Nursing resources and patient outcomes in intensive care: A systematic review of the literature

School of Health and Social Care, University of Greenwich, Southwood Site, Avery Hill Road, Eltham, London SE9 2UG, UK.
International journal of nursing studies (Impact Factor: 2.9). 11/2007; 46(7):993-1011. DOI: 10.1016/j.ijnurstu.2007.07.011
Source: PubMed


To evaluate the empirical evidence linking nursing resources to patient outcomes in intensive care settings as a framework for future research in this area.
Concerns about patient safety and the quality of care are driving research on the clinical and cost-effectiveness of health care interventions, including the deployment of human resources. This is particularly important in intensive care where a large proportion of the health care budget is consumed and where nursing staff is the main item of expenditure. Recommendations about staffing levels have been made but may not be evidence based and may not always be achieved in practice.
We searched systematically for studies of the impact of nursing resources (e.g. nurse-patient ratios, nurses' level of education, training and experience) on patient outcomes, including mortality and adverse events, in adult intensive care. Abstracts of articles were reviewed and retrieved if they investigated the relationship between nursing resources and patient outcomes. Characteristics of the studies were tabulated and the quality of the studies assessed.
Of the 15 studies included in this review, two reported a statistical relationship between nursing resources and both mortality and adverse events, one reported an association to mortality only, seven studies reported that they could not reject the null hypothesis of no relationship to mortality and 10 studies (out of 10 that tested the hypothesis) reported a relationship to adverse events. The main explanatory mechanisms were the lack of time for nurses to perform preventative measures, or for patient surveillance. The nurses' role in pain control was noted by one author. Studies were mainly observational and retrospective and varied in scope from 1 to 52 units. Recommendations for future research include developing the mechanisms linking nursing resources to patient outcomes, and designing large multi-centre prospective studies that link patient's exposure to nursing care on a shift-by-shift basis over time.

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Available from: Colin Sanderson, Nov 18, 2014
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    • "Three measures of workload were particularly important: peak occupancy, average nursing requirement (as defined by the UK Intensive Care Society) per occupied bed per shift, and the ratio of occupied to appropriately staffed beds. Although this was a study of only one unit, it was conducted over 4 years and meets many of the criteria of a high quality study (West et al., 2009). "
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    ABSTRACT: Objectives To investigate whether the size of the workforce (nurses, doctors and support staff) has an impact of the survival chances of critically ill patients both in the intensive care unit (ICU) and in the hospital. Background Investigations of intensive care outcomes suggest that some of the variation in patient survival rates might be related to staffing levels and workload, but the evidence is still equivocal. Data: Information about patients, including the outcome of care (whether the patient lived or died) came from the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme. An Audit Commission survey of ICUs conducted in 1998 gave information about staffing levels. The merged dataset had information on 65 ICUs and 38,168 patients. This is currently the best available dataset for testing the relationship between staffing and outcomes in UK ICUs Design A cross-sectional, retrospective, risk adjusted observational study. Methods Multivariable, multilevel logistic regression. Outcome Measures: ICU and in-hospital mortality. Results After controlling for patient characteristics and workload we found that higher numbers of nurses per bed (odds ratio: 0.90, 95% confidence interval: [0.83, 0.97]) and higher numbers of consultants (0.85, [0.76, 0.95]) were associated with higher survival rates. Further exploration revealed that the number of nurses had the greatest impact on patients at high risk of death (0.98, [0.96, 0.99]) whereas the effect of medical staffing was unchanged across the range of patient acuity (1.00, [0.97, 1.03]). No relationship between patient outcomes and the number of support staff (administrative, clerical, technical and scientific staff) was found. Distinguishing between direct care and supernumerary nurses and restricting the analysis to patients who had been in the unit for more than 8 hours made little difference to the results. Separate analysis of in-unit and in-hospital survival showed that the clinical workforce in intensive care had a greater impact on ICU mortality than on hospital mortality which gives the study additional credibility. Conclusion This study supports claims that the availability of medical and nursing staff is associated with the survival of critically ill patients and suggests that future studies should focus on the resources of the health care team. The results emphasise the urgent need for a prospective study of staffing levels and the organisation of care in ICUs.
    International journal of nursing studies 05/2014; 51(5). DOI:10.1016/j.ijnurstu.2014.02.007 · 2.90 Impact Factor
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    • "Furthermore, the growing nursing workforce shortage also sets demands on competence assessment in clinical practice (e.g. Salonen et al. 2007, Cowan et al. 2008, King's College London 2009, West et al. 2009, Attree et al. 2011). Competence assessment tools developed specifically for intensive care nursing are needed. "
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    ABSTRACT: To describe and evaluate the basic competence of graduating nursing students in intensive and critical care nursing. Intensive and critical care nursing is focused on severely ill patients who benefit from the attention of skilled personnel. More intensive and critical care nurses are needed in Europe. Critical care nursing education is generally postqualification education that builds upon initial generalist nursing education. However, in Europe, new graduates practise in intensive care units. Empirical research on nursing students' competence in intensive and critical care nursing is scarce. A cross-sectional survey design. A basic competence scale (Intensive and Critical Care Nursing Competence Scale, version 1) and a knowledge test (Basic Knowledge Assessment Tool, version 7) were employed among graduating nursing students (n = 139). Sixty-nine per cent of the students self-rated their basic competence as good. No association between self-assessed Intensive and Critical Care Nursing-1 and the results of the Basic Knowledge Assessment Tool-7 was found. The strongest factor explaining the students' conception of their competence was their experience of autonomy in nursing after graduation. The students seem to trust their basic competence as they approach graduation. However, a knowledge test or other objective method of evaluation should be used together with a competence scale based on self-evaluation. In nursing education and in clinical practice, for example, during orientation programmes, it is important not only to teach broad basic skills and knowledge of intensive and critical care nursing, but also to develop self-evaluation skills through the use of special instruments constructed for this purpose.
    Journal of Clinical Nursing 06/2013; 23(5-6). DOI:10.1111/jocn.12244 · 1.26 Impact Factor
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    • "Authors have highlighted the difficulties of defining standard search terms when reviewing material on workload (Carmel & Rowan 2001, Pronovost et al. 2002). Other researchers conducting similar reviews have subsequently used diverse search terms and strategies to ensure as wide and as complete coverage of relevant material as possible (West et al. 2009). We have followed this approach in undertaking this review. "
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    ABSTRACT: New contractual frameworks for community pharmacy are believed to have increased workload for pharmacists; too much work has been implicated in high profile cases of dispensing errors leading to patient harm, and concerns about pharmacists' well-being. A review was undertaken to ascertain whether community pharmacists' workload has increased and whether links between workload and patient safety and pharmacists' well-being have been established. We searched Scopus; EMBASE; MEDLINE; PubMed; CINAHL; PsychINFO; ASSIA; E-pic, and International Pharmaceutical Abstracts for research published between 1989 and 2010 containing data on UK community pharmacy workload, and on its consequences when workload was found to be a determinant of either patient or pharmacist outcomes. Researchers assessed retrieved material against inclusion and exclusion criteria and synthesised findings using a data extraction form. Fifteen studies were retrieved that met the inclusion criteria. A number of methodological weaknesses were identified: studies categorised work tasks and workload differently making comparisons over time or between studies difficult; most studies were small scale or conducted in specific localities, or lacked sufficient methodological information to rule out bias; studies that control for possible confounders are rare. The reviewed research suggests that community pharmacists still spend the majority of their time involved in activities associated with the dispensing of prescriptions. There is some evidence that community pharmacists' workload has increased since the introduction of the new contracts in England and Wales, especially around the core activity of dispensing prescriptions and medicines use reviews. There is also some evidence to suggest a link between heavy workload and aspects of pharmacists' well-being but there is no robust evidence indicating threats to patient safety caused by their having too much work to do. More high quality research is required to examine what constitutes too much work, the impact of high workload, and associations with other work place factors.
    Health & Social Care in the Community 05/2011; 19(6):561-75. DOI:10.1111/j.1365-2524.2011.00997.x · 1.15 Impact Factor
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