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144BEvidence Tables for Chapter 34. Effect of Nurse-to-Patient Staffing Ratios on Patient Morbidity and MortalityTable 1, Chapter 34. Evidence tableAuthor, Year Description
of PSP
Multi-component
Study Design
Sample Size
Theory or Logic Model
Contexts Implementation Details
Outcomes: Benefits Outcomes: Harms
Influence of Contexts on Outcomes*
Overall Risk of Bias
Unruh and Zhang, 20121
Not a study of an intervention
Retrospective cohort
124 Florida hospitals between 1996 – 2004
A conceptual model is presented that relates case mix, location, ownership, size, and payer mix with changes in nurse staffing over time
124 Florida hospitals
USA
Academic status not reported
No assessment of existing quality / safety infrastructure
No assessment of organizational complexity
SCTL: Not assessed
Not relevant, not a study of an intervention
Higher RN FTE were associated with better outcome for most, but not all AHRQ patient safety indicators, including failure-to-rescue
None mentioned
Case mix, urban status, Medicaid, and HMO days of care were all positively related to changes to failure-to-rescue
High
Needleman, et al., 20112
Not a study of an intervention
Longitudinal assessment of changes in nurse staffing, and mortality in one hospital
197,961 patient admissions
176,696 nursing shifts
None A single tertiary academic hospital recognized for exemplary care
USA
Nurse: careful assessment of actual nurse workload for specific patients
Academic status assessed
Existing quality and safety infrastructure and organizational complexity inferred from recognition by authorities as a “high quality” hospital
Not relevant, not a study of an intervention
Exposure to each shift with a RN staffing level below target increased risk of death by 2%
In non-ICU patients, risk increased 4%
None mentioned
High patient turnover also associated with worse outcomes
Low
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Author, Year Description of PSP
Multi-component
Study Design
Sample Size
Theory or Logic Model
Contexts Implementation Details
Outcomes: Benefits Outcomes: Harms
Influence of Contexts on Outcomes*
Overall Risk of Bias
Twigg et al., 20113
Not a study of an intervention per se, Western Australia ordered the introduction of a new staffing method for nurses
Described as an interrupted time series, but presented as a pre / post assessment
236,454 patients150,925 nurse staffing records
None 3 adult tertiary teaching hospitals
Australia
Nurse hours of care and skill mix
Academic states assessed
No assessment of existing quality / safety infrastructure
Organizational infrastructure described in terms of comprehensive clinical services being provided
SCTL: Not assessed
Not relevant, not a study of an intervention per se
For allpatients and for medical and surgical patients the deathrate decreased significantly
None mentioned
None mentioned
High
Aiken et al., 20104
Not a study of an intervention per se, rather California legislation mandated certain nurse-to-patient ratios
Cross-sectional
22,336 hospital nurses in California
None California staff nurses
USA
RN staffing, patient-nurse workload
Academic status assessed
No assessment of existing quality / safety infrastructure
SCTL: Not assessed
Not relevant, not a study of an intervention per se
Lower patient-to-nurse staffing ratios were associated with lower 30-day mortality and failure to rescue
25% of RNs reported they perceived decreased support from LVNs, 34% of RNs reported decreased support from unlicensed personnel
None mentioned
High
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Author, Year Description of PSP
Multi-component
Study Design
Sample Size
Theory or Logic Model
Contexts Implementation Details
Outcomes: Benefits Outcomes: Harms
Influence of Contexts on Outcomes*
Overall Risk of Bias
Harless and Mark, 20105
Not a study of an intervention
Longitudinal analysis of changes in nurse staffing in California between 1996 - 2001
283 California hospitals
11,945,226 adult inpatients
None 283 acute care hospitals
USA
Numerous financial and economic payer variables
No assessment of quality / safety infrastructure
No assessment of organizational infrastructure
SCTL: Not assessed
Not relevant Each increase in one RN FTE per 1,000 patient days was associated with a 4.3% decrease in mortality
None mentioned
None mentioned
High
Schilling et al., 20106
Not a study of an intervention
Retrospective cohort
166,920 adults admitted to Michigan hospitals in 2003 - 2006 with an emergency department admission for any of 4 diagnosis
None 39 Michigan hospitals
USA
Nurse staffing estimated by taking the ratio of each hospital’s FTE for RN and dividing by patient-days
No assessment of existing quality / safety infrastructure
No assessment of organizational infrastructure
SCTL: Not assessed
Not relevant, not a study of an intervention
Each additional RN FTA per patient-day was associated with a 0.25% decrease in mortality
None mentioned
None mentioned
High
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Author, Year Description of PSP
Multi-component
Study Design
Sample Size
Theory or Logic Model
Contexts Implementation Details
Outcomes: Benefits Outcomes: Harms
Influence of Contexts on Outcomes*
Overall Risk of Bias
Aiken et al., 20087
Not a study of an intervention
Retrospective cross-sectional
10,184 nurses (50% random sample, response rate 52%) and 232,342 surgical patients
None 168 acute care hospitals in Pennsylvania 1998-1999
USA
RN staffing – mean patients per nurse, Nurse education , A composite score of the care environment, encompassing subscales from the Nursing Work Index
Academic status assessed
No assessment of existing quality safety infrastructure
High vs. low technology assessed
SCTL:Practice Environment Scale (PES) of the Nursing Work Index (NWI) gets at a related concept.
Not relevant, not a study of an intervention
30-day mortality rate for general surgical patients reported as 19.5 per 1,000 admissions (1.95%).
30-day-failure-to-resuce rate reported as 84.4 patients per 1,000 admissions (8.4%).
More nurse staffing and higher nurse education levels were found to be associated with lower 30 day mortality and lower 30-day failure-to-rescue.
None mentioned
Better care environments were found to be associated with lower 30 day mortality and lower 30-day failure-to-rescue.
High
Cho et al., 20088
Not a study of an intervention
Retrospective cross-sectional
27,372 ICU patients
None 236 hospitals
Korea
Mean years of ICU nurse experience, RN staffing
SCTL:Non- US/UK/Canada/Australia/New Zealand study
Not relevant, not a study of an intervention
Each additional assigned patient per RN in secondary hospitals was associated with a 9% increase in odds of dying; there was no statistically significant association of nursing experience with mortality.
None mentioned
None mentioned
High
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Author, Year Description of PSP
Multi-component
Study Design
Sample Size
Theory or Logic Model
Contexts Implementation Details
Outcomes: Benefits Outcomes: Harms
Influence of Contexts on Outcomes*
Overall Risk of Bias
Kiekkas et al., 20089
Not a study of an intervention
Observational prospective cross-sectional
Convenience sampling of 396 patients
None A general tertiary 14-bed academic hospital between October 2005 and September 2006
Greece
Daily nursing workload/ workload exposure
SCTL:Non- US/UK/Canada/Australia/New Zealand study
Not relevant, not a study of an intervention
No statistically significant associations were found in risk-adjusted ICU mortality.
None mentioned
None mentioned
High
Hamilton et al., 200710
Not a study of an intervention
Prospective cohort
2,636 low birth weight or preterm infants
None 54 neonatal ICUs.
UK
Total number of RNs per shift, Nursing provision ratio per shift, Specialist nursing provision ratio per shift
Academic status not reported
No assessment of existing quality / safety infrastructure
No assessment of organizational complexity
SCTL:Not assessed
Not relevant, not a study of an intervention
Higher specialist nursing provision was statistically significantly associated with a lower risk-adjusted observed mortality rate.
None mentioned
None mentioned
High
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Author, Year Description of PSP
Multi-component
Study Design
Sample Size
Theory or Logic Model
Contexts Implementation Details
Outcomes: Benefits Outcomes: Harms
Influence of Contexts on Outcomes*
Overall Risk of Bias
Mark et al., 200711
Not a study of an intervention
Retrospective cross-sectional
3.65 million pediatric patient discharges
None 286 general acute care and children’s hospitals in California between 1996 and 2001.
USA
RN staffing, Licensed vocational nurse (LVN) staffing, Unlicensed hours of care provided per patient day
Academic status assessed
No assessment of existing quality/safety infrastructure
Presence of pediatric ICU or NICU
SCTL:Not assessed
Not relevant, not a study of an intervention
No relationship was found between in-hospital pediatric death and nurse staffing for hospitalized California pediatric patients.
None mentioned
None mentioned
High
Rafferty et al., 200712
Not a study of an intervention
Retrospective cross-sectional
118,752 surgical patients and 3,984 nurses (mostly RNs) (response rate = 49.4%)
None 30 acute trusts in 1998.
UK
Mean hospital patient-nurse ratio derived from survey of nurses
Academic status assessed
No assessment of existing quality/safety infrastructure
No assessment of organizational infrastructure
SCTL:Not assessed
Not relevant, not a study of an intervention
The highest quartile of patient-to-nurse ratios was associated with a 26% higher mortality rate and 29% higher failure-to-rescue rate than the lowest quartile of patient-to-nurse ratios.
None mentioned
None mentioned
High
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Author, Year Description of PSP
Multi-component
Study Design
Sample Size
Theory or Logic Model
Contexts Implementation Details
Outcomes: Benefits Outcomes: Harms
Influence of Contexts on Outcomes*
Overall Risk of Bias
Stone et al., 200713
Not a study of an intervention
Retrospective cross-sectional
Convenience sample of 15,846 ICU patients and 1, 095 RN were surveyed (average response rate = 60%)
A conceptual framework was presented that related the potential contributions of patient characteristic, structures of care, and administrative processes including organizational climate, staffing, overtime and wages on patient outcomes.
51 ICUs in 31 acute care hospitals.
USA
Nursing staffing measured by RN hours per patient day in the ICU, Overtime use measured as proportion of overtime to regular hours, Organizational climate in ICU measured as composite score of Perception of Nurse Work Environment (Choi et al., 2004).
Academic status assessed
Financial status assessed
No assessment of existing quality/safety infrastructure
No assessment of organizational infrastructure
SCTL:Organizational climate assessed with the perceptions of Nurse Work Environment
Not relevant, not a study of an intervention
Patients admitted to ICUs with more RN hours per patient day had significantly lower 30-day mortality.
No significant relationship was observed between overtime use and 30-day mortality.
An increase in catheter-associated bloodstream infections in organization with a more positive organizational climate
No significant relationship was observed between organizational climate and 30-day mortality.
High
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Author, Year Description of PSP
Multi-component
Study Design
Sample Size
Theory or Logic Model
Contexts Implementation Details
Outcomes: Benefits Outcomes: Harms
Influence of Contexts on Outcomes*
Overall Risk of Bias
Tourangeau, Doran, et al., 200614
Not a study of an intervention
Retrospective cross-sectional
49,993 patients with four diagnoses: acute myocardial infarction, stroke, pneumonia, or septicemia and 3,886 nurses (response rate = 65%)
A conceptual framework was presented that included numerous variables in six categories: condition of the hospital practice environment, nurse staffing, physician expertise, nurse and nurse employment characteristic, care management processes (use of care maps/protocols), and hospital type/location on 30-day mortality.
75 Ontario teaching and community acute care hospitals in 2002-2003.
Canada
Nursing staff mix, Nursing staff dose, Percentage of full time nursing staff, Years experience on unit, Percentage of nurses with baccalaureate or higher, Overall health nurse level, Hours of missed work in preceding 3 months, Quality of nurse-physician relationships, Nurse-rated manager ability and support, Nurse-rated adequacy of staffing and resources, Amount of teamwork, Overall nurse job satisfaction, Nurse-reported quality of care, Nurse burnout.
Amount of professional role support available for nursing staff.
Frequency of use of care maps/protocols to guide patient care (one nurse survey item with 5-point frequency response options).
SCTL:Teamwork, nurse burnout, nurse-physician relationship all explicitly measured via nurse survey
Not relevant, not a study of an intervention
Lower 30-day mortality rates found to be associated with: higher proportion of registered nursing staff, higher proportion of baccalaureate-educated nurses, lower total dose of all categories of nursing staff, higher nurse-reported adequacy of staffing and resources, higher use of care maps/protocols, higher nurse-reported quality of care, lower nurse-reported manager ability and support, and higher nurse burnout
None mentioned
Teamwork and physician relationship were not associated with differences in mortality, but higher nurse burnout was associated with lower 30-day mortality.
High
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Author, Year Description of PSP
Multi-component
Study Design
Sample Size
Theory or Logic Model
Contexts Implementation Details
Outcomes: Benefits Outcomes: Harms
Influence of Contexts on Outcomes*
Overall Risk of Bias
Estabrooks et al., 200515
Not a study of an intervention
Retrospective cross-sectional
18,142 patients with an acute medical diagnosis of acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, pneumonia, or stroke
4,799 nurses working (response rate = 52.8%)
None 49 Alberta acute care hospitals during fiscal year 1998-1999.
Canada
Nurse: education level, Skill mix, employment status, Nurse-reported autonomy, job satisfaction, perception of staffing adequacy, perception of unmet patient needs, Amount of non-nursing activities performed, support for float policy, Nurse-physician relationship, Frequency of emotional abuse experience.
Academic status assessed
No assessment of existing quality / safety infrastructure
“use of high technology”
SCTL:Nursing Work Index and Maslach Burnout Inventory assessed
Not relevant, not a study of an intervention
Four factors were found in a multivariable regression to be associated with lower 30-day mortality rates: a higher proportion of baccalaureate prepared nurses; a higher proportion of RNs in nursing staff mix; a higher proportion of permanent RNs; and a higher reported nurse-physician collaboration.
None mentioned
Nurse-physician collaboration was associated with lower 30 day mortality rates.
High
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Author, Year Description of PSP
Multi-component
Study Design
Sample Size
Theory or Logic Model
Contexts Implementation Details
Outcomes: Benefits Outcomes: Harms
Influence of Contexts on Outcomes*
Overall Risk of Bias
Halm et al., 200516
Not a study of an intervention
Retrospective cross-sectional
2,709 general-surgical patients and 140 staff RNs
None One large Midwestern acute care hospital.
USA
RN staffing
Academic status not reported
No assessment of existing quality / safety infrastructure
No assessment of organizational complexity
SCTL:Maslach Burnout Inventory assessed
Not relevant, not a study of an intervention
Nurse staffing was not statistically significantly associated with 30-day mortality or inpatient failure-to-rescue.
None mentioned
None mentioned
High
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Author, Year Description of PSP
Multi-component
Study Design
Sample Size
Theory or Logic Model
Contexts Implementation Details
Outcomes: Benefits Outcomes: Harms
Influence of Contexts on Outcomes*
Overall Risk of Bias
Person et al., 200417
Not a study of an intervention
Retrospective cross-sectional
118,940 acute myocardial infarction (AMI) patients
None 4,401 acute care hospitals in 1994 – 1995.
USA
Ratio of full-time equivalent RNs to average daily census, Ratio of full-time equivalent licensed practical and vocational nurses per average daily census, Part-time nursing staff estimated as 0.5 full-time equivalent.
Academic status assessed
No assessment of existing quality / safety infrastructure
Types of cardiac services offeredSCTL:Not assessed
Not relevant, not a study of an intervention
Lower in-hospital mortality rates were associated with higher RN staffing in hospitals.
Higher in-hospital mortality rates were associated with higher licensed vocational/practical staffing in hospitals.
None mentioned
None mentioned
High
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Author, Year Description of PSP
Multi-component
Study Design
Sample Size
Theory or Logic Model
Contexts Implementation Details
Outcomes: Benefits Outcomes: Harms
Influence of Contexts on Outcomes*
Overall Risk of Bias
Aiken et al., 200318
Not a study of an intervention
Retrospective cross-sectional
10,184 nurses (50% random sample, response rate 52%) and 232,342 surgical patients
None 168 acute care hospitals in Pennsylvania 1998-1999
USA
Registered nurse education level, Nursing workload, Mean years of nurse experience
Academic status assessed
No assessment of existing quality or safety
High vs. low technology assessed
SCTL:Not assessed
Not relevant, not a study of an intervention
A higher proportion of baccalaureate educated nurses and lower nursing workload were associated with a lower risk-adjusted mortality and failure to rescue rates.
None mentioned
None mentioned
High
Sasichay-Akkadechanunt et al., 200319
Not a study of an intervention
Retrospective cross-sectional
2,531 medical-surgical patients with principal diagnoses in following groups: disease of the heart, malignant neoplasms, hypertension, cerebrovascular diseases, and pneumonia/other lung diseases.
None 17 inpatient units in one university hospital
Thailand
Ratio of total nursing staff to patients, Proportion of RN to total nursing staff, Mean years RN experience, Percentage of baccalaureate-educated nurses.
SCTL:Non- US/UK/Canada/ Australia/New Zealand study
Not relevant, not a study of an intervention
A higher nurse-patient ratio was significantly associated with lower inpatient unit mortality rates.
None mentioned
None mentioned
High
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Author, Year Description of PSP
Multi-component
Study Design
Sample Size
Theory or Logic Model
Contexts Implementation Details
Outcomes: Benefits Outcomes: Harms
Influence of Contexts on Outcomes*
Overall Risk of Bias
Aiken et al., 200220
Not a study of an intervention
Retrospective cross-sectional
10,184 nurses (50% random sample, response rate 52%) and 232,342 surgical patients
None 168 acute care hospitals in Pennsylvania 1998-1999
USA
RN staffing
Academic status assessed
No assessment of existing quality or safety
High vs. low technology assessed
SCTL:Not assessed
Not relevant, not a study of an intervention
Higher patient-to-nurse ratio found to be associated with higher 30-day mortality (p < .001). Odds of patient death increased by 7% for every additional patient in nurse workload.
None mentioned
None mentioned
High
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Author, Year Description of PSP
Multi-component
Study Design
Sample Size
Theory or Logic Model
Contexts Implementation Details
Outcomes: Benefits Outcomes: Harms
Influence of Contexts on Outcomes*
Overall Risk of Bias
Needleman et al., 200221
Not a study of an intervention
Retrospective cross-sectional
5,075,969 medical patient discharges and 1,104,659 surgical patient discharges
None 799 hospitals in 11 states from 1997 and 1998 fiscal years
USA
Eight nurse staffing indicators were assessed: Number of RN hours of nursing care per patient day, Number of licensed practical nurse hours per patient day, Number of aid hours of care per patient day, Total hours of nursing care per patient day, Proportion of RN hours of all hours of nursing care, Proportion of licensed practical nurse hours of all hours of nursing care, Number of hours of care provided by licensed nurses (RN + practical nurse) per patient day, RN hours as a proportion of licensed nurse hours.
Acute care hospitals
Academic status assessed
No assessment of existing quality / safety infrastructure
No assessment of organizational complexity
SCTL:Not assessed
Not relevant, not a study of an intervention
No statistically significant relationships were found between in-hospital mortality rates and nurse staffing indicators.
Two statistically significant relationships were found between lower hospital failure-to-rescue rates and nurse staffing:
For medical patients, a higher proportion of hours of care provided by RNs.
For surgical patients, a greater number of hours of care provided by RNs.
None mentioned
None mentioned
High
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Author, Year Description of PSP
Multi-component
Study Design
Sample Size
Theory or Logic Model
Contexts Implementation Details
Outcomes: Benefits Outcomes: Harms
Influence of Contexts on Outcomes*
Overall Risk of Bias
Tourangeau et al., 200222
Not a study of an intervention
Retrospective cross-sectional
49,993 patients with four diagnoses: acute myocardial infarction, stroke, pneumonia, or septicemia and 3,988 RNs (response rate = 57%)
A conceptual framework was presented that included eight domains: nurse staffing, nurse skill mix, professional role support, nurse characteristic, nurse practice environment condition, continuity of registered nurse care provider, and other determinants on 30-day mortality.
75 Ontario teaching and community acute care hospitals in 1998-1999.
Canada
Academic status assessed
No assessment of existing quality / safety infrastructure
No assessment of organizational complexities
SCTL:Canadian Practice Environment Index assessed (drawn from the Nursing Work Index NWI-R)
Not relevant, not a study of an intervention
Lower 30-day mortality was found to be significantly associated with: higher proportions of RN staffing, more years if nurse experience on the clinical unit, and higher number of shifts missed by nurses in the preceding 3 months
None mentioned
Condition of nursing practice environment was not associated with lower 30-day mortality.
High
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Author, Year Description of PSP
Multi-component
Study Design
Sample Size
Theory or Logic Model
Contexts Implementation Details
Outcomes: Benefits Outcomes: Harms
Influence of Contexts on Outcomes*
Overall Risk of Bias
Tarnow-Mordi et al., 200023
Not a study of an intervention
Retrospective cross-sectional
1,050 patient episodes
None One medical-surgical ICU in Scottish acute care hospital between 1992 and 1995.
UK
Average and peak values of nursing requirements per ICU shift were calculated for each patient’s day of stay in the ICU.
Academic status not reported
No assessment of existing quality / safety infrastructure
No assessment of organizational complexities
SCTL:Not assessed
Not relevant, not a study of an intervention
Higher hospital mortality was significantly associated with patients’ exposure to high versus moderate overall ICU workload.
None mentioned
None mentioned
High
Abbreviations: CI = confidence interval; FTR = failure-to-rescue; ICU = intensive care unit; OR = odds ratio; SCTL = Safety/Culture/Teamwork/Leadership*Since there are no interventional studies in this section, we used this column to report results of context variables other than nurse staffing or workload as a modifier of the effect of nurse staffing on patient outcome.
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Patient Safety in Hospitals New Variable and Longitudinal Approaches. Nursing Research. 2012 Jan-Feb;61(1):3-12. PMID WOS:000298158000002.
2. Needleman J, Buerhaus P, Pankratz VS, et al. Nurse Staffing and Inpatient Hospital Mortality. New England Journal of Medicine. 2011 Mar;364(11):1037-45. PMID WOS:000288439000009.
3. Twigg D, Duffield C, Bremner A, et al. The impact of the nursing hours per patient day (NHPPD) staffing method on patient outcomes: A retrospective analysis of patient and staffing data. International Journal of Nursing Studies. 2011 May;48(5):540-8. PMID WOS:000291713900003.
4. Aiken LH, Sloane DM, Cimiotti JP, et al. Implications of the California Nurse Staffing Mandate for Other States. Health Services Research. 2010 Aug;45(4):904-21. PMID WOS:000279734400002.
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6. Schilling PL, Campbell DA, Englesbe MJ, et al. A Comparison of In-hospital Mortality Risk Conferred by High Hospital Occupancy, Differences in Nurse Staffing Levels, Weekend Admission, and Seasonal Influenza. Medical Care. 2010 Mar;48(3):224-32. PMID WOS:000275198200006.
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