Minimum nurse staffing ratios for nursing homes

The authors explored minimum nurse staffing ratios for nursing homes using production function simulations. Minimum levels of registered nurse hours per resident day were 0.31, 1.83, and 3.3 at 50%, 75%, and 90% levels of quality respectively. These results suggest that efficiency-oriented minimum nurse staffing points exist, and could be used to inform policymakers and nursing home administrators on better resource allocation and health care delivery.     

The impact of nurse staffing on hospital costs and patient length of stay: a systematic review

Research examining the relationships between nurse staffing, hospital costs, and length of stay is varied using a range of methods and definitions. This lack of coherence in definitions and measurement tools for cost and length of stay makes it difficult to conclude with certainty the results of nurse staffing on hospital cost and length of stay. However, the evidence reflected that significant reductions in cost and length of stay may be possible with higher ratios of nursing personnel in hospital settings. Sufficient numbers of RNs may prevent patient adverse events that cause patients to stay longer than necessary. Patient costs were also reduced with greater RN staffing as RNs have higher knowledge and skill levels to provide more effective nursing care as well as reduce patient resource consumption. Hospital administrators are encouraged to use higher ratios of RNs to non-licensed personnel to achieve their objectives of quality patient outcomes and cost containment.     

Patients' perceptions of nurse staffing, nursing care, adverse events, and overall satisfaction with the hospital experience

Noticeably absent in the discussions surrounding nurse staffing and adverse events is the patients' perspective, except for their satisfaction with various aspects of their hospitalization experience. The results of a study undertaken to test a theoretical model of patients' perceptions of nurse staffing, the nursing care they receive, self-reported adverse events, and overall satisfaction with the hospital experience are presented. Perception of nurse staffing only weakly predicted the number of adverse events reported by patients, but was a strong predictor of the perception of nursing care received, and the perception of nursing care received was the only significant predictor of overall satisfaction with the hospital experience.     

Validation of a taxonomy of ambulatory nursing practice

Ambulatory care is a complex and challenging nursing specialty. This survey of 33 ambulatory nursing administrators addressed the roles and responsibilities of nurses in ambulatory care settings.     

The impact of nursing on patient and organizational outcomes

The impact of nursing on patient and organizational outcomes has received significant attention from researchers in the past 10 years. Although some research has been based on a theoretical framework, to date, there has not been one, consistent framework that can guide this research. In addition, the frameworks that have been used do not identify nursing as the pivotal concept in the model. The purpose of this article is to identify a framework to guide such research with an emphasis on nursing as the essential concept. Unit culture, nurse staffing, staffing mix, and other variables do not have a direct effect on outcomes. It is only through these variables' influence on the delivery of nursing care that outcomes are affected.     

Analysis of ambulatory nursing practice

A nursing patient classification system can be used in ambulatory care to facilitate decision making relative to staffing assignments and to begin examining differences in patients' nursing care requirements according to medical diagnosis or other patient characteristics.     

The implications of nurse staffing information: the real value of reporting nursing data

There is a dearth of information about the relationship between the patient care contributions of nursing and its financial contributions to an organization. As consumers and legislators are becoming more aware of the ramifications of nurse staffing issues, and as they endeavor to address them with legislative solutions, the decision on how best to develop optimal staffing strategies may soon be taken away from nursing leaders. To maintain control of this important issue and develop solutions that will help highlight the economic and patient care contributions of nurses, a thorough understanding of the problem, and a new commitment are needed from nursing leaders to take charge of the issue. To relate nursing care to patient outcomes, meaningful data on the nursing care provided is needed in addition to data on the nursing needs of patients. Staffing and performance monitoring tools should be used to effectively plan, implement, and control financial and operating resources as well as measure the economic value of the nursing profession's contribution to the cost and benefits of patient care.     

Expanded role of nursing in ambulatory managed care. Part I: Literature, role development, and justification

New expanded roles in nursing are developing in response to the health system switch from private, episodic care of individuals to health maintenance organizations (HMO's) focusing on disease prevention and promotion of health for populations of persons with chronic illness. This evaluation project explored the role of the nurse clinician in population and case management at a large HMO in the Northwest United States. In Part I of this two-part series, a literature review, is presented on chronic illness, ambulatory nursing, expanded role nursing, and nursing in HMOs. The development of the expanded role nurse clinician at the managed care organization is also described. Results could be used by HMOs to attract and retain nurses, improve care processes, and decrease costs in ambulatory care.     

The impact of state regulations on nursing home care practices

This article assesses the effect of the minimum quality standards of deficiencies and nurse staffing requirements on the nursing home care practices of physical restraint, indwelling urinary catheter, and feeding tube use. National longitudinal data on nursing homes reveal that the effect of specific deficiency citations on care practice use depends on the clinical complementarity or substitutability of the deficiency and the specific care practice, while a high number of deficiencies can lead to a greater use of each care practice. Higher direct care staffing requirements increased the use of physical restraints and decreased the use of feeding tubes. Increases in licensed nursing staff requirements had no effect on the care practices studied. Regulators should be aware that using minimum quality standards when quality is multidimensional creates incentives for offsetting quality improvement practices.     

Nurse staffing decisions: an integrative review of the literature

The author exhaustively explores the current literature and attempts to summarize the current thinking on how to best decide on the most cost-effective nurse staffing requirements. Between 1984 and 1994 FTE nursing employees decreased by 7.3%, causing some researchers to seek ways to explore the relationship between staffing levels, staff and patient satisfaction and outcomes of care. Satisfaction among staff nurses working in a self-scheduling environment was determined largely by the individual's ability to negotiate for the desired days and shifts and by the nurse manager's ability to stand back from the process and let the staff collaboratively work it out. Work structure related studies seemed to find that 12-hour shifts were reported to be "less fatiguing" than traditional 8-hour shifts. Staffing studies found that rural hospitals still used 0.27 more RNs per occupied bed than urban hospitals and that the presence of a unit secretary was associated with a decreased use of RNs.     

Ambulatory care nursing: growth as a professional specialty

Ambulatory care nursing has emerged as a distinct professional nursing specialty. Many characteristics differentiate ambulatory care nursing from other specialty practices, including the settings, the characteristics of the patient encounters and the focus upon groups, communities, and populations, as well as individual patients and their families. A conceptual framework for ambulatory care nursing was developed in 1998 and recently revised, through consensus of leaders in the specialty. The key elements of the Ambulatory Care Nursing Conceptual Framework are the patient, the environment (both internal and external), and the nurse, practicing in three major roles.     

Information technology, nurse staffing, and patient needs

As health care organizations increasingly adopt health information technology, time-sensitive data that track patients' requirements for nursing care and nurses' responsiveness to these needs might be available to support evidence-based nurse staffing decisions. care information technologies available in hospitals and on nursing units may provide valuable sources of information that can be translated into usable data. In this study, the usefulness of electronic data obtained from a nurse tracking call light system as a source of information for quality measurement was explored. The findings point to what might be under-utilization of existing health information technology to track patients' needs and nurses' responsiveness, patient census, and patient movements. The authors recommend health information technology be used less as support for other organizational systems and more as an administrative resource that can allow nurse executives to be more actively engaged within and across nursing environments.     

Value-added care: a paradigm shift in patient care delivery

Spiraling costs in health care have placed hospitals in a constant state of transition. As a result, nursing practice is now influenced by numerous factors and has remained in a continuous state of flux. Multiple changes within the last 2 decades in nurse/patient ratio and blend of front-line nurses are examples of this transition. To reframe the nursing practice into an economic equation that captures the cost, quality, and service, a paradigm shift in thinking is needed in order to assess work redesign. Nursing productivity must be evaluated in terms of value-added care, a vision that goes beyond direct care activities and includes team collaboration, physician rounding, increased RN-to-aide communication, and patient centeredness; all of which are crucial to the nurse's role and the patient's well-being. The science of appropriating staffing depends on assessment and implementation of systematic changes best illustrated through a "systems theory" framework. A throughput transformation is required to create process changes with input elements (number of front-line nurses) in order to increase time spent in value-added care and to decrease waste activities with an improvement in efficiency, quality, and service. The purpose of this pilot study was two-fold: (a) to gain an understanding of how much time RNs spent in value-added care, and (b) whether increasing the combined level of RNs and unlicensed assistive personnel increased the amount of time spent in value-added care compared to time spent in necessary tasks and waste.     

Evidence-based staffing: potential roles for informatics

Over the last 15 years, evidence has been accumulating relating higher levels of nurse staffing in both quantity and experience to lower rates of adverse patient outcomes. Consequently, to promote quality patient outcomes efficiently, making staffing decisions based in evidence is of increasing importance. However, there is still limited data to help decide how to effectively allocate scarce nurse resources in practice. Existing principles, frameworks, and guidelines provide a foundation for nurse staffing decisions but face poor adoption. To determine optimal nurse staffing practices and provide evidence-based recommendations for policy, and integration into operations, comprehensive data are necessary. Information technology can assist nurse staffing decisions. Four informatics processes that may support evidence-based nurse staffing are described: (a) Data acquisition from multiple data sources, (b) Representation of data in a way it can be re-used for multiple purposes, (c) Sophisticated data processing and mining, and (d) Presentation of data in standardized and user-configurable ways.     

Work satisfaction among California registered nurses: a longitudinal comparative analysis

California's minimum nurse-to-patient staffing ratio law, the nation's first, was implemented in 2004. This study had two aims: (a) to evaluate the effect of the nurse-to-patient ratios law on nurse job satisfaction in order to advance the debate over the merits of nurse staffing law, and (b) to compare California nurses who were satisfied against those who were not, in order to facilitate the development targeted retention interventions based on empirical evidence. The sample's overall job satisfaction increased significantly as the years passed, suggesting the nurse-to-patient ratios law was associated with improvements in nurse satisfaction. Satisfied RNs were more likely to have a balanced and financially secure life that included a partner, children living at home, higher hourly wages, and higher income from sources other than a nursing job. Nurses working in direct patient care positions remained dissatisfied in larger proportions than those working in other types of positions, even after the nurse-to-patient ratios were implemented. More nurses are satisfied today than before the ratios; nevertheless, far too many nurses (18.5%) have job satisfaction scores that are neutral or worse.     

Quality indicators for academic nursing primary care centers

ANCs, by definition, deliver more than clinical services to patients and communities. The unique identifier that separates ANCs from other primary care/ambulatory care centers is the educational service they offer to students and other faculty in the school of nursing to which they belong. Therefore, measuring the quality of an ANC must include a measurement of the educational properties that it possesses in addition to the usual quality measurements by such organizations as AAAHC, JCAHO, CHAP, and AAACN. Unless these properties are included and measured by an ANC, it becomes difficult to justify the existence of such a clinic within a school of nursing. ANCs are encouraged to develop quality evaluation programs aimed at evaluating the educational aspects as well as the administrative and clinical aspects of their operations.     

Capacity planning in hospital nursing: a model for minimum staff calculation

An aging population, emerging technology, heightening patient expectations, rising health care costs, shorter patient stays, and growing pressure to improve quality have made the management of nursing resources even more critical today. While approaching a model for staffing levels, the authors considered factors such as patient acuity, work redesign, and minimum quality standards. The methodology for analysis included estimating the time needed to complete nursing tasks and calculating the average number of tasks per patient. With respect to nursing quality measures, the study examined the adequacy of nursing documentation including admission history, assessments, nursing procedures, and discharge report as well as nursing-driven outcomes such as fall and phlebitis rates. Lastly, the authors determined the theoretical number of staff needed to provide nursing care according to quality standards.     

Outcomes and cost analysis of the impact of unit-level nurse staffing on post-discharg utilization

Under a proposal from the Centers for Medicare and Medicaid Services, hospitals would no longer be reimbursed for 30-day re-admissions or emergency department (ED) visits. Increasing RN staffing to reduce post-discharge utilization is one possible solution, but one that is not financially attractive to hospitals. This study demonstrates the impact of fluctuating staffing levels on ED visits within 30 days of discharge. RN overtime and RN vacancies also affected subsequent ED visits. It is important for nurse managers, directors, and administrators to recognize the impact of RN staffing on patient outcomes. Reimbursement models will need to be realigned to benefit both hospitals and payers.     

Models of care in outpatient cancer centers

While rapid changes in the treatment of cancer have been driven by research-based evidence, innovations in cancer care delivery have lagged behind that seen in cancer treatment. A literature review and ten semi-structured interviews were conducted to identify models of care in the ambulatory oncology setting to be adopted by a comprehensive cancer center. Four models were identified from the literature review but none were widely recognized or adopted by administrators. Findings suggested some common themes that should be included in an optimal model of care. These themes are in support of the burgeoning efforts seen in the promotion of interprofessional education and practice for quality improvement. Unique challenges related to the contextual factors in the ambulatory oncology settings suggest quality improvement interventions should be tailored to meet the specific needs of the care facility and its workforce.     

Making nursing-sensitive quality indicators real in ambulatory care

Pay-for-performance initiatives are changing the quality landscape. Gaps exist in quantifying and linking ambulatory care quality indicators to care provided by nurses in ambulatory care. Ambulatory care quality indicators that are sensitive to nursing care, standardized, and tested need to be identified and adopted by ambulatory care nurses, ambulatory care provider organizations, professional organizations, and endorsed by a consensus organization.