Is Hospital Nurse Staffing Legislation in the Public's Interest?: An Observational Study in New York State.

BACKGROUND: The Safe Staffing for Quality Care Act under consideration in the New York (NY) state assembly would require hospitals to staff enough nurses to safely care for patients. The impact of regulated minimum patient-to-nurse staffing ratios in acute care hospitals in NY is unknown. OBJECTIVES: To examine variation in patient-to-nurse staffing in NY hospitals and its association with adverse outcomes (ie, mortality and avoidable costs). RESEARCH DESIGN: Cross-sectional data on nurse staffing in 116 acute care general hospitals in NY are linked with Medicare claims data. SUBJECTS: A total of 417,861 Medicare medical and surgical patients. MEASURES: Patient-to-nurse staffing is the primary predictor variable. Outcomes include in-hospital mortality, length of stay, 30-day readmission, and estimated costs using Medicare-specific cost-to-charge ratios. RESULTS: Hospital staffing ranged from 4.3 to 10.5 patients per nurse (P/N), and averaged 6.3 P/N. After adjusting for potential confounders each additional patient per nurse, for surgical and medical patients, respectively, was associated with higher odds of in-hospital mortality [odds ratio (OR)=1.13, P=0.0262; OR=1.13, P=0.0019], longer lengths of stay (incidence rate ratio=1.09, P=0.0008; incidence rate ratio=1.05, P=0.0023), and higher odds of 30-day readmission (OR=1.08, P=0.0002; OR=1.06, P=0.0003). Were hospitals staffed at the 4:1 P/N ratio proposed in the legislation, we conservatively estimated 4370 lives saved and $720 million saved over the 2-year study period in shorter lengths of stay and avoided readmissions. CONCLUSIONS: Patient-to-nurse staffing varies substantially across NY hospitals and higher ratios adversely affect patients. Our estimates of potential lives and costs saved substantially underestimate potential benefits of improved hospital nurse staffing.

Assessing the Impact of the COVID-19 Pandemic on Nursing Education: A National Study of Prelicensure RN Programs.

Background: The COVID-19 pandemic has had a profound impact on prelicensure nursing education, leading to widespread disruptions that may have implications for nursing students' learning and engagement outcomes. Understanding how the rapid shift to online and simulation-based teaching methods has affected new graduates' clinical preparedness is critical to ensure patient safety moving forward. Purpose: To assess the impact of institutional, academic, and demographic characteristics on prelicensure nursing students' academic, initial postgraduation, and early career outcomes during the COVID-19 pandemic. Methods: We conducted a mixed-methods longitudinal study focused on prelicensure registered nurse (RN) students entering the core of their didactic and clinical nursing coursework during the pandemic. This study uses a combination of real-time student and faculty self-report data, including externally validated instruments, within and end-of-program standardized test scores, and focus group findings. Various statistical methods, ranging from simpler descriptive and non-parametric methods to Generalized Estimating Equation (GEE) models and detailed textual analysis, are applied to assess student, faculty, and institution-level data. Results: The final sample includes more than 1,100 student and faculty participants affiliated with 51 prelicensure RN programs located across 27 states. Leveraging more than 4,000 course observations collected from fall 2020 to spring 2022 and supplemented by the rich personal narratives of over 60 focus group participants, this study illuminates the breadth, scale, and ever-evolving nature of prelicensure RN programs' efforts to maintain the continuity of nursing students' education during the public health crisis. In doing so, it captures the many ways in which nursing administrators, faculty, and students sought to address the unparalleled challenges they confronted on a day-to-day basis. In particular, the findings provide critical insights into the efficacy of the changes nursing programs made to their course delivery formats to adjust to the confluence of rapidly evolving federal, state, and private restrictions to stem the spread of COVID-19. Conclusion: This study stands as the most comprehensive assessment of prelicensure nursing education in the United States since the onset of COVID-19. It extends knowledge by linking potential deficiencies in students' didactic and clinical education during the pandemic and their early career preparedness, clinical competence, and the patient safety implications therein.

Patient outcomes and cost savings associated with hospital safe nurse staffing legislation: an observational study.

OBJECTIVE: To evaluate variation in Illinois hospital nurse staffing ratios and to determine whether higher nurse workloads are associated with mortality and length of stay for patients, and cost outcomes for hospitals. DESIGN: Cross-sectional analysis of multiple data sources including a 2020 survey of nurses linked to patient outcomes data.Setting: 87 acute care hospitals in Illinois. PARTICIPANTS: 210 493 Medicare patients, 65 years and older, who were hospitalised in a study hospital. 1391 registered nurses employed in direct patient care on a medical-surgical unit in a study hospital. MAIN OUTCOME MEASURES: Primary outcomes were 30-day mortality and length of stay. Deaths avoided and cost savings to hospitals were predicted based on results from regression estimates if hospitals were to have staffed at a 4:1 ratio during the study period. Cost savings were computed from reductions in lengths of stay using cost-to-charge ratios. RESULTS: Patient-to-nurse staffing ratios on medical-surgical units ranged from 4.2 to 7.6 (mean=5.4; SD=0.7). After adjusting for hospital and patient characteristics, the odds of 30-day mortality for each patient increased by 16% for each additional patient in the average nurse's workload (95% CI 1.04 to 1.28; p=0.006). The odds of staying in the hospital a day longer at all intervals increased by 5% for each additional patient in the nurse's workload (95% CI 1.00 to 1.09, p=0.041). If study hospitals staffed at a 4:1 ratio during the 1-year study period, more than 1595 deaths would have been avoided and hospitals would have collectively saved over $117 million. CONCLUSIONS: Patient-to-nurse staffing ratios vary considerably across Illinois hospitals. If nurses in Illinois hospital medical-surgical units cared for no more than four patients each, thousands of deaths could be avoided, and patients would experience shorter lengths of stay, resulting in cost-savings for hospitals.

Chronic hospital nurse understaffing meets COVID-19: an observational study.

INTRODUCTION: Efforts to enact nurse staffing legislation often lack timely, local evidence about how specific policies could directly impact the public's health. Despite numerous studies indicating better staffing is associated with more favourable patient outcomes, only one US state (California) sets patient-to-nurse staffing standards. To inform staffing legislation actively under consideration in two other US states (New York, Illinois), we sought to determine whether staffing varies across hospitals and the consequences for patient outcomes. Coincidentally, data collection occurred just prior to the COVID-19 outbreak; thus, these data also provide a real-time example of the public health implications of chronic hospital nurse understaffing. METHODS: Survey data from nurses and patients in 254 hospitals in New York and Illinois between December 2019 and February 2020 document associations of nurse staffing with care quality, patient experiences and nurse burnout. RESULTS: Mean staffing in medical-surgical units varied from 3.3 to 9.7 patients per nurse, with the worst mean staffing in New York City. Over half the nurses in both states experienced high burnout. Half gave their hospitals unfavourable safety grades and two-thirds would not definitely recommend their hospitals. One-third of patients rated their hospitals less than excellent and would not definitely recommend it to others. After adjusting for confounding factors, each additional patient per nurse increased odds of nurses and per cent of patients giving unfavourable reports; ORs ranged from 1.15 to 1.52 for nurses on medical-surgical units and from 1.32 to 3.63 for nurses on intensive care units. CONCLUSIONS: Hospital nurses were burned out and working in understaffed conditions in the weeks prior to the first wave of COVID-19 cases, posing risks to the public's health. Such risks could be addressed by safe nurse staffing policies currently under consideration.

Evaluation of hospital nurse-to-patient staffing ratios and sepsis bundles on patient outcomes.

BACKGROUND: Despite nurses' responsibilities in recognition and treatment of sepsis, little evidence documents whether patient-to-nurse staffing ratios are associated with clinical outcomes for patients with sepsis. METHODS: Using linked data sources from 2017 including MEDPAR patient claims, Hospital Compare, American Hospital Association, and a large survey of nurses, we estimate the effect of hospital patient-to-nurse staffing ratios and adherence to the Early Management Bundle for patients with Severe Sepsis/Septic Shock SEP-1 sepsis bundles on patients' odds of in-hospital and 60-day mortality, readmission, and length of stay. Logistic regression is used to estimate mortality and readmission, while zero-truncated negative binomial models are used for length of stay. RESULTS: Each additional patient per nurse is associated with 12% higher odds of in-hospital mortality, 7% higher odds of 60-day mortality, 7% higher odds of 60-day readmission, and longer lengths of stay, even after accounting for patient and hospital covariates including hospital adherence to SEP-1 bundles. Adherence to SEP-1 bundles is associated with lower in-hospital mortality and shorter lengths of stay; however, the effects are markedly smaller than those observed for staffing. DISCUSSION: Improving hospital nurse staffing over and above implementing sepsis bundles holds promise for significant improvements in sepsis patient outcomes.

A novel method of screening combinations of angiostatics identifies bevacizumab and temsirolimus as synergistic inhibitors of glioma-induced angiogenesis.

Tumor angiogenesis is critical for the growth and progression of cancer. As such, angiostasis is a treatment modality for cancer with potential utility for multiple types of cancer and fewer side effects. However, clinical success of angiostatic monotherapies has been moderate, at best, causing angiostatic treatments to lose their early luster. Previous studies demonstrated compensatory mechanisms that drive tumor vascularization despite the use of angiostatic monotherapies, as well as the potential for combination angiostatic therapies to overcome these compensatory mechanisms. We screened clinically approved angiostatics to identify specific combinations that confer potent inhibition of tumor-induced angiogenesis. We used a novel modification of the ex ovo chick chorioallantoic membrane (CAM) model that combined confocal and automated analyses to quantify tumor angiogenesis induced by glioblastoma tumor onplants. This model is advantageous due to its low cost and moderate throughput capabilities, while maintaining complex in vivo cellular interactions that are difficult to replicate in vitro. After screening multiple combinations, we determined that glioblastoma-induced angiogenesis was significantly reduced using a combination of bevacizumab (Avastin®) and temsirolimus (Torisel®) at doses below those where neither monotherapy demonstrated activity. These preliminary results were verified extensively, with this combination therapy effective even at concentrations further reduced 10-fold with a CI value of 2.42E-5, demonstrating high levels of synergy. Thus, combining bevacizumab and temsirolimus has great potential to increase the efficacy of angiostatic therapy and lower required dosing for improved clinical success and reduced side effects in glioblastoma patients.

Exit exams from a regulatory perspective.

When programs do have problems with NCLEX-RN pass rates, the state boards of nursing often work with the program administrators and provide them with reasonable time to make changes. In the end, educators and regulators have the same goal: graduating safe and competent nurses in sufficient numbers to meet the needs of the public. NCSBN is committed to this goal and will continue to conduct research and disseminate information and data that will support the state boards of nursing and help nursing programs make innovative changes. We all share the common interest of promoting quality education for future nurses.