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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


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


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






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


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



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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Multi-component

Study Design

Sample Size






Harless and Mark, 20105


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


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



SCTL: Not assessed


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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Multi-component

Study Design

Sample Size






Aiken et al., 20087


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


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.


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



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


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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Multi-component

Study Design

Sample Size






Kiekkas et al., 20089


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


No statistically significant associations were found in risk-adjusted ICU mortality.

None mentioned

None mentioned

High

Hamilton et al., 200710


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




SCTL:Not assessed


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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Multi-component

Study Design

Sample Size






Mark et al., 200711



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


No assessment of existing quality/safety infrastructure

Presence of pediatric ICU or NICU

SCTL:Not assessed


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



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




SCTL:Not assessed


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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Multi-component

Study Design

Sample Size






Stone et al., 200713



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).


Financial status assessed



SCTL:Organizational climate assessed with the perceptions of Nurse Work Environment


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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Multi-component

Study Design

Sample Size






Tourangeau, Doran, et al., 200614



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


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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Multi-component

Study Design

Sample Size






Estabrooks et al., 200515



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.



“use of high technology”

SCTL:Nursing Work Index and Maslach Burnout Inventory assessed


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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Multi-component

Study Design

Sample Size






Halm et al., 200516



2,709 general-surgical patients and 140 staff RNs

None One large Midwestern acute care hospital.

USA

RN staffing




SCTL:Maslach Burnout Inventory assessed


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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Multi-component

Study Design

Sample Size






Person et al., 200417



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.



Types of cardiac services offeredSCTL:Not assessed


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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Multi-component

Study Design

Sample Size






Aiken et al., 200318





USA

Registered nurse education level, Nursing workload, Mean years of nurse experience


No assessment of existing quality or safety


SCTL:Not assessed


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



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


A higher nurse-patient ratio was significantly associated with lower inpatient unit mortality rates.

None mentioned

None mentioned

High

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Multi-component

Study Design

Sample Size






Aiken et al., 200220





USA

RN staffing


No assessment of existing quality or safety


SCTL:Not assessed


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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Multi-component

Study Design

Sample Size






Needleman et al., 200221



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




SCTL:Not assessed


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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Multi-component

Study Design

Sample Size






Tourangeau et al., 200222



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



No assessment of organizational complexities

SCTL:Canadian Practice Environment Index assessed (drawn from the Nursing Work Index NWI-R)


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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Multi-component

Study Design

Sample Size






Tarnow-Mordi et al., 200023



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.



No assessment of organizational complexities

SCTL:Not assessed


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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References1. Unruh LY, Zhang NJ. Nurse Staffing and

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.

5. Harless DW, Mark BA. Nurse Staffing and Quality of Care With Direct Measurement of Inpatient Staffing. Medical Care. 2010 Jul;48(7):659-63. PMID WOS:000279428200014.

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.

7. Aiken LH, Clarke SP, Sloane DM. Effects of hospital care environment on patient mortality and nurse outcomes. Journal of Nursing Administration. 2008 May;38(5):223-9. PMID WOS:000255996100012.

8. Cho SH, Hwang JH, Kim J. Nurse staffing and patient mortality in intensive care units. Nursing Research. 2008 Sep-Oct;57(5):322-30. PMID WOS:000259472200004.9. Kiekkas P, Sakellaropoulos GC, Brokalaki H, et al. Association between nursing workload and mortality of intensive care unit patients. J Nurs Scholarsh. 2008;40(4):385-90. PMID 19094155.

10. Hamilton KE, Redshaw ME, Tarnow-Mordi W. Nurse staffing in relation to risk-adjusted mortality in neonatal care. Arch Dis Child Fetal Neonatal Ed. 2007 Mar;92(2):F99-F103. PMID 17088341.

11. Mark BA, Harless DW, Berman WF. Nurse staffing and adverse events in hospitalized children. Policy Polit Nurs Pract. 2007 May;8(2):83-92. PMID 17652626.

12. Rafferty AM, Clarke SP, Coles J, et al. Outcomes of variation in hospital nurse staffing in English hospitals: cross-sectional analysis of survey data and discharge records. Int J Nurs Stud. 2007 Feb;44(2):175-82. PMID 17064706.

13. Stone PW, Mooney-Kane C, Larson EL, et al. Nurse working conditions and patient safety outcomes. Med Care. 2007 Jun;45(6):571-8. PMID 17515785.

14. Tourangeau AE, Doran DM, Hall LM, et al. Impact of hospital nursing care on 30-day mortality for acute medical patients. Journal of Advanced Nursing. 2006 Jan;57(1):32-44. PMID WOS:000243297400003.

15. Estabrooks CA, Midodzi WK, Cummings GG, et al. The impact of hospital nursing characteristics on 30-day mortality. Nurs Res. 2005 Mar-Apr;54(2):74-84. PMID 15778649.

16. Halm M, Peterson M, Kandels M, et al. Hospital nurse staffing and patient mortality, emotional exhaustion, and job dissatisfaction. Clin Nurse Spec. 2005 Sep-Oct;19(5):241-51; quiz 52-4. PMID 16179855.

17. Person SD, Allison JJ, Kiefe CI, et al. Nurse staffing and mortality for Medicare patients with acute myocardial infarction. Med Care. 2004 Jan;42(1):4-12. PMID 14713734.

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18. Aiken LH, Clarke SP, Cheung RB, et al. Educational levels of hospital nurses and surgical patient mortality. JAMA. 2003 Sep 24;290(12):1617-23. PMID 14506121.

19. Sasichay-Akkadechanunt T, Scalzi CC, Jawad AF. The relationship between nurse staffing and patient outcomes. J Nurs Adm. 2003 Sep;33(9):478-85. PMID 14501564.

20. Aiken LH, Clarke SP, Sloane DM, et al. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002 Oct 23-30;288(16):1987-93. PMID 12387650.

21. Needleman J, Buerhaus P, Mattke S, et al. Nurse-staffing levels and the quality of care in hospitals. N Engl J Med. 2002 May 30;346(22):1715-22. PMID 12037152.

22. Tourangeau AE, Giovannetti P, Tu JV, et al. Nursing-related determinants of 30-day mortality for hospitalized patients. Can J Nurs Res. 2002 Mar;33(4):71-88. PMID 11998198.

23. Tarnow-Mordi WO, Hau C, Warden A, et al. Hospital mortality in relation to staff workload: a 4-year study in an adult intensive-care unit. Lancet. 2000 Jul 15;356(9225):185-9. PMID 10963195.

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