Exploring the effects of emergency department crowding on emergency nurses.

Although the phenomenon of crowding in emergency departments (EDs) is not new, it remains a significant problem for patients, ED staff and the wider healthcare system. Crowding in EDs, which is also called overcrowding, has been widely explored in the literature, but there are relatively few studies of the subject from an emergency nurse perspective. This article reports the findings of a literature review that aimed to explore the effects of crowding on nurses working in EDs. Four key themes were identified from a synthesis of 16 articles included in the review: staffing and skill mix; inadequate care and the effect on nurses' well-being and stress levels; violence in the ED; and hospital metrics and patient flow. Further research is required to explore in more depth the effects of ED crowding on emergency nurses and to address the multiple factors that perpetuate the phenomenon.

Are we making the most of safe staffing research.

INTRODUCTION: The uptake of research evidence on staffing issues in nursing by nursing leadership, management and into organizational policies seems to vary across Europe. This study wants to assess this uptake of research evidence. DESIGN: Scoping survey. METHOD: The presidents of twelve country specific Sigma Chapters within the European Region answered written survey questions about work organisation, national staffing levels, national skill mix levels, staff characteristics, and education. RESULTS: Seven of the 12 chapters could not return complete data, reported that data was unavailable, there was no national policy or only guidance related to some settings. CONCLUSION: Enhancing the awareness of nursing research and of nursing leaders and managers regarding staffing level evidence is not enough. It seems necessary to encourage nurse leaders to lobby for staffing policies. CLINICAL RELEVANCE: Research evidence on staffing issues in nursing and how it benefits health care is available. In Europe this evidence should be used more to lobby for change in staffing policies.

Diverse perspectives on unit-level nurse staffing ratios in medical-surgical units: A Delphi policy analysis.

BACKGROUND: Appropriate staffing is essential to acute care delivery. Staffing ratio policy generates controversy. PURPOSE: This study examines perspectives on unit-level nurse-to-patient ratio policy in adult medical-surgical units. METHOD: Delphi methodology uses an invited diverse panel to analyze a policy's effects. Panelists completed iterative surveys about the impact they expect from unit-level ratio policy. FINDINGS: Panelists demonstrated moderate agreement that the proposed policy could increase staffing levels, decrease patient length of stay, and reduce nurse attrition. Other potential outcomes included reducing staffing in units above the minimum and increasing short-term costs. Panelists agreed that the policy could increase patient safety and nurse satisfaction and did not agree about the effect on long-term cost and innovation. Panelists also anticipated a mostly positive effect on patients and nurses. DISCUSSION: Policies that set unit-level nurse-to-patient ratios offer a potential strategy to improve medical-surgical staffing. Policy design should consider the range of expected outcomes.

Nursing notes on a scandal.

10 years on from the publication of the Francis report, the nursing profession is facing unprecedented challenges; Robert Francis has recently sounded the alarm that the NHS is currently facing 'the Mid Staffordshire scandal playing out on a national level'. In this perspective, we consider the opportunities missed in the last decade in the attempt to secure safe staffing in nursing.

Developing a model for quantifying staffing requirements in the post-anaesthesia care unit.

Nurse managers in charge of a post-anaesthesia care unit (PACU) face the task of optimising staffing levels and must be able to justify staffing needs to the wider operational team. The high variability in patient numbers and acuity that characterises the PACU, as well as the broader factors that affect patient flow to and from the PACU, make it challenging to quantify staffing requirements. Staffing models often fail to reflect accurately the needs of patients and therefore the needs of the unit and there is no recommended model for quantifying PACU staffing requirements. In this article, the author describes the challenges of quantifying PACU staffing requirements and the suitability of different types of data. The author also discusses factors to consider when developing model for quantifying PACU staffing requirements.

Managing missing and erroneous data in nurse staffing surveys.

BACKGROUND: Analysis can be problematic in research when data are missing or erroneous. Various methods are available for managing missing and erroneous data, but little is known about which are the best to use when conducting cross-sectional surveys of nurse staffing. AIM: To explore how missing and erroneous data were managed in a study that involved a cross-sectional survey of nurse staffing. DISCUSSION: The article describes a study that used a cross-sectional survey to estimate the ratio of registered nurses to patients, using self-reported data by nurses. It details the techniques used in the study to manage missing and erroneous data and presents the results of the survey before and after the treatment of missing data. CONCLUSION: Managing missing data effectively and reporting procedures transparently reduces the possibility of bias in a study's results and increases its reproducibility. Nurse researchers need to understand the methods available to handle missing and erroneous data. Surveys must contain unambiguous questions, as every participant should have the same understanding of a question's meaning. IMPLICATION FOR PRACTICE: Researchers should pilot surveys - even when using validated tools - to ensure participants interpret the questions as intended.

Improving hospital nurse staffing during the pandemic: Implementation of the 2019 Fund for Health Care Staff in Belgium.

Chronic hospital nurse understaffing is a pre-existing condition of the COVID-19 pandemic. With nurses on the frontline against the pandemic, safe nurse staffing in hospitals is high on the political agenda of the responsible ministers of Health. This paper presents a recent Belgian policy reform to improve nurse staffing levels. Although the reform was initiated before the pandemic, its roll-out took place from 2020 onwards. Through a substantial increase of the hospital budget, policy makers envisaged to improve patient-to-nurse ratios. Yet, this ambition was considerably toned down during the implementation. Due to a shortage of nurses in the labour market, hospital associations successfully lobbied to allocate part of the budget to hire non-nursing staff. Moreover, other healthcare settings claimed their share of the pie. Elements of international best-practice examples such as ward managers supernumerary to the team and increasing the transparency on staffing decisions were adopted. Other measures, such as mandated patient-to-nurse ratios, nurse staffing committees, or the monitoring or public reporting of ratios, were not retained. Additional measures were taken to safeguard that bedside staffing levels would improve, such as the requirement to demonstrate a net increase in staff to obtain additional budget, staffing plan's approval by local work councils and recommendation to base staff allocation on patient acuity measures. This policy process makes clear that the engagement of budgets is only a first step towards safe staffing levels, which needs to be embedded in a comprehensive policy plan. Future evaluation of bedside nurse staffing levels and nurse wellbeing is needed to conclude about the effectiveness of these measures and the intended and unintended effects they provoked.

No more unimplementable nurse workforce planning.

Objective: This paper aims to spur thought-provoking practical debates on current nurse workforce staffing and scheduling systems in relation to a critical review of Ang and colleagues' (2018) article entitled "Nurse workforce scheduling in the emergency department: A sequential decision support system considering multiple objectives."Design: Discussion paper on a practical discourse in connection with the aforementioned published article.Discussion: Mathematical Programming (optimisation) (MP)-based nursing research has been published for nearly thirty years almost exclusively in industrial engineering or health business administration journals, demonstrating a widening gap between nursing research and practice. Nurse scientists' knowledge and skill of MP is insufficient, as are their interdisciplinary collaborations, setting back the advancement of nursing science. Above all, nurse scientists skilled in decision science are desperately needed for that analytic intellection which is rooted in the 'intrinsic nature and value of nursing care.' It is imperative that nurse scientists be well-prepared for the new age of the Fourth Industrial Revolution through both an education in MP and interdisciplinary collaboration with decision science experts in order to prevent potential stereotyped MP-based algorithm-driven destructive influences.Conclusions: The current global nursing shortage makes optimal nursing workforce staffing and scheduling more important. MP helps nurse executives and leaders to ensure the most efficient number of nurses with the most effective composition of nurse staffing at the right time for a reasonable cost. Nurse scientists urgently need to produce a new nursing knowledge base that is directly implementable in nursing practice.Impact Statement: Nurse scientists should take the leading role in producing the mathematical programming-integrated knowledge base that is directly implementable in practice.

Implementation of a ward staff self-rostering system: improving morale and retention.

Staff morale is an important factor in maintaining and improving nurse recruitment and retention. Evidence suggests more flexible working patterns can improve nurses' work-life balance and subsequently their workplace satisfaction. This article describes a ward-based quality improvement project that introduced a self-rostering system that enabled nurses to select their own shifts for a given four-week roster period. The aim was to increase staff satisfaction and subsequently improve retention and recruitment. The article describes the project and discusses the positive outcomes.

Analysing the implementation and effects of safe staffing policies in acute hospitals.

Several high-profile inquiries and reports, including the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, by Sir Robert Francis QC, have identified that nurse staffing is an essential factor in patient safety and patient mortality rates. Since the Francis report, several policies and initiatives aimed at ensuring safe staffing in the NHS have been developed alongside guidance and evidence-based safe staffing tools, while the Care Quality Commission has been tasked with ensuring compliance with these policies. In 2015, the National Institute for Health Research (NIHR) Policy Research Programme commissioned research to examine the extent to which safe staffing policies have translated into practice locally in the NHS. This article summarises and examines the main findings of this research and suggests that, although policies have raised the profile of nurse staffing, nursing shortages have impeded their implementation.

Shift length and working practices in UK hospital settings: An online survey of heads of midwifery.

OBJECTIVE: There is currently a lack of data that records how midwives are expected to work in hospital settings. The aim of this study was to determine the prevalence of 12-h shifts and current working practices of hospital-based midwives. DESIGN: An online survey conducted between December 2018 and March 2019. Descriptive data are summarised regionally and nationally. SETTING: NHS Trusts providing maternity services in hospital settings in the UK PARTICIPANTS: The link to the survey was emailed to Heads of Midwifery in 155 NHS Trusts FINDINGS: Responses were received from 94 of the 155 NHS Trusts (60.65%). Some responses included data for more than one hospital, so results are summarised for 97 hospitals. 12-h shifts were the most prevalent shift length, with only 4.1% of hospitals still routinely operating shorter shifts. 55% of hospitals limit the maximum number of consecutive shifts to three, but this can be influenced by different factors. More than half of midwives (55.67%) will be rostered to start a day shift within 24-h of finishing a night shift. 70% of hospitals do not currently record the number of midwives working beyond their contracted hours but 68% report formal methods of recording missed rest breaks. Regional differences were seen in the use of other personnel to support the midwifery workforce. CONCLUSIONS: Shift schedules and the lack of formal methods to record the number of midwives working beyond their contracted hours may be a cause for concern due to the potential impact on recovery times. Further research is required to explore how working practices may affect midwives and their ability to provide care for women and their babies.

Abordagem na sala de emergência: dotação adequada de recursos de enfermagem / Emergency room approach: safe nursing staffing / Enfoque en la sala de urgencias: dotación adecuada de los recursos de enfermería

Enquadramento: O prognóstico da pessoa em situação crítica na sala de emergência depende da eficácia da atuação da equipa que a assiste. Objetivos: Perceber e justificar a necessidade de alocar um enfermeiro que tenha como função a abordagem em exclusivo a clientes da sala de emergência num hospital da região de Lisboa e Vale do Tejo com um serviço de urgência polivalente. Metodologia: Estudo retrospetivo, descritivo, exploratório, quantitativo. 3185 clientes críticos, recolha de informação por grelha de observação. Análise estatística foi realizada com o software IBM SPSS Statistics, versão 25.0. Recorreu-se ao teste de Kruskal-Wallis e Qui-quadrado. Resultados: No ano de 2017, na sala de emergência admitiram-se em média 9 clientes por dia, os cuidados diretos prestados exigiram em média 45,4 minutos, 65% foram admitidos na unidade de internamento médico-cirúrgico do serviço de urgência ou na área de observação clínica do mesmo serviço. Conclusão: Emerge a necessidade de garantir dotação adequada aquando da prestação de cuidados à pessoa em situação crítica, sendo necessário um enfermeiro para funções exclusivas à sala de emergência.

Background: The prognosis of the critically ill person in the emergency room depends on the effective performance of the health team in operation. Objectives: To understand and justify the need to allocate a nurse who works exclusively in the assistance to patients in the emergency room of a hospital in the Great Lisbon and Tagus Valley region with multipurpose emergency service. Methodology: Retrospective, descriptive, exploratory, and quantitative study, with a sample of 3185 critically ill patients. Data collection through observation grid. Statistical analysis was performed using the IBM SPSS Statistics software, version 25.0. The Kruskal-Wallis test and chi-square test were used. Results: In 2017, an average of 9 patients per day were admitted in the emergency room. The direct care delivered lasted, on average, 45.4 minutes, 65% were admitted to the surgical admission unit service or the area of clinical observation of the emergency department. Conclusion: It is crucial to ensure safe staffing in care delivery to the critically ill person, being necessary a nurse working exclusively in the emergency room.

Marco contextual: El pronóstico de la persona en una situación crítica en la sala de urgencias depende de la eficacia del equipo que la asiste. Objetivos: Comprender y justificar la necesidad de asignar un enfermero cuya función sea atender exclusivamente a los pacientes de la sala de urgencias de un hospital de la región de Lisboa y Valle del Tajo con un servicio de urgencias polivalente. Metodología: Estudio retrospectivo, descriptivo, exploratorio y cuantitativo. 3185 pacientes críticos, recopilación de información mediante una parilla de observación. El análisis estadístico se realizó con el programa IBM SPSS Statistics, versión 25.0. Se utilizó la prueba de Kruskal-Wallis y la de ji al cuadrado. Resultados: En 2017, se admitió una media de 9 pacientes por día en la sala de urgencias, la atención directa prestada exigió un promedio de 45,4 minutos, el 65% fue admitido en la unidad de internamiento médico-quirúrgico del servicio de urgencias o en el área de observación clínica del mismo servicio. Conclusión: Es necesario garantizar una dotación adecuada cuando se atiende a la persona en una situación crítica, y es necesario un enfermero para las funciones exclusivas de la sala de urgencias.

How safe staffing can improve emergency nursing: time to cut the Gordian knot.

The phrase 'cut the Gordian knot' describes a bold and direct solution to a complicated problem. Nursing presence has been defined as nurses' ability to pay attention to patients and make them feel that their needs have been considered. In the emergency department (ED), nursing presence can be adversely affected by factors such as fatigue, workplace bullying, moral distress and inadequate staffing levels, which could lead to suboptimal patient outcomes and compromise the goals of nursing. Nursing presence is also important for nurses' job satisfaction and therefore for staff retention. This article explores the combined effects of fatigue, workplace bullying, moral distress and inadequate staffing levels on emergency nurses. To cut the Gordian knot it also provides recommendations for mitigating these issues in EDs through safe staffing decisions that consider patient acuity and skill mix.

Staffing in hospital transfusion laboratories: UKTLC surveys show cause for concern.

OBJECTIVES: To monitor minimum standards in hospital transfusion laboratories in relation to qualifications, training, competency and the use of information technology over time against published recommendations. BACKGROUND: The United Kingdom Transfusion Laboratory Collaborative was formed in 2006 with representatives from relevant organisations and has published standards for transfusion laboratory practice. The standards are set to ensure safe transfusion laboratory practice. Regular surveys are performed to see the extent to which laboratories are able to meet these standards and where any problems lie. METHODS: An electronic survey is sent to hospital transfusion laboratories on a single mid-week day in the spring and is repeated every 2 years from 2011, to be completed by the lead in transfusion for the day. The questions cover staffing, training, funding and workload. RESULTS: Transfusion laboratories are having difficulty with staffing, particularly recruitment of suitably trained biomedical scientists, and with funding and time for training and education. Laboratory errors reported to the Serious Hazards of Transfusion haemovigilance scheme (SHOT) have not decreased with time, related to the under-resourced workforce. CONCLUSION: Problems in laboratory staffing and expertise in hospital transfusion laboratories need to be urgently addressed. The transfusion laboratory provides a key service to hospitals. The Blood Services in England and Wales are developing supportive strategies.

Development of approaches and legislation to optimise nurse staffing levels.

Nurses and the environment in which they work have an important role in patient safety and quality of care. Evidence demonstrates a link between lower nurse staffing levels and higher nurse workloads on hospital wards with adverse patient outcomes such as increased mortality, infections, falls and hospital stay, as well as adverse effects on staff well-being. Therefore, ensuring adequate numbers of nurses are on duty and available to care for patients safely has become a crucial task for nurses and hospital managers. In March 2016, Wales became the first country in Europe and one of only a small number of countries globally to legislate on nurse staffing levels. In April 2018, the Nurse Staffing Levels (Wales) Act 2016 was fully implemented in acute medical and surgical hospital wards. This article outlines the background to, and development of, nurse staffing approaches in Wales that preceded the introduction of this legislation. It aims to provide nurses with an understanding of the journey towards introducing legislation for nurse staffing levels and workforce planning in Wales, which will be relevant to those affected by the implementation of any legislation in this important area of healthcare. This article also provides information about how the nurse staffing legislation evolved as a result of important work and collaboration that was already undertaken throughout NHS Wales.

What impact does nursing care left undone have on patient outcomes? Review of the literature.

AIMS AND OBJECTIVES: Systematic review of the impact of missed nursing care on outcomes in adults, on acute hospital wards and in nursing homes. BACKGROUND: A considerable body of evidence supports the hypothesis that lower levels of registered nurses on duty increase the likelihood of patients dying on hospital wards, and the risk of many aspects of care being either delayed or left undone (missed). However, the direct consequence of missed care remains unclear. DESIGN: Systematic review. METHODS: We searched Medline (via Ovid), CINAHL (EBSCOhost) and Scopus for studies examining the association of missed nursing care and at least one patient outcome. Studies regarding registered nurses, healthcare assistants/support workers/nurses' aides were retained. Only adult settings were included. Because of the nature of the review, qualitative studies, editorials, letters and commentaries were excluded. PRISMA guidelines were followed in reporting the review. RESULTS: Fourteen studies reported associations between missed care and patient outcomes. Some studies were secondary analyses of a large parent study. Most of the studies used nurse or patient reports to capture outcomes, with some using administrative data. Four studies found significantly decreased patient satisfaction associated with missed care. Seven studies reported associations with one or more patient outcomes including medication errors, urinary tract infections, patient falls, pressure ulcers, critical incidents, quality of care and patient readmissions. Three studies investigated whether there was a link between missed care and mortality and from these results no clear associations emerged. CONCLUSIONS: The review shows the modest evidence base of studies exploring missed care and patient outcomes generated mostly from nurse and patient self-reported data. To support the assertion that nurse staffing levels and skill mix are associated with adverse outcomes as a result of missed care, more research that uses objective staffing and outcome measures is required. RELEVANCE TO CLINICAL PRACTICE: Although nurses may exercise judgements in rationing care in the face of pressure, there are nonetheless adverse consequences for patients (ranging from poor experience of care to increased risk of infection, readmissions and complications due to critical incidents from undetected physiological deterioration). Hospitals should pay attention to nurses' reports of missed care and consider routine monitoring as a quality and safety indicator.

Do nurse staffing levels affect patient mortality in acute secondary care?

This systematic literature review explores and considers whether registered nurse staffing levels affect patient mortality in acute secondary care settings. A discussion makes particular reference to the philosophical foundations of contrasting research approaches used within the literature. At the time of writing, the author was a modern matron for surgery, managing the ear, nose and throat; head and neck; airway; and reconstructive plastic surgery services in a large acute teaching hospital in central London. Effective management and leadership of acute clinical areas requires appropriate nurse:patient ratios. In practice settings, patient to staff ratios are based on care being provided by highly skilled and competent nurses providing best-quality, evidence-based practice.

A review of safe-staffing models and their applicability to care homes.

Presently, there are a range of evidence-based staffing tools that have been used to inform nursing, midwifery and health care capacity. These tools are designed to be used with professional judgement and include frameworks such as Rhys Hearn, the National Services Scotland Care Home Staffing Project, a variety of Royal College of Nursing Tool Kits including the Older People in Hospital's tool and the only National Institute of Clinical Excellence approved safe-staffing tool, Shelford's Safer Nursing Tool. These safe-staffing tools are used to score a patient's or resident's level of dependency across a number of domains, for example a patient/resident's ability to wash, dress, mobilise or fulfil their own elimination needs. While these tools have been beneficial with regards to informing staff levels there are a number of limitations that are important to highlight. Succinctly, most are not readily applicable to care home settings nor do they focus on more person-centred aspects of care.

An overview of the challenges facing care homes in the UK.

Care homes are an increasingly important part of the UK's healthcare system. Despite their importance, particularly in providing care for older people with complex needs, the sector is often disadvantaged and overlooked by commissioners, policymakers and researchers. The authors provide an overview of some important challenges for the sector. These challenges relate to funding, education and research, overseas staff, career pathways and staff recruitment and retention. They conclude that recruitment and retention of registered nurses is arguably the greatest challenge, as high staff turnover is the catalyst for other challenges identified. The care home sector should be considered as equal to hospitals, community settings and hospices. Care homes offer registered nurses many opportunities for development of clinical and organisational skills.

Managers' use of nursing workforce planning and deployment technologies: protocol for a realist synthesis of implementation and impact.

INTRODUCTION: Nursing staffing levels in hospitals appear to be associated with improved patient outcomes. National guidance indicates that the triangulation of information from workforce planning and deployment technologies (WPTs; eg, the Safer Nursing Care Tool) and 'local knowledge' is important for managers to achieve appropriate staffing levels for better patient outcomes. Although WPTs provide managers with predictive information about future staffing requirements, ensuring patient safety and quality care also requires the consideration of information from other sources in real time. Yet little attention has been given to how to support managers to implement WPTs in practice. Given this lack of understanding, this evidence synthesis is designed to address the research question: managers' use of WPTs and their impacts on nurse staffing and patient care: what works, for whom, how and in what circumstances? METHODS AND ANALYSIS: To explain how WPTs may work and in what contexts, we will conduct a realist evidence synthesis through sourcing relevant evidence, and consulting with stakeholders about the impacts of WPTs on health and relevant public service fields. The review will be in 4 phases over 18 months. Phase 1: we will construct an initial theoretical framework that provides plausible explanations of what works about WPTs. Phase 2: evidence retrieval, review and synthesis guided by the theoretical framework; phase 3: testing and refining of programme theories, to determine their relevance; phase 4: formulating actionable recommendations about how WPTs should be implemented in clinical practice. ETHICS AND DISSEMINATION: Ethical approval has been gained from the study's institutional sponsors. Ethical review from the National Health Service (NHS) is not required; however research and development permissions will be obtained. Findings will be disseminated through stakeholder engagement and knowledge mobilisation activities. The synthesis will develop an explanatory programme theory of the implementation and impact of nursing WPTs, and practical guidance for nurse managers. TRIAL REGISTRATION NUMBER: CRD42016038132.