Cost-consequence analysis of an intervention for the management of neuropsychiatric symptoms in young-onset dementia: Results from the BEYOND-II study.

OBJECTIVE: To evaluate the cost-consequences of an intervention for the management of neuropsychiatric symptoms in nursing home residents with young-onset dementia. METHODS: A stepped wedge design was used. The intervention consisted of an educational program and a multidisciplinary care program and was implemented in 13 nursing homes from September 2015 to March 2017. Costs' outcomes included the time investment of the elderly care physician and health care psychologists regarding the management of neuropsychiatric symptoms, residents' psychotropic drug use, nursing staff absenteeism, and costs of the educational program. Composite cost measure contained the sum of costs of staff absenteeism, costs on psychotropic drugs, and costs of the educational program. Costs of time investment were investigated by comparing means. Costs of psychotropic drug use were analyzed with mixed models at resident level and as part of the composite cost measure on unit level. Staff absenteeism was also analyzed at unit level. RESULTS: Compared with care as usual, the mean costs of time invested decreased with €36.79 for the elderly care physician but increased with €46.05 for the health care psychologist in the intervention condition. Mixed model analysis showed no effect of the intervention compared with care as usual on the costs of psychotropic drug use, staff absenteeism, and the composite cost measure. The costs of the educational program were on average €174.13 per resident. CONCLUSION: The intervention did not result in increased costs compared with care as usual. Other aspects, such as the lack of a structured working method, should be taken into account when considering implementation of the intervention.

From staff nurse to nurse consultant: Survival Guide part 8: Surviving on a basic wage.

John Fowler, Educational Consultant, explores how to survive your nursing career.

Five-layer border dressings as part of a quality improvement bundle to prevent pressure injuries in US skilled nursing facilities and Australian nursing homes: A cost-effectiveness analysis.

The BORDER III trial found that five-layer silicone border dressings effectively prevented pressure injuries in long-term care, but the value of this approach is unknown. Our objective was to analyse the cost-effectiveness of preventing facility-acquired pressure injuries with a quality improvement bundle, including prophylactic five-layer dressings in US and Australian long-term care. Markov models analysed the cost utility for pressure injuries acquired during long-term care from US and Australian perspectives. Models calibrated outcomes for standard care compared with a dressing-inclusive bundle over 18 monthly cycles or until death based on BORDER III outcomes. Patients who developed a pressure injury simulated advancement through stages 1 to 4. Univariate and multivariate probabilistic sensitivity analyses tested modelling uncertainty. Costs in 2017 USD and quality-adjusted life years (QALYs) were used to calculate an incremental cost-effectiveness ratio (ICER). Dressing use yielded greater QALYs at slightly higher costs from perspectives. The US ICER was $36 652/QALY, while the Australian ICER was $15 898/QALY, both of which fell below a willingness-to-pay threshold of $100 000/QALY. Probabilistic sensitivity analysis favoured dressings as cost-effective for most simulations. A quality improvement bundle, including prophylactic five-layer dressings, is a cost-effective approach for pressure injury prevention in all US and Australia long-term care residents.

The potential of task-shifting in scaling up services for prevention of mother-to-child transmission of HIV: a time and motion study in Dar es Salaam, Tanzania.

BACKGROUND: In many African countries, prevention of mother-to-child transmission of HIV (PMTCT) services are predominantly delivered by nurses. Although task-shifting is not yet well established, community health workers (CHWs) are often informally used as part of PMTCT delivery. According to the 2008 World Health Organization (WHO) Task-shifting Guidelines, many PMTCT tasks can be shifted from nurses to CHWs. METHODS: The aim of this time and motion study in Dar es Salaam, Tanzania, was to estimate the potential of task-shifting in PMTCT service delivery to reduce nurses' workload and health system costs. The time used by nurses to accomplish PMTCT activities during antenatal care (ANC) and postnatal care (PNC) visits was measured. These data were then used to estimate the costs that could be saved by shifting tasks from nurses to CHWs in the Tanzanian public-sector health system. RESULTS: A total of 1121 PMTCT-related tasks carried out by nurses involving 179 patients at ANC and PNC visits were observed at 26 health facilities. The average time of the first ANC visit was the longest, 54 (95% confidence interval (CI) 42-65) min, followed by the first PNC visit which took 29 (95% CI 26-32) minutes on average. ANC and PNC follow-up visits were substantially shorter, 15 (95% CI 14-17) and 13 (95% CI 11-16) minutes, respectively. During both the first and the follow-up ANC visits, 94% of nurses' time could be shifted to CHWs, while 84% spent on the first PNC visit and 100% of the time spent on the follow-up PNC visit could be task-shifted. Depending on CHW salary estimates, the cost savings due to task-shifting in PMTCT ranged from US$ 1.3 to 2.0 (first ANC visit), US$ 0.4 to 0.6 (ANC follow-up visit), US$ 0.7 to 1.0 (first PNC visit), and US$ 0.4 to 0.5 (PNC follow-up visit). CONCLUSIONS: Nurses working in PMTCT spend large proportions of their time on tasks that could be shifted to CHWs. Such task-shifting could allow nurses to spend more time on specialized PMTCT tasks and can substantially reduce the average cost per PMTCT patient.

Nursing performance under high workload: a diary study on the moderating role of selection, optimization and compensation strategies.

AIMS: The aim of this study was to investigate whether selective optimization with compensation constitutes an individualized action strategy for nurses wanting to maintain job performance under high workload. BACKGROUND: High workload is a major threat to healthcare quality and performance. Selective optimization with compensation is considered to enhance the efficient use of intra-individual resources and, therefore, is expected to act as a buffer against the negative effects of high workload. DESIGN: The study applied a diary design. Over five consecutive workday shifts, self-report data on workload was collected at three randomized occasions during each shift. Self-reported job performance was assessed in the evening. Self-reported selective optimization with compensation was assessed prior to the diary reporting. METHODS: Data were collected in 2010. Overall, 136 nurses from 10 German hospitals participated. Selective optimization with compensation was assessed with a nine-item scale that was specifically developed for nursing. The NASA-TLX scale indicating the pace of task accomplishment was used to measure workload. Job performance was assessed with one item each concerning performance quality and forgetting of intentions. RESULTS: There was a weaker negative association between workload and both indicators of job performance in nurses with a high level of selective optimization with compensation, compared with nurses with a low level. Considering the separate strategies, selection and compensation turned out to be effective. CONCLUSION: The use of selective optimization with compensation is conducive to nurses' job performance under high workload levels. This finding is in line with calls to empower nurses' individual decision-making.

From Twitter.

Nurses on Twitter.

Intended and unintended consequences of minimum staffing standards for nursing homes.

Staffing is the dominant input in the production of nursing home services. Because of concerns about understaffing in many US nursing homes, a number of states have adopted minimum staffing standards. Focusing on policy changes in California and Ohio, this paper examined the effects of minimum nursing hours per resident day regulations on nursing home staffing levels and care quality. Panel data analyses of facility-level nursing inputs and quality revealed that minimum staffing standards increased total nursing hours per resident day by 5% on average. However, because the minimum staffing standards treated all direct care staff uniformly and ignored indirect care staff, the regulation had the unintended consequences of both lowering the direct care nursing skill mix (i.e., fewer professional nurses relative to nurse aides) and reducing the absolute level of indirect care staff. Overall, the staffing regulations led to a reduction in severe deficiency citations and improvement in certain health conditions that required intensive nursing care.

Emergency Department Visit Forecasting and Dynamic Nursing Staff Allocation Using Machine Learning Techniques With Readily Available Open-Source Software.

Although emergency department visit forecasting can be of use for nurse staff planning, previous research has focused on models that lacked sufficient resolution and realistic error metrics for these predictions to be applied in practice. Using data from a 1100-bed specialized care hospital with 553,000 patients assigned to its healthcare area, forecasts with different prediction horizons, from 2 to 24 weeks ahead, with an 8-hour granularity, using support vector regression, M5P, and stratified average time-series models were generated with an open-source software package. As overstaffing and understaffing errors have different implications, error metrics and potential personnel monetary savings were calculated with a custom validation scheme, which simulated subsequent generation of predictions during a 4-year period. Results were then compared with a generalized estimating equation regression. Support vector regression and M5P models were found to be superior to the stratified average model with a 95% confidence interval. Our findings suggest that medium and severe understaffing situations could be reduced in more than an order of magnitude and average yearly savings of up to €683,500 could be achieved if dynamic nursing staff allocation was performed with support vector regression instead of the static staffing levels currently in use.

The Relationship Between Registered Nurses and Nursing Home Quality: An Integrative Review (2008-2014).

Nursing home care is expensive; second only to acute hospital care for inpatient Medicare costs. The increased focus on costs of care accrued by Medicare beneficiaries in nursing homes presents a valuable opportunity for registered nurses (RNs) to further demonstrate quantitatively the value they add to the capacity of the nursing home nursing skill mix to provide cost-effective and efficient quality care. Most of the studies included in this review consistently reported that higher RN staffing and higher ratios of RNs in the nursing skill mix are related to better NH quality. Concerns about the costs of employing more highly skilled RNs and directors of nursing that have the potential to positively influence members of the nursing skill mix will continue to influence nursing home industry hiring practices. For both the advancement of nursing as an applied science and the benefit of society at large, nursing researchers are challenged to better demonstrate how the increased presence of a RN on each shift has the potential to enhance the cost effectiveness, efficiency, and quality of nursing homes.

The high price of obesity in nursing homes.

This article provides a commentary on the costs of obese nursing home patients. We conducted a comprehensive literature search, which found 46 relevant articles on obesity in older adults and effects on nursing home facilities. This review indicated obesity is increasing globally for all age groups and older adults are facing increased challenges with chronic diseases associated with obesity more than ever before. With medical advances comes greater life expectancy, but obese adults often experience more disabilities, which require nursing home care. In the United States, the prevalence of obesity in adults aged 60 years and older increased from 9.9 million (23.6%) to 22.2 million (37.0%) in 2010. Obese older adults are twice as likely to be admitted to a nursing home. Many obese adults have comorbidities such as Type 2 diabetes; patients with diabetes incurred 1 in every 4 nursing home days. Besides the costs of early entrance into nursing facilities, caring for obese residents is different than caring for nonobese residents. Obese residents have more care needs for additional equipment, supplies, and staff costs. Unlike emergency rooms and hospitals, nursing homes do not have federal requirements that require them to serve all patients. Currently, some nursing homes are not prepared to deal with very obese patients. This is a public health concern because there are more obese people than ever in history before and the future appears to have even a heavier generation moving forward. Policymakers need to become aware of this serious gap in nursing home care.

Building Economic Value for Professional Nurses at the Gateway to the Health Care System.

An enhanced role for professional nurses as directed care practitioners will lead to improved effectiveness of the health care system, establish independent economic value for nursing activities, and use the full range of nurses' expertise.

Source country perceptions, experiences, and recommendations regarding health workforce migration: a case study from the Philippines.

BACKGROUND: The Philippines continues to overproduce nurses for export. Little first-hand evidence exists from leading organisations in the Philippines concerning their experiences and perceptions in relation to Filipino nurse migration. What are their views about health workforce migration? This paper addresses this research gap by providing a source country perspective on Filipino nurse migration to Australia. METHODS: Focus-group interviews were conducted with key informants from nine Filipino organisations in the Philippines by an Australian-Filipino research team. The organisations were purposively selected and contacted in person, by phone, and/or email. Qualitative thematic analysis was performed using a coding framework. RESULTS: Health workforce migration is perceived to have both positive and negative consequences. On the one hand, emigration offers a welcome opportunity for individual Filipino nurses to migrate abroad in order to achieve economic, professional, lifestyle, and social benefits. On the other, as senior and experienced nurses are attracted overseas, this results in the maldistribution of health workers particularly affecting rural health outcomes for people in developing countries. Problems such as 'volunteerism' also emerged in our study. CONCLUSIONS: In the context of the WHO (2010) Code of Practice on the International Recruitment of Health Personnel it is to be hoped that, in the future, government recruiters, managers, and nursing leaders can utilise these insights in designing recruitment, orientation, and support programmes for migrant nurses that are more sensitive to the experience of the Philippines' education and health sectors and their needs.

Why do older RNs keep working?

OBJECTIVE: To identify the reasons older RNs (≥45 years) remain in the healthcare workforce. BACKGROUND: Despite predictions of early retirements of older nurses, many continue to work past the age when they can gain access to their retirement funds. METHODS: The authors surveyed nurses older than 45 years in New South Wales, Australia. RESULTS: The need for income was the most common reason for staying in nursing (61.9%; n = 210), with nearly 43% (n = 130) identifying this as the main reason for staying. CONCLUSIONS: Retaining older nurses in the workforce is an important strategy for managing workforce shortages. Nurse executives will need to consider strategies that will enhance retention of older nurses and focus on the reasons older nurses want to keep working.

Nurse Credentials: What Is the Economic Value?

A workshop sponsored by the Institute of Medicine brought together health care leaders to focus on the impact of credentials on nurse, patient, and organization outcomes. Demonstrating the value of credentials is very challenging. Does the credential cause improvement? Or does it simply indicate which organizations are the better performers (and thus does not cause improvement)? As our health care system moves toward rewarding the value of health care, proponents of credentials will need to demonstrate credentials reflect true differences in the capacity to deliver health care. Credentialing is expensive; thus, it is imperative to critically assess the overall value of credentials, whether some credentials are more important than others, and how to support attainment of the most important credentials.

Ensuring the availability of the nursing workforce through philanthropy: a case study.

The Institute of Medicine report on the Future of Nursing identified the need to increase the preparation of nurses, create pathways for nurses to lead as partners to improve health by promoting interprofessional education and practice, and to remove barriers to full practice of nurses across the continuum. This case study shares the experience of large systems and their creativity using philanthropy in their quest to ensure the availability of a qualified nursing workforce.

New York's Health Care Workforce Recruitment and Retention Act: an investigation of the effects of nonrecurring increases in health worker wage on health worker supply.

This article analyzes New York's Health Care Workforce Recruitment and Retention Act of 2002. The analysis comes in 4 parts: part 1 provides a brief overview of New York's economy as it relates to health care, a feel for the political climate at the time, and a detailed presentation of the chain of events that connect this climate to the birth of the Health Care Workforce Recruitment and Retention Act of 2002; part 2 consists of a breakdown of the provisions contained within bill, including major and minor goals, intended effects, and the mechanics behind raising supporting funds; part 3 explores what actually happened by evaluating available data to determine whether the bill's 2 major goals of workforce recruitment and retention were fulfilled; and finally, part 4 will take all the aforementioned information to determine the overall success of the bill, the implications, and specific suggestions for future policy changes that time has revealed since its inception.

Further freezes would make pay 'unfair and uncompetitive' say MPs.

A group of influential MPs has warned the government against continuing to freeze nurses' pay to address the financial challenges facing the NHS.

The DH is talking utter nonsense about pay.

'Union leaders talk tough on pay' is a headline that could have been written thousands of times over the past 100 years, but rarely have nurses' representatives been so furious as they are now. Two weeks on from the decision to withhold a 1 per cent pay award from most NHS nursing staff in England and Wales, and tempers are continuing to flare.

Five dilemmas associated with e-rostering.

Increased use of e-rostering is likely to benefit nurses and patients, but will also create dilemmas for staff. Rosters may not be flexible enough to accommodate day-to-day changes, and may also foster unfair treatment and disempower staff.

Evaluating palliative care ward staffing using bed occupancy, patient dependency, staff activity, service quality and cost data.

BACKGROUND: Palliative care staffing has remained unchallenged for decades while service provision has changed markedly, bringing new workforce demands. There is little evidence to inform hospice workforce structures, which strive to deliver the highest-quality holistic care. AIM: The study had three main aims, to: (i) adapt the acuity-quality workforce planning method used extensively in the UK National Health Service (NHS) for use in hospices; (ii) compare hospice and NHS palliative care staffing establishments and their implications; and (iii) create ward staffing benchmarks and formulae for hospice managers. DESIGN: A method adapted from a widely used nursing workforce planning and development (WP&D) study was used to collect data in hospice and palliative care wards. SETTING: Twenty-three palliative care and hospice wards, geographically representing England, were studied. RESULTS: A dataset, which profiles and benchmarks hospice and NHS palliative care ward occupancy, patient dependency, staff activity, ward establishments, quality and costs in 23 palliative care and hospice wards has been created. The database reveals large differences between hospice and palliative care wards. For example, hospice wards are better staffed and more expensive to run but staff deliver higher-quality care (measured using an established service quality audit) despite facing heavier workloads. Consequently, staffing multipliers are created to help managers estimate workload-based ward staffing. CONCLUSIONS: This dataset provides evidence-based recommendations to inform palliative care nursing workforce modelling, including deciding future nursing workforce size and mix based on rising workloads. The new dataset is suitable for use in UK hospice wards and may be appropriate for future international use.