Assessing the impacts of nurse staffing and work schedules on nurse turnover: A systematic review.

AIM: This study aimed to investigate and synthesize the impacts of nurse staffing and work schedules on nurse turnover in acute hospitals. BACKGROUND: The retention of nurses during the COVID-19 pandemic was critical due to the increased demand for nurses. Among the multifaceted factors contributing to nurse turnover, it is worth examining nurse staffing and work schedules while considering policy intervention. METHODS: The findings of this systematic literature review were reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Using eight databases, including CINAHL and PubMed, research articles published from January 2000 until June 2021 were reviewed. The inclusion criteria were original peer-reviewed research, nonexperimental studies published in English or Korean languages, and studies examining the impacts of nurse staffing and work schedules on nurses' actual turnover. RESULTS: Fourteen articles were reviewed. Among them, 12 studies investigated the relationship between nurse staffing and turnover, and four examined the impact of work schedules on nurse turnover. Nurse staffing levels are strongly related to nurse turnover in the expected direction. However, few studies have found that work schedules are significantly related to nurse turnover. CONCLUSION: Inadequate and unsafe nurse staffing leads to increased nurse turnover rates. More studies are needed to investigate the impacts of work schedules on nurse turnover. IMPLICATIONS FOR NURSING, HEALTH, AND SOCIAL POLICY: Several states in the United States have adopted the nurse staffing policy during the COVID-19 pandemic. More hospitals and the government should adopt and implement policies to regulate nurse staffing, reduce nurse turnover, and increase retention. Policy intervention in nurse work schedules should also be considered to prevent nurse turnover.

Comprehensive assessment of factors contributing to the actual turnover of newly licensed registered nurses working in acute care hospitals: a systematic review.

BACKGROUND: During the COVID-19 pandemic, the demand for nursing care increased, making the retention of nurses even more important. Among staff nurses, it is reported that the turnover rate of newly licensed registered nurses is higher. However, no systematic reviews have focused on the factors that influence newly licensed registered nurses' turnover. Additionally, because newly licensed registered nurses are a major source of the supply of nurses, it is critical to retain them to meet patient needs. Therefore, this study aimed to systematically synthesize the factors contributing to the actual turnover of newly licensed registered nurses working in acute care hospitals. METHODS: CINAHL, Cochrane Library, DBpia, EBSCO, PubMed, PsycINFO, RISS, and Web of Science were searched for studies published between January 2000 and June 2021. This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: Ten articles from 9029 were included in this review. All studies used a longitudinal design. The annual turnover rates of newly licensed registered nurses ranged from 12 to 25%. Health status, including sleep and healthy lifestyles, were significant factors affecting turnover. Most studies focused on work environment factors, and emotional exhaustion, job satisfaction, peer support, and intent to leave, were significantly associated with newly licensed registered nurses' turnover. Small hospitals located in nonmetropolitan areas were at risk of high turnover of newly licensed registered nurses. CONCLUSIONS: Turnover is inevitable in the process of employment, but high turnover can be prevented. Through reviewing ten articles, significant contributing factors for newly licensed registered nurses' turnover included personal factors of health status; work environment factors of physical exhaustion, emotional exhaustion, depersonalization, occupational injuries, income, intent to stay, job satisfaction, and peer support; and hospital factors of hospital size, location, and unionization. Most existing studies focus on work environment factors, which reflects the significance of fostering healthy work conditions to prevent high turnover. These findings can be used to develop strategies and policies for work environment to reduce high turnover of newly licensed registered nurses, and support high-risk groups, such as small hospitals located in nonmetropolitan areas with high levels of nurses' turnover.

Noneconomic and economic impacts of nurse turnover in hospitals: A systematic review.

AIM: To examine and synthesize the noneconomic and economic impacts of nurse turnover in acute hospitals. BACKGROUND: Nurse turnover occurs when nurses leave their jobs or the profession and is a major concern for the healthcare industry. Many studies have investigated the determinants of nurse turnover. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist was utilized in the current review. Article search was conducted in June 2021. Research articles published since January 2000 were included. Eight databases (e.g., CINAHL, PubMed, PsycINFO, and Web of Science) were used. The following eligibility criteria were applied for inclusion: Articles that (1) were nonexperimental quantitative studies, (2) examined the impact of actual nurse turnover in acute hospitals, (3) were a peer-reviewed original research article, and (4) were written in English or Korean. RESULTS: Among 9,041 searched articles, 16 were included in the review. Seven studies investigated the association of nurse turnover with processes and outcomes (workgroup processes, nurse staffing, nurse outcomes, and patient outcomes), and partially supported the negative impact of turnover. Nine studies found that nurse turnover is very costly. CONCLUSION: Most studies investigated the turnover cost, which is costly. The negative noneconomic impact of nurse turnover was partially supported. IMPLICATIONS FOR NURSING PRACTICE AND NURSING POLICY: To prevent the adverse noneconomic and economic impacts of nurse turnover and retain nurses, healthcare organizations, nurse managers, and hospital staff nurses need to develop and implement prevention strategies and policies to address nurse turnover. Efforts to address nurse turnover can increase hospital competency to improve the quality of nursing care services and patient safety.

Work hours and overtime of nurses working in Cambodian hospitals.

AIM: To examine the nature and prevalence of Cambodian nurses' work hours and overtime and related factors BACKGROUND: The chronic shortage of nursing workforce is a major cause of overtime among nurses. INTRODUCTION: Nursing shortage and working overtime among nurses negatively affect nurse and patient outcomes, but nurses' work hours and overtime in Cambodia have not been comprehensively examined. METHODS: A multicenter cross-sectional study was conducted in four Cambodian hospitals. Data were collected from 253 nurses providing direct nursing care using a questionnaire. The STROBE checklist was used for reporting this study. RESULTS: More than a fifth of staff nurses worked more than 48 h, which is the legal work hour limit in Cambodia. Two major reasons for working mandatory or voluntary overtime, on-call or 24-h on-call were (a) not wanting to let down colleagues and (b) able to get all work done. The number of patients cared for was related to whether or not nurses worked 48 h or more. CONCLUSION: Overtime work and adverse nurse scheduling are common in Cambodia. IMPLICATIONS FOR NURSING AND HEALTH POLICY: Nurse managers and healthcare institutes in Cambodia need to monitor Cambodian nurses' work hours, which are often beyond the legal work hour limit. Moreover, it is important to understand why nurses work overtime and develop health policies, strategies, and programs that can help promote patient and nurse safety and retain qualified nursing staff. The 24-h on-call practice needs to be regulated according to the labor policy in healthcare institutes to prevent adverse nurse and patient outcomes.

Relationships between comprehensive characteristics of nurse work schedules and adverse patient outcomes: A systematic literature review.

AIMS: To review the comprehensive characteristics of adverse nurse work schedules and to synthesise the evidence of their relationships with adverse patient outcomes. BACKGROUND: To manage nurse shortages and fluctuations in patient censuses, nurses often work overtime. This increases nurses' work hours and causes them to have fewer breaks. Such extended work schedules, long shift length, long weekly work hours and insufficient beaks can be considered as adverse nurse work schedules. Understanding how these adverse nurse work schedules affect patient outcomes is important to ensure patient safety. DESIGN: A systematic review of nursing and healthcare literature was conducted in this study. METHODS: Eight electronic bibliographic databases (CINAHL, Cochrane Library, DBpia, EBSCO, PubMed, PsycINFO, RISS and Web of Science) were used to search research articles published from 2000 to 2019. The study selection process followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). RESULTS: From the search, 2,366 articles were identified, 22 of which were included in this review. Working more than 12 hours in a day had an adverse effect on patient outcomes, as was working more than 40 hours per week. There were mixed findings in the relationship between nurse overtime and adverse patient outcomes. CONCLUSIONS: This study found a conclusive relationship between excessive nurse work hours and adverse patient outcomes. This review highlights the importance of managing adverse nurse schedules such as long daily and weekly work hours to improve patient safety and prevent adverse patient outcomes. RELEVANCE TO CLINICAL PRACTICE: Study findings support the importance of monitoring and regulating nurse work schedules and adverse scheduling practices to improve nurse well-being and health and to prevent adverse patient outcomes.

The association between health status and job satisfaction among female workers: A nationwide cross-sectional study.

The purpose of this study was to determine the job satisfaction among female workers in Korea and the association between health status and job satisfaction. The Korean Longitudinal Survey of Women and Families was used for this nationwide cross-sectional study. Data from 1570 female workers were analyzed to determine job satisfaction and examine the association between health status and job satisfaction, controlling for other variables such as personal characteristics, work attributes, job opportunities, and work conditions. Analyses included descriptive statistics, independent t-tests, ANOVA, Pearson's correlation, and multivariate regression. Subjective health status was positively related, while diagnosed disease and depressive symptoms were negatively associated with job satisfaction. Monthly salary, work hours, fringe benefits, and geographical region were also significantly related to female workers' job satisfaction, and commute distance was related to job satisfaction with a small effect size. This study thus found that subjective health status, diagnosed disease, and depressive symptoms were related to female workers' job satisfaction. Health promotion and supporting mental health among female workers may be important managerial strategies for supporting increased job satisfaction in female workers.

Predictors of actual turnover among nurses working in Korean hospitals: A nationwide longitudinal survey study.

AIM: To examine the factors affecting actual turnover among nurses working in hospitals using the Brewer-Kovner synthesis model. BACKGROUND: To increase retention of nurses, it is important to understand factors contributing to actual turnover among nurses. METHODS: A longitudinal study design was utilized with 2,633 of 20,613 eligible female hospital nurses who participated in Korea Nurses' Health Study. We created two age groups: a younger group (20-35 years) and an older group (36-49 years). Multivariate logistic regression was used to identify the factors influencing turnover by age group. RESULTS: Pregnancy and childbirth increased young nurses' turnover. When we excluded intent to leave, depression and burnout were significant factors affecting young nurses' turnover. Salary and hospital size were factors predicting nurse turnover among nurses older than 36 years. CONCLUSIONS: It is essential to develop prevention strategies of female nurse turnover based on the age group in Korea. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers and health care institutes need to develop new managerial and policy strategies to reduce nurse turnover in each age group.

Intensive care nurse staffing and nurse outcomes: A systematic review.

BACKGROUND: Intensive care units (ICU) are associated with significant work stress and exert continuous physical and emotional demand upon health care providers. The health and well-being of care providers, including ICU nurses, is a matter of great concern. However, to the researcher's knowledge, there have been no reviews synthesizing the evidence about the relationship between nurse staffing and nurse outcomes in the ICU. PURPOSE: The purpose of this systematic review was to examine nurse staffing in the ICU and synthesize literature to examine the relationship with nurse outcomes such as job satisfaction, burnout, fatigue, and intent to leave. METHODS: This review was reported based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Peer-reviewed articles published between January 2000 and September 2019 were identified via eight electronic bibliographic databases. Articles were included and reviewed if they were correlational studies examining the relationships between nurse staffing and nurse outcomes in the ICU, and were published in peer-reviewed journals written in either English or Korean. The Quality Assessment and Validity Tool for Correlation Studies was used for quality appraisal. RESULTS: From 5086 articles, eight published between 2006 and 2019 were included in this review. Three studies found expected relationships between worse nurse staffing and adverse nurse outcomes (high burnout, fatigue state, emotional exhaustion, depersonalization, and stress). However, the relationships between nurse staffing and other adverse nurse outcomes were not significant. Perceived adequate staffing was negatively related to adverse nurse outcomes. However, a non-significant relationship also was found. CONCLUSION: This study found limited evidence on relationships between nurse staffing and nurse outcomes in the ICU. More studies are needed to conduct to find a conclusive relationship. RELEVANCE TO CLINICAL PRACTICE: Given high demands and workload in the ICU, nurse staffing levels should be closely monitored to prevent adverse nurse outcomes.

Impact of nurse staffing on intent to leave, job satisfaction, and occupational injuries in Korean hospitals: A cross-sectional study.

The purpose of this study was to examine nurse staffing in comprehensive nursing care units in Korea and examine the corresponding nurse outcomes, including intent to leave, job satisfaction, and occupational injuries. A total of 356 nurses working in comprehensive nursing care units at eight small-medium sized Korean hospitals participated in this cross-sectional study. In the day, evening, and night shifts, nurse staffing ranged from 9.00 to 24.82, 9.04 to 24.26, and 9.02 to 25.80, respectively. The nurse staffing on each shift did not have a significant impact on nurses' intent to leave, job satisfaction, and occupational injuries. However, workload had a strong relationship with intent to leave and job satisfaction. Voluntary overtime was related to occupational injuries. These findings demonstrate that workload is an important factor for intent to leave and job satisfaction among nurses working in comprehensive nursing care units. Improvements of the work environment, as well as rearrangement of nurse workload to account for patient acuity and nursing needs, are required for the future expansion of comprehensive nursing care services.

Nurse staffing and hospital-acquired conditions: A systematic review.

AIMS AND OBJECTIVES: To systematically review and synthesise primary studies on the relationship between nurse staffing and hospital-acquired conditions. BACKGROUND: Research examining the association between nurse staffing and hospital-acquired conditions is varied owing to the use of different definitions and methods. DESIGN: This study was conducted based on a systematic review of related nursing literature. METHODS: The CINAHL, Cochrane Library, DBpia, EBSCO, PubMed, PsycINFO and RISS databases were searched for either English or Korean language studies published between January 2000 and August 2018 that examined the association between nurse staffing and hospital-acquired conditions. We used Preferred Reporting Items for Systematic Reviews and Meta-Analyses check list. RESULTS: Totally, 19 published studies were included in the systematic review. Various measures were used to examine association between nurse staffing and hospital-acquired conditions. The majority of the reviewed studies revealed negative relationships between nurse staffing levels and hospital-acquired conditions. However, a substantial number of relationships were not significant. CONCLUSIONS: There is a need for future studies to examine the differences in the relationship between nurse staffing and hospital-acquired conditions and to use precise data collection on registered nurses' hours per patient day and total hours per patient day, as it is difficult to collect data on these measures. The findings of this study suggest that sufficient nurse staffing is a strong indicator of the provision of quality patient care. However, continuous efforts are recommended to find more conclusive relationships between nurse staffing and hospital-acquired conditions and to formulate guidelines regarding nurse staffing strategies. RELEVANCE TO CLINICAL PRACTICE: Nurse staffing is an important managerial strategy. Especially, given health policy changes, hospitals need to develop staffing strategies to prevent hospital-acquired conditions.

Nurse staffing and nurse outcomes: A systematic review and meta-analysis.

BACKGROUND: A great number of studies have been conducted to examine the relationship between nurse staffing and patient outcomes. However, none of the reviews have rigorously assessed the evidence about the effect of nurse staffing on nurse outcomes through meta-analysis. PURPOSE: The purpose of this review was to systematically assess empirical studies on the relationship between nurse staffing and nurse outcomes through meta-analysis. METHODS: Published peer-reviewed articles published between January 2000 and November 2016 were identified in CINAHL, PubMed, PsycINFO, Cochrane Library, EBSCO, RISS, and DBpia databases. FINDINGS: This meta-analysis showed that greater nurse-to-patient ratio was consistently associated with higher degree of burnout among nurses (odds ratio: 1.07; 95% confidence interval [CI]: 1.04-1.11), increased job dissatisfaction (odds ratio: 1.08; 95% CI: 1.04-1.11), and higher intent to leave (odds ratio: 1.05; 95% CI: 1.02-1.07). With respect to needlestick injury, the overall effect size was 1.33 without statistical significance. DISCUSSION: The study findings demonstrate that higher nurse-to-patient ratio is related to negative nurse outcomes. Future studies assessing the optimal nurse-to-patient ratio level in relation to nurse outcomes are needed to reduce adverse nurse outcomes and to help retain nursing staff in hospital settings.

CMS Nonpayment Policy, Quality Improvement, and Hospital-Acquired Conditions: An Integrative Review.

This integrative review synthesized evidence on the consequences of the Centers for Medicare & Medicaid Services (CMS) nonpayment policy on quality improvement initiatives and hospital-acquired conditions. Fourteen articles were included. This review presents strong evidence that the CMS policy has spurred quality improvement initiatives; however, the relationships between the CMS policy and hospital-acquired conditions are inconclusive. In future research, a comprehensive model of implementation of the CMS nonpayment policy would help us understand the effectiveness of this policy.

Nursing teams: behind the charts.

AIMS: To examine the nature and characteristics of both received and provided mutual support in a social network within an acute care hospital unit. BACKGROUND: Current evidence regarding the social network in the health care workforce reveals the nature of social ties. Most studies of social network-related support that measured the characteristics of social support used self-reported perception from workers receiving support. There is a gap in studies that focus on back-up behaviour. METHODS: The evaluation included a social network analysis of a nursing unit employing 54 staff members. A 12 item electronic survey was administered. Descriptive statistics were calculated using the Statistical Package for the Social Sciences. Social network analyses were carried out using ucinet, r 3.2.3 and gephi. RESULTS: Based on the study findings, as providers of mutual support the nursing staff claimed to give their peers more help than these peers gave them credit for. Those who worked overtime provided more mutual support. CONCLUSION: Mutual support is a key teamwork characteristic, essential to quality and safety in hospital nursing teams that can be evaluated using social network analysis. IMPLICATIONS FOR NURSING MANAGEMENT: Because of a discrepancy regarding receiving and providing help, examining both receiver and provider networks is a superior approach to understanding mutual support.

Do Clinician Disruptive Behaviors Make an Unsafe Environment for Patients?

The magnitude of negative consequences of clinician disruptive behaviors on patients and clinicians was examined using data collected from 1559 clinicians working at an urban academic medical center in the United States. For the impact of disruptive behavior on patient safety, psychological aggression as caused by disruptive behavior or incivility increased the likelihood of patient harm as well as job dissatisfaction and physical symptoms.

The Centers for Medicare & Medicaid Services Reimbursement Policy and Nursing-Sensitive Adverse Patient Outcomes.

The Centers for Medicare & Medicaid Services (CMS) reimbursement policy identified 11 preventable adverse outcomes. Of these 11 patient outcomes, four (severe pressure ulcers, falls and trauma, catheter-associated urinary tract infections, and vascular catheter-associated infections) are considered nursing-sensitive quality outcomes that can be decreased with greater and better nursing care. A cross-sectional study examined the CMS reimbursement policy focusing on nursing-sensitive adverse patient outcomes. The percentage of Medicare patients served as a proxy for a measure of the CMS changes in reimbursement. The CMS reimbursement policy measured by the proxy variable was not related to a reduction of the four adverse outcomes.

Use of temporary nursing staff and nosocomial infections in intensive care units.

AIMS AND OBJECTIVES: To examine the nature and prevalence of the use of temporary nursing staff in intensive care units and relationships between the use of temporary nursing staff and the occurrence of nosocomial infections (central line-associated blood stream infections and ventilator-associated pneumonia). BACKGROUND: Hiring temporary nurses raises controversial issues with respect to nurse staffing, care processes and patient outcomes, yet empirical findings regarding the use of temporary nurses are mixed. Whether adverse patient outcomes in intensive care units are related to the use of temporary nursing staff remains unexamined. DESIGN: A retrospective longitudinal design was used. METHODS: Data were collected monthly from 12 intensive care units at six hospitals; 144 ICU-month data points were used for the analysis. Chi-square, anova and logit regression models were used to examine the research questions. RESULTS: The intensive care units used higher levels of temporary nursing staff, but the use of temporary nursing staff was not significantly associated with nosocomial infections. Nurses' perceptions regarding staffing and resource adequacy were significantly associated with nosocomial infections. CONCLUSIONS: No evidence was found to link the use of temporary nursing staff and nosocomial infections. Instead, nurses' perceptions of staffing adequacy were related to nosocomial infections. RELEVANCE TO CLINICAL PRACTICE: Given the greater use of temporary nursing staff in intensive care units, nurse managers in intensive care units need to monitor the levels of temporary nurse staffing and develop a systematic approach for hospitals to assist in these nurses' adjustment, which can reduce the burden of both temporary and permanent intensive care unit nurses. In addition to quantitative measures of nurse staffing, nurses' perceptions regarding staffing adequacy can be used to measure nurse staffing in relation to adverse patient outcomes.

Implementation of the Centers for Medicare & Medicaid Services' Nonpayment Policy for Preventable Hospital-Acquired Conditions in Rural and Nonrural US Hospitals.

Preventable adverse patient outcomes and hospital characteristics in rural versus nonrural US hospitals under the new Centers for Medicare & Medicaid Services reimbursement policy were examined using the American Hospital Association Annual Survey and Hospital Compare data. Under the new Centers for Medicare & Medicaid Services policy, rural hospitals tended to have fewer hospital-acquired conditions than nonrural hospitals except for patient falls. Case mix was consistently related to falls after controlling for hospital characteristics.

Health care provider social network analysis: A systematic review.

OBJECTIVES: Although considerable progress has been made in understanding networks, their structure, and their development, little has been known about their effectiveness in the health care setting and their contributions to quality of care and patient safety.The purpose of this study was to examine studies using social network analysis (SNA) in the health care workforce and assess factors contributing to social network and their relationships with care processes and patient outcomes. METHODS: We identified all published peer-reviewed SNA articles in CINAHL, PubMed, PsycINFO, JSTOR, Medline (OVID), and Web of Science databases up to April 2013. RESULTS: Twenty-nine published articles met the inclusion criteria. Current evidence of the health care workforce's social networks reveals the nature of social ties are related to personal characteristics, practice setting, and types of patients. A few studies also revealed the social network effects adoption and the use of a health information system, patient outcomes, and coordination. CONCLUSIONS: Current studies on the social ties of health care workforce professionals include several assessments of inefficiencies. The level of technical sophistication in these studies tended to be low. Future study using enhanced sophistication in study design, analysis, and patient outcome testing are warranted to fully leverage the potential of SNA in health care studies.

Analysis of nurse staffing and patient outcomes using comprehensive nurse staffing characteristics in acute care nursing units.

Associations between comprehensive nurse staffing characteristics and patient falls and pressure ulcers were examined using negative binomial regression modeling with hospital- and time-fixed effects. A convenience sample was collected from 35 nursing units in 3 hospitals. Rates of patient falls and injury falls were found to be greater with higher temporary registered nurse staffing levels but decreased with greater levels of licensed practical nursing care hours per patient day. Pressure ulcers were not related to any staffing characteristics.

Assessing the relationships between nurse work hours/overtime and nurse and patient outcomes: systematic literature review.

BACKGROUND: The effects of work hours/overtime on nurse and patient outcomes and specific components of work hours (per shift and per week) and overtime on these effects have not been systematically examined. PURPOSE: The purpose of this review was to systematically evaluate the effect of nurse overtime and long work hours on nurse and patient outcomes. METHODS: An online search of six electronic bibliographic databases was conducted for research published from 2000 to 2013. DISCUSSION: Twenty-one nurse outcome measures and 19 patient outcome measures were found in relationships with work hours and overtime. A total of 67 relationships to nurse outcomes and 41 relationships to patient outcomes were examined. CONCLUSIONS: The findings of this review suggested that evidence supporting positive relationships between working long hours and adverse outcomes to the nurses is strong. However, to make a conclusion of the positive relationship between long work hours and adverse patient outcomes, more evidence is needed.