Evidence Based Practice Welcome to the EBP presentation by Karilyn Bufka, Jennifer Edgell and Jessica Riley Karilyn Bufka Jennifer Edgell Jessica Riley

Do nurse shortages affect patient outcomes? Problem Statement Do nurse shortages affect patient outcomes? Nursing shortages are a topic that has been of much debate and discussion over the past few years The authors of this paper wondered if evidence has shown whether or not an increase in patient to nurse ratios would affect patient outcomes. The goal of this presentation is to summarize findings from four recent research studies in the area of nursing shortages to determine if patient outcomes are negatively affected by increased patient to nurse ratios.

Evidence – Article 1 Failure to rescue rates (patients that died in the hospital after complications) were lower in the units where patient to nurse ratios were lower. Decubitus ulcers in hospitals that had initial low patient to nurse ratios actually showed higher rates of ulcers over time (Cook, Gaynor, Stephens, & Taylor, 2012). The goal of this study was to determine if the California regulation on nurse staffing levels passed in 1999 and implemented in 2004 had the intended effect of lower patient to nurse ratios in the institutions that previously did not comply and determine the impact on patient health outcomes. The authors examined failure to rescue rates and rates of decubitus ulcers. Failure to rescue rates were lower in the units where patient to nurse ratios were lower. The regulation did decrease patient to nurse ratios in those facilities that had higher ratios prior to implementation of the regulation Failure to rescue rates did not improve in those same facilities. Decubitus ulcers in hospitals that had initial low patient to nurse ratios actually showed higher rates of ulcers over time This was attributed to the fact that more attention has been given to pressure ulcers over the past decade. There is no way to determine if this is true so the authors decided it was not relevant to the study. Due to this limitation the study cannot determine that the regulation change improved patient outcomes

Evidence – Article 2 Data was compiled collecting errors that resulted from prescription, transcription, dispensing, and administration including if a wrong medication, method, dosage, inappropriate continuation, inadvertent omission, wrong time/delay or administration of medication despite a known allergy had not been intercepted. A significant relationship between RN staffing levels and medication errors was not indicated, although, findings do indicate that "a supportive practice environment is associated with a higher quality of nursing care" (Flynn, Liang, Dickson, Xie, & Suh, 2012) (Limitations to the study include: under-reporting, perception of error and items used to measure error. ) This study was conducted to determine the association of environmental factors that lead to increased rates of medication errors. Data was compiled by collecting errors that resulted from prescription, transcription, dispensing, and administration. Data also included instances of a wrong medication, method, dosage, inappropriate continuation, inadvertent omission, wrong time/delay or administration of medication despite a known allergy. A significant relationship between RN staffing levels and medication errors was not indicated, although findings do indicate that "a supportive practice environment is associated with a higher quality of nursing care"

Evidence – Article 3 “A ¼ hour increase in LPN hours per patient day was associated with a 15% increase in the odds of death and a 27% increase in the odds of sepsis” (Glance et al., 2012, p. 4). Nurse aide staffing increases of ¼ hour decreased pneumonia odds by 8% Increased rates of infection and mortality were observed (Glance et al., 2012). The goal of this study was to determine if nurse staffing had any association with healthcare associated infections, mortality, and failure-to-rescue rates in Level I and II trauma centers The number of hours per patient day were estimated using previous studies for RNs, licensed particles nurses (LPNs), and nurses’ aides (NA) determined that “a ¼ hour increase in LPN hours per patient day was associated with a 15% increase in the odds of deal and a 27% increase in the odds of sepsis” (p. 4). It was also found that NA staffing increases of ¼ hour decreased pneumonia odds by 8% It was believed that even though nurse aides have a lower education level, they are less likely than LPNs to be substituted for RNs because of the difference in responsibilities the study found that when more of the nursing care is provided by LPNs, increased rates of infection and mortality are observed

Evidence – Article 4 Staffing with RNs was compared with staffing with LPNs and NAs as hours per patient day in relation to patient falls. Noted staffing differences included higher RN staffing ratios and lower fall rates in ICUs, where it was identified that the patients are a lower fall risk because the patients are critically ill and often sedated.  LPNs and NAs care for less ill patients who are able to move, particularly in rehabilitation units, resulting in a higher fall risk.  An additional consideration identified is that Magnet hospitals had higher RN staffing than non-Magnet hospitals. Limitations in the study have been identified as: age of data, convenience of the sample and inability to establish causality, it is suggested that management can reference values in the article to support staffing decisions (Lake, Shang, Klaus & Dunton, 2010).   The purpose of this study “was to examine the relationships among nurse staffing, RN composition, hospital Magnet status, and patient falls” Fall rates in Magnet hospitals were 5 - 8.3% lower than non-Magnet hospitals Fall rates fell 2% with each additional hour of RN care per patient day, while an increase in LPN care by each hour increased falls by 2.9% and NA increased it by 1.5% RN composition did not significantly impact fall rates Noted staffing differences included higher RN staffing ratios and lower fall rates in ICUs, where it was identified that the patients are a lower fall risk because the patients are critically ill and often sedated LPNs and NAs care for less ill patients who are able to move, particularly in rehabilitation units, resulting in a higher fall risk.   An additional consideration identified is that Magnet hospitals had higher RN staffing than non-Magnet hospitals Limitations of the study identified in the article include the age of the data, convenience of the sample and inability to establish causality It is suggested in spite of the limitations that management can reference values in the article to support staffing decisions.

Experience The effect of patient to nurse ratios is of concern to the authors as they are all registered nurses working in the patient population.  When there are higher patient to nurse ratios, nurses experience an increase in job related stress, job dissatisfaction and job related burnout.  Burnout results in more nurse turnover which affects patient safety.  Patient to nurse ratios also impact patients’ level of satisfaction with their experience and perceived quality of care.  A lower patient load allows the nurse to spend more time with each patient, making them feel more important and that they are receiving a higher level of care.  The effect of patient to nurse ratios is a concern to the authors as they are all registered nurses working in the patient population.  When there are higher patient to nurse ratios, nurses experience an increase in job related stress, job dissatisfaction and job related burnout.  Burnout results in more nurse turnover which could affect patient safety.  Patient to nurse ratios also impact patients’ level of satisfaction with their experience and perceived quality of care.  A lower patient load allows the nurse to spend more time with each patient, making them feel more important and that they are receiving a higher level of care. 

Recommendations Critique studies to decrease limitations and variables to conduct further studies/clinical trials (document errors, length of hours worked, nurse to patient ratios, varying levels of education and acuity). Individual units and management need to take the information at hand into consideration while determining appropriate staffing levels for their facility to create a safer patient environment. Each of these studies conducted had multiple variances that effect patient safety. Fall risk, medication errors and deaths are suspected to be in relation to staffing, although, despite the supportive statistics, the study is inconclusive. The limitations and variables to the study may have been significant to the results of data. There is need to critique the studies that are available and know their limitations Conduct several additional clinical trials while monitoring previous limitations by documenting errors, length of hours worked, nurse to patient ratios, varying levels of education and acuity Individual units and need to take the information at hand into consideration while determining appropriate staffing levels for their facility to create a safer patient environment.  

Recommendations Implementation of safety programs should be put into place or enforced to minimize the risk to our patients.   Scanning medications against an electronic medical record Increase frequency of monitoring Co-signatures of  potentially harmful medications Fall risk bands to notify members of the healthcare team that a patient needs more assistance with ambulation because they at higher risk for falling. If additional staffing is deemed unnecessary, safety programs should be put into place or enforced to minimize the risk to our patients.   Programs such as scanning medications against an electronic medical record, increase frequency of monitoring, co-signatures of  potentially harmful medications and fall risk bands to notify members of the healthcare team that a patient needs more assistance with ambulation because they at higher risk for falling. The four research studies that were analyzed for this study did not find conclusive evidence on whether higher patient to nurse ratios decreased patient care. However, all of the studies agreed that ratios should be considered when staffing levels are determined. Continuing research should review studies already conducted and attempt to control the variables that were noted to be a concern in these studies. Doing so may improve patient outcomes and help managers and administrators determine an appropriate nurse to patient ratio to ensure quality and safe patient care.

References References Cook, A., Gaynor, M., Stephens Jr., M., & Taylor, L. (2012). The effect of a hospital nurse staffing mandate on patient health outcomes: Evidence from California’s minimum staffing regulation. Journal of Health Economics, 31, 340-348. Flynn, L., Liang, Y., Dickson, G. L., Xie, M. and Suh, D.-C. (2012), Nurses’ Practice Environments, Error Interception Practices, and Inpatient Medication Errors. Journal of Nursing Scholarship, 44, 180–186. doi: 10.1111/j.1547-5069.2012.01443.x Glance, L.G., Dick, A.W., Osler, T.M., Mukamel, D.B., Li, Y. & Stone, P.W. (2012). The association between nurse staffing and hospital outcomes in injured patients. BMC Health Services Research, 12(247), 1-8. doi:10.1186/1472-6963-12-247 Lake, E. T., Shang, J., Klaus, S., & Dunton, N. E. (2010, July 10). Patient falls: Association with hospital Magnet status and nursing unit staffing. Research in Nursing & Heath, 33, 413-425. Thank you for your attention during the presentation.