Hospital nurse staffing models and patient and staff-related outcomes.

BACKGROUND: Nurse staffing interventions have been introduced across countries in recent years in response to changing patient requirements, developments in patient care, and shortages of qualified nursing staff. These include changes in skill mix, grade mix or qualification mix, staffing levels, nursing shifts or nurses' work patterns. Nurse staffing has been closely linked to patient outcomes, organisational outcomes such as costs, and staff-related outcomes. OBJECTIVES: Our aim was to explore the effect of hospital nurse staffing models on patient and staff-related outcomes. SEARCH STRATEGY: We searched the following databases from inception through to May 2009: Cochrane/EPOC resources (DARE, CENTRAL, the EPOC Specialised Register), PubMed, EMBASE, CINAHL Plus, CAB Health, Virginia Henderson International Nursing Library, the Joanna Briggs Institute database, the British Library, international theses databases, as well as generic search engines. SELECTION CRITERIA: Randomised control trials, controlled clinical trials, controlled before and after studies and interrupted time series analyses of interventions relating to hospital nurse staffing models. Participants were patients and nursing staff working in hospital settings. We included any objective measure of patient or staff-related outcome. DATA COLLECTION AND ANALYSIS: Seven reviewers working in pairs independently extracted data from each potentially relevant study and assessed risk of bias. MAIN RESULTS: We identified 6,202 studies that were potentially relevant to our review. Following detailed examination of each study, we included 15 studies in the review. Despite the number of studies conducted on this topic, the quality of evidence overall was very limited. We found no evidence that the addition of specialist nurses to nursing staff reduces patient death rates, attendance at the emergency department, or readmission rates, but it is likely to result in shorter patient hospital stays, and reductions in pressure ulcers. The evidence in relation to the impact of replacing Registered Nurses with unqualified nursing assistants on patient outcomes is very limited. However, it is suggested that specialist support staff, such as dietary assistants, may have an important impact on patient outcomes. Self-scheduling and primary nursing may reduce staff turnover. The introduction of team midwifery (versus standard care) may reduce medical procedures in labour and result in a shorter length of stay without compromising maternal or perinatal safety. We found no eligible studies of educational interventions, grade mix interventions, or staffing levels and therefore we are unable to draw conclusions in relation to these interventions. AUTHORS' CONCLUSIONS: The findings suggest interventions relating to hospital nurse staffing models may improve some patient outcomes, particularly the addition of specialist nursing and specialist support roles to the nursing workforce. Interventions relating to hospital nurse staffing models may also improve staff-related outcomes, particularly the introduction of primary nursing and self-scheduling. However, these findings should be treated with extreme caution due to the limited evidence available from the research conducted to date.

Systems biology in critical-care nursing.

Systems biology applies advances in technology and new fields of study including genomics, transcriptomics, proteomics, and metabolomics to the development of new treatments and approaches of care for the critically ill and injured patient. An understanding of systems biology enhances a nurse's ability to implement evidence-based practice and to educate patients and families on novel testing and therapies. Systems biology is an integrated and holistic view of humans in relationship with the environment. Biomarkers are used to measure the presence and severity of disease and are rapidly expanding in systems biology endeavors. A systems biology approach using predictive, preventive, and participatory involvement is being utilized in a plethora of conditions of critical illness and injury including sepsis, cancer, pulmonary disease, and traumatic injuries.

Collaboration of a model osteoporosis prevention and management program in a faith community.

This article describes the collaborative efforts of a parish nurse, family nurse practitioner, and a registered dietitian in a faith-based setting to address the women's health issue of osteoporosis. A model for education and treatment including lifestyle changes, nutrition, and pharmacological therapies is discussed. The whole person perspective of prevention and management for women with this chronic disease is explored. Implications for practice and education for women across the life span are described.

Progress in ethical decision making in the care of the dying.

Practitioners in critical care have made a significant progress in caring for dying patients in critical care by taking advantage of the suggestions from their professional groups. Progress has been made in responding to and controlling patients' pain. Major initiatives from the Joint Commission and the American Pain Society have helped direct this improvement. Palliative care consultations as well as ethics consultations have improved symptom control in the critically ill. Issues of consent have been problematic for dying patients in critical care especially in the area of discontinuing therapies. But, better policies related to advance directives have been developed to ensure good care. Spiritual care has received more attention, and now chaplains are recognized by the Society for Critical Care Medicine as integral to the critical care team. The American Association of Critical-Care Nurses has been a leader in improving end-of-life issues and continues to spearhead many projects to improve end-of-life care.

The case manager: an essential link in quality care.

The role of case manager is often untapped or underutilized. Nursing case management is recognized by accrediting entities as a unique specialty practice and, when consistently applied, is the holistic implementation of the nursing process focused on an individual's needs, coupled with a commitment to the role of advocate and educator. Case managers on multidisciplinary teams help ensure continuity of care and consistency of communication; they are invaluable advocates for patients navigating the complexities of the current health care system.

The times they are a changin.

AIM: A discussion paper outlining the potential for a multi-qualified health practitioner who has undertaken a programme of study incorporating the strengths of the specialist nurse with other professional routes. BACKGROUND AND RATIONALE: The concept and the context of 'nursing' is wide and generalized across the healthcare spectrum with a huge number of practitioners in separate branches, specialities and sub-specialities. As a profession, nursing consists of different groups in alliance with each other. How different is the work of the mental health forensic expert from an acute interventionalist, or a nurse therapist, from a clinical expert in neurological deterioration? The alliance holds because of the way nurses are educated and culturalized into the profession, and the influence of the statutory bodies and the context of a historical nationalized health system. This paper discusses the potential for a new type of healthcare professional, one which pushes the intra- and inter-professional agenda towards multi-qualified staff who would be able to work across current care boundaries and be more flexible regarding future care delivery. In September 2003, the Nursing and Midwifery Council stated that there were 'more than 656 000 practitioners' on its register and proposed that from April 2004, there were new entry descriptors. Identifying such large numbers of practitioners across a wide range of specialities brings several areas of the profession into question. Above all else, it highlights how nursing has fought and gained recognition for specialisms and that through this, it may be argued client groups receive the best possible 'fit' for their needs, wants and demands. However, it also highlights deficits in certain disciplines of care, for example, in mental health and learning disabilities. We argue that a practitioner holding different professional qualifications would be in a position to provide a more holistic service to the client. Is there then a gap for a 'new breed' of practitioner; 'a hybrid' that can achieve a balanced care provision to reduce the stress of multiple visits and multiple explanations? METHODS: Review of the literature but essentially informed by the authors personal vision relating to the future of health practitioner education. IMPLICATIONS FOR NURSING MANAGEMENT: This article is of significance for nurse managers as the future workforce and skill mix of both acute and community settings will be strongly influenced by the initial preregistration nurse education.

Nursing care in the chronic phase of COPD: a call for innovative disciplinary research.

AIM: The literature on nursing care in nurse clinics that focus on chronic management of chronic obstructive pulmonary disease (COPD) is analysed and synthesised with the purpose of advancing research of practice in nurse clinics. BACKGROUND: Along with the rising prevalence of COPD and a growing recognition of long-lasting, comprehensive and complex healthcare needs of people with COPD and their families, nurses are challenged to restructure their practice. METHODS: An integrated review was conducted. The databases searched were NCBI's PubMed database, Scopus, CINAHL and Web of Science from 1996 to 2006. Terms searched were 'COPD' and 'nurse managed clinic' with all subheadings. A nurse had to be primary in managing and providing the services and the methodological approach was inclusive. RESULTS: Of 385 potentially relevant papers, 20 papers reporting 16 studies met the inclusion criteria. The methodological approach was diverse with randomised controlled trials being most common. Significant benefits from experimental treatments were seldom demonstrated. Nursing care in the chronic phase of COPD has mainly been conceptualised as: home-based respiratory care; self-management educational programmes and telephone service with influences of specialisation in respiratory nursing care on patients' outcomes as an emphasis as well. Family focus was not found in any of the studies. CONCLUSION: Research on nurse clinics that focus on the chronic phase of COPD is in its infancy. Innovative research that addresses the structure and content of the nursing care is essential. RELEVANCE TO CLINICAL PRACTICE: Nursing care in nurse clinics that focus on the chronic phase of COPD needs to be based on nursing knowledge, evidence based, comprehensive, family-centred, focused on health and the health experience and be situated within the service system. Diversity, creativity and nursing values should prevail when developing nurse clinics for the purpose of creating possibilities to attend to the whole of patients' and their families' needs and experiences.

A cancer pain primer.

Opportunities exist for improving cancer pain management. Medical-surgical nurses must partner with patients and families to achieve optimal pain management. They must use valid tools to assess patients and be knowledgeable about pharmacologic and nonpharmacologic measures to manage pain.