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Grading Rubric Module C NURS4342 Incorporation of Evidence into Practice Evidence Based Practice Aspects Content/Criteria PICOT Question. One PICOT question based on a current issue (Joint Commission and/or IOM) will be developed. Research Article Review. Complete the provided grid with information concerning three research articles addressing the PICOT question. Summary of Findings. The group will provide a summary related to the strengths and weaknesses found from all three articles reviewed. Application of Findings to Policies and Procedures. What policies and procedure should be reviewed based on what was learned from the review of articles. Individual discussion of Application of Evidence to Own Practice. In one page discuss how you are going to use the information learned during this course in your own practice and how you can initiate a policy or procedure change within your practice setting based on what you have learned in this class. Scholarly Presentation Writing style allows for clear communication of thoughts through logical presentation of ideas with correct spelling, grammar, and punctuation. APA Style Citations/References A title page is required for this assignment. Assignment is to be submitted as one document. Narratives are supported by proper citation and use of references following APA guidelines. Total: Expert Proficient Competent Substantial Areas for Improvement Unsatisfactory The PICOT question does not identify key parts of the question. (1 points) Discussion of the research articles demonstrated more than 6 omitted parts requested within the grid. (43 points) Information given does not provide descriptions of the strengths and weaknesses of all 3 articles. (2points) No discussion of policies and procedures related to the topic are provided. (2 points) Minimal and nonspecific discussion related to using the information learned was provided. (10 points) The PICOT question effectively and clearly identifies all relevant parts of the question. (5 points) Three research articles were discussed in depth with clear and concise information provided with all of the information requested included within the grid. (53 points) Summary discussion results exceed objectives with clear and concise information descriptions of the strengths and weaknesses of all 3 articles. (6 points) Specific policies and procedures related to the topic that need review are identified. (6 points) Clear, individualized detailed discussion provided. Specific examples of using the information learned was provided. (15 points) The PICOT question identifies all relevant parts of the question. (4 points) Discussion of the three research articles met assignment objectives related to the information requested included within the grid. The PICOT question minimally identifies all relevant parts of the question. (3 points) Discussion of the research articles demonstrated 2 to 3 omitted parts requested within the grid. The PICOT question does not identifies all relevant parts of the question. (2 points) Discussion of the research articles demonstrated 4 to 5 omitted parts requested within the grid. (51 points) Summary discussion results met objectives with descriptions of the strengths and weaknesses of all 3 articles. 5 points) General discussion of policies and procedures related to the topic that need review are provided. (5 points) Individualized discussion provided on utilization of information learned was provided. (46 points) Summary discussion results provide minimal descriptions of the strengths and weaknesses of all 3 articles. (4 points) Less than one page of individualized discussion was provided on the utilization of EBP material into own practice. (45 points) Summary discussion results do not address both the strengths and weaknesses of all 3 articles. (3 points) Vague discussion of policies and procedures related to the topic are provided. (3 points) No individualization of how the learned content would be integrated into practice was provided. (13 points) (12 points) (11 points) Thoughts are logically organized without errors in spelling, grammar, or punctuation. (5 points) Thoughts are logically organized with no more than 3 errors in spelling, grammar, or punctuation. (4 points) Thoughts are logically organized with no more than 4 errors in spelling, grammar, or punctuation. (3 points) Thoughts show no logical organization. APA format used for all citations and reference listings with no errors. No more than 3 APA formatting errors noted. 4 to 5 APA formatting errors noted. Thoughts are logically organized with no more than 5 errors in spelling, grammar, or punctuation. (2 points) 6 to 7 APA formatting errors noted. (10 points) (8 points) (6 points) (4 points) (2 points) (4 points) Minimal discussion of policies and procedures related to the topic are provided. (0 points) More than 7 APA errors noted in both citations and reference listings. Comments: PLAGIARISM: Plagiarism is considered cheating and is a violation of academic integrity as outlined in the Student Handbook. Any student who plagiarizes any portion of the assignment may receive a grade of zero on the assignment. LATE ASSIGNMENTS: Unless prior faculty notification and negotiation of an extended deadline, ten points will be deducted per day if submitted late. Assignment will not be accepted if submitted more than 3 days late and assigned grade will be 0 (zero). HEALTH POLICY AND SYSTEMS Impact of Nurse Work Environment and Staffing on Hospital Nurse and Quality of Care in Thailand Apiradee Nantsupawat, PhD1 , Wichit Srisuphan, DrPH2 , Wipada Kunaviktikul, DNS3 , Orn-Anong Wichaikhum, PhD4 , Yupin Aungsuroch, PhD5 , & Linda H. Aiken, PhD6 1 Lecturer, Chiang Mai University, Faculty of Nursing, Chiang Mai, Thailand 2 Professor, Chiang Mai University, Faculty of Nursing, Chiang Mai, Thailand 3 Professor, Chiang Mai University, Faculty of Nursing, Chiang Mai, Thailand 4 Lecturer, Chiang Mai University, Faculty of Nursing, Chiang Mai, Thailand 5 Associate Professor, Chulalongkorn University, Faculty of Nursing, Bangkok, Thailand 6 Professor, Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, PA, USA. Key words Nurse work environment, staffing, nurse burnout, job dissatisfaction, quality of care, Thailand Correspondence Wichit Srisuphan, Chiang Mai University, Faculty of Nursing 110 Inthawarorot Road, Chiang Mai, 50200, Thailand. E-mail: wichit@mail.chiangmai.ac.th Accepted June 29, 2011 doi: 10.1111/j.1547-5069.2011.01419.x Abstract Purpose: To determine the impact of nurse work environment and staffing on nurse outcomes, including job satisfaction and burnout, and on quality of nursing care. Design: Secondary data analysis of the 2007 Thai Nurse Survey. Methods: The sample consisted of 5,247 nurses who provided direct care for patients across 39 public hospitals in Thailand. Multivariate logistic regression was used to estimate the impact of nurse work environment and staffing on nurse outcomes and quality of care. Findings: Nurses cared for an average of 10 patients each. Forty-one percent of nurses had a high burnout score as measured by the Maslach Burnout Inventory; 28% of nurses were dissatisfied with their job; and 27% rated quality of nursing care as fair or poor. At the hospital level, after controlling for nurse characteristics (age, years in unit), the addition of each patient to a nurse’s workload was associated with a 2% increase in the odds on nurses reporting high emotional exhaustion (odds ratio [OR] 1.02; 95% confidence interval [CI] 1.00–1.03; p < .05). Nurses who reported favorable work environments were about 30% less likely to report fair to poor care quality (OR 0.69; 95% CI 0.48–0.98; p < .05) compared with nurses who reported unfavorable work environments. The addition of each patient to a nurse’s workload was associated with a 4% increase in the odds on nurses reporting quality of nursing care as fair or poor (OR 1.04; 95% CI 1.02–1.05; p < .001). Conclusions: Improving nurse work environments and nurse staffing in Thai hospitals holds promise for reducing nurse burnout, thus improving nurse retention at the hospital bedside as well as potentially improving the quality of care. Clinical Relevance: Nurses should work with management and policymakers to achieve safe staffing levels and good work environments in hospitals throughout the world. The nursing shortage is a global problem. Major concerns about the nursing shortage have been compounded by evidence of undesirable outcomes such as job dissatisfaction and burnout, which are major contributory 426 factors of intention to leave, absenteeism, turnover (Hayes et al., 2006), and adverse outcomes in hospital care (Aiken, Clarke, & Sloane, 2002; Estabrooks, Midodzi, Cummings, Ricker, & Giovannettii, 2005; Needleman, Journal of Nursing Scholarship, 2011; 43:4, 426–433.  C 2011 Sigma Theta Tau International Work Environment and Staffing on Outcomes Nantsupawat et al. Buerhaus, Mattke, Stewart, & Zelevinsky, 2002). Previous studies have indicated that nurses in hospitals with supportive nurse work environments and adequate nurse staffing are more satisfied in their jobs (Aiken, Clarke, Sloane, Lake, & Cheney, 2008; Laschinger, Almost, & Tuer-Hodes, 2003), experience less nurse burnout (Vahey, Aiken, Sloane, Clarke, & Vargas, 2004), and report better quality of nursing care (Aiken, Clarke, & Sloane, 2002). Most of the research has been undertaken in North America and Western Europe. This is one of the first studies to examine factors associated with nurse retention and quality of care in Southeast Asia. If there are similarities in research findings in other parts of the world, the possibility of global approaches to solving nursing shortage may be suggested. Thailand is a developing country, categorized as “lower middle income” by the World Bank, located in Southeast Asia. Nurses and midwifery personnel comprise 70% of all the health personnel of Thailand’s healthcare system. Thailand is a leader in nursing education attainment in the region. Most registered nurses have a bachelor’s degree education, signifying the generally high regard with which nursing is viewed. Public hospitals under the jurisdiction of the Ministry of Public Health are the mainstay of health care in Thailand. They provide health services that include health promotion, disease prevention, and management of acute and chronic health. Citizens of Thailand have universal access to public sector health facilities and services. Private healthcare facilities play a significant role in providing health services in urban areas, especially to higher income patients. Globalization, international trade, and medical hubs policy are leading to more international clients and the expansion of private hospitals (Bureau of Policy and Strategy, Ministry of Public Health, 2007). Thai hospitals have been experiencing nurse shortages (Thailand Nursing and Midwifery Council [TNC], 2009). An analysis of the nursing workforce based on a geographic information system survey and overtime paid revealed a shortage of nurses with vacancies of 15% to 26% of all nursing positions in public hospitals (TNC, 2008). The issues of undesirable patient outcomes such as mistakes in patients’ identification, patient falls, medication errors, pressure ulcers, and urinary tract infections were found in Thai public hospitals (Asavaroengchai, 2003; Kessomboon, Panarunothai, & Chongsuvivatwong, 2003; Nantsupawat, Akkadechanunt, Ketlertnapa, & Padungsak, 2010; Padungsak, 2007). The model that guided the study was adapted from the Quality Health Outcomes Model (QHOM; Mitchell, Ferketich, & Jennings, 1998). The QHOM was adapted from Donabedian’s (1966) conceptualization of quality as a linear relationship between structure, process, and outcomes to include multiple-level analysis among system, client characteristics, interventions, and outcomes. The QHOM is particularly pertinent to this research because it posits that nursing interventions are mediated by the organizational context in which care takes place. One of the innovations of this study is an empirical measure of the quality of nurses’ work environments that permits a direct test of the QHOM. A literature review shows that the QHOM is useful to theoretically guide studies that evaluate system interventions such as nurse staffing, improved patient care, and outcomes (Borglund, 2008; Gerolamo, 2006; Mayberry & Gennaro, 2001; Newhouse, Johantgen, Pronovost, & Johnson, 2005; Vahey et al., 2004). Nursing can be thought of as a healthcare organization’s surveillance system for the early detection of adverse events (Clarke & Aiken, 2003). Nurse staffing levels influence the timing of problem identification, and timing is important in patient rescue. More supportive work environments and better staffing facilitate a high quality of nursing care, resulting in more favorable nurse and patient outcomes (Aiken, Clarke, & Sloane, 2002; Aiken et al., 2008). Although a few international studies have documented an association between nurse work environment and nurse staffing for nurse outcomes and quality of care (Aiken, Clarke, & Sloane, 2002; Aiken et al., 2008), little is known about this relationship in Asian countries. This study aims to determine the impact of nurse work environment and nurse staffing on nurse outcomes, including job dissatisfaction and burnout, and on quality of care in public hospitals in Thailand. The results will provide evidence of relationships that will help create strategies to promote desirable outcomes in public hospitals in Thailand and elsewhere around the world. Methods This study is a predictive correlational design using secondary data analysis of the 2007 Thai nurse survey directed by Dr. Yupin Aungsuroch of Chulalongkorn University in Bangkok and made available to this investigator. The instrument was adapted from an instrument used in the International Hospital Outcomes Study (IHOS; Aiken, Clarke, & Sloane, 2002). The survey was conducted at 13 general and 26 regional hospitals for a total of 39 out of 94 general and regional hospitals in Thailand selected by multistage sampling to achieve geographic representation from every public health region and to include both general and regional hospitals. All nurses within participating hospitals were requested to complete the questionnaire, which was accompanied by a cover letter explaining the purpose of the survey, its voluntary nature, and the strict protection of anonymity. The final 427 Work Environment and Staffing on Outcomes response rate for the nurse survey was 92%, for a total of 8,222 registered nurses (Aungsuroch & Wanant, 2007). This study was approved by the Graduate School at Chiang Mai University and the Research Ethical Committees of the Faculty of Nursing, Chiang Mai University. Sample for the Study The hospital sample included 13 general and 26 regional hospitals in the 2007 Thai nurse survey. Nurses included in the study were limited to those who provided direct care for patients in the study hospitals and reported having responsibility for at least 1 but fewer than 21 patients on their last shift. We were primarily interested in nurses providing direct care at the bedside and thus eliminated nurses without a patient assignment and nurses who provided partial care to large numbers of patients. There were 5,247 nurses in the final sample. Measures Nurses were asked general demographic questions about themselves and their backgrounds, including age, gender, years as a registered nurse, years as a registered nurse on the current unit, highest degree of education attained, and employment status. The IHOS questionnaire was translated into Thai. The face validity of the Thai version was verified and back-translated by qualified academic experts who determined that the Thai version and English version did not differ in meaning. Nurse work environment. Nurse work environment was assessed by the Practice Environment Scale of the Nursing Work Index (PES-NWI; Lake, 2002), the most widely reported measure used to gauge the quality of nursing practice environment (Warshawsky & Havens, 2011). The PES-NWI is composed of 29 items that have been organized into five subscales: nurse participation in hospital affairs; nursing foundations for quality of care; nurse manager ability, leadership, and support for nurses; staffing and resource adequacy; and collegial nurse-physician relations. The potential scores ranged from 1 (strongly disagree) to 4 (strongly agree) on a 4-point Likert scale. Higher scores indicated more agreement that the subscale items were present in the current job. Nurse responses in each item were aggregated for each subscale to create a hospital-level mean of the subscales (Verran, Gerber, & Milton, 1995). In multivariate models the resource adequacy subscale was excluded because a direct measure of nurse staffing that is highly correlated with the resource adequacy scale was included in the analytic modeling. A categorical variable of the four remaining subscales was created, adapting the method of Aiken et al. (2008): hospitals above the median on all four subscales; on one, two, or three 428 Nantsupawat et al. subscales; and on none of the subscales were classified as having “favorable”, “mixed”, “unfavorable” results, indicating the most supportive environment; a moderately supportive environment; and the least supportive environment, respectively. Reliability of the PES-NWI subscales was 0.64 to 0.72 (Lake, 2002). Based on 2007 Thai Nurse Dataset, the Cronbach’s α coefficient of the PES-NWI in subscales 1 to 5 was 0.87, 0.90, 0.87, 0.91, and 0.85. Its discriminant validity has been shown in its ability to detect differences in the nurse practice environments of hospitals (Lake & Friese, 2006). Nurse staffing. Nurse staffing was measured based on nurse reports of the number of patients assigned to each nurse. Nurses were asked to indicate how many patients were assigned on their last shift. Nurse responses were calculated as the mean patient load across all nurses in a hospital who reported having responsibility for at least 1 but fewer than 21 patients. The mean number of patients cared for was aggregated to the hospital level. Analyses of nurse staffing levels were conducted with a continuous measure. The predictive validity of using nurse reports in this manner to assess staffing levels has been shown previously (Aiken, Clarke, Slone, Sochalski, & Silber, 2002). Because the nurse sample is large and individual nurses’ responses to the staffing questions were aggregated to the hospital level, nontypical staffing for individual nurses was unlikely to affect the overall hospital mean. Job dissatisfaction. Job dissatisfaction was measured by a single item that asked nurses’ perception about their satisfaction with their present job. The response categories ranged from 1 (very satisfied) to 4 (very dissatisfied) on a Likert scale. Higher scores indicated that nurses were dissatisfied with their current job. Reliability of published tests for a single item of nurse job satisfaction was in the range of 0.70 (Wanous, Reichers, & Hudy, 1997). Burnout. Burnout was measured using the Maslach Burnout Inventory–Human Services Survey (MBI-HSS), a standardized instrument with published norms for medical personnel that has been used previously in international research (Aiken et al., 2001; Poghosyan, Aiken, & Sloane, 2009; Poghosyan, Clarke, Finlayson, & Aiken, 2010). Nurses with a total score of 27 or above on the nine-item emotional exhaustion subscale exceeded norms for healthcare workers published by Maslach and were considered to have high burnout. The reliability coefficients were 0.89 for the emotional exhaustion subscale (Maslach & Jackson, 1981), and the Cronbach’s α coefficient of the emotional exhaustion based on 2007 Thai Nurse dataset was 0.87. Quality of care. Quality of care was measured by a single item that asked nurses’ perception about the Work Environment and Staffing on Outcomes Nantsupawat et al. quality of nursing care delivered on the last shift. The response categories ranged from 1 (excellent) to 4 (poor) on a Likert-scale, with higher scores indicating poorer levels of quality. The Cronbach’s coefficients for previous quality of nursing care were in the range of 0.92 to 0.94 (Pearson et al., 2000). This single-item measure has been used extensively in international work and has established predictive validity (Aiken, Clarke, & Sloane, 2002; Bruyneel, Van den Heede, Diya, Sermeus, & Aiken, 2009). Data Analysis Categorical variables were examined by frequency, percentage, and range. Mean and standard deviation were used to assess distribution and central tendency of continuous variables. Multivariate logistic regression analysis controlling for nurse characteristics (age and years in unit), was performed to assess the impact of nurse work environment and nurse staffing for nurse outcomes and quality of care. STATA version 10 was used to analyze the data, and p < .05 was considered statistically significant in all analyses. Results Table 1 provides characteristics of sample nurses and reported outcomes. The majority of study nurses were 34 years old on average, 98% were female, they had nearly 8 years of nursing experience and 6 years of experience in their current hospital position, and they were almost totally full-time. All the nurses in the study had earned a bachelor’s of science in nursing or higher. Twenty-eight percent of nurses were dissatisfied with their jobs, 41% experienced high burnout, and 27% reported quality of care as fair or poor. Table 2 describes nurse staffing and the nurse work environment in study hospitals. The average number of patients per nurse was 10, with significant variation from 7 to 13 patients. The study nurses rated collegial nursephysician relationships to be the most positive of the five PES-NWI subscales and staffing and resource adequacy to be the lowest or of greatest concern. Table 3 presents logistic regression odd ratios indicating the impact of nurse work environment and nurse staffing on job dissatisfaction, high emotional exhaustion, and fair or poor quality of care. After controlling for nurse characteristics, nurse burnout (measured by emotional exhaustion) was found to be associated with nurse staffing levels. The addition of each patient to a nurse’s workload was associated with an increase of 1.02 times in the odds on nurses reporting high emotional exhaustion (odds ratio [OR] 1.02; 95% confidence interval [CI] 1.00–1.03; p < .05). Given the range in workloads in the study hospitals from roughly 7 to 13 patients per Table 1. Characteristics of Sample Nurses and Reported Outcomes Variables Mean SD Range Age (yr) Years as RN Years as RN on current unit Gender Male Female Highest degree Bachelor’s degree or equivalent in nursing Master’s degree in nursing Master’s degree in other fields Employment status Full-time Part-time Job satisfaction Very satisfied Moderately satisfied A little unsatisfied Very dissatisfied Quality of nursing care Excellent Good Fair Poor Emotional exhaustion High Average Low 33.57 8.43 6.12 6.51 5.96 4.69 22–58 1–33 1–29 Frequency (%) 92(1.75) 5, 141(97.98) 5, 019(95.65) 140(2.67) 86(1.64) 5, 211(99.31) 36(0.69) 466(8.88) 3, 330(63.46) 343(6.54) 1, 108(21.12) 140(2.67) 3, 709(70.84) 1, 356(25.90) 32(0.59) 2, 166(41.28) 1, 406(26.80) 1, 675(31.92) nurse, this OR of 1.02 implies that nurses in hospitals with the highest ratios of patients to nurse are roughly 12% ([(1.02 – 1.00) × 100] × [13 – 7]) more likely to be emotionally exhausted than nurses in hospitals with the lowest ratios. The quality of nursing care was also significantly associated with the hospitals’ nurse work environments and staffing levels. After controlling for nurse characteristics, nurses in hospitals with favorable work environments were roughly 30% less likely than nurses in hospitals with poor environments to report that the quality of care was only poor or fair as opposed to good or excellent (OR 0.69; 95% CI 0.48–0.98; p < .05). Here too, the addition of each patient to nurses’ workloads was associated with an increase of 1.04 times in the odds of nurses reporting that the quality of nursing care on their unit was only fair or poor (OR 1.04; 95% CI, 1.02–1.05; p < .001), which implies that nurses in the hospitals with the highest ratios of patients to nurse were roughly 24% ([(1.04 – 1.00) × 100] × [13 – 7]) more likely to report only poor or fair quality care than nurses in hospitals with the lowest ratios. 429 Work Environment and Staffing on Outcomes Nantsupawat et al. Table 2. Characteristics of Nurses’ Work Environment and Nurse Staffing Levels in Study Hospitals Characteristics Nurse staffing levels Patient-to-nurse ratio Nurses’ work environment Nurse participation in hospital affairs Nursing foundation for quality of care Nurse manager ability, leadership, and support of nurse Staffing and resource adequacy Collegial nurse-physician relationship Composite Mean (SD) Range 10:1 7:1–13:1 2.81 (0.10) 2.94 (0.11) 2.80 (0.11) 2.70 (0.14) 3.09 (0.11) 2.87 (0.11) Table 3. Logistic Regression Odd Ratios Indicating the Impact of Nurse Work Environment and Nurse Staffing Levels on Job Dissatisfaction, High Emotional Exhaustion, and Fair or Poor Quality of Care Fair or Job High emotional poor quality dissatisfaction dxhaustion of care Nurses’ work environment Unfavorable (as reference) Mixed Favorable Nurse staffing levels 0.79 (0.48–1.29) 1.34 (0.88–2.05) 1.01 (0.98–1.03) 0.99 (0.76–1.27) 1.06 (0.81–1.38) 1.02∗ (1.00–1.03) 0.87 (0.61–1.22) 0.69∗ (0.48–0.98) 1.04∗∗ (1.02–1.05) Note. Model was adjusted for nurse characteristics (age and years in unit). ∗ p < .05; ∗∗ p < .001. Discussion This study investigates nurse work environment, patient-to-nurse staffing ratios, nurse outcomes, and quality of nursing care in public hospitals in Thailand. Nurses, on average, cared for 10 patients each, which is higher than the recommended ratio from the TNC (2005). The quality of the nurse work environment in Thailand varies across hospitals. Inadequate staffing and resources were nurses’ major concerns, while nursephysician relationships were generally positive. This study indicates that almost one out of four nurses was dissatisfied with their job and close to 40% of study nurses experienced high burnout. This is notable because prior research has demonstrated an as430 sociation between job dissatisfaction and nurses’ intent to leave and turnover (Coomber & Barriball, 2007; Hayes et al., 2006); nurses’ intent to leave was also negatively associated with patient satisfaction (Leiter, Harvie, & Frizzell, 1998). Moreover, prior studies have shown that high nurse burnout is associated with lower levels of patient satisfaction (Poghosyan et al., 2010; Vahey et al., 2004), quality of care (Kutney et al., 2009), and nurse turnover and absenteeism (Maslach, Jackson, & Leiter, 1996). Additionally, almost one out of four study nurses reported quality of care as fair or poor, suggesting that many patients may be at significant risk for preventable adverse outcomes. The empirical evidence from this study supports the QHOM in that the impact of nurse work environment and nurse staffing, both features of the organizational system in which nursing care is delivered, is shown to be associated with outcomes– job dissatisfaction, high emotional exhaustion, and fair or poor quality of care. This finding verifies the usefulness of the QHOM in explaining variations in hospital nurse outcomes as mediated by the organizational context of care, and points to the potential for improving nursing outcomes by improving the organizational context in which nursing care is delivered. Our findings show that hospitals with favorable work environments and nurse staffing had lower likelihoods of having lower nurse-assessed quality of care. Also, nurses practicing in hospitals with a favorable work environment had lower burnout. This result is consistent with previous studies which found that organizational support for nursing, as an indicator of a supportive work environment, was positively correlated with nurse-assessed quality of care (Aiken, Clarke, & Sloane, 2002; Aiken et al., 2008; Bogaert, Clarke, Vermeyen, Meulemans, & Heyning, 2009; Laschinger, Shamian, & Thomson, 2001; Patrician, Shang, & Lake, 2010) and negatively associated with burnout (Aiken et al., 2008; Aiken, Clarke, Sloane, Sochalski, et al., 2002) and nurses in hospitals with lower nursing staff were higher in reporting quality of nursing care as fair or poor (Aiken, Clarke, & Sloane, 2002; Aiken et al, 2008; Solchalski, 2004). The main conclusions from this study are that modifying organizational characteristics to improve nurse work environments and improving nurse staffing constitute promising strategies for enhancing nurse retention and quality of care. The American Nurses Credentialing Center’s magnet application represents a blueprint for how hospitals could improve their nurse work environments (www.nursecredentialing.org). The nurse work environment measure used in this study suggests that the areas that managers could improve to create better work environments include improving nurse participation in Work Environment and Staffing on Outcomes Nantsupawat et al. hospital affairs; developing ongoing programs to support nursing foundations for quality of care; investing in the expertise of nurse managers; and promoting collegial nurse-physician relations and teamwork. Several limitations of the study should be noted. Generalizability, which is the extension of research findings and conclusions from a study conducted on a sample population to the population at large, may be limited because all data were collected at public regional and general hospitals; thus, we cannot generalize to private hospitals. Also, the study uses cross-sectional data at a single point in time, thus limiting our ability to assert a causal link between more favorable staffing and work environments and nurse outcomes and quality of nursing care. Additionally, the nurse staffing measure is a general measure of average hospital staffing that should not be interpreted as an actual patient-to-nurse ratio in a clinical sense because the staffing on the shift requested may not be typical for any given nurse, but the measure has nevertheless shown very good predictive validity in relation to nurse and patient outcomes in many published studies. Similarly, while job satisfaction and quality of nursing care were measured with single items, both have established predictive validity in international research (Aiken, Clarke, & Sloane, 2002; Bruyneel et al., 2009). Conclusions This study found remarkable similarities in Thailand and a number of other previously studied countries showing a significant association between more favorable nurse staffing and work environments and more favorable outcomes for nurses and better quality of care. These findings add to the growing nursing outcomes research evidence showing the importance of adequate staffing and work environment to reduce nurse burnout and improve the quality of nursing care. Results suggest that evidence-based “best practices” like magnet hospital recognition that have been shown to improve work environments in countries with similar problems of high nurse dissatisfaction and burnout might have a positive effect if implemented in Thailand. The findings suggest that, at the very least, support of efforts to improve staffing and work environments in hospitals that currently fall below average by Thai standards may bring important benefits to Thai patients in terms of better quality of care and help retain a qualified nurse workforce in public hospitals. Acknowledgments We thank and express our appreciation to Dr. Yupin Aungsuroch of Chulalongkorn University Faculty of Nursing and Dr. Wanida Wanant of Shenandoah University School of Health Professions for their permission to use the 2007 Thai Nurse Dataset. Clinical Resources r To learn more about r how to implement safe nurse staffing, see www.safestaffingsaveslives.org/ WhatisSafeStaffing/UtilizationGuide.aspx To learn more about how to improve nurse work environments, see information provided by the American Nurses Credentialing Center’s Magnet Recognition Program:www.nursecredentialing. org/Magnet/ProgramOverview.aspx References Aiken, L. H., Clarke, S. 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Kessomboon, P., Panarunothai, S., & Chongsuvivatwong, V. (2003). Detecting adverse events in hospitalized patients in Thailand: Recommendations from a pilot study. Journal of Health Science, 12(4), 509–521. Kutney-Lee, A., McHugh, M. D., Sloane, D. M., Cimiotti, J. P., Fynn, L., Neff, D. F., & Aiken, L. H. (2009). Nursing: A key to patient satisfaction. Health Affair, 28, w669–w667 Lake, E. T. (2002). Development of the practice environment scale of the nursing work index. Research in Nursing & Health, 25(3), 176–188. Lake, E. T., & Friese, C. R. (2006). Variations in nursing practice environments: Relation to staffing and hospital characteristics. Nursing Research, 55(1), 1–9. Laschinger, H. K. S., Almost, J., & Tuer-Hodes, D. (2003). Workplace empowerment and magnet hospital characteristics: Making the link. Journal of Nursing Administration, 33(7/8), 410–422. Laschinger, H. K. S., Shamian, J., & Thomson, D. (2001). Impact of magnet hospital characteristics on nurses’ perceptions of trust, burnout, quality of care, and work satisfaction. Nursing Economics, 19(5), 209–219. Leiter, M., Harvie, P., & Frizzell, C. (1998). The correspondence of patient satisfaction and nurse burnout. Social Science and Medicine, 47(10), 1611–1617. Maslach, C., & Jackson, S. E. (1981). The measurement of experienced burnout. Journal of Occupational Behavior, 2, 99–113. Maslach, C., Jackson, S. E., & Leiter, M. P. (1996). Maslach burnout inventory manual (3rd ed.). Palo Alto, CA: Consulting Psychologists Press. 432 Nantsupawat et al. Mayberry, L. J., & Gennaro, S. (2001). A quality of health outcomes model for guiding obstetrical practice. Journal of Nursing Scholarship, 33(2), 141–146. Mitchell, P. H., Ferketich, S., & Jennings, B. M. (1998). Quality health outcomes model. Journal of Nursing Scholarship, 30(1), 43–46. Nantsupawat, R., Akkadechanunt, T., Ketlertnapa, P., & Padungsak, S. (2010). Patient safety culture and nursing outcomes among professional nurses in Northern regional hospitals in Thailand. Chiang Mai, Thailand: Good Work Media. Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinsky, K. (2002). Nurse-staffing levels and the quality of care in hospitals. New England Journal of Medicine, 346(22), 1715–1722. Newhouse, R. P., Johantgen, M., Pronovost, P. J., & Johnson, E. (2005). Perioperative nurses and patient outcomes– Mortality, complications, and length of stay. Association of PeriOperative Registered Nurses Journal, 81(3), 508–528. Padungsak, S. (2007). Nurse’s perception on patient safety culture and incidence of adverse events in northern regional hospitals (Unpublished master’s thesis). Chiang Mai University, Chiang Mai, Thailand. Pantrician, A. P., Shang, J., & Lake, E. T. (2010). Organizational determinants of work outcomes and quality care ratings among army medical department registered nurses. Research in Nursing & Health, 33, 99–110. Pearson, M. L., Lee, J. L, Chang, B. L., Elliott, M., Kahn, K. L., & Rubenstein, L. V. (2000). Structural implicit review: A new method for monitoring nursing care quality. Medical Care, 38, 1074–1091. Poghosyan, L., Aiken, L. H., & Sloane, D. M. (2009). Factor structure of the Maslach burnout inventory: An analysis of data from large scale cross-sectional surveys of nurses from eight countries. International Journal of Nursing Studies, 46, 894–902. Poghosyan, L., Clarke, S., Finlayson, M., & Aiken, L. H. (2010). Nurse burnout and quality of care: Cross-national investigation in six countries. Research in Nursing & Health, 33, 288–298. Sochalski, J. (2004). Is more better? The relationship between nurse staffing and the quality of nursing care in hospitals. Medical Care, 42(2), II67–II73. Thailand Nursing and Midwifery Council. (2005). Standard of nursing and midwifery service in secondary and tertiary level. Nontaburi, Thailand: Author. Thailand Nursing and Midwifery Council. (2008). The suggestion to the minister of the Ministry of Public Health for solving nursing shortage. Retrieved March 15, 2008, from http://www.tnc.or.th/file attach/22Feb200838AttachFile1203671618.pdf Thailand Nursing and Midwifery Council. (2009). The national nurse and midwifery development plan: 2007–2016. Bangkok, Thailand: Siriyot Printing. Nantsupawat et al. Vahey, D. C., Aiken, L. H., Sloane, D. M., Clarke, S. P., & Vargas, D. (2004). Nurse burnout and patient satisfaction. Medical Care, 42, II57–II66. Verran, J. A., Gerber, R. M., & Milton, D. A. (1995). Data aggregation: Criteria for psychometric evaluation. Research in Nursing and Health, 18(1), 77–80. Work Environment and Staffing on Outcomes Wanous, J. P., Reichers, A. E, & Hudy, M. J. (1997). Overall job satisfaction: How good are single-item measure? Journal of Applied Psychology, 82(2), 247–252. Warshawsky, N. E., & Havens, D.S. (2011). Global use of the practice environment scale of the nursing work index. Nursing Research, 60(1), 17–31. Expression of Concern The following article from the Journal of Nursing Scholarship, “Development and Evaluation of an Undergraduate Training Course for Developing International Council of Nurses Disaster Nursing Competencies in China,” by S.S.S. Chan et al., published online on September 9, 2010 in Wiley Online Library (www.wileyonlinelibrary.com) has raised concerns among the authors, the journal Editor-in-Chief and Wiley Periodicals, Inc. This expression of concern is being provided due to significant overlap between the above-named article and Pang et al., “Pilot training program for developing disaster nursing competencies among undergraduate students in China,” published in Nursing & Health Sciences, Volume 11, Issue 4, December 2009, pp 367–373, which was first published online October 27, 2009, as was noted in the article by S.S.S. Chan et al. 433 The Effect of Nurse Staffing Patterns on Medical Errors and Nurse Burnout CONNIE GARRETT, RN, BSN, CNOR L ittle disagreement exists about the relationship between nurse staffing levels and patient outcomes in health care settings. Higher staffing levels have been shown to result in better patient outcomes compared with lower nurse staffing levels.1-15 Various measures such as managed health care and reduced reimbursement from insurance companies have combined with the nursing shortage to lead hospital administrators to rely on voluntary and mandatory overtime to solve their nurse staffing problems. According to a 2007 report published by the Agency for Healthcare Research and Quality (AHRQ),16 chronic fatigue and poor global sleep quality (ie, a measure of sleep quality that includes indicators such as time needed to fall asleep, sleep duration, waking up during the night, use of sleeping medication, and difficulty staying awake during the day17) are common among health care personnel. Voluntary overtime requests may be made too often of nurses who do not have families or who suffer financially because of low salaries in nursing,18 and working overtime can lead to dangerous levels of fatigue. On July 4, 2006, Julie Thao, RN, a veteran obstetrical nurse in Wisconsin, worked two eight-hour shifts back to back. Thao slept on a cot at the hospital overnight and was near the end of her shift on July 5 when she administered the wrong medication to a patient, which resulted in a fatal medication error. She was charged with a felony, “criminal neglect of a patient causing great bodily harm,” the sentence for which is three years on probation and mandatory exclusion from working in a critical care setting. She ultimately pled © AORN, Inc, 2008 no contest to two misdemeanors.19 This was the first time a nurse in Wisconsin had been criminally charged for a medical error.20 The human error component of medical errors18 may be affected by staffing patterns. Although few studies on the topic have been conducted with hospital personnel, studies outside the field of health care demonstrate a relationship between fatigue and degradation in performance. Fatigue has been shown to result in slowed reaction time and lapses of attention to detail that can result in errors of omission, which are known to compromise problem solving, reduce motivation, and decrease energy for successful completion of required tasks.21 Fatigue has been implicated in disasters such as the Exxon Valdez, Bhopal, Chernobyl, and Three Mile Island.22 The working hours for airline pilots and air traffic controllers are regulated to reduce ABSTRACT HOSPITAL ADMINISTRATORS frequently rely on the use of mandatory or voluntary overtime to cover staff nurse vacancies. This practice is common in the perioperative setting, but it can lead to staff-member fatigue that may adversely affect patient safety. THIS LITERATURE REVIEW explores the effect that nurse staffing patterns have on the frequency of medical errors, fatigue, and nurse burnout. THE EVIDENCE INDICATES that inadequate nurse staffing leads to adverse patient outcomes and increased nurse burnout. Hospital administrators should invest in adequate nurse staffing to improve patient safety and increase nurse retention. AORN J 87 (June 2008) 1191-1204. © AORN, Inc, 2008. JUNE 2008, VOL 87, NO 6 • AORN JOURNAL • 1191 Garrett JUNE 2008, VOL 87, NO 6 The perioperative setting is unique in that nurses not only consider it normal to work more than 40 hours a week but also are required to take call, which may result in fatigue. The effects of extreme fatigue can be compared to being under the influence of alcohol. the possibility of human error brought on by fatigue. To improve patient outcomes and reduce medical errors, nurse staffing patterns also should be reviewed to ensure that direct patient care is not compromised by the use of mandatory overtime to cover staffing shortfalls.23 This literature review explores the effect that nurse staffing patterns have on the frequency of medical errors, fatigue, and nurse burnout. OVERTIME In many perioperative settings, mandatory overtime is used daily to staff the OR for elective, unplanned, and emergent procedures or to cover staff nurse vacancies.1 There seems to be a double standard in some ORs when the first day shift is relieved of duty and the shift change occurs. Staffing is usually at the highest level in the morning and decreases as the day progresses to the second shift, possibly as the result of a belief that the perioperative area is not as busy in the afternoon and therefore staffing can be decreased for the second shift. This situation creates a problem of voluntary overtime at the shift change resulting from delayed start times, underestimation for the length of a procedure, and changes in patient status or the complexity of a procedure. Periop- 1192 • AORN JOURNAL erative personnel sometimes refer to staffing in the surgical suite as “Russian roulette” regarding who will have to stay late to act as the circulating nurse in a procedure that has not finished by the shift change. Often, a circulating nurse expects a request to stay late to finish the procedure when there is no available relief. If the nurse objects to staying late, the situation becomes one of mandatory overtime because the nurse’s preferences do not change the fact that no relief is available. Unrealistic workload may result in chronic fatigue and poor global sleep quality. The literature provides examples of overtime use resulting in fatigue, burnout, absenteeism, and job dissatisfaction among hospital nurses.2,24 In addition, working overtime has been shown to increase the odds of nurses making at least one medication-related error, and the risk of making errors increased for nurses who worked overtime after long shifts.17 FATIGUE Fatigue is a contributing factor for nurse absenteeism, burnout, and job dissatisfaction.2,24 In addition, rotating shifts and extended work hours of 12.5 hours or more have been shown to increase injuries and automobile accidents among nurses,25 and chronic fatigue has been found to result in depression and poor global sleep quality.18 Minimal data, however, are available in the perioperative setting related to fatigue and increased errors. The perioperative specialty is unique in that nurses not only consider it normal to work more than 40 hours a week but also are required to take call, which may be abused to the extent that the effects of a nurse’s fatigue can be compared to being under the influence of alcohol. Research has shown that after 17 hours without sleep, performance degrades to the equivalent of having a blood alcohol concentration of 0.05%,21 and after 24 hours without sleep, the effect on performance is equivalent to a blood alcohol level of 0.10%.26 Call hours may vary from four hours to 72 hours or more, though actual hours worked during the call period are unpredictable and can range from 30 minutes to the entire length of the call period.27 A normal day for a perioperative Garrett JUNE 2008, VOL 87, NO 6 nurse who is on call consists of an eight-, 10-, or 12-hour shift. Nurses on call then may have to work call hours to complete or relieve for elective procedures that are scheduled to start when there are no other available RNs to fill the role of circulating nurse. It is not unusual for the oncall nurse to complete elective cases and continue working for up to 16 hours without rest or relief. That same nurse must then hope that he or she is not called back for an emergency procedure in the middle of the night, which interrupts the sleep cycle and circadian rhythms. The cycle of fatigue starts when the nurse, whether called in the middle of the night to work an emergency procedure or not, is expected to be back at work the next morning at the start of his or her daily shift. ed 6% increase in the number of nurses by the year 2020 will not keep up with the 40% expected growth in demand. In addition, the elimination of perioperative curriculum in nursing schools has contributed to the shortage of available perioperative nurses in the OR.30 Health care facilities cannot afford to have their perioperative nurses burn out and leave the perioperative setting, so hospital administrators should look for ways to increase nurse retention. STAFFING PATTERNS AND MEDICAL ERRORS A study by Rogers et al1 examined the relationship between medical errors and both staff work patterns and hours worked by nurses. The researchers found that mandatory overtime was NURSE BURNOUT used frequently to cover hosUnrealistic workloads in pital nurse staffing vacancies. the perioperative setting, This policy produces fatigue Mandatory overtime including call, are the result of and nurse burnout, which a shortage of nurses and can ultimately results in more frequently is used to lead to increased absenteeism mandatory overtime to solve and high rates of nurse burnstaffing issues, a practice that cover staff vacancies. out that exceed the norm for is both controversial and health care workers.28 Job dispotentially dangerous.31-33 This results in fatigue satisfaction for nurses is four The study by Rogers et al times higher than the average included 393 RNs—most of and nurse burnout and, rate for all US workers, and whom were women—who ultimately, in more one in five nurses have worked full time. More than reported that they intend to half worked in hospitals with mandatory overtime to leave their current jobs within 300 beds or more, 56% a year.28 Nurses often cope worked in urban areas, 19% solve staffing issues. worked in suburban areas, with increased stress and 18% worked in small town burnout by calling in sick, and hospitals, and 17% worked in patient safety is compromised rural areas.1 The nurses were by the effect of high nursing 18 turnover rates. Perioperative given logbooks to track their nurse turnover rates increase when nurses scheduled work hours, overtime, days off, burn out and leave the OR to work in other sleep and wake cycles, and errors and near nursing specialties where call is not required errors for 28 days; the logbooks also provided or used as a staffing solution. the opportunity to describe the errors. AlAccording to the American Hospital Assothough the response rate was lower than usual ciation, the current nursing shortage reflects for this type of nurse survey, the lower re“fundamental changes in population demosponse rate was attributed to the increased graphics, career expectations, work attitudes, effort required for the nurses to record 17 to 40 and worker dissatisfaction.”29(p80) Hospital items each day for 28 days. The researchers nursing vacancies are expected to reach took care in the collection of data to ensure 800,000 (ie, 29%) by the year 2020. An expectthat participants’ identities were protected and 1194 • AORN JOURNAL Garrett JUNE 2008, VOL 87, NO 6 to alleviate fears related to reporting errors. The nurses in the study generally worked more than 40 hours per week and longer than their scheduled shifts: 39% of the shifts worked lasted 12.5 or more consecutive hours, 14% of the nurses reported working 16 or more hours at least once during the study period, and the longest shift reported was 23.6 hours. The nurses reported working 360 shifts of mandatory overtime, and nurses were coerced to work voluntary overtime for 143 shifts. Health care facilities can avoid preventable patient mortality and low nurse retention rates by investing in RN staffing. During the data-gathering period, 199 errors and 213 near errors were reported, with medication errors accounting for more than half of the total errors. Other errors included procedural, charting, and transcription errors, as well as 6% of errors and 29% of near errors that could not be categorized. Of the respondents, 30% reported making at least one error and 32% reported making at least one near error. Analysis of the data indicated that work duration, overtime, and number of hours worked per week had significant effects on errors, with the likelihood of making an error increasing with longer work hours. Nurses were three times more likely to make an error when working shifts that lasted 12.5 hours or more. Regardless of how long the shift was originally scheduled to last, working overtime increased the odds of making at least one error. The data also indicated a trend of increased risk for errors when nurses worked overtime after longer shifts, with the risks being significantly elevated for overtime worked after a 12-hour shift. 1196 • AORN JOURNAL PATIENT-TO-NURSE RATIOS, ADVERSE OUTCOMES, AND NURSE RETENTION A study by Aiken et al2 examined the association between patient-to-nurse ratios and patient mortality, failure to rescue among surgical patients, and factors related to nurse retention. A cross-sectional analysis was performed on linked data from nurses surveyed (N = 10,184) and patients discharged from the hospital (N = 232,342) between April 1, 1998, and November 30, 1999. The researchers found that after adjusting for patient characteristics and hospital characteristics such as size, teaching status, and availability of advanced technology, each additional patient per nurse was associated with a 7% increase in the odds of failure to rescue and a 7% increase in the likelihood of 30-day mortality. Furthermore, each additional patient per nurse was associated with a 23% increase in the odds of nurse burnout and a 15% increase in the odds of job dissatisfaction. This study provides evidence that a high patient-to-nurse ratio is directly responsible for nurses’ job-related burnout and job dissatisfaction. Aiken et al suggest that hospitals can avoid low nurse retention rates and preventable patient mortality by investing in RN staffing. This study provides the necessary evidence that nurse staffing ratios are major indicators when hospital mortality is used as a variable. The authors suggest that the approach California has taken in legislating nurse staffing to reduce patient mortality is credible, and they agree with government officials’ decisions to reject hospital stakeholders’ support of up to 10 patients to each nurse. The ratios mandated in the legislation were five or six patients per nurse on medical and surgical units, depending on the phase of implementation.34 NURSES’ ASSESSMENTS OF QUALITY OF CARE Sochalski3 studied the effects of nurse staffing and indicators of nursing care processes on nurses’ assessments of the quality of nursing care delivered. A mail and telephone survey was designed to collect information including patient load, quality of care, and work environment for nurses in acute care hospitals in Pennsylvania. The nine-page survey Garrett captured information on nurses’ work environments and the nurses’ perceptions of the quality of care delivered. The survey included variables on patient load; tasks left undone during the previous shift; and patient safety problems (eg, frequency of medication errors, patient falls with injuries) during the previous year. Of the nurses who responded to the survey, a total of 8,670 were included in the data analysis. Nurses reported caring for an average of 6.3 patients on general inpatient units and 1.2 patients on intensive care units (ICUs), with an overall average of 5.3 patients across all respondents. An average of 2.1 tasks were left undone at the completion of the last shift, with 40% of nurses reporting three or more tasks left incomplete. Sixteen percent of the nurses reported that medication errors occurred more than rarely in a period of one year, and more than 20% of nurses reported that patient falls with injuries occurred occasionally or frequently during the same period. Regarding quality of care assessments, 25% of respondents rated the care delivered as excellent, and slightly more than 20% rated the care delivered as poor or fair. Analysis of the data showed that as the number of patients assigned to nurses dropped, quality assessments increased and reports of unfinished tasks and patient safety problems decreased, indicating that nurses with lower numbers of patients assigned to them felt that they were providing a higher level of care. This study demonstrates the relationship between workload versus quality of care and how increased workload results in compromised patient safety and unfinished tasks. More importantly, Sochalski asserted that the results of this study indicate that nurses’ assessments of quality could provide a critical overview of the process of care (ie, the clinical interventions that comprise the nursing care that patients receive). The author discusses several limitations to the study, including that the cross-sectional data do not permit inference of causality and that the analyses suggest associations between workload changes and patient outcomes but are not equipped to provide definitive links. The data are based on self-reports, which JUNE 2008, VOL 87, NO 6 could be biased because of the associated factors of self-reporting and fear of punitive action. In addition, the subjective variable of “excellent” quality of nursing care also could result in unmeasured bias. UNIT STAFFING AND ADVERSE PATIENT OUTCOMES The question of what effect nurse staffing patterns have on patient care has stimulated a number of studies that report links between staffing levels on specific units and adverse patient outcomes.4-8 Central line infections (CLIs), pressure ulcers, medication errors, falls, urinary tract infections (UTIs), and respiratory infections are all examples of negative outcomes associated with low staffing levels. Whitman et al9 attempted to identify which units should increase nursing hours based on patient outcomes. The researchers collected data across several different types of hospital units (ie, cardiac and noncardiac ICUs, cardiac and noncardiac intermediate care, medicalsurgical) and then analyzed the data separately for each unit. This study was a secondary analysis of observational data that included 95 patient care units from 10 adult acute care hospitals. Variables included total staff member work hours and nurse-sensitive outcome rates for CLIs, pressure ulcers, medication errors, falls, and restraint application duration rates (ie, duration for use of mechanical restraints). Descriptive statistics were used to summarize all variables, and average monthly rates were calculated. The researchers found no significant relationship between CLI and pressure ulcer rates and staffing hours worked for any of the specialty units. There was, however, an inverse relationship between falls in cardiac intermediate care units and staff hours worked. Medication errors also were inversely related to staff hours worked in the cardiac ICU and noncardiac intermediate care units. The restraint application duration rate was significantly inversely related to staff hours worked only in medical-surgical units. Overall, the results of the Whitman et al study suggest that the effect of staffing on patient outcomes is highly variable across specialty units but, when present, the relationships AORN JOURNAL • 1197 Garrett JUNE 2008, VOL 87, NO 6 Excerpt from “AORN position statement: Safe work/on-call practices” ecognizing the potential negative consequences of sleep deprivation and sustained work hours and further recognizing that adequate rest and recuperation periods are essential to patient and perioperative personnel safety, AORN suggests the following strategies. • Perioperative registered nurses should not be required to work in direct patient care more than 12 consecutive hours in a 24-hour period and not more than 60 hours in a seven-day period. Sufficient transition time is required for appropriate patient handoff and staff relief. Under extreme conditions exceptions to the 12-hour limit may be required (eg, disasters). Organization policy should outline exceptions to the 12-hour limitation. All worked hours (ie, regular hours and call hours worked) should be included in calculating total hours worked.1-3 continu• Off-duty periods should be inclusive of an uninterrupted eight-hour sleep cycle, a break from ous professional responsibilities, and time to perform individual activities of daily living.4-6 • Arrangements should be made, in relation to the hours worked, to relieve a perioperative registered nurse who has worked on-call during his or her off shift and who is scheduled to work the following shift to accommodate an adequate off-duty recuperation period. • The number of on-call shifts assigned in a seven-day period depends on the type of facility and should be coordinated with the number of sustained work hours and adequate recuperation periods mentioned above. • An individual’s ability to meet the anticipated work demand should be considered for on-call assignments. Limited research indicates older people are more likely than younger people to be adversely affected by sleep deprivation; however, there is no research specific to the effects of on-call assignment and a person’s age. • Orientation to on-call should be included in the orientation process and should be accomplished using the preceptor system (ie, having an experienced nurse serve as an immediate resource for the orientee). The time frame depends on the type of procedures and the scope of services. responsibility to patients and themselves to • Perioperative registered nurses should uphold their ethical arrive at work adequately rested and prepared for duty.2,7 • Health care organizations should support perioperative RNs in changing cultural attitudes so that fatigue is recognized as an unacceptable risk to patient and worker safety rather than a sign of a worker’s dedication to the job.2 R DEFINITIONS On-call: A designated period of time, outside of designated hours of operation, during which perioperative RNs and other perioperative personnel are available to respond to patient care needs for unplanned circumstances or urgent or emergent procedures. Call hours worked: This is the actual time the on-call perioperative registered nurse or other perioperative personnel are called into the facility for a procedure. Extended work period: Work schedules having a longer than normal workday; however, there is no clear consensus nor are there regulations about the length of the extended workday. Some sources regard time worked in excess of eight hours to be extended work periods, while others consider shifts longer than 12 hours to be extended shifts.8,9 Sustained work hours: Work periods of 12 or more hours with limited opportunity for rest and no opportunity for sleep.10 1198 • AORN JOURNAL Garrett JUNE 2008, VOL 87, NO 6 Excerpt from “AORN position statement: Safe work/on-call practices” (continued) Off duty: A period of uninterrupted time during which an individual is free from work-related duties.6 Fatigue: A response to predefined conditions that has physiological and performance consequences. Fatigue is identified as deterioration in human performance arising as a consequence of changes in the physiological condition. Factors contributing to fatigue include, but may not be limited to, time on task, time and duty period duration, time since awake when beginning the duty period, acute and chronic sleep debt, circadian disruption, multiple time zones, and shift work.11 Circadian rhythms: Twenty-four-hour cycles of behavior and physiology generated by an internal biological clock located in the suprachiasmatic nuclei of the hypothalamus. It regulates the daily cyclical patterns of sleep and wakefulness. It compels the body to fall asleep and wake up and regulates hour-tohour waking behavior reflected in fatigue, alertness, and cognitive performance.12 REFERENCES 1. Rosekind M, Gander PH, Gregory KB, et al. Managing fatigue in operational settings 2: an integrated approach. Hosp Top. 1997;75(3):31-35. 2. Gaba DM, Howard SK. Patient safety: fatigue among clinicians and the safety of patients. New Engl J Med. 2002;347(16):1249-1255. 3. Page A. Work and workspace design to prevent and mitigate errors. In: Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academies Press; 2004:237. 4. Page A. Appendix C: Work hour regulation in safety-sensitive industries. In: Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academies Press; 2004:384-435. 5. Rogers AE, Hwang WT, Scott LD, Aiken LH, Dinges DF. The working hours of hospital staff nurses and patient safety. Health Aff (Millwood). 2004;23(4):202-212. 6. Dinges DF, Graeber RC, Rosekind MR, Samuel A, Wegmann MH. Principles and Guidelines for Duty and Rest Scheduling in Commercial Aviation. Moffett Field, CA: National Aeronautics and Space Administration; 1996. http://humanfactors.arc.nasa.gov/zteam/fcp/pubs/p.and.g.intro.html. Accessed March 8, 2008. 7. AORN explications for perioperative nursing. In: Standards, Recommended Practices, and Guidelines. Denver, CO: AORN, Inc; 2004:53-83. 8. Extended unusual work shifts. US Department of Labor, Occupational Safety and Health Administration. http://www.osha.gov/OshDoc/data_Hurricane_Facts/faq_longhours.html. Accessed March 6, 2008. 9. OSH answers. Canadian Centre for Occupational Health and Safety. http://www.ccohs.ca/oshanswers/work_ schedules/workday.html. Accessed March 6, 2008. 10. Kruger GP. Sustained work, fatigue, sleep loss and performance: a review of the issues. Work Stress. 1989;3(2): 129-141. 11. Battelle Memorial Institute, JIL Information Systems. An overview of the scientific literature concerning fatigue, sleep, and the circadian cycle. January 1998. Federal Aviation Administration. http://cf.alpa.org/internet/projects /ftdt/backgr/batelle.htm. Accessed March 6, 2008. 12. Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine. 3rd ed. Philadelphia, PA: W B Saunders Co; 2000:319, 334. Reprinted with permission from “AORN position statement: Safe work/on-call practices.” In: Standards, Recommended Practices, and Guidelines. Denver, CO: AORN, Inc; 2007:409-412. http://www.aorn.org/Practice Resources/AORNPositionStatements/Position_SafeWorkOnCallPractices/. Accessed March 6, 2008. AORN JOURNAL • 1199 JUNE 2008, VOL 87, NO 6 Garrett are inversely related, with lower staffing levels reviewed, the dependent variables of shock, resulting in higher rates of all negative outcardiac arrest, UTIs, and pneumonia were all comes. In this study, there was a lack of signifinegative outcomes associated with low nurse cance between CLIs and nurse staffing and pres- staffing levels. sure ulcers and nurse staffing, which differs ADVERSE OUTCOMES. An AHRQ-funded report from other reports4,5 but may be explained by titled The Effect of Health Care Working Conditions methodological differences in determining on Patient Safety35 reviewed 26 studies on nurse staffing hours. This study is consistent with oth- staffing levels and patient safety measures. Many of the studies reviewed found an associaers when variables of fall rates and nurse staffing levels are observed.7,8 In this study, actu- tion between lower nurse staffing levels and al negative outcomes (ie, CLIs, pressure ulcers) various adverse patient outcomes. The largest were not associated with staffing levels, but study of nurse staffing examined the records of staffing was consistently, statis5 million medical patients and tically, and inversely associated 1.1 million surgical patients with falls, medication errors, who had been treated in 1993 and restraint application duraat 799 hospitals.11 The principal tion rates. The small sample findings included that in hosA vast amount of size could explain the lack of pitals with high rates of RN research has found a relationship in those variables staffing, medical patients had that were different from other lower rates of five adverse relationship between studies. patient outcomes (ie, UTIs, Results from this study pneumonia, shock, upper gaslower nurse staffing have a commonality with the trointestinal bleeding, longer others presented in this literahospital stay) than patients rates and higher rates ture review in the finding that in hospitals with low RN staffing can have an impact on staffing. Higher RN staffing of adverse patient nurse-sensitive outcomes. This was associated with a 3% to study is unique, however, in 12% reduction in patients’ outcomes. that most studies have identiadverse outcomes, depending fied a relationship between on the outcome. Higher staffing patterns and adverse staffing at all levels of nursing outcomes at the hospital level (ie, RNs, licensed practical or on a specific unit, whereas this one reviewed nurses [LPNs], and nurses’ aides) was associatthe issue across multiple units and then ed with a 2% to 25% reduction in adverse outapplied the data to individual units. The data comes, depending on the outcome. For surgical from this study may help hospital administrapatients, higher rates of RN staffing were associtors anticipate which units need higher levels ated with a 5% to 6% reduction in rates of UTIs, of staffing and at what time of day these higher a 4% to 6% reduction in rates of failure to rescue, levels of staffing are needed, and the data may and an 11% reduction in rates of pneumonia be useful in developing staffing patterns that compared to facilities with low RN staffing. are linked to quality. A study by Unruh12 of acute care hospitals in Pennsylvania found that hospitals with AHRQ REPORTS more licensed nurses had a lower incidence of The AHRQ reports that a vast amount of nearly all of the adverse outcomes studied. A research has shown a relationship between 10% increase in the number of RNs and LPNs lower nurse staffing and higher rates of decreased adverse patient outcomes,10 with two research • lung collapse by 1.5%, reports from the AHRQ10,35 presenting evi• pressure ulcers by 2%, dence that shows hospital staffing is directly • falls by 3%, and related to patient outcomes. In the studies • UTIs by less than 1%.12 1200 • AORN JOURNAL Garrett JUNE 2008, VOL 87, NO 6 PNEUMONIA. Three studies found that lower nurse staffing is directly related to increased rates of pneumonia in particular.13-15 A study by Kovner et al13 found that adding half an hour of RN staffing per patient day could reduce pneumonia in surgical patients by more than 4%. Another study by Kovner et al14 revealed that fewer RN hours per patient were significantly correlated with a higher incidence of pneumonia. Instead of placing blame on nurses for lapses in patient care, hospital administrators should ensure patient safety by examining how health care is provided in their facilities and changing nurses’ working conditions so that they are able to more safely care for patients. A study by Cho et al15 of nurse staffing and adverse outcomes in California found an 8.9% decrease in the odds of a surgical patient acquiring pneumonia when RNs were available for one additional hour per patient day. This study also showed a 9.5% decrease in the odds of a patient acquiring pneumonia when the proportion of RNs was increased by 10%. The researchers suggested that heavy responsibilities placed on RNs for respiratory care of surgical patients is directly related to rates of RN staffing and pneumonia. Unlike many other studies, these researchers examined only adverse outcomes that were not present at the time of admission.15 1202 • AORN JOURNAL ENSURING PATIENT SAFETY THROUGH ADEQUATE NURSE STAFFING This literature review included various studies that compared staffing patterns with patient outcomes and explored the relationship of fatigue and nursing errors. The evidence indicates that nurse staffing patterns can have positive and negative effects on patient care, and low levels of nurse staffing can result in medical errors and adverse outcomes. Rather than placing blame on nurses for lapses in patient care, hospital administrators should ensure the safety of patients by examining how health care is provided in their facilities and changing nurses’ working conditions so that they are able to more safely care for patients. Nurses who suffer fatigue as a result of working mandatory overtime or call are set up for the potential to make medical mistakes, which not only have a negative effect on nurses and their coworkers but also may result in adverse outcomes for patients. Inadequate staffing and unrealistic workloads place an unnecessary burden on nursing staff members, reduce the quality of care that nurses are able to provide, lead to fatigue and unachievable expectations, and result in uncompleted tasks. Physicians also agree with hospital nurses who report that nurse staffing levels are inadequate for safe and effective care and that inadequate nurse staffing is a major impediment to providing high-quality hospital care.36 An AHRQ report10 reveals the financial burden of adverse events, which can raise the cost of total treatment by 84%; for example, this translates to an increase of $22,390 to $28,505 to treat pneumonia. Adverse events also were shown to increase length of stay by 5.1 to 5.4 days and probability of death by 4.67% to 5.5%.10 When adverse outcomes occur as a result of low nurse staffing, placing blame on nurses provides no solution to the problems that managed care and budget cuts have caused. Ensuring an adequate number of nurses to provide good quality patient care is a challenge for many hospitals, but the rewards can be more positive outcomes, higher nurse retention, less nurse burnout, and higher quality patient care. Garrett REFERENCES 1. Rogers AE, Hwang WT, Scott LD, Aiken LH, Dinges DF. The working hours of hospital staff nurses and patient safety. Health Aff (Millwood). 2004;23(4):202-212. 2. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16):1 987-1993. 3. Sochalski J. Is more better? The relationship between nurse staffing and the quality of nursing care in hospitals. Med Care. 2004;42(2 Suppl):II67-II73. 4. Archibald LK, Manning ML, Bell LM, Banerjee S, Jarvis WR. Patient density, nurse-to-patient ratio and nosocomial infection risk in a pediatric cardiac intensive care unit. Pediatr Infect Dis J. 1997;16(11): 1045-1048. 5. Fridkin SK, Pear SM, Williamson TH, Galgiani JN, Jarvis WR. The role of understaffing in central venous catheter-associated bloodstream infections. Infect Control Hosp Epidemiol. 1996;17(3):150-158. 6. Blegen MA, Vaughn T. A multisite study of nurse staffing and patient occurrences. Nurs Econ. 1998; 16(4):196-203. 7. Blegen MA, Goode CJ, Reed L. Nurse staffing and patient outcomes. Nurs Res. 1998;47(1):43-50. 8. Sovie MD, Jawad AF. Hospital restructuring and its impact on outcomes: nursing staff regulations are premature. J Nurs Adm. 2001;31(12):588-600. 9. Whitman GR, Kim Y, Davidson LJ, Wolf GA, Wang SL. The impact of staffing on patient outcomes across specialty units. J Nurs Adm. 2002;32 (12):633-639. 10. Stanton MW. Hospital nurse staffing and quality of care. Res In Action. March 2004;14:1-10. http:// www.ahrq.gov/research/nursestaffing/nursestaff .pdf. Accessed March 1, 2008. 11. Needleman J, Buerhaus P, Mattke S, et al. Nurse-staffing levels and patient outcomes in hospitals. Final report for Health Resources and Services Administration. Boston, MA: Harvard School of Public Health; 2001. 12. Unruh L. Licensed nurse staffing and adverse events in hospitals. Med Care. 2003;41(1):142-152. 13. Kovner C, Mezey M, Harrington C. Research priorities for staffing, case mix, and quality of care in US nursing homes. J Nurs Scholarsh. 2000;32(1): 77-80. 14. Kovner C, Jones C, Zhan C, Gergen PJ, Basu J. Nurse staffing and postsurgical adverse outcomes: an analysis of administrative data from a sample of US hospitals, 1990-1996. Health Serv Res. 2002;37(3): 611-629. 15. Cho SH, Ketefian S, Barkauskas VH, Smith DG. The effects of nurse staffing on adverse events, morbidity, mortality, and medical costs. Nurs Res. 2003;52(2):71-79. 16. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Rockville, MD: Agency for Healthcare Research and Quality; July 2001. http:// JUNE 2008, VOL 87, NO 6 www.ahrq.gov/clinic/ptsafety/pdf/ptsafety.pdf. Accessed March 1, 2008. 17. Mystakidou K, Parpa E, Tsilika E, et al. The relationship of subjective sleep quality, pain, and quality of life in advanced cancer patients. Sleep. 2007;30(6):737-742. 18. Kane RL, Shamliyan T, Mueller C, Duval S, Wilt TJ. Nurse Staffing and Quality of Patient Care. Rockville, MD: Agency for Healthcare Research and Quality; March 2007. http://www.ahrq.gov/down loads/pub/evidence/pdf/nursestaff/nursestaff.pdf. Accessed March 1, 2008. 19. Mason DJ. Good nurse—bad nurse [Editorial]. Am J Nurs. 2007;107(3):11. 20. Wahlberg D, Treleven E. Nurse is charged in death of patient. Wisconsin State Journal. November 3, 2006:A1. http://www.madison.com/archives /read.php?ref=/wsj/2006/11/03/0611030019.php. Accessed March 1, 2008. 21. Committee on the Work Environment for Nurses and Patient Safety; Board on Health Care Services; Page A, ed. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academies Press; 2004. http://www.nap .edu/openbook/0309090679/html/1.html. Accessed March 2, 2008. 22. Mitler MM, Carskadon MA, Czeisler CA, Dement WC, Dinges DF, Graeber RC. Catastrophes, sleep, and public policy: consensus report. Sleep. 1988;11 (1):100-109. 23. Beyea SC. Too tired to work safely? AORN J. 2004;80(3):559-562. 24. Zboril-Benson LR. Why nurses are calling in sick: the impact of health-care restructuring. Can J Nurs Res. 2002;33(4):89-107. 25. Gold DR, Rogacz S, Bock N, et al. Rotating shift work, sleep, and accidents related to sleepiness in hospital nurses. Am J Public Health. 1992;82(7):1011-1014. 26. Rosekind M, Gander PH, Gregory KB, et al. Managing fatigue in operational settings 2: an integrated approach. Hosp Top. 1997;75(3):31-35. 27. AORN position statement: Safe work/on-call practices. In: AORN Standards, Recommended Practices, and Guidelines. Denver, CO: AORN, Inc; 2007: 409-412. http://www.aorn.org/PracticeResources /AORNPositionStatements/Position_SafeWork OnCallPractices/. Accessed March 6, 2008. 28. Aiken LH, Clarke SP, Sloane DM, et al. Nurses’ reports on hospital care in five countries. Health Aff (Millwood). 2001;20(3):43-53. 29. AHA Commission on Workforce for Hospitals and Health Systems. In Our Hands: How Hospital Leaders Can Build a Thriving Workforce. Chicago, IL: American Hospital Association: April 2002. http:// www.aha.org/aha/resource-center/Statistics-andStudies/ioh.html. Accessed March 1, 2008. 30. Girard NJ. Perioperative education—perspective from the think tank. AORN J. 2004;80(5):827-838. 31. Bosek MS. Mandatory overtime: professional duty, harms, and justice. JONAS Healthc Law Ethics AORN JOURNAL • 1203 Garrett JUNE 2008, VOL 87, NO 6 Regul. 2001;3(4):99-102. 32. Capitulo KL, Ankner ML, Miller J. Professional responsibility versus mandatory overtime. J Nur Adm. 2001;31(6):290-292. 33. Curtin LL. The case against mandatory overtime. Semin Nurse Manag. 2002;10(4):274-278. 34. Governor Davis announces nurse workforce initiative [news release]. Sacramento, CA: Office of the Governor; January 23, 2002. http://psychtechs.net /idx/PSYCH-HEALTH1/nurse02.htm. Accessed March 1, 2008. 35. Hickam DH, Severance S, Feldstein A, et al. The Effect of Health Care Working Conditions on Patient Safety. Rockville, MD: Agency for Healthcare Research and Quality: May 2003. http://www .ahrq.gov/downloads/pub/evidence/pdf/work /work.pdf. Accessed March 1, 2008. 36. Doctors in five countries see decline in health care quality. Commonw Fund Q. 2000;6(3):1-4. Connie Garrett, RN, BSN, CNOR, is an OR nurse educator at James A. Haley Veterans Hospital, Tampa, FL. DASH Diet May Prevent Strokes in Women T he Dietary Approaches to Stop Hypertension (DASH) diet was found to lower the risk of coronary heart disease (CHD) and stroke in middle-aged women, according to a study in the April 14, 2008, Archives of Internal Medicine. The prospective cohort study included 88,517 female nurses, ages 34 to 59 years, with no history of cardiovascular disease or diabetes in 1980. After seven dietary assessments during 24 years of follow up, researchers recorded the following: • 2,129 cases of incident nonfatal myocardial infarction, • 976 CHD deaths, and • 3,105 cases of stroke. After adjusting for cardiovascular risk factors (eg, age, smoking), researchers found that DASH scores were associated with a significantly reduced risk of stroke in women. The DASH score, based on consumption of certain foods and nutrients (eg, whole grains, low-fat dairy, sodium), was also significantly associated with lower plasma levels of Creactive protein (ie, an indicator of inflammation and stroke risk). Fung TT, Chiuve SE, McCullough ML, Rexrode KM, Logroscino G, Hu FB. Adherence to a DASH-style diet and risk of coronary heart disease and stroke in women. Arch Intern Med. 2008;168(7):713-720. US Pharmacopeia Revises Glycerin Monograph A revised glycerin monograph is scheduled for publication in the United States Pharmacopeia as a means to increase consumer safety and prevent fatalities associated with adulteration of the sweetener, according to a March 17, 2008, news release from the US Pharmacopeia (USP). The revised monograph includes an updated procedure for quantifying impurities in glycerin and a new procedure for identifying the presence of diethylene glycol. Diethylene glycol, a poisonous chemical used in industrial solvents and antifreeze, has been found as an adulterant in glycerin, which is used as a sweetener in pharmaceutical syrups and various consumer products. In 1938, more than 100 US citizens died of poisoning from diethylene glycol. Since then, the 1204 • AORN JOURNAL USP has worked with the US Food and Drug Administration (FDA) to increase consumer safety. The FDA issued a “Guidance for Industry Testing of Glycerin for Diethylene Glycol” in May 2007, emphasizing the importance of screening for the chemical. The revised monograph and FDA guidelines require any medication manufacturer using glycerin to prove diethylene glycol is not present in its product. The revised monograph goes into effect on May 15, 2008. The USP currently is working to update additional monographs for ingredients that may also be susceptible to diethylene glycol contamination. USP announces revised glycerin monograph [news release]. Rockville, MD: US Pharmacopeia; March 17, 2008. Spring 2018 Module C Page 1 of 2 NURS4342 Incorporation of Evidence into Practice Critique Process Introduction For this module, the synthesizing of evidence-based practice will be the focus. Following the completion of this module, the student is expected to be able to function as a competent consumer of evidence in nursing demanding an understanding and application of evidence and basic reserach principles to advance the practice of safe and competent nursing care. Objectives 2. Summarize the essential components of evaluating evidence, such as determining the PICOT, assessing research aspects, ethical considerations and assessing other forms of evidence. 5. Apply evidence with a partner for clinical decision making to promote patient safety and quality. Learning Activities 1. Actively participate in the appropriate discussion board per the class schedule. 2. Read appropriate areas within selected research text. 3. Access and view a narrative PowerPoint file related to how to develop a PICOT question effectively. The file is located at: http://www.ttuhsc.edu/son/ceebp/. It is entitled: PICOT Development. Within the Center of Excellence in Evidence-Based Practice, it is located under the “Learning Resources” found on the right-hand side of the page. 4. Completion of the assignment entitled: Documenting Evidence-based Practice Aspects.   Practical rationale for Module C assignment: This assignment provides a full look at how to complete an evidence-based practice project. Within this assignment, the group has to determine a PICOT question then access and evaluate articles to find out the evidence available for that topic. The final part of this assignment is individual work to help the student to implement EBP into their own practice in a functional manner. ONLY ONE MEMBER OF THE GROUP NEEDS TO SUBMIT THE ASSIGNMENT. THE ASSIGNMENT SHOULD BE SUBMITTED AS ONE DOCUMENT NOT MULTIPLE FILES. Please save the assignment as: NURS4342_ModuleC_ last name & last name  Group work: The team will select a current health topic to concentrate on for this assignment. You could find suggested topics from your agency, Institute of Medicine (IOM), or Joint Commission. Confirm with the course facilitator the team members and the selected priority area. It is strongly advised that the team submits a draft of the PICOT question to the faculty member for review prior to working with the research articles. The team will locate 3 research articles for use within this assignment. The team will summarize these articles using the grading criteria and document the findings on the form provided.  Individual work: After completing the EBP grid with the PICOT question, EBP grid, and two questions included on the grid, each member of the group will Spring 2018 Module C Page 2 of 2 NURS4342 Incorporation of Evidence into Practice prepare a ONE page discussion about how they are using the material learned within this course in their unique practice of nursing and how you can initiate a policy or procedure change within your practice setting based on what you have learned in this class.  A grading rubric is provided for use with this assignment. "All papers will be automatically scanned for evidence of plagiarism. A paper containing any plagiarism will receive a grade of zero and a complaint for academic misconduct may be submitted to the Assistant Dean of Student Affairs. Other reporting requirements may also apply." Resources Boswell and Cannon; appropriate chapters as needed. Resources from the Boswell and Cannon (2017) textbook for use with the Documenting Evidence-Based Practice Aspect form:          Examples of the form completed: Pages 470-475 Writing a PICOT: Pages 14-19 Level of evidence: Page 53 Strength of evidence: Page 54 Sampling: Pages 282-287 Quantitative aspects: Pages 111-124 Qualitative aspects: Pages 136-159 Validity: Pages 359-365 Qualitative control: Pages 145-146 Kevin M. Shimp Systematic Review Of Turnover/Retention and Staff Perception of Staffing and Resource Adequacy Related to Staffing EXECUTIVE SUMMARY Strategies identified in the literature that support the impact of staffing on registered nurse (RN) turnover/retention and RN staff perceptions of staffing and resource adequacy are summarized and reviewed. Staffing and environment that impacts the resources of RNs directly impacts RNs’ intent to leave their current institution as well as their perception of staffing and resource adequacy. Organizational leadership needs to be innovative and creative in their approach to staffing, allowing for education, empowerment, professional development, and equitable assignments that foster a better perception of the individual RN’s ability to provide high-quality care. KEVIN M. SHIMP, MSN, RN, CCRN, is DNP Student, James Madison University School of Nursing, Harrisonburg, VA. ACKNOWLEDGMENT: The author wishes to thank Professor Linda Hulton for her feedback on an early draft of this paper. A nurse-to-patient ratio is a national challenge. Finding the correct ratio without addressing acuity should not be overlooked even though there is a lack of literature existing to address this aspect of the overall concern of inadequate resources to meet patient needs. According to the American Nurses Association (ANA, 2015), adequate staffing levels have shown reduced medical and medication errors, decreased patient complications, decreased mortality, improved patient satisfaction, reduced nurse fatigue, decreased nurse burnout, and improved nurse retention and job satisfaction. In July 2002, The Joint Commission stated that staffing effectiveness is the appropriate level of nurse staffing that will provide for the best possible outcome of individual patients throughout a particular facility (Health Leaders Media, 2010). This requires hospital administration to track two patient outcome indicators such as falls and hospital-acquired pressure ulcers and determine the variation in performance caused by the number, skill mix, or competency of the staff. In June 2009, this standard was suspended due to the debate that N OPTIMAL NURSING ECONOMIC$/September-October 2017/Vol. 35/No. 5 nurse staffing impacted patient outcomes. As a result, interim staffing effectiveness standards came into effect July 1, 2010 and will remain in effect while further research is conducted on staffing’s impact on patient outcomes (Health Leaders Media, 2010). Healthcare leaders have been creative in developing strategies to build a safer environment for patients and registered nurses (RNs). Any optimal staffing model must include patient acuity, unlicensed assistive personnel, and the skills, education, and training of the workforce within specific unit settings to be effective. Appropriate staffing is imperative to provide safe and quality patient care (ANA, 2015). There is a lack of evidence that addresses the influence of staffing and scheduling committees on RN turnover, retention, and their perception of staffing and resource adequacy. A systematic review of the current literature was conducted to add to the overall literature, developing a baseline for RN turnover, retention, and RN perception of staffing and resources adequacy. The purpose of this systematic review was to identify common themes that can be used to evaluate the 239 author’s future descriptive study on staffing and scheduling committees’ influence on turnover, retention, and staff perception of staffing and resource adequacy at the institutional level when the committee utilizes staff RNs in their decision process. Background Since California mandated the ratio between nurses and patients, seven states (Oregon, Washington, Ohio, Illinois, Connecticut, Rhode Island, and Texas) enacted laws or adopted regulations regarding nurse staffing. These states did not follow California’s lead in mandating specific nurse-to-patient ratios. Most of these states modeled legislation from the ANA Safe Staffing Principles which address the problem by requiring hospitals to create nurse staffing committees comprising at least 50% clinical nurses. These committees are responsible for developing staffing plans tailored to the institution (Shullanberger, 2000). Identifying and maintaining the number and mix of nursing staff to patients while considering patient acuity is critical to the delivery of safe and quality care. Frequent studies have revealed an association between higher levels of experienced RN staffing and lower rates of adverse patient outcomes including mortality. The literature shows the number of RNs at the bedside impacts the safety of both patient and nurse (ANA, 2015). Some authors suggest legislation and regulation is the only way to achieve adequate staffing, but in reality regulation is already in place. At the federal level, legislation was created in 2008 to amend or introduce new staffing guidelines for the healthcare industry. In the 114th Congress, House Bill 2083 and Senate Bill 1132 sought to amend Title XVIII (Medicare) of the Social Security Act which requires Medicare-participating hospitals to implement a hospital-wide staffing plan for 240 nursing services within their organization. The amendment called for a plan that would require an appropriate number of RNs providing direct patient care in each unit of the hospital to ensure staffing levels that: (a) address the unique characteristics of the patients and hospital units, and (b) result in the delivery of safe, quality patient care consistent with specified requirements. The proposals also sought to require each participating hospital to establish a hospital nurse staffing committee to implement such a plan. Nationally, efforts continue to amend or introduce new legislation. State staffing laws have three general approaches (ANA, 2015). The first requires hospitals to have a nurse-driven staffing committee to create staffing plans that reflect the needs of the patient population and match the skills and experience of the staff. The second approach is for legislators to mandate specific nurse-to-patient ratios in legislation or regulation. The third approach requires facilities to disclose staffing levels to the public and/or a regulatory body. The ANA platform for safe staffing calls for a legislative model that requires nurses to be empowered to create staffing plans that meet specific unit demands. This approach establishes staffing levels that are flexible and allows for changes in intensity of patients’ needs; number of admissions, discharges, and transfers during a shift; level of experience of nursing staff; unit layout; and availability of resources (ancillary staff, technology, etc.) (ANA, 2015). The development of staffing and scheduling committees has occurred throughout the nation because of ANA’s platform, the desire for Magnet® recognition by the institution, and legislation and regulation. The American Nurses Credentialing Center (ANCC, 2015) Magnet Recognition Pro- gram® is viewed around the world as the ultimate seal of quality and confidence. Magnet organizations are recognized for superior nursing processes and quality patient care, which lead to the highest levels of safety, quality, and patient satisfaction (ANCC, 2015). Little is known on how to develop these committees. However, Dawson (2014) provided recommendations for staffing and scheduling committees. 1. Involve nurses in the design of work schedules using a regular and predictable schedule, so nurses can plan for work and personal responsibilities. 2. Limit work weeks to 40 hours within 7 days and work shifts to 12 hours in duration. 3. Establish at least 10 consecutive hours per day of protected time off duty for nurses to obtain 7 to 9 hours of sleep. 4. Eliminate the use of mandatory overtime as a “staffing solution.” 5. Promote frequent, uninterrupted rest breaks during work shifts and facilitate the use of naps during scheduled breaks. To promote staff recruitment and retention, nurses on a 13-bed medical oncology unit proposed the following goals for their staffing committee: increase staff morale; increase staff control over their work environment through self-governance activities; and offer flexible scheduling options. The committee goals to address these concerns were to examine and evaluate scheduling options for the unit on an ongoing basis, promote and maintain staff input into decision making, and educate staff and provide hands-on scheduling experiences for committee members (Dearholt & Feathers, 1997). In another study, a nursing productivity committee was formed to analyze productive and nonproductive hours and seek improvements in staffing models and scheduling processes, which re- NURSING ECONOMIC$/September-October 2017/Vol. 35/No. 5 sulted in lower nurse-to-patient ratios, better control of labor costs, elimination of agency staff, greater staff satisfaction, and introduction of new technologies (McKenna et al., 2011). The goals of this committee were: 1. Review/revise staffing formulas for budgeted full-time equivalent requirements. 2. Understand hours per patient day (HPPD), productive and nonproductive hours, how the standards are determined, and how variances occur. 3. Establish standards for productive and nonproductive time. 4. Discuss staffing strategies to reach target HPPD on all nursing units. 5. Analyze computerized staffing reports to ensure accuracy and determine opportunities for improvement. 6. Collaborate with nursing councils to address staff morale related to turnover and workload. 7. Seek opportunities to make cost savings without adversely affecting patient care. Methods A literature search was undertaken in October 2015 of the major healthcare-related databases: CINAHL, Medline, and ProQuest. The keywords “nurs* AND practice AND environment AND committee* and governance” were used initially. Additional keywords “retention strategies” were also searched. Abstracts were reviewed and articles which included a purpose to improve the practice environment of nurses in relation to RN turnover, retention, and RN’s perception of staffing and resource adequacy were identified. Reference lists of selected articles were reviewed for other potential articles. Articles were excluded if not written in English. The initial search located 79 articles and all abstracts were reviewed. Ten papers were reviewed for reported processes aimed at assessing turnover and retention and 12 papers were identified that looked at staffing perception and resource adequacy. All articles were published within the last 5 years, allowing for the most recent literature to be reviewed. After screening, one acrossmethod triangulation study, one literature review, one triangulated methodology study, nine crosssectional surveys, one cross-sectional correlational design, three surveys, one retrospective study of data, one mixed-method survey, one survey with focus groups, one survey with focus groups, one qualitative descriptive study, and one secondary analysis were included in the systematic review. The years of publication ranged from 2009-2015 and the level of evidence included six Level 6, one Level 5, and 15 Level 3. Results See Tables 1 and 2. Discussion The literature supports the cost...
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