ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE

The impact of three nursing staffing models on nursing outcomes Pei-Hsuan Yang, Chich-Hsiu Hung & Yu-Chin Chen Accepted for publication 27 January 2015

Correspondence to C.-H. Hung: e-mail: [email protected] Pei-Hsuan Yang PhD RN Head Nurse Department of Nursing, Kaohsiung Medical University Hospital, Taiwan Chich-Hsiu Hung PhD RN Director and Professor School of Nursing, Kaohsiung Medical University, Taiwan Yu-Chin Chen PhD RN Consultant Taipei Veterans General Hospital, Taiwan

Y A N G P . - H . , H U N G C . - H . & C H E N Y . - C . ( 2 0 1 5 ) The impact of three nursing staffing models on nursing outcomes. Journal of Advanced Nursing 71(8), 1847– 1856. doi: 101111/jan.12643

Abstract Aim. To examine the impact of application of different nursing staffing models on patient safety, quality of care and nursing costs. Background. One proposed means of addressing the staff shortage while decreasing nursing costs is the application of nursing staffing models. However, the optimal proportion of registered nurses to nurse aides remains unclear. Design. A retrospective cohort study. Methods. To examine a total of 667 inpatients of a 20-bed respiratory care centre at a medical centre located in southern Taiwan. Three mixed models of nursing staffing, where the portion of nurses compared with nurse aides was 76% (n = 213), 100% (n = 209) and 92% (n = 245), were applied during three different periods between 2006 – 2010. Results. The 76% RNs group made fewer medication errors than the 100% RNs group; the 76% and 92% RNs groups had a higher rate of urinary tract infections; the 92% RNs group had a lower rate of bloodstream infections; the 76% RNs group had a lower rate of ventilator weaning; and the 76% and 92% RNs groups incurred higher nursing costs. Conclusions. Use of different nursing staffing models that substitute nurse aides for RNs may negatively affect patient safety and quality of care and increase nursing costs. To avoid this risk, hospitals should employ and train their own nurse aides and develop a training system and education materials for RN and nurse aides. Keywords: bloodstream infections, nurse aids, nurses, nursing costs, nursing outcomes, nursing staffing model, patient safety, respiratory care centre, urinary tract infections, ventilator weaning

Introduction As the largest group of healthcare providers in a hospital, nurses are first-line clinicians who assume great responsibility © 2015 John Wiley & Sons Ltd

in maintaining their patients’ health. The nursing staffing shortage has thus become a difficult issue for global medical institutions, one exacerbated by the increasing ageing of populations throughout the world and their resulting care needs. In Taiwan, a nation characterized by an increasingly ageing population, the Taiwan National Union of Nurses’ 1847

P.-H. Yang et al.

Why is this research needed?  The effectiveness of different nursing skill mix models remains unclear after years of the application in medical institutions.  RN staffing shortage and excessive workload are associated with negative patient outcomes.  Further exploration of the impact of nurse staffing on patient outcomes is needed.

What are the key findings?  Patients in respiratory care centres should be cared for and regularly evaluated for weaning from ventilators by RNs, who cannot be replaced by nurse aides.  Nursing skill mix models will change nursing care activities and procedures which could impact quality of care.

proportion of RNs to nurse aides for enhancing patient safety and quality of care remains unclear and its determination requires the collection of more evidence. In recent years, the Positive Practice Environments campaign has been introduced worldwide with the goal of changing healthcare policies to provide nurses with safe and comfortable working environments, thereby facilitating the retention of nursing professionals and the improvement of staffing support (World Health Organization 2010). Task shifting, a practice by which nurses delegate nonprofessional nursing duties to lower ranking professional workers who have undergone short-term training, has been advocated as a strategy to improve the effectiveness, reasonableness and accessibility of nursing staffing and enhance nurses’ professional autonomy.

 The use of nursing skill mix models can reduce RNs’ workload but may affect patient safety and quality of care.

How should the findings be used to influence policy/ practice/research/education?  For nursing outcomes, hospitals should employ and train their own nurse aides to reduce their turnover and RNs’ workload.  RNs and nurse aides should be monitored for infection control to reduce the occurrence of nosocomial infections.  The future study should apply a prospective study design with a random assignment to explore nursing outcomes among the different nursing staffing models.

Association (2012) reported an employment rate of less than 60% among registered nurses (RNs). Of the 90 hospitals currently operating in Taiwan, the turnover rate among new nurses has been reported to range from 22-29% and 89% of the hospitals have reported difficulty in recruiting nurses. These figures are troubling, as nursing shortage and/or excessive workload is associated with negative patient outcomes, such as medication errors (Whitman et al. 2002, Mahmood et al. 2011), increased rates of nosocomial infections (Stone et al. 2007, Feng et al. 2008) and unplanned endotracheal self-extubation (Grap et al. 1995, Penoyer 2010). As a means of addressing the nursing shortage, hospitals in Taiwan often assign nonprofessional nurse aides to different job duties, depending on the care needs of the medical institution. These hospitals emphasize that such assignment of nurse aides does not sacrifice patient safety and quality of care. This claim is supported by previous studies that have suggested that nurse aides can share nurses’ nonprofessional nursing duties and enhance nurse and patient satisfaction (Lee et al. 2005, Feng et al. 2008). However, the optimal

1848

Background In 2005, the Taiwanese government initiated application of several nursing skill mix models (i.e., nursing staffing models) where specific job duties were assigned to RNs and to nurse aides (Lu 2009). Application of nursing skill mix models is expected to assist RNs in performing nursing duties. By helping overcome the nursing staffing shortage, the application of the models can reduce RN workload, provide RNs with sufficient time to engage in patient education or care plans, improve RN job satisfaction and maintain good quality of care. Several studies have examined the effects of application of different nursing skill mix models to patient outcomes and patient safety. Among them, Blegan et al. (1998) found that a ward where the proportion of RNs to RN aides was higher than 85% had lower rates of medication errors. In accordance, Needleman et al. (2002) found that all patients who received a greater number of hours of care by RNs had a shorter length of stay and lower rates of urinary tract infections, pneumonia, shock and cardiac arrest, while surgical patients had lower rates of urinary tract infections. In contrast, Van den Heede et al. (2008) reported that application of different nursing skill mix models had no statistically significant impact on patient outcomes. Likewise, Sun and Yen (2010) reported that application of a 1-year intervention that included assignment of a day shift nurse aide to a ward resulted in no improvement in the rates of pressure ulcers, falls or infections. Several studies have reported mixed results. Lee et al. (2005) found that although application of skill mix models effectively reduced personnel costs and enhanced nurse and patient satisfaction, it resulted in no statistically significant

© 2015 John Wiley & Sons Ltd

JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE

change in patient falls or medication errors. In an examination of the effectiveness of 3 different skill mix models where the proportion of RNs to nurse aides was 100-0%, 90-10% and 85-15%, respectively, Feng et al. (2008) found that the ward that applied the 90-10% model experienced reduced rates of infections, while the ward that applied the 100-0% model experienced increased rates of infections. As indicated by these mixed results, the effectiveness of application of different nursing skill mix models on nursing outcomes remains unclear despite years of study.

The study Aims To help clarify this important issue, the purpose of this study was to compare the impact of the application of 3 different nursing staffing models on patient safety, quality of care and nursing costs.

Design This retrospective cohort study design was used to compare 3 nursing staffing models.

Participants A total of 667 inpatients of a 20-bed respiratory care centre (RCC) at a medical centre in southern Taiwan from 2006– 2010 were included in the study. Exclusion criteria were death, referral to other units or discharge in 3 days of admission to the RCC. Data were collected in three phases according to the nursing staffing models. The first phase included 213 patients who received care by an average of 19 RNs and 6 nurse aides who had been dispatched from a care centre (i.e. 2 nurse aides were substituted for each RN such that the proportion of RNs was 76%) per month for 11 months from 1 July 2006–30 June 2007 (excluding the period from 1 January–31 January 31 in 2007). The nurse aides primarily performed nonprofessional nursing duties, primarily bed bathing and, time permitting, diaper changing, turning and nasogastric tube feeding. The second phase included 209 patients who received care by an average of 23 RNs and 0 nurse aides (i.e. the proportion of RNs was 100%) per month for 11 months from February 1–December 31 in 2008. The third phase included 245 patients who received care by an average of 23 RNs and 2 nurse aides who had been dispatched from a care centre (i.e. the proportion of RNs was 92%) per month for 11 months from 1 February–31 December 31 2010. © 2015 John Wiley & Sons Ltd

Nursing staffing models on nursing outcomes

Data collection Data from the monitoring records of the nursing care quality and patient safety departments, from patient records and from the hospital accounting office regarding nursing personnel costs were collected for the study period of 2006–2010. Patient outcome data included rates of pressure ulcers; urinary tract, respiratory tract and bloodstream infections; medication errors; unplanned endotracheal tube extubation; ventilator weaning and mortality, in addition to length of ventilator use and hospital stay. Data related to patients included transfer-in division, sex, age, Acute Physiology and Chronic Health Evaluation (APACHE II) score and underlying diseases. Data regarding RN years of work experience were collected from the nursing unit. Successful ventilator weaning was defined as liberation from mechanical ventilation for more than 72 consecutive hours. The proportion of RNs refers to the percentage of RNs to total nursing staff (RNs and nurse aides). In 24 hours of admission to the RCC, the patient’s APACHE II score, a severity-of-disease score, was computed based on several measurements, including body temperature, heart rate, mean arterial pressure, respiratory rate, PaO2 level, serum sodium level, white blood cell count, platelet count and Glasgow coma score and adjusted for patient age and for chronic health problems. A higher APACHE II score indicates more severe disease and higher risk of death (Knaus et al. 1985). The monthly nursing cost spent for RNs was determined by adding the monthly salary of all RNs employed by the hospital, dividing the sum by the total number of RNs employed during the same month to calculate the average salary per RN and then multiplying the number of RNs working in the RCC in the same month. The monthly nursing cost spent for nurse aides, who were paid a fixed salary, was determined by multiplying their salary by the number of shifts (12 hours is considered one shift) worked in the same month. Thus, the monthly nursing cost was determined by adding the monthly nursing cost for employing the RNs to the nursing cost of employing the nurse aides in the same month.

Ethical considerations The University Committee for Ethics in Research approved the study.

Data analysis Data were encoded and repeatedly verified for accuracy and then analysed using JMP 8.0 statistical software (SAS Insti1849

P.-H. Yang et al.

tute Inc, Cary, NC, USA) based on the purpose and variable characteristics. The mean and standard deviation were used to describe continuous variables and the frequency distribution and percentage were used describe categorical variables. We tested differences in nominal variables using Chi-square test and for continuous variables using ANOVA. With ANOVA, when a significant difference was found among the means, post hoc Scheffe’s test was applied. Those significant at P < 005 were considered for inclusion in multivariate (logistic regression model) analyses after collinearity was assessed.

Results Comparison of patient and RN demographical and clinical variables Patient and RN demographical and clinical variables were indicated in Table 1. The mean years of work experience of the RNs in the three groups were 471 (SD 022), 464 (SD 033) and 426 (SD 032) years respectively. The education

ratios of the 3 groups, defined as the number of nurses with a university degree divided by the number of all nurses, were 047 (SD 001), 055 (SD 009) and 086 (SD 004), respectively. The ICU experience ratios of the 3 groups, defined as the number of nurses with ICU experience divided by the number of all nurses, were 044 (SD 002), 028 (SD 002) and 022 (SD 001) respectively (Table 1). The results of statistical analysis indicated the absence of statistically significant differences about demographical characteristics and clinical variables (age, sex, transfer-in division, cause of respiratory failure and APACHE II score) among the 3 groups. In contrast, statistically significant differences were found about days of ventilator use prior to admission to the RCC and number of RN years of work experience, education ratio and ICU experience ratio (Table 1).

Comparison of patient safety, quality of care and nursing costs In terms of patient safety, no statistically significant differences were found about the rate of unplanned endotracheal

Table 1 Relationships of different proportions of RNs to demographics and clinical variables of patients and RNs.

Variables Age Gender Male Female Transfer-in division Medical ICU Surgical ICU General ward Days of ventilator use prior to admission Causes of respiratory failure Respiratory disease Postsurgery Neuromuscular disease Cardiovascular disease Sepsis and other Cancer APACHE II RNs’ years of work experience Education ratio at university level ICU experience ratio

Proportion of RNs 76% n (%)/M (SD) N = 213

Proportion of RNs 100% n (%)/M (SD) N = 209

Proportion of RNs 92% n (%)/M (SD) N = 245

v2/F

P

6794 (1570)

6964 (1440)

6929 (1686)

069

050*

120 (5634) 93 (4366)

116 (5550) 93 (4450)

151 (6163) 94 (3837)

210

035†

412

039†

726

The impact of three nursing staffing models on nursing outcomes.

To examine the impact of application of different nursing staffing models on patient safety, quality of care and nursing costs...
105KB Sizes 0 Downloads 9 Views