Relationships Between Nurse Staffing and Patients’ Experiences, and the Mediating Effects of Missed Nursing Care

Cho, Sung Hyun; Mark, Barbara A.; Knafl, George J.; Chang, Hyoung Eun; Yoon, Hyo Jeong

doi:10.1111/jnu.12292

Cited by 51 publications

(73 citation statements)

References 13 publications

(17 reference statements)

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“…In addition, a small number of cross-sectional studies published during the current project have demonstrated that associations between low nurse staffing and adverse patient outcomes, including falls, patient experience and mortality, are mediated by nurses' reports of missed care. [23][24][25][26] Although they provide more direct evidence of a causal pathway, these studies have, thus far, relied on intermittent, retrospective nurse reports of missed care, which must be regarded as subjective measures. Taken as a whole, these studies do suggest that care omissions may provide more direct indicators of nurse staffing adequacy, which are, in turn, related to important outcomes.…”

Section: Discussionmentioning

confidence: 99%

Nurse staffing levels, missed vital signs and mortality in hospitals: retrospective longitudinal observational study

Griffiths

Ball

Bloor

et al. 2018

Health Serv Deliv Res

112

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Background Low nurse staffing levels are associated with adverse patient outcomes from hospital care, but the causal relationship is unclear. Limited capacity to observe patients has been hypothesised as a causal mechanism. Objectives This study determines whether or not adverse outcomes are more likely to occur after patients experience low nurse staffing levels, and whether or not missed vital signs observations mediate any relationship. Design Retrospective longitudinal observational study. Multilevel/hierarchical mixed-effects regression models were used to explore the association between registered nurse (RN) and health-care assistant (HCA) staffing levels and outcomes, controlling for ward and patient factors. Setting and participants A total of 138,133 admissions to 32 general adult wards of an acute hospital from 2012 to 2015. Main outcomes Death in hospital, adverse event (death, cardiac arrest or unplanned intensive care unit admission), length of stay and missed vital signs observations. Data sources Patient administration system, cardiac arrest database, eRoster, temporary staff bookings and the Vitalpac system (System C Healthcare Ltd, Maidstone, Kent; formerly The Learning Clinic Limited) for observations. Results Over the first 5 days of stay, each additional hour of RN care was associated with a 3% reduction in the hazard of death [hazard ratio (HR) 0.97, 95% confidence interval (CI) 0.94 to 1.0]. Days on which the HCA staffing level fell below the mean were associated with an increased hazard of death (HR 1.04, 95% CI 1.02 to 1.07), but the hazard of death increased as cumulative staffing exposures varied from the mean in either direction. Higher levels of temporary staffing were associated with increased mortality. Adverse events and length of stay were reduced with higher RN staffing. Overall, 16% of observations were missed. Higher RN staffing was associated with fewer missed observations in high-acuity patients (incidence rate ratio 0.98, 95% CI 0.97 to 0.99), whereas the overall rate of missed observations was related to overall care hours (RN + HCA) but not to skill mix. The relationship between low RN staffing and mortality was mediated by missed observations, but other relationships between staffing and mortality were not. Changing average skill mix and staffing levels to the levels planned by the Trust, involving an increase of 0.32 RN hours per patient day (HPPD) and a similar decrease in HCA HPPD, would be associated with reduced mortality, an increase in staffing costs of £28 per patient and a saving of £0.52 per patient per hospital stay, after accounting for the value of reduced stays. Limitations This was an observational study in a single site. Evidence of cause is not definitive. Variation in staffing could be influenced by variation in the assessed need for staff. Our economic analysis did not consider quality or length of life. Conclusions Higher RN staffing levels are associated with lower mortality, and this study provides evidence of a causal mechanism. There may be several causal pathways and the absolute rate of missed observations cannot be used to guide staffing decisions. Increases in nursing skill mix may be cost-effective for improving patient safety. Future work More evidence is required to validate approaches to setting staffing levels. Other aspects of missed nursing care should be explored using objective data. The implications of findings about both costs and temporary staffing need further exploration. Trial registration This study is registered as ISRCTN17930973. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 6, No. 38. See the NIHR Journals Library website for further project information.

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Section: Discussionmentioning

confidence: 99%

Nurse staffing levels, missed vital signs and mortality in hospitals: retrospective longitudinal observational study

Griffiths

Ball

Bloor

et al. 2018

Health Serv Deliv Res

112

View full text Add to dashboard Cite

show abstract

“…A previous analysis focused on patients (ie, patientreported missed care and patient experiences) was published elsewhere (Cho et al, 2017) The study examined the relationships among nurse staffing, missed care reported by nurses and patients, patient experiences, and nurse outcomes.…”

Section: Design and Samplementioning

confidence: 99%

“…The study examined the relationships among nurse staffing, missed care reported by nurses and patients, patient experiences, and nurse outcomes. A previous analysis focused on patients (ie, patientreported missed care and patient experiences) was published elsewhere (Cho et al, 2017), whereas the current study focused on nurses. A notice of request for participation in the study was mailed to 183 hospitals by the Korean Hospital Nurses Association, and 52 hospitals agreed to participate in the study.…”

Section: Design and Samplementioning

confidence: 99%

“…Empirical evidence has suggested that poorer nurse staffing was associated with an increase in nurse-reported missed care, and increased missed care was associated with nurse-reported quality of nursing care and patient safety, adverse events, mortality, and patient satisfaction Jones et al, 2015;Lake, Germack, & Viscardi, 2016;Recio-Saucedo et al, 2017). Patientreported missed care was also found to mediate the relationship between nurse staffing and patients experiences (Cho, Mark, Knafl, Chang, & Yoon, 2017).…”

Section: Introductionmentioning

confidence: 96%

“…The proposed mechanism is that inappropriate nurse staffing leads nurses to experience time scarcity and to miss some nursing activities, resulting in negative patient outcomes (Jones, Hamilton, & Murry, 2015;Martsolf et al, 2016). Patientreported missed care was also found to mediate the relationship between nurse staffing and patients experiences (Cho, Mark, Knafl, Chang, & Yoon, 2017). Patientreported missed care was also found to mediate the relationship between nurse staffing and patients experiences (Cho, Mark, Knafl, Chang, & Yoon, 2017).…”

Section: Introductionmentioning

confidence: 97%

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Nurse staffing, nurses prioritization, missed care, quality of nursing care, and nurse outcomes

Cho

Lee

You

et al. 2019

Int J of Nursing Practice

128

148

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Aim:To examine the relationships among nurse staffing, nurses prioritization of nursing activities, missed care, quality of nursing care, and nurse outcomes.Background: Inadequate staffing is associated with increased missed care, which threatens the quality of care and nurse outcomes. Methods:The study sample included 2114 staff nurses from 156 medical or surgical units of 49 general hospitals who had participated in a cross-sectional survey conducted in 2015. Nurse staffing was measured using the patient-to-nurse ratio and perceived staffing adequacy. The Missed Nursing Care Survey was used to measure how frequently nurses had missed each of 24 activities. Multilevel regression analyses were employed to examine the relationships among variables. Results:The prevalence of missed care differed by nursing activity. Poorer staffing was associated with an increased number of missed activities. A higher number of missed activities and poorer staffing were associated with poorer patient safety, quality of nursing care and job satisfaction, and a higher intent to leave. Nurses gave the highest priority to focused patient reassessments, timely medications, and patient teaching, under hypothetical conditions of improved staffing. Conclusion:Adequate staffing is required to reduce missed care and to improve quality of care and nurse outcomes. K E Y W O R D SJob satisfaction, missed nursing care, nurse staffing, quality, safety SUMMARY STATEMENTWhat is already known about this topic?• Low nurse staffing is associated with a high prevalence of missed care, which has negative effects on patient and nurse outcomes.• Nurses are known to prioritize their nursing tasks in the face of time scarcity. However, insufficient studies have investigated how nurses prioritize nursing care and, further, how their prioritization would be modified if nurse staffing were to improve.What is already known about this topic?• Poorer perceptions of staffing adequacy and the patient-to-RN ratio had a significant association with a higher number of missed nursing activities.

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The lived experience of Chinese medical tourists receiving cancer care: A qualitative study

Liu

Cesario

et al. 2023

Nursing Open

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The rapid growth of inbound medical tourists in the United States (U.S.) highlights the need for providing culturally appropriate healthcare. This is particularly important for medical tourists come from diverse background. The Institute of Medicine report in 2003 (Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, 2003) emphasized the importance of healthcare providers being aware of and responsive to patients' cultural and social backgrounds, thus improving healthcare delivery. The Allied Market Research report indicates that the number of medical tourists worldwide was 23 million

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Relationships Between Nurse Staffing and Patients’ Experiences, and the Mediating Effects of Missed Nursing Care

Abstract: Appropriate nurse staffing is required to reduce missed care and to improve patients' experiences.

Cited by 51 publications

References 13 publications

Nurse staffing levels, missed vital signs and mortality in hospitals: retrospective longitudinal observational study

Nurse staffing levels, missed vital signs and mortality in hospitals: retrospective longitudinal observational study

Nurse staffing, nurses prioritization, missed care, quality of nursing care, and nurse outcomes

The lived experience of Chinese medical tourists receiving cancer care: A qualitative study

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