March, 2017 - SUPPORT Summary of a systematic review | print this article |

Do changes to hospital nurse staffing models improve patient and staff-related outcomes?

Many countries have introduced new nurse staffing models in hospitals to respond to changing patient care needs and shortages of qualified nursing staff. These new models include changes in the mix of skills, qualifications or staffing levels within the hospital workforce, and changes in nursing shifts or work patterns. Nurse staffing might be associated with the quality of care that patients receive and with patient outcomes.

Key messages

 

  • The addition of a specialist nursing post to staffing may decrease patient length of stay; and may lead to little or no difference in in-hospital mortality, readmissions, attendance at emergency departments within 30 days, or post-discharge adverse events.
  • Adding support staff (dietary assistants) to nurse staffing may decrease mortality in trauma units, in hospital, and at 4 months after discharge.
  • Team midwifery shortens the length of stay in special care nurseries for infants, slightly shortens the length of stay in hospital for women giving birth, and probably leads to little or no difference in perinatal deaths.
  • None of the included studies was conducted in a low-income country.

 

Background

Hospitalised patients have become more seriously ill, requiring more intensive nursing care and ageing populations are further stretching nursing resources. A range of nurse staffing model interventions has been introduced across countries to address nursing shortages. These models include changes to nurse staffing levels and skill mix, changes in nurse education, changes to staff allocation models and shift patterns, and greater use of overtime and agency staff. The numbers of nurses available in a hospital or hospital unit (staffing levels) can be quantified in relation to the nurse per patient ratio or in terms of hours of nursing care. Skill mix may refer to the mix of “licensed/registered” and “unlicensed/unregistered” staff or the proportion of different nursing levels of qualification, expertise, or experience.

 



About the systematic review underlying this summary

Review objectives: To determine the effect of hospital nurse staffing models on patient and staff-related outcomes
Type of What the review authors searched for What the review authors found
Study designs & interventions Randomised trials, non-randomised trials, controlled before- after studies, and interrupted time series studies of interventions relating to hospital nurse staffing models
15 studies (8 randomised trials, 2 non-randomised trials, and 5 controlled before- after studies). 4 studies assessed primary nursing, self-scheduling, and team midwifery; and 11 studies related to nursing skill-mix (9 examining the addition of specialist nurses to usual staffing; 2 examining increases in the proportion of support staff versus usual nursing staff).
Participants Patients and nursing staff

Nursing staff: midwives; surgical, medical and gynaecological ward nurses; nurse case managers; clinical nurse specialists; nursing assistants; advance practice nurses

Patients: pregnant women; women scheduled for surgery; women admitted with hip fractures; people with breast cancer, diabetes, mental health problems, multiple sclerosis, myocardial infarctions


Settings Hospital settings worldwide
Unites States (7), United Kingdom (4), Australia (1), The Netherlands (2), and Canada (1)
Outcomes Any objective measure of patient or staff-related outcome

Staff-related outcomes: absenteeism, staff retention and staff turnover; Patient outcomes: patient falls, medication errors and adverse incidents, length of stay, patient mortality, re-admission and attendance at the emergency department post-discharge; and Costs

Date of most recent search: May 2009
Limitations:This is well-conducted systematic review with only minor limitations.

Butler M, Collins R, Drennan J, et al. Hospital nurse staffing models and patient and staff-related outcomes. Cochrane Database Syst Rev 2011; (7):CD007019.

 

Summary of findings

15 studies were included on the impacts of nurse staffing models.

1) Addition of a specialist nursing post to nurse staffing 

The impact of specialist nursing roles on patient outcomes was assessed in eight studies. Specialist nurse roles varied from study to study, but all were focused around the needs of specific groups of patients, such as patients with diabetes, multiple sclerosis, myocardial infarction, mental health problems, or gynaecological problems. The role of the specialist nurse usually involved co-ordinating care, including arranging tests and procedures, assessing patients, planning their care and reviewing their progress, undertaking or prescribing specific interventions based on assessed needs, and educating patients, nurses, and other staff.

 

  • The addition of a specialist nursing post to staffing may decrease patient length of stay. The certainty of this evidence is low.
  • The addition of a specialist nursing post to staffing may lead to little or no difference in in-hospital mortality, readmissions, attendance at emergency departments within 30 days of discharge, or post-discharge adverse events. The certainty of this evidence is low.

Adding a specialist nursing post to nurse staffing compared to usual nurse staffing

People

Patients with a range of health issues

Settings

Hospital

Intervention

The addition of a specialist nursing post(s) to staffing

Comparison

Usual nurse staffing

Outcomes Usual nurse staffing The addition of a specialist nursing post(s) to staffing Relative effect
(95% CI)
Certainty
of the evidence
(GRADE)
Absolute effect (95% CI)

In-hospital mortality

97 per 1000

93 per 1000

(57 to 151)

RR 0.96

(0.59 to 1.56)

Low

Re-admission

Study population

174 per 1000

200 per 1000

(153 to 264)

RR 1.15
(0.88 to 1.52)

Low

Medium risk* population

144 per 1000

166 per 1000

(127 to 219)

Attendance at ED within 30 days

192 per 1000

219 per 1000

(152 to 311)

RR 1.14

(0.79 to 1.62)

Low

Post-discharge adverse events#

228 per 1000

235 per 1000

(160 to 349)

RR 1.03

(0.7 to 1.53)

Low 

Patient length of stay

 

1.35 fewer days

(1.92 to 0.78 fewer days)

 

Low 

Margin of error = Confidence interval (95% CI) RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page)

*The assumed risks are drawn from the control group risk across the studies and in part imply patients with less serious health problems.

# One study found that the use of specialist nurses may reduce the incidence of pressure ulcers.


 

2) Adding support staff (dietary/dietetic assistants) to nurse staffing

The review identified two studies that assessed the addition of dietetic technicians to nurse staffing. This staff, trained (during one or two years) in dietetics and nutrition care, is involved in planning, implementing and monitoring nutritional programs and services in facilities.

 

  • Adding dietary assistants to nurse staffing decrease mortality in trauma units, in hospital, and 4 months after discharge. The certainty of this evidence is low.

Adding dietary assistants to nurse staffing compared to usual nurse staffing

People

Women aged over 65 admitted to a single trauma ward with hip fracture

Settings

Hospital

Intervention

The addition of dietary assistants (with 14 days of orientation and training) to nurse staffing

Comparison

Usual nurse staffing

Outcomes Usual nurse staffing Adding dietary assistants to nurse staffing Relative effect (95% CI) Certainty of the evidence (GRADE)
Absolute effect (95% CI)

Mortality - Deaths in trauma unit

102 per 1000

42 per 1000

(16 to 103)

RR 0.41

(0.16 to 1.01)

Low

Mortality - Deaths in hospital

146 per 1000

82 per 1000

(43 to 160)

RR 0.56

(0.29 to 1.09)

Low

Mortality - Deaths at 4 months after discharge

229 per 1000

131 per 1000

(78 to 218)

RR 0.57

(0.34 to 0.95)

Low

Margin of error = Confidence interval (95% CI) RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page)

3) Introducing new rosters or shifts versus usual shifts

One study that examined the effect of introducing a self-scheduling system on staff-related outcomes found that this may lead to a reduction in staff turnover. The certainty of this evidence is low.

4) Primary nursing versus usual nursing models

Primary nursing is a system for the distribution of nursing care in which care of one patient is managed for the entire 24-hour day by one nurse who directs and coordinates nurses and other personnel. Two studies examined the effect of introducing primary nursing on staff-related outcomes. The effect of these interventions on absenteeism and turnover rates is uncertain because the evidence is of very low certainty.

5) Team midwifery versus standard care

The introduction of team midwifery (defined as a group of midwives providing care and taking shared responsibility for a group of women from the antenatal period through the intrapartum and postnatal periods) versus standard care, was evaluated in one study.

 

  • Team midwifery shortens the length of stay in special care nurseries for infants and slightly shortens the length of stay in hospital for women giving birth. The certainty of this evidence is high.
  • Team midwifery probably leads to little or no difference in perinatal deaths. The certainty of this evidence is low.

Team midwifery compared to standard maternity care

People

Patients with maternity care outcomes

Settings

Hospital

Intervention

Team midwifery

Comparison

Standard care

Outcomes Standard maternity care Use of team midwifery Relative effect
(95% CI)
Certainty
of the evidence
(GRADE)
Absolute effect (95% CI)

Perinatal deaths

9 per 1000

11 per 1000

(3 to 40)

RR 1.22

(0.33 to 4.5)

Moderate

Length of stay in special care nursery for infants

 

2 fewer days

(2.07 to 1.93 lower)

 

High

Length of stay in hospital for women giving birth

 

0.3 fewer days

(0.54 to 0.06 fewer days)

 

High

Margin of error = Confidence interval (95% CI) RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page)

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY
The trials included in the review were conducted in high-income countries.

When assessing the transferability of these findings to low-income countries the following factors should be considered:

− The availability and training of nurses

− The acceptability, feasibility and costs of different nurse staffing models. In particular, nurse and other health professional associations may need to be consulted

The ability of the health system and hospitals to support the implementation of new nurse staffing models


EQUITY
There was no information in the included studies regarding the differential effects of the interventions on resource-disadvantaged populations.

The resources needed for training may be less available in disadvantaged settings.

These interventions may increase inequities if they are not applied or adapted to populations in rural or remote areas.


ECONOMIC CONSIDERATIONS
The systematic review did not address economic considerations.

Scaling up nurse staffing will require resources, and a well functioning and coordinated health system.

Local cost studies should be considered prior to scaling up nurse staffing.


MONITORING & EVALUATION
There is little evidence from rigorous studies for several of the comparisons considered in this review.

Larger and more rigorous studies to determine the effects and the cost-effectiveness of alternative nurse staffing models and educational interventions are needed, particualarly in low-income countries.


 

*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods


 

Additional information

Related literature

These systematic reviews provide additional information on the effects of nurse staffing on other outcomes:

Fernandez R, Johnson M, Tran DT, et al. Models of care in nursing: a systematic review. Int J Evid Based Healthc 2012; 10(4):324-37.

 

Pearson A, Pallas LO, Thomson D, et al. Systematic review of evidence on the impact of nursing workload and staffing on establishing healthy work environments. Int J Evid Based Healthc 2006; 4(4):337-84.

 

This systematic review provides information about team midwifery:

Sandall J, Soltani H, Gates S, et al. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database Syst Rev 2013; (8):CD004667.

 

This summary was prepared by

Agustín Ciapponi, Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by: Michelle Butler and Laetitia Rispel.

 

This review should be cited as

Butler M, Collins R, Drennan J, et al. Hospital nurse staffing models and patient and staff-related outcomes. Cochrane Database Syst Rev 2011; (7):CD007019.

 

The summary should be cited as

Ciapponi A. Do changes to hospital nurse staffing models improve patient and staff-related outcomes? A SUPPORT Summary of a systematic review. March 2017. www.supportsummaries.org

 

Keywords

evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care, models, nursing, nursing staff, hospital, outcome assessment (health care); personnel staffing and scheduling

 



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