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Performance of the Safer Nursing Care Tool to measure nurse staffing requirements in acute hospitals: a multicentre observational study.

ABSTRACT: OBJECTIVES:The best way to determine nurse staffing requirements on hospital wards is unclear. This study explores the precision of estimates of nurse staffing requirements made using the Safer Nursing Care Tool (SNCT) patient classification system for different sample sizes and investigates whether recommended staff levels correspond with professional judgements of adequate staffing. DESIGN:Observational study linking datasets of staffing requirements (estimated using a tool) to professional judgements of adequate staffing. Multilevel logistic regression modelling. SETTING:81 medical/surgical units in four acute care hospitals. PARTICIPANTS:22?364 unit days where staffing levels and SNCT ratings were linked to nurse reports of "enough staff for quality". PRIMARY OUTCOME MEASURES:SNCT-estimated staffing requirements and nurses' assessments of staffing adequacy. RESULTS:The recommended minimum sample of 20 days allowed the required number to employ (the establishment) to be estimated with a mean precision (defined as half the width of the CI as a percentage of the mean) of 4.1%. For most units, much larger samples were required to estimate establishments within ±1 whole time equivalent staff member. When staffing was lower than that required according to the SNCT, for each hour per patient day of registered nurse staffing below the required staffing level, the odds of nurses reporting that there were enough staff to provide quality care were reduced by 11%. Correspondingly, the odds of nurses reporting that necessary nursing care was left undone were increased by 14%. No threshold indicating an optimal staffing level was observed. Surgical specialty, patient turnover and more single rooms were associated with lower odds of staffing adequacy. CONCLUSIONS:The SNCT can provide reliable estimates of the number of nurses to employ on a unit, but larger samples than the recommended minimum are usually required. The SNCT provides a measure of nursing workload that correlates with professional judgements, but the recommended staffing levels may not be optimal. Some important sources of systematic variations in staffing requirements for some units are not accounted for. SNCT measurements are a potentially useful adjunct to professional judgement but cannot replace it. TRIAL REGISTRATION NUMBER:ISRCTN12307968.

SUBMITTER: Griffiths P

PROVIDER: S-EPMC7232629 | biostudies-literature | 2020 May

REPOSITORIES: biostudies-literature

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Performance of the Safer Nursing Care Tool to measure nurse staffing requirements in acute hospitals: a multicentre observational study.

Griffiths Peter P Saville Christina C Ball Jane J Culliford David D Pattison Natalie N Monks Thomas T

BMJ open 20200515 5

<h4>Objectives</h4>The best way to determine nurse staffing requirements on hospital wards is unclear. This study explores the precision of estimates of nurse staffing requirements made using the Safer Nursing Care Tool (SNCT) patient classification system for different sample sizes and investigates whether recommended staff levels correspond with professional judgements of adequate staffing.<h4>Design</h4>Observational study linking datasets of staffing requirements (estimated using a tool) to ...[more]

PMID: 32414828

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Project description:ObjectiveTo estimate and contrast the relationships between nurse staffing and health outcomes in nursing homes with low and high dementia census, to understand the association of staffing hours with dementia care quality.Data sources and study settingA national sample of nursing homes during 2017-2019 (pre-COVID). Data included the Payroll-Based Journal, Medicare Claims, Nursing Home Care Compare, and Long-Term Care Focus.Study designRetrospective, regression analyses. We estimated separate linear models predicting six long-term facility-level outcomes. Independent variables included staffing hours per resident-day (HPRD) interacted with the facility percentage of dementia residents, controlling for other resident and facility characteristics.Data collection/extraction methodsHospital-based nursing homes, those with fewer than 30% dementia residents, and missing data were excluded.Principal findingsWe found that registered nurses and certified nurse assistants HPRDs were likely to exhibit positive returns in terms of outcomes throughout most of the range of HPRD for both high and low-census dementia facilities, although, high- and low-dementia facilities differed in most outcome rates at all staffing levels. Average predicted antipsychotics and activities of daily living as functions of HPRD were worse in higher dementia facilities, independent movement, and hospitalizations did not differ significantly, and Emergency Rooms and pressure sores were worse in lower dementia facilities. Average marginal effects were not statistically different [CI included zero] between the high and low dementia facilities for any outcome.ConclusionsThese findings suggest that increasing staffing will improve outcomes by similar increments in both low- and high-dementia facilities for all outcomes. However, at any given level of staffing, absolute differences in outcomes between low- and high-dementia facilities remain, suggesting that additional staffing alone will not suffice to close these gaps. Further studies are required to identify opportunities for improvement in performance for both low- and high-dementia census facilities.

Project description:ObjectiveTo examine the impact of nurse staffing on patient-perceived quality of nursing care. We differentiate nurse staffing levels and nursing skill mix as two facets of nurse staffing and use a multidimensional instrument for patient-perceived quality of nursing care. We investigate non-linear and interaction effects.SettingThe study setting was 3458 hospital units in 1017 hospitals in Germany.ParticipantsWe contacted 212 554 patients discharged from non-paediatric, non-intensive and non-psychiatric hospital units who stayed at least two nights in the hospital between January and October 2019. Of those, 30 174 responded, yielding a response rate of 14.2%. Our sample included only those patients. After excluding extreme values for our nurse staffing variables and removing observations with missing values, our final sample comprised 28 136 patients ranging from 18 to 97 years of age (average: 61.12 years) who had been discharged from 3458 distinct hospital units in 1017 hospitals.Primary and secondary outcome measuresPatient-perceived quality of nursing care (general nursing care, guidance provided by nurses, and patient loyalty to the hospital).ResultsFor all three dimensions of patient-perceived quality of nursing care, we found that they significantly decreased as (1) nurse staffing levels decreased (with decreasing marginal effects) and (2) the proportion of assistant nurses in a hospital unit increased. The association between nurse staffing levels and quality of nursing care was more pronounced among patients who were less clinically complex, were admitted to smaller hospitals or were admitted to medical units.ConclusionsOur results indicate that, in addition to nurse staffing levels, nursing skill mix is crucial for providing the best possible quality of nursing care from the patient perspective and both should be considered when designing policies such as minimum staffing regulations to improve the quality of nursing care in hospitals.

Project description:BackgroundThe importance of nurse staffing levels in acute hospital wards is widely recognised but evidence for tools to determine staffing requirements although extensive, has been reported to be weak. Building on a review of reviews undertaken in 2014, we set out to give an overview of the major approaches to assessing nurse staffing requirements and identify recent evidence in order to address unanswered questions including the accuracy and effectiveness of tools.MethodsWe undertook a systematic scoping review. Searches of Medline, the Cochrane Library and CINAHL were used to identify recent primary research, which was reviewed in the context of conclusions from existing reviews.ResultsThe published literature is extensive and describes a variety of uses for tools including establishment setting, daily deployment and retrospective review. There are a variety of approaches including professional judgement, simple volume-based methods (such as patient-to-nurse ratios), patient prototype/classification and timed-task approaches. Tools generally attempt to match staffing to a mean average demand or time requirement despite evidence of skewed demand distributions. The largest group of recent studies reported the evaluation of (mainly new) tools and systems, but provides little evidence of impacts on patient care and none on costs. Benefits of staffing levels set using the tools appear to be linked to increased staffing with no evidence of tools providing a more efficient or effective use of a given staff resource. Although there is evidence that staffing assessments made using tools may correlate with other assessments, different systems lead to dramatically different estimates of staffing requirements. While it is evident that there are many sources of variation in demand, the extent to which systems can deliver staffing levels to meet such demand is unclear. The assumption that staffing to meet average need is the optimal response to varying demand is untested and may be incorrect.ConclusionsDespite the importance of the question and the large volume of publication evidence about nurse staffing methods remains highly limited. There is no evidence to support the choice of any particular tool. Future research should focus on learning more about the use of existing tools rather than simply developing new ones. Priority research questions include how best to use tools to identify the required staffing level to meet varying patient need and the costs and consequences of using tools.Tweetable abstractDecades of research on tools to determine nurse staffing requirements is largely uninformative. Little is known about the costs or consequences of widely used tools.

Project description:ObjectivesTo examine the effect of Hurricane Irma on staff-related financial expenditures and daily direct-care nurse staffing levels.DesignRetrospective cohort study.SettingSeptember 3-24, 2017 in the state of Florida, United States. Hurricane Irma made landfall on September 10, 2017.ParticipantsSix hundred and fifty-three nursing homes (NHs), 81 evacuated facilities, and 572 facilities that sheltered-in-place.MeasurementsThis study used data from Payroll-Based Journaling (PBJ), Certification and Survey Provider Enhanced Reports (CASPER), and Florida's health providers' emergency reporting system. PBJ provided estimates of daily direct-care nurse staffing levels for registered nurses, licensed practical nurses, and certified nursing assistants. CASPER reported facility-level characteristics such as profit status, chain membership, and special care unit availability. Florida's emergency reporting system identified evacuation status during Hurricane Irma. Linear mixed-effects models were used to estimate the unique contribution of evacuation status on daily staffing increases over time from September 3 to 10.ResultsAmong all facilities, we found significant increases in staffing for licensed practical nurses (p = 0.02) and certified nursing assistants (p < 0.001), but not for registered nurses (p = 0.10) before Hurricane Irma made landfall. From 1 week before landfall to 2 weeks after landfall (September 3-24), an additional estimated $2.41 million was spent on direct-care nurse staffing. In comparison to facilities that sheltered-in-place, evacuated facilities increased staffing levels of all nurse types (all p < 0.001). At landfall, evacuated facilities spent an estimated $93.74 on nurse staffing per resident whereas facilities that sheltered-in-place spent $76.10 on nurse staffing per resident.ConclusionNHs face unprecedented challenges during hurricanes, including maintaining adequate direct-care nurse staffing levels to meet the needs of their residents. NHs that evacuated residents had an increase in direct-care nurse staffing that was greater than that seen in NHs that sheltered-in-place.

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Performance of the Safer Nursing Care Tool to measure nurse staffing requirements in acute hospitals: a multicentre observational study.

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Performance of the Safer Nursing Care Tool to measure nurse staffing requirements in acute hospitals: a multicentre observational study.

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