Contemporary Nurse
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Status of nurse staffing and nursing care delivery in Pudong, Shanghai Hui Jiang, Chen Li, Yan Gu, Haiyan Lu & Wenqin Ye To cite this article: Hui Jiang, Chen Li, Yan Gu, Haiyan Lu & Wenqin Ye (2015) Status of nurse staffing and nursing care delivery in Pudong, Shanghai, Contemporary Nurse, 50:1, 104-114, DOI: 10.1080/10376178.2015.1010255 To link to this article: http://dx.doi.org/10.1080/10376178.2015.1010255
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Date: 29 October 2015, At: 11:16
Contemporary Nurse, 2015 Vol. 50, No. 1, 104–114, http://dx.doi.org/10.1080/10376178.2015.1010255
Status of nurse staffing and nursing care delivery in Pudong, Shanghai Hui Jianga*, Chen Lib, Yan Gua, Haiyan Lua and Wenqin Yec
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a Nursing Department of Shanghai East Hospital, Tongji University School of Medicine, Yuntai Road No. 1800, Pudong New Area, Shanghai, China, 200123; bCollege of Humanities and Social Science, Shanghai University, Shangda Road, No. 99, Baoshan District, Shanghai, China, 200444; cNursing Department of Changhai Hospital, The Second Military Medical University, Changhai Road No.168, Yangpu Area, Shanghai, China, 200433
(Received 6 September 2013; accepted 3 October 2014) Aim: To evaluate nurse staffing levels and nursing care delivery in adult general medical or surgical wards of hospitals in the Pudong district of Shanghai, China. Background: Rapid economic development and improved Chinese living standards have spurred increased demands for high-quality health care. Thus, the quality of nursing services has become a focus of attention. Design: A cross-sectional, descriptive design was used for the study. Methods: We used an anonymous survey to collect data from 1614 nurses from 98 wards in seven general hospitals in Pudong, Shanghai. Results: During day shifts, the nurse-to-patient ratios were >1:10. However, these ratios were much higher during evening and night shifts. The clinical frontline nursing workforce primarily consisted of nurses with junior college degrees that had limited working experience. Junior nurses with different educational backgrounds, professional levels and work experiences were assigned almost similar nursing care work as senior nurses. Conclusions: In the surveyed hospitals in the Pudong district, nurse staffing levels and skill mix may be inadequate to meet the increasing demands of patient care. The clinical nursing workforce needs to be strengthened and used effectively to enhance the quality and safety of patient care. Relevance to clinical practice: We should focus on the quantity and quality of the nursing workforce, as well as nursing skill utilisation. Keywords: China; nurse staffing; inpatient nursing care; nursing management; questionnaire survey
What does this paper contribute to the wider global clinical community? .
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The development of nursing care based on effective distribution and utilisation of nursing resources is necessary for frontline inpatient units to insure the safety of patients and quality of nursing care. Hospital management plays an important role in reshaping the size and scope of the nursing workforce to meet the changing patterns of caregiving and the demands of rapid medical development.
*Corresponding author. Email: [email protected]. Authors (a) and (b) contributed equally to this work. © 2015 Taylor & Francis
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Introduction
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Nurses are the primary professional ‘frontline’ staff in most health-care systems. The contribution of nurses is essential for meeting development goals and delivering safe and effective patient care (DeVandry & Cooper, 2009). The current trends toward greater disease severity, proliferation of new medical technology, and shorter hospital stays has greatly increased nursing workloads. Reasonable nurse staffing and proper nursing care assignments are required to secure patient safety and provide high-quality nursing care (Flynn & Mckeown, 2009). A delicate balance exists between the increased nursing care needs for patients and cost containment requirements of hospitals (Ayre, Gerdtz, Parker, & Nelson, 2007; Crossan & Ferguson, 2005). Thus, there is considerable interest in determining how nurses use their skills effectively and contribute to patient outcomes in a cost-effective manner. Moreover, changes in the availability and roles of nurses, as well as their responsibilities, have heightened this interest. Therefore, it is important for health-care delivery systems in China to re-examine nurse staffing and nursing care delivery. Background China is the world’s most populated country, with 1.3 billon people living in approximately 10 million square kilometres. Over the past three decades, China has experienced rapid economic growth, important technologic advances and global exposure. Rapid economic development has improved living standards. These improvements, accompanied by the aging population and one-child policy in China, have spurred demands for higher quality health care (Liu et al., 2012). In response to these societal demands, the Chinese government announced a health-care reform policy in 2009 that places a priority on improving care in public hospitals (Chen, 2009). The 2009 policy focused on quality nursing services, and indicated they are highly valued by the government, society and patients’ families. Therefore, nurses in China are facing serious challenges to provide high-quality nursing care in a rapidly changing environment, at a time when cost containment and efficiency are increasingly becoming important considerations. These two factors, combined with the promotion and advancement of high-quality nursing service, have advanced the concept of nursing team building in an attempt to improve the quantity and quality of care. Nurse staffing levels are reported to be a determinant of nursing care quality and patient outcomes (Cho, Ketefian, Barkauskas, & Smith, 2003). Seminal studies in this area have emphasised the importance of nursing work to ensure high-quality care and safety in hospitals (Aiken, Clarke, & Sloane, 2002; Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002). A systematic review and meta-analysis of studies published in English between 1990 and 2006 demonstrated that higher nurse staffing levels are significantly associated with better patient outcomes, including lower mortality rates, lower failure-to-rescue rates and shorter hospital stays (Kane, Shamliyan, Mueller, Duval, & Wilt, 2007). Studies conducted in China surveying 7802 nurses and 5430 patients from 600 medical and surgical units also found that inadequate nurse staffing might result in missed (but necessary) nursing care and negative patient outcomes. Additionally, better staffing levels could be an effective strategy to improve patient outcomes (Zhu et al., 2012). Another questionnaire survey done by You (You et al., 2013) from 9688 nurses and 5786 patients in 181 Chinese hospitals indicated that higher patient-to-nurse ratios were associated with poorer nurse outcomes (i.e. increased nurse burnout and job dissatisfaction) and higher likelihoods of nurses reporting poor or fair quality of care. The study also indicated that higher percentages of baccalaureate nurses were strongly related to better patient outcomes. Internationally, nurse staffing models can be classified as nurse-to-patient ratios and nursing hours per patient day (NHPPD). These staffing models are used to develop patient classifications or nursing workload measurement systems to determine the nurse staffing needs for safe patient
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care and to justify nursing resource allocation amid the cost-conscious health-care environment (Hoi, Ismail, Ong, & Kang, 2010; Spetz, 2004). In the US, nurse-to-patient ratios are used in almost every institution as a basis for staffing assignments and form the core from which adjustments are made (Minnick & Mion, 2009). Historically in China, a bed-to-nurse ratio staffing model was used to determine the inpatient ward nurse staffing needs. According to government policy #1689 issued by the Ministry of Health in 1978 (Wong, 2010), this ratio should be 1:0.4, which was considered the accepted standard. In 2011, the nurse-to-patient ratio staffing model was introduced and guided by China’s 2011–2015 Nursing Development Plan (MHC, 2011– 2015). This new policy set a goal of a 1:8 nurse-to-patient ratio for general nursing units. Currently, the nursing education system in China produces nurses with diplomas and associate degrees, as well as bachelor’s, master’s and doctoral degrees (Sherwood & Liu, 2005). Nurses who graduate from nursing school and pass the Chinese registration examination are allowed to work and care for patients. Associate degree nurses account for a large proportion of Chinese nurses. These nurses are trained for three years after high school (Xiao, 2010). In an effort to improve nursing care, the government introduced an independent nursing profession hierarchy structure in 1979. This layered system consists of five nursing levels. Nurses are given academic titles in accordance with their educational background, nursing ability and nursing practice experience (Li & Sonia, 1996; Yun, Shen, & Jiang, 2010). Level 1 and 2 nurses are considered junior nurses. Level 1 nurses with a diploma must work five years in a clinical setting before getting promoted to level 2. Associate degree nurses must work for three years, whereas bachelor’s degree nurses must work for only one year in a clinical setting prior to level 2 promotion. Promotion from level 2 requires working for five years, as well as passing computer, English and nursing skill examinations. Level 4 and 5 nurses are expected to meet higher criteria, including authorship on publications, passing advanced clinical skills examinations and hospital recommendations. Aims The purpose of the current study was to understand the nurse staffing and skill mix of frontline nurses in the adult medical and surgical wards of secondary and tertiary general hospitals in Pudong, Shanghai. We analysed nursing staff configuration and the implementation of nursing care activities of different nursing levels to determine the utilisation efficiency and effectiveness of the nursing workforce. Study design Methods This study used a cross-sectional, descriptive design. An internally-developed questionnaire was used as the study instrument, and data were collected from a survey of clinical nurses’ self-report questionnaires. All general hospitals in the Pudong New Area were evaluated, and all nurses from the inpatient general medical and surgical wards were invited to participate in the survey. Setting and participants This study was conducted in all secondary and tertiary general hospitals in the Pudong New Area, which is the largest district among the 17 Shanghai districts. Ninety-eight wards from seven hospitals (six secondary and one tertiary general hospital) were selected for the survey. All of the hospitals were directly under the charge of the Pudong New Area Health Bureau and collectively provided a comprehensive range of clinical services. The six secondary hospitals were all
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non-teaching hospitals with 300–500 inpatient beds. The tertiary hospital was a general teaching hospital equipped with 1000 inpatient beds. The survey target population included nurses working in the inpatient units (adult general medical and surgical wards). All staff nurses working in these units were invited to participate. Inclusion criteria were: (1) employed nurse graduates; (2) possession of a practising nurse certificate and active registration; (3) providing bedside patient care in the wards; and (4) working continuously for at least three months in the department. Exclusion criteria were nurse managers, nurses on leave or not-on-the-job staff.
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Questionnaire A questionnaire was developed to measure the implementation of nursing care activities in clinical nursing units during the latest one-week period. An anonymous, 101-item survey was created. After a careful review of the literature, the questionnaire was designed to meet the purpose of the study. It consisted of three parts: demographic information of the nursing staff (six items), nurse staffing level (three items) and the status of clinical nursing work implementation (92 items). A convenience sampling method was used by selecting 21 nurses working in the Department of Neurology of a tertiary general hospital as a pilot study. The internal consistency reliability (Cronbach’s α coefficient) of the questionnaire was .94, and the Guttman Split-Half coefficient was .83. The survey was re-conducted a week later, and the average score of each question was calculated. The test-retest reliability measured by Pearson’s correlation coefficient was .94. Five experts in the fields of clinical nursing, nursing management and nursing education were recruited to evaluate the content validity of the questionnaire. The index of content validity was .92, indicating that the designed questionnaire was of good reliability and validity. Data collection Data were collected between March 2013 and April 2013. The nursing departments of participating hospitals were approached to participate. A research information sheet that provided instructions and assured the confidentiality of responses was provided with each questionnaire. Two investigators were trained to distribute and collect the questionnaires. The investigators delivered the survey to the sampled units and the nurse manager delivered them to nurses who met the eligibility criteria. Nurses anonymously completed the questionnaires during their work break or after work and returned them in a sealed envelope to a sealed box in the unit. This strategy aimed to protect the privacy of nurses, increase the response rate and minimise missed recalls. Subsequently, the nurse manager returned the sealed questionnaires to the investigators. Measures Nursing care activities Nursing care activities in this study refer to direct nursing care work activities that were implemented daily by the nurses. Clinical nursing work implementation was measured by seven dimensions on the survey, including assisting daily living (ADL; 20 questions), nursing assessment (four questions), vital signs and discomfort monitoring (14 questions), patient education (nine questions), administration of medications (seven questions), specimen collection (seven questions) and nursing procedures (31 questions). The response to each item was rated on a five-point Likert scale, as follows: 5 = often; 4 = frequent; 3 = moderate; 2 = occasionally and 1 = never. Respondents were required to self-evaluate based on their own assessment of implementation for each nursing task during the latest one-week period.
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Nurse staffing Nurse staffing levels were assessed using nurse-to-patient ratios that were collected from the survey. Nurses reported the data regarding the number of patients they cared for during their last day shift, evening shift and night shift.
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Demographics The nursing staff demographics collected on the survey included age, gender, working experience, educational background, professional level and marital status. Educational background was divided into three groups: technical secondary school (diploma); junior college (associate degree); and college (bachelor’s degree or above). The working experience of nurses was divided into four groups: four years or less, 5–9 years, 10–14 years and greater than 15 years. The professional levels of the nursing staff were divided into three groups: level 1, level 2 and level 3 or above. Ethical considerations The Ethical Committee of Shanghai East Hospital of Tongji University approved this study. Informed consent was obtained from each hospital and each nurse. To ensure rights and privacy, all participants were informed that study data would be kept confidential and anonymity was assured. Data analyses SPSS (version 17.0) was used to input survey data. Two investigators evaluated all results. Demographic data, such as age, educational background, work experience and professional levels, were collected to describe study participants. Implementation of nursing care activities was described using the mean and standard deviation (SD), and comparisons between different educational groups were analysed using single-factor analysis of variance (ANOVA) tests. Two-tailed tests of mean differences were also used. A p-value less than .05 was considered statistically significant.
Results Demographics A total of 1789 questionnaires were distributed, 1614 valid questionnaires were collected, and the valid response rate was 90.23%. Participants ranged in age from 21 to 59 years (Mean 29.03, SD 6.35); Working experience ranged from 0.3 to 38 years (Mean 8.97, SD 7.56) and 64.06% of nurses had less than 10 years of professional nurse working experience. Approximately twothirds of the nurses (65.99%) had an associate nursing degree. Most participants were female (99.44%). The majority of nurses were of level 1 or 2 professional status (89.72%). There were 166 level 3 nurses (10.28%) and no level 4 or 5 nurses. The average nurse-to-patient ratio for the three shifts was >1:10. Evening and night shift nurses cared for more patients than day shift nurses. (Table 1)
Comparison of the implementation of nursing care activities Table 2 compares the implementation of nursing care activities of direct nursing care in the seven dimensions. The most frequent nursing care activities performed by staff nurses in the ward was
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Table 1. Characteristics of study nurses (n = 1614).
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Characteristics
n (%)
Age, in years Working experience, in years Nurse patient ratio Day shift Evening shift Night shift Gender Male Female Working experience 15 yrs Educational background Diploma Associate degree Bachelor degree Master degree Professional level Level 1 Level 2 Level 3 Marital status Single Married without children Married with children Others
Mean ± SD
Range
29.03 ± 6.35 8.97 ± 7.56
21–59 0.3–38
10.59 ± 7.32 24.07 ± 22.02 25.78 ± 23.09
6–20 10–50 12–58
9 (0.56) 1605 (99.44) 637 (39.47) 397 (24.60) 267 (16.54) 313 (19.39) 209 (12.95) 1065 (65.99) 337 (20.88) 3 (0.19) 739 (45.79) 709 (43.93) 166 (10.28) 530 288 691 105
(32.84) (17.84) (42.81) (6.51)
Table 2. Comparison of implementation of nursing care activities*. Dimensions
Mean
SD
Range
Medication Monitoring Assessment Teach patient Procedure Specimen ADL
4.57 4.51 4.39 4.39 3.89 3.85 3.54
0.76 0.65 0.79 0.77 0.84 1.10 0.79
2–5 2–5 2–5 2–5 2–5 1–5 1–5
Notes: *Response scale: 1 = never; 2 = occasionally; 3 = moderate; 4 = often; 5 = frequent.
medication administration, followed by monitoring and assessments. ADL was the least performed nursing care activity by the nursing staff in the ward. Comparative analyses of nursing care delivery among different groups The implementation of nursing care activities by nursing staff with different educational backgrounds, different professional levels and different working experience were compared (Tables 3–5). Table 3 shows that there were no significant differences in direct nursing work by
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Comparative analyses of different educational backgrounds (mean ± SD).
Dimensions ADL Assessment Monitoring Teach patient Medication Specimen Procedure
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Table 4.
Diploma (n = 209)
Associate degree (n = 1065)
Bachelor and above (n = 340)
F value
p value
3.48 ± 0.82 4.31 ± 0.83 4.55 ± 0.65 4.40 ± 0.80 4.61 ± 0.72 3.80 ± 1.26 3.82 ± 0.88
3.56 ± 0.78 4.42 ± 0.77 4.51 ± 0.63 4.40 ± 0.76 4.57 ± 0.75 3.88 ± 1.06 3.90 ± 0.83
3.52 ± 0.81 4.36 ± 0.82 4.50 ± 0.69 4.36 ± 0.81 4.56 ± 0.83 3.80 ± 1.13 3.92 ± 0.86
1.050 2.310 0.423 0.335 0.263 0.837 1.172
.350 .100 .655 .716 .769 .433 .310
Comparative analyses among different professional levels (mean ± SD).
Dimensions ADL Assessment Monitoring Teach patient Medication Specimen Procedure
Level 1 nurse (n = 739)
Level 2 nurse (n = 709)
Level 3 nurse (n = 166)
F value
p value
3.68 ± 1.10 4.50 ± 0.77 4.44 ± 0.71 4.51 ± 0.77 4.50 ± 0.82 3.84 ± 1.04 3.91 ± 0.80
3.58 ± 1.14 4.61 ± 0.70 4.56 ± 0.69 4.56 ± 0.67 4.56 ± 0.76 3.92 ± 1.12 3.93 ± 0.85
3.28 ± 1.09 4.47 ± 0.80 4.44 ± 0.85 4.51 ± 0.62 4.37 ± 1.06 3.62 ± 1.29 3.68 ± 0.94
1.527 0.978 1.121 0.215 0.711 4.843 5.996
.219 .377 .327 .807 .492 *.008 *.003
Notes: *p < .01 LSD test between groups: specimen, level 1* level 3, p < .05, level 2* level 3, p < .01, level 1* level 2, p > .05; procedures, level 1* level 3, p < .01, level 2* level 3, p < .01, level 1* level 2, p > .05
Table 5.
Comparative analyses between different working experience (mean ± SD).
Dimensions ADL Assessment Monitoring Teach patient Medication Specimen Procedure
4yrs or less (n = 637)
5∼9yrs (n = 397)
10∼14yrs (n = 267)
15yrs or above (n = 313)
F value
p value
3.69 ± 1.08 4.55 ± 0.66 4.47 ± 0.61 4.54 ± 0.68 4.56 ± 0.71 3.85 ± 1.01 3.95 ± 0.78
3.63 ± 1.19 4.53 ± 0.89 4.47 ± 0.88 4.47 ± 0.85 4.44 ± 0.99 3.90 ± 1.07 3.97 ± 0.80
3.49 ± 1.10 4.59 ± 0.64 4.64 ± 0.56 4.62 ± 0.59 4.59 ± 0.61 4.00 ± 1.18 3.96 ± 0.74
3.21 ± 1.02 4.33 ± 0.98 4.33 ± 0.90 4.43 ± 0.57 4.27 ± 1.13 3.67 ± 1.24 3.63 ± 1.02
1.570 0.699 1.521 0.800 1.338 4.783 12.91
.196 .553 .209 .495 .262 *.003 *.000
Notes: *p < .01. LSD test between groups: specimen, 4yrs* ≥ 15yrs, 5∼9yrs* ≥ 15yrs, p < .05, 10∼14yrs* ≥ 15yrs, p < .01, 4yrs*5∼9yrs, 5∼9yrs*10∼14yrs, 4yrs*10∼14yrs, p > .05; procedures, ≤ 4yrs* ≥ 15yrs, 5∼9yrs* ≥ 15yrs, 10∼14yrs* ≥ 15yrs, p < .01, 4yrs*5∼9yrs, 5∼9yrs*10∼14yrs, 4yrs*10∼14yrs, p > .05.
nursing staff with different educational backgrounds. In Tables 4 and 5, the results show that there were no significant differences in implementing the ADL, assessments, monitoring, patient teaching and medications among nurses with different professional levels and different working experiences. However, there were significant differences in implementing the specimen collection and patient care procedures (p < .01). Least significant difference (LSD) analysis of the two groups indicated that in the dimensions of specimen and procedure, experienced level 3 nurses and nurses with more than 15 years of experience performed significantly fewer activities than other groups.
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Discussion Nurse staffing and skill mix may not meet the increasing demands of patient care Nurse staffing levels and skill mix are recognised as the primary determinants to guarantee care quality and patient safety. (Buchan & Aiken, 2008; Buchan & Dal Poz, 2002). Inadequate levels of staffing (high nurse-to-patient ratios) and skill mix (experience, education and professional level) affect quality of care in a range of ways (Buchan & Dal Poz, 2002; Lang, Hodge, Olson, Romano, & Kravitz, 2004). While patients’ needs and nurses’ workloads have been increasing, the appropriate number of nurses needed to care for an increasingly sicker population has increased. Legislation of the nurse-to-patient ratio is being widely discussed amongst nursing professionals worldwide (Rassin & Silner, 2007). In 1999, the California State Legislature passed Assembly Bill 394. The bill requires the California State Department of Health Service to establish minimum nurse-to-patient ratios in acute care general, special and psychiatric hospitals. The ratio was set at six patients per nurse on general medical-surgical wards and decreased to five per nurse when the bill was fully implemented in 2005 (Lang et al., 2004). In Australia, the state of Victoria has recommended that the nurse-to-patient ratio should be 5:20 for day shifts in general medical and surgery wards, depending on the type of hospital (Gerdtz & Nelson, 2007; Lankshear, Sheldon, & Maynard, 2005). Our results show that nurse-to-patient ratios in China are much higher than the mandated ratios enacted by California and Australia, and the problem is aggravated on evening and night shifts. We also clearly show that nurse staffing in Pudong does not provide sufficient care compared to accepted international standards. This inadequacy remains even following Chinese standards. Moreover, the nurse educational mix, experience mix and professional level mix may also be insufficient to meet the present and future challenges to nursing. Clinical ‘frontline’ nurses in Pudong were mainly associate degree, with a working experience lower than 10 years, and level 1 or level 2 junior nurses. Thus, according to our findings, the staffing levels and the skill mix are not adequate to meet the patients’ changing health-care needs. Therefore, intense research is required to evaluate the needs of increased nursing staff to suit the clinical workload conditions, as well as patients’ needs, in all hospitals and all departments while simultaneously minimising costs. Nurse managers in China should take measures to reshape the size and scope of the nursing workforce to meet the changing patterns of caregiving and the demands of rapid medical development.
Nursing work assignment does not reflect the skill level of nursing staff The nursing shortage is affected by the number of available nurses as well as by the way nurses use their skills effectively (Lang et al., 2004). In China, the current nursing workforce consists entirely of registered nurses (Hui, Wenqin, &Yan, 2013). The present hospital system does not have any support staff to help nurses perform non-nursing tasks. In addition, families usually accompany patients and stay with them in the hospital. We previously reported that patients’ relatives or family-paid caregivers provided much of the bedside patient care in hospitals rather than nurses (Hui et al., 2013). As a result, much of the nurses’ time and energy is diverted to medical tasks or other non-nursing duties. Our findings demonstrate that nurses spend most of their time on medications, monitoring and assessments. ADL was the least frequent work done by the nurses, followed by specimen collection. These results coincide with the fact that nurses in China are more treatment-oriented and ADL is tasked to relatives or family-hired caregivers. Therefore, nurse staffing levels need to be improved to ensure nurses have more time for patient care in order to secure the quality and safety of nursing care.
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In our study, the implementation of nursing care activities were examined in relation to the nursing staff work experience, educational background and professional level. The results of this survey show that although there were clear differences between educational background, professional level and working experience, there were almost no significant differences in the frequency of implementing most of the direct nursing work except in the dimensions of collecting specimens and performing procedures. These data suggest that nursing staff skills are not being used effectively. This lack of distinction in performing clinical tasks among nurses may be caused by an insufficient number of nurses and may also be caused by the special Chinese health-care system. Neglecting these differences in educational background, professional level and working experience will discourage the enthusiasm and morale of highly educated, experienced nursing staff. It also wastes nursing resources and poorly utilises human assets. Therefore, managing nursing asset allocation based on the abilities, talents and expertize of the nurses is very important. This represents the inevitable trend in ensuring the clinical nursing quality and promoting nursing work towards refinement and specialisation.
Relevance to clinical practice Adequate attention should be paid to the nursing shortage and nursing care delivery status in hospitals. Proper nurse staffing and skill mix are a fundamental requirement that maximises nursing resources, boosts nursing team growth, stimulates professional development for team members, acknowledges the hospital budget, secures nursing care quality and improves patient satisfaction.
Limitations There are some limitations to this study. First, this study was conducted at hospitals in only one district in Shanghai. It is unknown whether our results can be generalised to other hospitals in Shanghai or in China. Second, this study didn’t collect the data of patient outcomes, thus failing to analyse the correlation between the delivery of nursing care activities and patients’ outcomes. A significantly larger sample size and the collection of patients’ outcome data will be necessary to better understand nurse staffing and nursing care delivery status in China.
Conclusion The aim of distributing nursing resources is to provide proper nursing care in an effort to meet the needs of patients. Therefore, the quantity and quality of nursing staff resources are important factors that affect the quality of nursing. To proceed from the current clinical reality, more nursing staff should be allocated and nurses must be used effectively according to their educational background, experience and ability to improve nursing care quality and safety. Nursing management must also assign nursing positions scientifically, configure nursing staff rationally, optimise nursing team structure and reasonably match nursing staff with different competencies. The goal of this management approach is to place the appropriate personnel in appropriate positions while also saving money, ensuring quality care and improving patient satisfaction.
Acknowledgements The authors are grateful to all the participating nurses, the research nurses for data collection and directors of the nursing departments for their cooperation. The authors would also like to thank the funding support for this project from the Department of Health in Pudong and the Shanghai health and family planning commission. The views expressed in this paper are those of the authors.
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Source of Funding This project was funded by the Scientific Development Research Funds founded by Pudong New Area Health Bureau [Grant-in-Aid No. PW2012A-3] and the Shanghai Health Bureau [Grant-in-Aid No. 20134061].
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Status of nurse staffing and nursing care delivery in Pudong, Shanghai Hui Jiang, Chen Li, Yan Gu, Haiyan Lu & Wenqin Ye To cite this article: Hui Jiang, Chen Li, Yan Gu, Haiyan Lu & Wenqin Ye (2015) Status of nurse staffing and nursing care delivery in Pudong, Shanghai, Contemporary Nurse, 50:1, 104-114, DOI: 10.1080/10376178.2015.1010255 To link to this article: http://dx.doi.org/10.1080/10376178.2015.1010255
Published online: 05 Jun 2015.
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Date: 29 October 2015, At: 11:16
Contemporary Nurse, 2015 Vol. 50, No. 1, 104–114, http://dx.doi.org/10.1080/10376178.2015.1010255
Status of nurse staffing and nursing care delivery in Pudong, Shanghai Hui Jianga*, Chen Lib, Yan Gua, Haiyan Lua and Wenqin Yec
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a Nursing Department of Shanghai East Hospital, Tongji University School of Medicine, Yuntai Road No. 1800, Pudong New Area, Shanghai, China, 200123; bCollege of Humanities and Social Science, Shanghai University, Shangda Road, No. 99, Baoshan District, Shanghai, China, 200444; cNursing Department of Changhai Hospital, The Second Military Medical University, Changhai Road No.168, Yangpu Area, Shanghai, China, 200433
(Received 6 September 2013; accepted 3 October 2014) Aim: To evaluate nurse staffing levels and nursing care delivery in adult general medical or surgical wards of hospitals in the Pudong district of Shanghai, China. Background: Rapid economic development and improved Chinese living standards have spurred increased demands for high-quality health care. Thus, the quality of nursing services has become a focus of attention. Design: A cross-sectional, descriptive design was used for the study. Methods: We used an anonymous survey to collect data from 1614 nurses from 98 wards in seven general hospitals in Pudong, Shanghai. Results: During day shifts, the nurse-to-patient ratios were >1:10. However, these ratios were much higher during evening and night shifts. The clinical frontline nursing workforce primarily consisted of nurses with junior college degrees that had limited working experience. Junior nurses with different educational backgrounds, professional levels and work experiences were assigned almost similar nursing care work as senior nurses. Conclusions: In the surveyed hospitals in the Pudong district, nurse staffing levels and skill mix may be inadequate to meet the increasing demands of patient care. The clinical nursing workforce needs to be strengthened and used effectively to enhance the quality and safety of patient care. Relevance to clinical practice: We should focus on the quantity and quality of the nursing workforce, as well as nursing skill utilisation. Keywords: China; nurse staffing; inpatient nursing care; nursing management; questionnaire survey
What does this paper contribute to the wider global clinical community? .
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The development of nursing care based on effective distribution and utilisation of nursing resources is necessary for frontline inpatient units to insure the safety of patients and quality of nursing care. Hospital management plays an important role in reshaping the size and scope of the nursing workforce to meet the changing patterns of caregiving and the demands of rapid medical development.
*Corresponding author. Email: [email protected]. Authors (a) and (b) contributed equally to this work. © 2015 Taylor & Francis
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Introduction
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Nurses are the primary professional ‘frontline’ staff in most health-care systems. The contribution of nurses is essential for meeting development goals and delivering safe and effective patient care (DeVandry & Cooper, 2009). The current trends toward greater disease severity, proliferation of new medical technology, and shorter hospital stays has greatly increased nursing workloads. Reasonable nurse staffing and proper nursing care assignments are required to secure patient safety and provide high-quality nursing care (Flynn & Mckeown, 2009). A delicate balance exists between the increased nursing care needs for patients and cost containment requirements of hospitals (Ayre, Gerdtz, Parker, & Nelson, 2007; Crossan & Ferguson, 2005). Thus, there is considerable interest in determining how nurses use their skills effectively and contribute to patient outcomes in a cost-effective manner. Moreover, changes in the availability and roles of nurses, as well as their responsibilities, have heightened this interest. Therefore, it is important for health-care delivery systems in China to re-examine nurse staffing and nursing care delivery. Background China is the world’s most populated country, with 1.3 billon people living in approximately 10 million square kilometres. Over the past three decades, China has experienced rapid economic growth, important technologic advances and global exposure. Rapid economic development has improved living standards. These improvements, accompanied by the aging population and one-child policy in China, have spurred demands for higher quality health care (Liu et al., 2012). In response to these societal demands, the Chinese government announced a health-care reform policy in 2009 that places a priority on improving care in public hospitals (Chen, 2009). The 2009 policy focused on quality nursing services, and indicated they are highly valued by the government, society and patients’ families. Therefore, nurses in China are facing serious challenges to provide high-quality nursing care in a rapidly changing environment, at a time when cost containment and efficiency are increasingly becoming important considerations. These two factors, combined with the promotion and advancement of high-quality nursing service, have advanced the concept of nursing team building in an attempt to improve the quantity and quality of care. Nurse staffing levels are reported to be a determinant of nursing care quality and patient outcomes (Cho, Ketefian, Barkauskas, & Smith, 2003). Seminal studies in this area have emphasised the importance of nursing work to ensure high-quality care and safety in hospitals (Aiken, Clarke, & Sloane, 2002; Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002). A systematic review and meta-analysis of studies published in English between 1990 and 2006 demonstrated that higher nurse staffing levels are significantly associated with better patient outcomes, including lower mortality rates, lower failure-to-rescue rates and shorter hospital stays (Kane, Shamliyan, Mueller, Duval, & Wilt, 2007). Studies conducted in China surveying 7802 nurses and 5430 patients from 600 medical and surgical units also found that inadequate nurse staffing might result in missed (but necessary) nursing care and negative patient outcomes. Additionally, better staffing levels could be an effective strategy to improve patient outcomes (Zhu et al., 2012). Another questionnaire survey done by You (You et al., 2013) from 9688 nurses and 5786 patients in 181 Chinese hospitals indicated that higher patient-to-nurse ratios were associated with poorer nurse outcomes (i.e. increased nurse burnout and job dissatisfaction) and higher likelihoods of nurses reporting poor or fair quality of care. The study also indicated that higher percentages of baccalaureate nurses were strongly related to better patient outcomes. Internationally, nurse staffing models can be classified as nurse-to-patient ratios and nursing hours per patient day (NHPPD). These staffing models are used to develop patient classifications or nursing workload measurement systems to determine the nurse staffing needs for safe patient
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care and to justify nursing resource allocation amid the cost-conscious health-care environment (Hoi, Ismail, Ong, & Kang, 2010; Spetz, 2004). In the US, nurse-to-patient ratios are used in almost every institution as a basis for staffing assignments and form the core from which adjustments are made (Minnick & Mion, 2009). Historically in China, a bed-to-nurse ratio staffing model was used to determine the inpatient ward nurse staffing needs. According to government policy #1689 issued by the Ministry of Health in 1978 (Wong, 2010), this ratio should be 1:0.4, which was considered the accepted standard. In 2011, the nurse-to-patient ratio staffing model was introduced and guided by China’s 2011–2015 Nursing Development Plan (MHC, 2011– 2015). This new policy set a goal of a 1:8 nurse-to-patient ratio for general nursing units. Currently, the nursing education system in China produces nurses with diplomas and associate degrees, as well as bachelor’s, master’s and doctoral degrees (Sherwood & Liu, 2005). Nurses who graduate from nursing school and pass the Chinese registration examination are allowed to work and care for patients. Associate degree nurses account for a large proportion of Chinese nurses. These nurses are trained for three years after high school (Xiao, 2010). In an effort to improve nursing care, the government introduced an independent nursing profession hierarchy structure in 1979. This layered system consists of five nursing levels. Nurses are given academic titles in accordance with their educational background, nursing ability and nursing practice experience (Li & Sonia, 1996; Yun, Shen, & Jiang, 2010). Level 1 and 2 nurses are considered junior nurses. Level 1 nurses with a diploma must work five years in a clinical setting before getting promoted to level 2. Associate degree nurses must work for three years, whereas bachelor’s degree nurses must work for only one year in a clinical setting prior to level 2 promotion. Promotion from level 2 requires working for five years, as well as passing computer, English and nursing skill examinations. Level 4 and 5 nurses are expected to meet higher criteria, including authorship on publications, passing advanced clinical skills examinations and hospital recommendations. Aims The purpose of the current study was to understand the nurse staffing and skill mix of frontline nurses in the adult medical and surgical wards of secondary and tertiary general hospitals in Pudong, Shanghai. We analysed nursing staff configuration and the implementation of nursing care activities of different nursing levels to determine the utilisation efficiency and effectiveness of the nursing workforce. Study design Methods This study used a cross-sectional, descriptive design. An internally-developed questionnaire was used as the study instrument, and data were collected from a survey of clinical nurses’ self-report questionnaires. All general hospitals in the Pudong New Area were evaluated, and all nurses from the inpatient general medical and surgical wards were invited to participate in the survey. Setting and participants This study was conducted in all secondary and tertiary general hospitals in the Pudong New Area, which is the largest district among the 17 Shanghai districts. Ninety-eight wards from seven hospitals (six secondary and one tertiary general hospital) were selected for the survey. All of the hospitals were directly under the charge of the Pudong New Area Health Bureau and collectively provided a comprehensive range of clinical services. The six secondary hospitals were all
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non-teaching hospitals with 300–500 inpatient beds. The tertiary hospital was a general teaching hospital equipped with 1000 inpatient beds. The survey target population included nurses working in the inpatient units (adult general medical and surgical wards). All staff nurses working in these units were invited to participate. Inclusion criteria were: (1) employed nurse graduates; (2) possession of a practising nurse certificate and active registration; (3) providing bedside patient care in the wards; and (4) working continuously for at least three months in the department. Exclusion criteria were nurse managers, nurses on leave or not-on-the-job staff.
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Questionnaire A questionnaire was developed to measure the implementation of nursing care activities in clinical nursing units during the latest one-week period. An anonymous, 101-item survey was created. After a careful review of the literature, the questionnaire was designed to meet the purpose of the study. It consisted of three parts: demographic information of the nursing staff (six items), nurse staffing level (three items) and the status of clinical nursing work implementation (92 items). A convenience sampling method was used by selecting 21 nurses working in the Department of Neurology of a tertiary general hospital as a pilot study. The internal consistency reliability (Cronbach’s α coefficient) of the questionnaire was .94, and the Guttman Split-Half coefficient was .83. The survey was re-conducted a week later, and the average score of each question was calculated. The test-retest reliability measured by Pearson’s correlation coefficient was .94. Five experts in the fields of clinical nursing, nursing management and nursing education were recruited to evaluate the content validity of the questionnaire. The index of content validity was .92, indicating that the designed questionnaire was of good reliability and validity. Data collection Data were collected between March 2013 and April 2013. The nursing departments of participating hospitals were approached to participate. A research information sheet that provided instructions and assured the confidentiality of responses was provided with each questionnaire. Two investigators were trained to distribute and collect the questionnaires. The investigators delivered the survey to the sampled units and the nurse manager delivered them to nurses who met the eligibility criteria. Nurses anonymously completed the questionnaires during their work break or after work and returned them in a sealed envelope to a sealed box in the unit. This strategy aimed to protect the privacy of nurses, increase the response rate and minimise missed recalls. Subsequently, the nurse manager returned the sealed questionnaires to the investigators. Measures Nursing care activities Nursing care activities in this study refer to direct nursing care work activities that were implemented daily by the nurses. Clinical nursing work implementation was measured by seven dimensions on the survey, including assisting daily living (ADL; 20 questions), nursing assessment (four questions), vital signs and discomfort monitoring (14 questions), patient education (nine questions), administration of medications (seven questions), specimen collection (seven questions) and nursing procedures (31 questions). The response to each item was rated on a five-point Likert scale, as follows: 5 = often; 4 = frequent; 3 = moderate; 2 = occasionally and 1 = never. Respondents were required to self-evaluate based on their own assessment of implementation for each nursing task during the latest one-week period.
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Nurse staffing Nurse staffing levels were assessed using nurse-to-patient ratios that were collected from the survey. Nurses reported the data regarding the number of patients they cared for during their last day shift, evening shift and night shift.
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Demographics The nursing staff demographics collected on the survey included age, gender, working experience, educational background, professional level and marital status. Educational background was divided into three groups: technical secondary school (diploma); junior college (associate degree); and college (bachelor’s degree or above). The working experience of nurses was divided into four groups: four years or less, 5–9 years, 10–14 years and greater than 15 years. The professional levels of the nursing staff were divided into three groups: level 1, level 2 and level 3 or above. Ethical considerations The Ethical Committee of Shanghai East Hospital of Tongji University approved this study. Informed consent was obtained from each hospital and each nurse. To ensure rights and privacy, all participants were informed that study data would be kept confidential and anonymity was assured. Data analyses SPSS (version 17.0) was used to input survey data. Two investigators evaluated all results. Demographic data, such as age, educational background, work experience and professional levels, were collected to describe study participants. Implementation of nursing care activities was described using the mean and standard deviation (SD), and comparisons between different educational groups were analysed using single-factor analysis of variance (ANOVA) tests. Two-tailed tests of mean differences were also used. A p-value less than .05 was considered statistically significant.
Results Demographics A total of 1789 questionnaires were distributed, 1614 valid questionnaires were collected, and the valid response rate was 90.23%. Participants ranged in age from 21 to 59 years (Mean 29.03, SD 6.35); Working experience ranged from 0.3 to 38 years (Mean 8.97, SD 7.56) and 64.06% of nurses had less than 10 years of professional nurse working experience. Approximately twothirds of the nurses (65.99%) had an associate nursing degree. Most participants were female (99.44%). The majority of nurses were of level 1 or 2 professional status (89.72%). There were 166 level 3 nurses (10.28%) and no level 4 or 5 nurses. The average nurse-to-patient ratio for the three shifts was >1:10. Evening and night shift nurses cared for more patients than day shift nurses. (Table 1)
Comparison of the implementation of nursing care activities Table 2 compares the implementation of nursing care activities of direct nursing care in the seven dimensions. The most frequent nursing care activities performed by staff nurses in the ward was
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Table 1. Characteristics of study nurses (n = 1614).
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Characteristics
n (%)
Age, in years Working experience, in years Nurse patient ratio Day shift Evening shift Night shift Gender Male Female Working experience 15 yrs Educational background Diploma Associate degree Bachelor degree Master degree Professional level Level 1 Level 2 Level 3 Marital status Single Married without children Married with children Others
Mean ± SD
Range
29.03 ± 6.35 8.97 ± 7.56
21–59 0.3–38
10.59 ± 7.32 24.07 ± 22.02 25.78 ± 23.09
6–20 10–50 12–58
9 (0.56) 1605 (99.44) 637 (39.47) 397 (24.60) 267 (16.54) 313 (19.39) 209 (12.95) 1065 (65.99) 337 (20.88) 3 (0.19) 739 (45.79) 709 (43.93) 166 (10.28) 530 288 691 105
(32.84) (17.84) (42.81) (6.51)
Table 2. Comparison of implementation of nursing care activities*. Dimensions
Mean
SD
Range
Medication Monitoring Assessment Teach patient Procedure Specimen ADL
4.57 4.51 4.39 4.39 3.89 3.85 3.54
0.76 0.65 0.79 0.77 0.84 1.10 0.79
2–5 2–5 2–5 2–5 2–5 1–5 1–5
Notes: *Response scale: 1 = never; 2 = occasionally; 3 = moderate; 4 = often; 5 = frequent.
medication administration, followed by monitoring and assessments. ADL was the least performed nursing care activity by the nursing staff in the ward. Comparative analyses of nursing care delivery among different groups The implementation of nursing care activities by nursing staff with different educational backgrounds, different professional levels and different working experience were compared (Tables 3–5). Table 3 shows that there were no significant differences in direct nursing work by
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Comparative analyses of different educational backgrounds (mean ± SD).
Dimensions ADL Assessment Monitoring Teach patient Medication Specimen Procedure
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Table 4.
Diploma (n = 209)
Associate degree (n = 1065)
Bachelor and above (n = 340)
F value
p value
3.48 ± 0.82 4.31 ± 0.83 4.55 ± 0.65 4.40 ± 0.80 4.61 ± 0.72 3.80 ± 1.26 3.82 ± 0.88
3.56 ± 0.78 4.42 ± 0.77 4.51 ± 0.63 4.40 ± 0.76 4.57 ± 0.75 3.88 ± 1.06 3.90 ± 0.83
3.52 ± 0.81 4.36 ± 0.82 4.50 ± 0.69 4.36 ± 0.81 4.56 ± 0.83 3.80 ± 1.13 3.92 ± 0.86
1.050 2.310 0.423 0.335 0.263 0.837 1.172
.350 .100 .655 .716 .769 .433 .310
Comparative analyses among different professional levels (mean ± SD).
Dimensions ADL Assessment Monitoring Teach patient Medication Specimen Procedure
Level 1 nurse (n = 739)
Level 2 nurse (n = 709)
Level 3 nurse (n = 166)
F value
p value
3.68 ± 1.10 4.50 ± 0.77 4.44 ± 0.71 4.51 ± 0.77 4.50 ± 0.82 3.84 ± 1.04 3.91 ± 0.80
3.58 ± 1.14 4.61 ± 0.70 4.56 ± 0.69 4.56 ± 0.67 4.56 ± 0.76 3.92 ± 1.12 3.93 ± 0.85
3.28 ± 1.09 4.47 ± 0.80 4.44 ± 0.85 4.51 ± 0.62 4.37 ± 1.06 3.62 ± 1.29 3.68 ± 0.94
1.527 0.978 1.121 0.215 0.711 4.843 5.996
.219 .377 .327 .807 .492 *.008 *.003
Notes: *p < .01 LSD test between groups: specimen, level 1* level 3, p < .05, level 2* level 3, p < .01, level 1* level 2, p > .05; procedures, level 1* level 3, p < .01, level 2* level 3, p < .01, level 1* level 2, p > .05
Table 5.
Comparative analyses between different working experience (mean ± SD).
Dimensions ADL Assessment Monitoring Teach patient Medication Specimen Procedure
4yrs or less (n = 637)
5∼9yrs (n = 397)
10∼14yrs (n = 267)
15yrs or above (n = 313)
F value
p value
3.69 ± 1.08 4.55 ± 0.66 4.47 ± 0.61 4.54 ± 0.68 4.56 ± 0.71 3.85 ± 1.01 3.95 ± 0.78
3.63 ± 1.19 4.53 ± 0.89 4.47 ± 0.88 4.47 ± 0.85 4.44 ± 0.99 3.90 ± 1.07 3.97 ± 0.80
3.49 ± 1.10 4.59 ± 0.64 4.64 ± 0.56 4.62 ± 0.59 4.59 ± 0.61 4.00 ± 1.18 3.96 ± 0.74
3.21 ± 1.02 4.33 ± 0.98 4.33 ± 0.90 4.43 ± 0.57 4.27 ± 1.13 3.67 ± 1.24 3.63 ± 1.02
1.570 0.699 1.521 0.800 1.338 4.783 12.91
.196 .553 .209 .495 .262 *.003 *.000
Notes: *p < .01. LSD test between groups: specimen, 4yrs* ≥ 15yrs, 5∼9yrs* ≥ 15yrs, p < .05, 10∼14yrs* ≥ 15yrs, p < .01, 4yrs*5∼9yrs, 5∼9yrs*10∼14yrs, 4yrs*10∼14yrs, p > .05; procedures, ≤ 4yrs* ≥ 15yrs, 5∼9yrs* ≥ 15yrs, 10∼14yrs* ≥ 15yrs, p < .01, 4yrs*5∼9yrs, 5∼9yrs*10∼14yrs, 4yrs*10∼14yrs, p > .05.
nursing staff with different educational backgrounds. In Tables 4 and 5, the results show that there were no significant differences in implementing the ADL, assessments, monitoring, patient teaching and medications among nurses with different professional levels and different working experiences. However, there were significant differences in implementing the specimen collection and patient care procedures (p < .01). Least significant difference (LSD) analysis of the two groups indicated that in the dimensions of specimen and procedure, experienced level 3 nurses and nurses with more than 15 years of experience performed significantly fewer activities than other groups.
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Discussion Nurse staffing and skill mix may not meet the increasing demands of patient care Nurse staffing levels and skill mix are recognised as the primary determinants to guarantee care quality and patient safety. (Buchan & Aiken, 2008; Buchan & Dal Poz, 2002). Inadequate levels of staffing (high nurse-to-patient ratios) and skill mix (experience, education and professional level) affect quality of care in a range of ways (Buchan & Dal Poz, 2002; Lang, Hodge, Olson, Romano, & Kravitz, 2004). While patients’ needs and nurses’ workloads have been increasing, the appropriate number of nurses needed to care for an increasingly sicker population has increased. Legislation of the nurse-to-patient ratio is being widely discussed amongst nursing professionals worldwide (Rassin & Silner, 2007). In 1999, the California State Legislature passed Assembly Bill 394. The bill requires the California State Department of Health Service to establish minimum nurse-to-patient ratios in acute care general, special and psychiatric hospitals. The ratio was set at six patients per nurse on general medical-surgical wards and decreased to five per nurse when the bill was fully implemented in 2005 (Lang et al., 2004). In Australia, the state of Victoria has recommended that the nurse-to-patient ratio should be 5:20 for day shifts in general medical and surgery wards, depending on the type of hospital (Gerdtz & Nelson, 2007; Lankshear, Sheldon, & Maynard, 2005). Our results show that nurse-to-patient ratios in China are much higher than the mandated ratios enacted by California and Australia, and the problem is aggravated on evening and night shifts. We also clearly show that nurse staffing in Pudong does not provide sufficient care compared to accepted international standards. This inadequacy remains even following Chinese standards. Moreover, the nurse educational mix, experience mix and professional level mix may also be insufficient to meet the present and future challenges to nursing. Clinical ‘frontline’ nurses in Pudong were mainly associate degree, with a working experience lower than 10 years, and level 1 or level 2 junior nurses. Thus, according to our findings, the staffing levels and the skill mix are not adequate to meet the patients’ changing health-care needs. Therefore, intense research is required to evaluate the needs of increased nursing staff to suit the clinical workload conditions, as well as patients’ needs, in all hospitals and all departments while simultaneously minimising costs. Nurse managers in China should take measures to reshape the size and scope of the nursing workforce to meet the changing patterns of caregiving and the demands of rapid medical development.
Nursing work assignment does not reflect the skill level of nursing staff The nursing shortage is affected by the number of available nurses as well as by the way nurses use their skills effectively (Lang et al., 2004). In China, the current nursing workforce consists entirely of registered nurses (Hui, Wenqin, &Yan, 2013). The present hospital system does not have any support staff to help nurses perform non-nursing tasks. In addition, families usually accompany patients and stay with them in the hospital. We previously reported that patients’ relatives or family-paid caregivers provided much of the bedside patient care in hospitals rather than nurses (Hui et al., 2013). As a result, much of the nurses’ time and energy is diverted to medical tasks or other non-nursing duties. Our findings demonstrate that nurses spend most of their time on medications, monitoring and assessments. ADL was the least frequent work done by the nurses, followed by specimen collection. These results coincide with the fact that nurses in China are more treatment-oriented and ADL is tasked to relatives or family-hired caregivers. Therefore, nurse staffing levels need to be improved to ensure nurses have more time for patient care in order to secure the quality and safety of nursing care.
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In our study, the implementation of nursing care activities were examined in relation to the nursing staff work experience, educational background and professional level. The results of this survey show that although there were clear differences between educational background, professional level and working experience, there were almost no significant differences in the frequency of implementing most of the direct nursing work except in the dimensions of collecting specimens and performing procedures. These data suggest that nursing staff skills are not being used effectively. This lack of distinction in performing clinical tasks among nurses may be caused by an insufficient number of nurses and may also be caused by the special Chinese health-care system. Neglecting these differences in educational background, professional level and working experience will discourage the enthusiasm and morale of highly educated, experienced nursing staff. It also wastes nursing resources and poorly utilises human assets. Therefore, managing nursing asset allocation based on the abilities, talents and expertize of the nurses is very important. This represents the inevitable trend in ensuring the clinical nursing quality and promoting nursing work towards refinement and specialisation.
Relevance to clinical practice Adequate attention should be paid to the nursing shortage and nursing care delivery status in hospitals. Proper nurse staffing and skill mix are a fundamental requirement that maximises nursing resources, boosts nursing team growth, stimulates professional development for team members, acknowledges the hospital budget, secures nursing care quality and improves patient satisfaction.
Limitations There are some limitations to this study. First, this study was conducted at hospitals in only one district in Shanghai. It is unknown whether our results can be generalised to other hospitals in Shanghai or in China. Second, this study didn’t collect the data of patient outcomes, thus failing to analyse the correlation between the delivery of nursing care activities and patients’ outcomes. A significantly larger sample size and the collection of patients’ outcome data will be necessary to better understand nurse staffing and nursing care delivery status in China.
Conclusion The aim of distributing nursing resources is to provide proper nursing care in an effort to meet the needs of patients. Therefore, the quantity and quality of nursing staff resources are important factors that affect the quality of nursing. To proceed from the current clinical reality, more nursing staff should be allocated and nurses must be used effectively according to their educational background, experience and ability to improve nursing care quality and safety. Nursing management must also assign nursing positions scientifically, configure nursing staff rationally, optimise nursing team structure and reasonably match nursing staff with different competencies. The goal of this management approach is to place the appropriate personnel in appropriate positions while also saving money, ensuring quality care and improving patient satisfaction.
Acknowledgements The authors are grateful to all the participating nurses, the research nurses for data collection and directors of the nursing departments for their cooperation. The authors would also like to thank the funding support for this project from the Department of Health in Pudong and the Shanghai health and family planning commission. The views expressed in this paper are those of the authors.
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Source of Funding This project was funded by the Scientific Development Research Funds founded by Pudong New Area Health Bureau [Grant-in-Aid No. PW2012A-3] and the Shanghai Health Bureau [Grant-in-Aid No. 20134061].
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