effects on Functional Outcomes and Recovery (HoPE-FOR) cohort study combined with day-level administrative nurse staffing data and clinical day-level aggregated data for all patients hospitalized during the HoPE-FOR study period. SettingInternal medicine units in two medical centers in Israel. ParticipantsEight hundred seventy-three older adults. MethodsMobility, continence care and food intake were assessed within 2 days of admission using validated questionnaires. Nurse-to-patient ratios and nursing-skill mix (i.e. registered nurses (RNs), nurse aides, nurses with advanced clinical training and RNs with an academic degree) were assessed using administrative data. Decision trees were developed for mobility, continence care and food intake, applying classification and regression-tree analysis. ResultsThe mobility decision tree identified three characteristics subdividing patients into six nodes: pre-admission functioning, pre-admission activity level and percentage of nurses with advanced training. The percentage of nurses with advanced training classified low-functioning patients into those walking in corridors versus walking or sitting only inside the room. The continence-care classification decision tree identified two characteristics that subdivided the patients into four nodes: pre-admission functioning and bladder control. Nurse-to-patient-ratio variables and patients’ nursing-related care needs did not contribute to this classification. The food-intake decision tree identified four characteristics—pre-admission functioning, gender, percentage of nurses with advanced training and percentage of nurse aides—subdividing patients into eight nodes. Low-functioning patients exposed to a higher percentage of nurses with advanced training had food-intake scores 14% higher than patients exposed to a lower percentage of nurses with advanced training. Independent men exposed to a higher percentage of nurse aides had a 14% higher habitual daily in-hospital food-intake score than independent men exposed to a lower percentage of nurse aides. ConclusionsA higher percentage of nurses with post-graduate education is associated with better performance of mobility and food intake of hospitalized older adults. To maintain the potential benefits of highly trained staff, education levels should be considered in scheduling and assignment decision-making processes in internal medicine units.Tweetable abstract: A higher percentage of nurses with post-graduate education is associated with better mobility and food intake of hospitalized older adults.

Nursing surveillance and immediate jeopardy in Veteran Health Administration community living centers unannounced survey program 2018 to 2019

BackgroundThe VA Community Living Center (CLC) Unannounced Survey Program aims to assess standards of care set by the government to protect residents. PurposeTo describe patterns of practice failures in nursing surveillance causing or having potential to cause immediate jeopardy, as defined by the Centers for Medicare and Medicaid Services. MethodsUsing CLC survey data consisting of 200 statements of deficiency (SODs) for 2018 to 2019, we collected a SOD sample (n = 20) of immediate jeopardy events. They were described using descriptive statistics and discourse content analysis. FindingsWe identified clinical events, their duration, work shift, and nursing skill mix for each SOD. Most to least common themes about failures in nursing surveillance were acquisition/transfer of information; decision-making; and early recognition of problems. DiscussionOur analysis of nursing surveillance failures in CLC immediate jeopardy SODs provides insight into opportunities for registered nurses and the nursing skill mix to reduce avoidable harms.

Impact of Nurse Staffing, Skill Mix and Stability on Resident Health Outcomes in Korean Nursing Homes

Impact of Nurse Staffing, Skill Mix and Stability on Resident Health Outcomes in Korean Nursing Homes

The Association between Nursing Skill Mix and Mortality for Adult Medical and Surgical Patients: Protocol for a Systematic Review.

Skill mix refers to the number and educational experience of nurses working in clinical settings. Authors have used several measures to determine the skill mix, which includes nurse-to-patient ratio and the proportion of baccalaureate-prepared nurses. Observational studies have tested the association between nursing skill mix and patient outcomes (mortality). To date, this body of research has not been subject to systematic review or meta-analysis. The aim of this study is to systematically review and meta-analyse observational and experimental research that tests the association between nursing skill mix and patient mortality in medical and surgical settings. We will search four key electronic databases—MEDLINE [OVID], EMBASE [OVID], CINAHL [EBSCOhost], and ProQuest Central (five databases)—from inception. Title, abstract, and full-text screening will be undertaken independently by at least two researchers using COVIDENCE review management software. We will include studies where the authors report an association between nursing skill mix and outcomes in adult medical and surgical inpatients. Extracted data from included studies will consist measures of nursing skill mix and inpatient mortality outcomes. A meta-analysis will be undertaken if there are at least two studies with similar designs, exposures, and outcomes. The findings will inform future research and workforce planning in health systems internationally.

Nurse Staffing and Skill Mix Patterns in Relation to Resident Care Outcomes in US Nursing Homes

ObjectivesThe purpose of this study was to identify patterns of nurse staffing and skill mix and estimate the impact of these patterns on rehospitalization and emergency department (ED) visits in nursing home (NH) residents. We also estimated the relative contribution of unique staffing patterns on variations in hospital and ED use rates. DesignRetrospective secondary data analysis at the facility level, using administrative data. Setting and ParticipantsData from Medicare/Medicaid certified NHs in the 2018 Certification and Survey Provider Enhanced Reporting System were merged with the NH Compare Claims-Based Quality Measures file, for those facilities with complete data available (N = 14,325). MethodsCluster analysis was performed to identify groups of NHs with similar nursing skill mix patterns, using measures that captured hours per resident day (HPRD) for registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs). We estimated the impact of cluster assignment on unplanned rehospitalization and ED visits using multivariate generalized estimating equations. Plots were generated to visualize simulation models that showed the relative contribution of unique staffing strategies to the outcomes, while holding other factors constant. ResultsWe identified 3 nursing skill mix clusters: high-RN, high-LPN, and high-CNA, relative to national staffing averages. After controlling for regional and organizational characteristics, residents in NHs in the high-RN cluster had significantly lower rehospitalization and ED use compared with those in the high-LPN cluster, with a similar nonsignificant trend for the high-CNA vs high-LPN clusters. Though the high-RN cluster had CNA HPRD similar to the high-CNA cluster, it relied much less on LPN staffing. Whereas NHs in the high-LPN cluster had proportionally fewer hours of care by both CNAs and RNs. Conclusions and ImplicationsNHs that emphasize LPN care in place of either RN or CNA care appears to exhibit higher rates of unplanned rehospitalization and ED visits among residents.

SOARING: A Residency Program for Unlicensed Assistive Personnel: Meeting the Demands While Retaining Highly Skilled, Engaged Clinical Technicians.

A complex healthcare environment requires an optimal nursing skill mix at a reasonable cost to sustain safe, quality, and efficient patient care. An innovative, unlicensed assistive personnel residency program was developed to fill open positions with a skillful, confident, and engaged clinical technician workforce. The program resulted in highly skilled and confident clinical technicians, a 4% increase in engagement scores, and a 14% increase in retention rate.