The important factors nurses consider when choosing shift patterns: A cross-sectional study.

AIM: To gain a deeper understanding of what is important to nurses when thinking about shift patterns and the organisation of working time. DESIGN: A cross-sectional survey of nursing staff working across the UK and Ireland collected quantitative and qualitative responses. METHODS: We recruited from two National Health Service Trusts and through an open call via trade union membership, online/print nursing profession magazines and social media. Worked versus preferred shift length/pattern, satisfaction and choice over shift patterns and nurses' views on aspects related to work and life (when working short, long, rotating shifts) were analysed with comparisons of proportions of agreement and crosstabulation. Qualitative responses on important factors related to shift preferences were analysed with inductive thematic analysis. RESULTS: Eight hundred and seventy-three survey responses were collected. When nurses worked long shifts and rotating shifts, lower proportions reported being satisfied with their shifts and working their preferred shift length and pattern. Limited advantages were realised when comparing different shift types; however, respondents more frequently associated 'low travel costs' and 'better ability to do paid overtime' with long shifts and 'healthy diet/exercise' with short shifts; aspects related to rotating shifts often had the lowest proportions of agreement. In the qualitative analysis, three themes were developed: 'When I want to work', 'Impacts to my life outside work' and 'Improving my work environment'. Reasons for nurses' shift preferences were frequently related to nurses' priorities outside of work, highlighting the importance of organising schedules that support a good work-life balance. RELEVANCE TO CLINICAL PRACTICE: General scheduling practices like adhering to existing shift work guidelines, using consistent and predictable shift patterns and facilitating flexibility over working time were identified by nurses as enablers for their preferences and priorities. These practices warrant meaningful consideration when establishing safe and efficient nurse rosters. PATIENT OR PUBLIC CONTRIBUTION: This survey was developed and tested with a diverse group of stakeholders, including nursing staff, patients, union leads and ward managers. REPORTING METHOD: The Strengthening the Reporting of Observational Studies (STROBE) checklist for cross-sectional studies was used to guide reporting.

The association between multi-disciplinary staffing levels and mortality in acute hospitals: a systematic review.

OBJECTIVES: Health systems worldwide are faced with the challenge of adequately staffing their hospital services. Much of the current research and subsequent policy has been focusing on nurse staffing and minimum ratios to ensure quality and safety of patient care. Nonetheless, nurses are not the only profession who interact with patients, and, therefore, not the only professional group who has the potential to influence the outcomes of patients while in hospital. We aimed to synthesise the evidence on the relationship between multi-disciplinary staffing levels in hospital including nursing, medical and allied health professionals and the risk of death. METHODS: Systematic review. We searched Embase, Medline, CINAHL, and the Cochrane Library for quantitative or mixed methods studies with a quantitative component exploring the association between multi-disciplinary hospital staffing levels and mortality. RESULTS: We included 12 studies. Hospitals with more physicians and registered nurses had lower mortality rates. Higher levels of nursing assistants were associated with higher patient mortality. Only two studies included other health professionals, providing scant evidence about their effect. CONCLUSIONS: Pathways for allied health professionals such as physiotherapists, occupational therapists, dietitians, pharmacists, to impact safety and other patient outcomes are plausible and should be explored in future studies.

Because they're worth it? A discussion paper on the value of 12-h shifts for hospital nursing.

The organisation of the 24-h day for hospital nurses in two 12-h shifts has been introduced with value propositions of reduced staffing costs, better quality of care, more efficient work organisation, and increased nurse recruitment and retention. While existing reviews consider the impact of 12-h shifts on nurses' wellbeing and performance, this discussion paper aims to specifically shed light on whether the current evidence supports the value propositions around 12-h shifts. We found little evidence of the value propositions being realised. Staffing costs are not reduced with 12-h shifts, and outcomes related to productivity and efficiency, including sickness absence and missed nursing care are negatively affected. Nurses working 12-h shifts do not perform more safely than their counterparts working shorter shifts, with evidence pointing to a likely negative effect on safe care due to increased fatigue and sleepiness. In addition, nurses working 12-h shifts may have access to fewer educational opportunities than nurses working shorter shifts. Despite some nurses preferring 12-h shifts, the literature does not indicate that this shift pattern leads to increased recruitment, with studies reporting that nurses working long shifts are more likely to express intention to leave their job. In conclusion, there is little if any support for the value propositions that were advanced when 12-h shifts were introduced. While 12-h shifts might be here to stay, it is important that the limitations, including reduced productivity and efficiency, are recognised and accepted by those in charge of implementing schedules for hospital nurses.

The organisation of nurse staffing in intensive care units: A qualitative study.

AIMS: To examine the organisation of the nursing workforce in intensive care units and identify factors that influence how the workforce operates. BACKGROUND: Pre-pandemic UK survey data show that up to 60% of intensive care units did not meet locally agreed staffing numbers and 40% of ICUs were closing beds at least once a week because of workforce shortages, specifically nursing. Nurse staffing in intensive care is based on the assumption that sicker patients need more nursing resource than those recovering from critical illness. These standards are based on historical working, and expert professional consensus, deemed the weakest form of evidence. METHODS: Focus groups with intensive care health care professionals (n = 52 participants) and individual interviews with critical care network leads and policy leads (n = 14 participants) in England between December 2019 and July 2020. Data were analysed using framework analysis. FINDINGS: Three themes were identified: the constraining or enabling nature of intensive care and hospital structures; whole team processes to mitigate nurse staffing shortfalls; and the impact of nurse staffing on patient, staff and intensive care flow outcomes. Staff made decisions about staffing throughout a shift and were influenced by a combination of factors illuminated in the three themes. CONCLUSIONS: Whilst nurse:patient ratios were clearly used to set the nursing establishment, it was clear that rostering and allocation/re-allocation during a shift took into account many other factors, such as patient and family nursing needs, staff well-being, intensive care layout and the experience, and availability, of other members of the multi-professional team. This has important implications for future planning for intensive care nurse staffing and highlights important factors to be accounted for in future research studies. IMPLICATIONS FOR NURSING MANAGEMENT: In order to safeguard patient and staff safety, factors such as the ICU layout need to be considered in staffing decisions and the local business case for nurse staffing needs to reflect these factors. Patient safety in intensive care may not be best served by a blanket 'ratio' approach to nurse staffing, intended to apply uniformly across health services.

Burnout in nursing: a theoretical review.

BACKGROUND: Workforce studies often identify burnout as a nursing 'outcome'. Yet, burnout itself-what constitutes it, what factors contribute to its development, and what the wider consequences are for individuals, organisations, or their patients-is rarely made explicit. We aimed to provide a comprehensive summary of research that examines theorised relationships between burnout and other variables, in order to determine what is known (and not known) about the causes and consequences of burnout in nursing, and how this relates to theories of burnout. METHODS: We searched MEDLINE, CINAHL, and PsycINFO. We included quantitative primary empirical studies (published in English) which examined associations between burnout and work-related factors in the nursing workforce. RESULTS: Ninety-one papers were identified. The majority (n = 87) were cross-sectional studies; 39 studies used all three subscales of the Maslach Burnout Inventory (MBI) Scale to measure burnout. As hypothesised by Maslach, we identified high workload, value incongruence, low control over the job, low decision latitude, poor social climate/social support, and low rewards as predictors of burnout. Maslach suggested that turnover, sickness absence, and general health were effects of burnout; however, we identified relationships only with general health and sickness absence. Other factors that were classified as predictors of burnout in the nursing literature were low/inadequate nurse staffing levels, ≥ 12-h shifts, low schedule flexibility, time pressure, high job and psychological demands, low task variety, role conflict, low autonomy, negative nurse-physician relationship, poor supervisor/leader support, poor leadership, negative team relationship, and job insecurity. Among the outcomes of burnout, we found reduced job performance, poor quality of care, poor patient safety, adverse events, patient negative experience, medication errors, infections, patient falls, and intention to leave. CONCLUSIONS: The patterns identified by these studies consistently show that adverse job characteristics-high workload, low staffing levels, long shifts, and low control-are associated with burnout in nursing. The potential consequences for staff and patients are severe. The literature on burnout in nursing partly supports Maslach's theory, but some areas are insufficiently tested, in particular, the association between burnout and turnover, and relationships were found for some MBI dimensions only.

Temporary Staffing and Patient Death in Acute Care Hospitals: A Retrospective Longitudinal Study.

PURPOSE: To explore the association between the levels of temporary nurse staffing and patient mortality. Achieving adequate nurse staffing levels plays a vital role in keeping patients safe from harm. The evidence around deploying temporary staffing to maintain safe staffing levels is mixed, with some studies reporting no adverse effects on patient mortality. DESIGN: A retrospective longitudinal observational study using routinely collected data on 138,133 patients admitted to a large hospital in the south of England. Data were collected between April 2012 and April 2015. METHODS: We used multilevel survival models to explore the association between in-hospital deaths and daily variation in registered nurse (RN) and nursing assistant (NA) temporary staffing, measured as hours per patient per day. Analyses controlled for unit and patient risk. FINDINGS: Use of temporary staffing was common, with only 24% (n = 7,529) of the 30,980 unit-days having no temporary RN staff and 13% (n = 3,951) having no temporary NAs. The hazard of death was increased by 12% for every day a patient experienced high levels (1.5 hr or more per day) of RN temporary staffing (adjusted hazard ratio [aHR] 1.12, 95% confidence interval [CI] 1.03-1.21). The hazard of death was increased on days when NA temporary staffing was more than 0.5 hr per patient (aHR 1.06; 95% CI 1.03-1.08). CONCLUSIONS: Days with more than 1.5 hr per patient of temporary RNs and days with more than 0.5 hr of temporary NAs were associated with increased hazard of death. CLINICAL RELEVANCE: Heavy reliance on temporary staff is associated with higher risk for patients dying. There is no evidence of harm associated with modest use of temporary RNs so that required staffing levels can be maintained.

12-hr shifts in nursing: Do they remove unproductive time and information loss or do they reduce education and discussion opportunities for nurses? A cross-sectional study in 12 European countries.

AIMS AND OBJECTIVES: To examine the association between registered nurses' (referred to as "nurses" for brevity) shifts of 12 hr or more and presence of continuing educational programmes; ability to discuss patient care with other nurses; assignments that foster continuity of care; and patient care information being lost during handovers. BACKGROUND: The introduction of long shifts (i.e., shifts of 12 hr or more) remains controversial. While there are claims of efficiency, studies have shown long shifts to be associated with adverse effects on quality of care. Efficiency claims are predicated on the assumption that long shifts reduce overlaps between shifts; these overlaps are believed to be unproductive and dangerous. However, there are potentially valuable educational and communication activities that occur during these overlaps. DESIGN: Cross-sectional survey of 31,627 nurses within 487 hospitals in 12 European countries. METHODS: The associations were measured through generalised linear mixed models. The study methods were compliant with the STROBE checklist. RESULTS: When nurses worked shifts of 12 hr or more, they were less likely to report having continuing educational programmes; and time to discuss patient care with other nurses, compared to nurses working 8 hr or less. Nurses working shifts of 12 hr or more were less likely to report assignments that foster continuity of care, albeit the association was not significant. Similarly, working long shifts was associated with reports of patient care information being lost during handovers, although association was not significant. CONCLUSION: Working shifts of 12 hr or more is associated with reduced educational activities and fewer opportunities to discuss patient care, with potential negative consequences for safe and effective care. RELEVANCE TO CLINICAL PRACTICE: Implementation of long shifts should be questioned, as reduced opportunity to discuss care or participate in educational activities may jeopardise the quality and safety of care for patients.

What is the nursing time and workload involved in taking and recording patients' vital signs? A systematic review.

AIMS AND OBJECTIVES: To synthesise evidence regarding the time nurses take to monitor and record vital signs observations and to calculate early warning scores. BACKGROUND: While the importance of vital signs' monitoring is increasingly highlighted as a fundamental means of maintaining patient safety and avoiding patient deterioration, the time and associated workload involved in vital signs activities for nurses are currently unknown. DESIGN: Systematic review. METHODS: A literature search was performed up to 17 December 2019 in CINAHL, Medline, EMBASE and the Cochrane Library using the following terms: vital signs; monitoring; surveillance; observation; recording; early warning scores; workload; time; and nursing. We included studies performed in secondary or tertiary ward settings, where vital signs activities were performed by nurses, and we excluded qualitative studies and any research conducted exclusively in paediatric or maternity settings. The study methods were compliant with the PRISMA checklist. RESULTS: Of 1,277 articles, we included 16 papers. Studies described taking vital signs observations as the time to measure/collect vital signs and time to record/document vital signs. As well as mean times being variable between studies, there was considerable variation in the time taken within some studies as standard deviations were high. Documenting vital signs observations electronically at the bedside was faster than documenting vital signs away from the bed. CONCLUSIONS: Variation in the method(s) of vital signs measurement, the timing of entry into the patient record, the method of recording and the calculation of early warning scores values across the literature make direct comparisons of their influence on total time taken difficult or impossible. RELEVANCE TO CLINICAL PRACTICE: There is a very limited body of research that might inform workload planning around vital signs observations. This uncertainty means the resource implications of any recommendation to change the frequency of observations associated with early warning scores are unknown.

Association between 12-hr shifts and nursing resource use in an acute hospital: Longitudinal study.

AIM: To evaluate whether ≥12-hr shifts are associated with a decrease in resource use, in terms of care hours per patient day and staffing costs per patient day. BACKGROUND: Nurses working long shifts may become less productive and no research has investigated whether potential cost savings are realized. METHOD: A retrospective longitudinal study using routinely collected data from 32 wards within an English hospital across 3 years (1 April 2012-31 March 2015). There were 24,005 ward-days. Hierarchical linear mixed models measured the association between the proportion of ≥12-hr shifts worked on a ward-day, care hours per patient day and staffing costs per patient day. RESULTS: Compared with days with no ≥12-hr shifts, days with between 50% and 75% ≥12-hr shifts had more care hours per patient day and higher costs (estimate for care hours per patient day: 0.32; 95% CI: 0.28-0.36; estimate for staffing costs per patient day: £8.86; 95% CI: 7.59-10.12). CONCLUSIONS: We did not find reductions in total care hours and costs associated with the use of ≥12-hr shifts. The reason why mixed shift patterns are associated with increased cost needs further exploration. IMPLICATIONS FOR NURSING MANAGEMENT: Increases in resource use could result in additional costs or loss of productivity for hospitals. Implementation of long shifts should be questioned.

Are long nursing shifts on hospital wards associated with sickness absence? A longitudinal retrospective observational study.

OBJECTIVE: To investigate whether working 12 hr shifts is associated with increased sickness absence among registered nurses and health care assistants. BACKGROUND: Previous studies reported negative impacts on nurses' 12 hr shifts; however, these studies used cross-sectional techniques and subjective nurse-reported data. METHODS: A retrospective longitudinal study using routinely collected data across 32 general inpatient wards at an acute hospital in England. We used generalized linear mixed models to explore the association between shift patterns and the subsequent occurrence of short (<7 days) or long-term (≥7 days) sickness absence. RESULTS: We analysed 601,282 shifts and 8,090 distinct episodes of sickness absence. When more than 75% of shifts worked in the past 7 days were 12 hr in length, the odds of both a short-term (adjusted odds ratio = 1.28; 95% confidence index: 1.18-1.39) and long-term sickness episode (adjusted odds ratio = 1.22; 95% confidence index: 1.08-1.37) were increased compared with working none. CONCLUSION: Working long shifts on hospital wards is associated with a higher risk of sickness absence for registered nurses and health care assistants. IMPLICATIONS FOR NURSING MANAGEMENT: The higher sickness absence rates associated with long shifts could result in additional costs or loss of productivity for hospitals. The routine implementation of long shifts should be avoided.

The association between nurse staffing and omissions in nursing care: A systematic review.

AIMS: To identify nursing care most frequently missed in acute adult inpatient wards and to determine evidence for the association of missed care with nurse staffing. BACKGROUND: Research has established associations between nurse staffing levels and adverse patient outcomes including in-hospital mortality. However, the causal nature of this relationship is uncertain and omissions of nursing care (referred as missed care, care left undone or rationed care) have been proposed as a factor which may provide a more direct indicator of nurse staffing adequacy. DESIGN: Systematic review. DATA SOURCES: We searched the Cochrane Library, CINAHL, Embase and Medline for quantitative studies of associations between staffing and missed care. We searched key journals, personal libraries and reference lists of articles. REVIEW METHODS: Two reviewers independently selected studies. Quality appraisal was based on the National Institute for Health and Care Excellence quality appraisal checklist for studies reporting correlations and associations. Data were abstracted on study design, missed care prevalence and measures of association. Synthesis was narrative. RESULTS: Eighteen studies gave subjective reports of missed care. Seventy-five per cent or more nurses reported omitting some care. Fourteen studies found low nurse staffing levels were significantly associated with higher reports of missed care. There was little evidence that adding support workers to the team reduced missed care. CONCLUSIONS: Low Registered Nurse staffing is associated with reports of missed nursing care in hospitals. Missed care is a promising indicator of nurse staffing adequacy. The extent to which the relationships observed represent actual failures, is yet to be investigated.

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.

Cross-sectional examination of the association between shift length and hospital nurses job satisfaction and nurse reported quality measures.

BACKGROUND: Twenty-four hour nursing care involves shift work including 12-h shifts. England is unusual in deploying a mix of shift patterns. International evidence on the effects of such shifts is growing. A secondary analysis of data collected in England exploring outcomes with 12-h shifts examined the association between shift length, job satisfaction, scheduling flexibility, care quality, patient safety, and care left undone. METHODS: Data were collected from a questionnaire survey of nurses in a sample of English hospitals, conducted as part of the RN4CAST study, an EU 7th Framework funded study. The sample comprised 31 NHS acute hospital Trusts from 401 wards, in 46 acute hospital sites. Descriptive analysis included frequencies, percentages and mean scores by shift length, working beyond contracted hours and day or night shift. Multi-level regression models established statistical associations between shift length and nurse self-reported measures. RESULTS: Seventy-four percent (1898) of nurses worked a day shift and 26% (670) a night shift. Most Trusts had a mixture of shifts lengths. Self-reported quality of care was higher amongst nurses working ≤8 h (15.9%) compared to those working longer hours (20.0 to 21.1%). The odds of poor quality care were 1.64 times higher for nurses working ≥12 h (OR = 1.64, 95% CI 1.18-2.28, p = 0.003). Mean 'care left undone' scores varied by shift length: 3.85 (≤8 h), 3.72 (8.01-10.00 h), 3.80 (10.01-11.99 h) and were highest amongst those working ≥12 h (4.23) (p < 0.001). The rate of care left undone was 1.13 times higher for nurses working ≥12 h (RR = 1.13, 95% CI 1.06-1.20, p < 0.001). Job dissatisfaction was higher the longer the shift length: 42.9% (≥12 h (OR = 1.51, 95% CI 1.17-1.95, p = .001); 35.1% (≤8 h) 45.0% (8.01-10.00 h), 39.5% (10.01-11.99 h). CONCLUSIONS: Our findings add to the growing international body of evidence reporting that ≥12 shifts are associated with poor ratings of quality of care and higher rates of care left undone. Future research should focus on how 12-h shifts can be optimised to minimise potential risks.

Twelve-hour shifts: burnout or job satisfaction?

Job satisfaction and burnout in the nursing workforce are global concerns. Not only do job satisfaction and burnout affect the quality and safety of care, but job satisfaction is also a factor in nurses' decisions to stay or leave their jobs. Shift patterns may be an important aspect influencing wellbeing and satisfaction among nurses. Many hospitals worldwide are moving to 12-hour shifts in an effort to improve efficiency and cope with nursing shortages. But what is the effect of these work patterns on the wellbeing of nurses working on hospital wards? This article reports on the results of a study performed in 12 European countries exploring whether 12-hour shifts are associated with burnout, job satisfaction and intention to leave the job.

Safe staffing for nursing in emergency departments: evidence review.

OBJECTIVE: Getting staffing levels wrong in hospitals is linked to excess mortality and poor patient experiences but establishing the safe nurse staffing levels in the emergency department (ED) is challenging because patient demand is so variable. This paper reports a review conducted for the National Institute for Health and Care Excellence (NICE) which sought to identify the research evidence to inform UK nursing workforce planning. DESIGN: We searched 10 electronic databases and relevant websites for English language studies published from 1994. Studies included reported a direct measure of nurse staffing relative to an activity measure (eg, attendances, patient throughput) or an estimate of nurse staffing requirements. Randomised or non-randomised trials, prospective or retrospective observational, cross-sectional or correlational studies, interrupted time-series, and controlled before and after studies were considered. RESULTS: We identified 16,132 items via databases and 2193 items through manual and other searching. After title/abstract screening (by one reviewer, checked by a second) 55 studies underwent full assessment by the review team. 18 studies met the inclusion criteria for the NICE review, however 3 simulation studies that reported simulated rather than measured outcomes are not reported here. CONCLUSIONS: The evidence is weak but indicates that levels of nurse staffing in the ED are associated with patients leaving without being seen, ED care time and patient satisfaction. Lower staffing is associated with worse outcomes. There remain significant gaps and in particular a lack of evidence on the impact of staffing on direct patient outcomes and adequate economic analyses to inform decisions about nurse staffing. Given that an association between nurse staffing levels and patient outcomes on inpatient wards has been demonstrated, this gap in the evidence about nurse staffing in EDs needs to be addressed.

Nurses' shift length and overtime working in 12 European countries: the association with perceived quality of care and patient safety.

BACKGROUND: Despite concerns as to whether nurses can perform reliably and effectively when working longer shifts, a pattern of two 12- to 13-hour shifts per day is becoming common in many hospitals to reduce shift to shift handovers, staffing overlap, and hence costs. OBJECTIVES: To describe shift patterns of European nurses and investigate whether shift length and working beyond contracted hours (overtime) is associated with nurse-reported care quality, safety, and care left undone. METHODS: Cross-sectional survey of 31,627 registered nurses in general medical/surgical units within 488 hospitals across 12 European countries. RESULTS: A total of 50% of nurses worked shifts of ≤ 8 hours, but 15% worked ≥ 12 hours. Typical shift length varied between countries and within some countries. Nurses working for ≥ 12 hours were more likely to report poor or failing patient safety [odds ratio (OR)=1.41; 95% confidence interval (CI), 1.13-1.76], poor/fair quality of care (OR=1.30; 95% CI, 1.10-1.53), and more care activities left undone (RR=1.13; 95% CI, 1.09-1.16). Working overtime was also associated with reports of poor or failing patient safety (OR=1.67; 95% CI, 1.51-1.86), poor/fair quality of care (OR=1.32; 95% CI, 1.23-1.42), and more care left undone (RR=1.29; 95% CI, 1.27-1.31). CONCLUSIONS: European registered nurses working shifts of ≥ 12 hours and those working overtime report lower quality and safety and more care left undone. Policies to adopt a 12-hour nursing shift pattern should proceed with caution. Use of overtime working to mitigate staffing shortages or increase flexibility may also incur additional risk to quality.

A literature review on self-care of chronic illness: definition, assessment and related outcomes.

INTRODUCTION: Chronic illnesses care represents a challenging issue for people well-being and future health systems' sustainability. Promotion of self-care is considered a key point for chronically ill patients' care. The aim of this literature was to explore: how self-care of chronic illness has been theoretically defined; how self-care can be assessed in clinical and research settings; what associations exist between self-care and health outcomes of chronically ill patients. RESULTS: A wide range of definitions and terminologies related to self-care of chronic illness has been found in the literature. Although some common elements useful to explain the concept of self-care have been identified, the physical, cognitive, emotional and social processes underlying self-care remain controversial and poorly defined. Valid and reliable disease-specific assessment tools have been developed and used in a growing number of studies; however, the lack of utilization of standardized instruments in clinical practice has been referred by many authors. Significant correlations between self-care of chronic illness and outcome measures e.g. general health status, quality of life and healthcare costs, are reported by a limited number of studies. CONCLUSION: Supporting patient self-care is recognized as a crucial factor in chronic illness care. A deeper analysis of variables and processes influencing self-care could help for a full description of the phenomenon. A systematic evaluation of self-care in health professionals' everyday clinical practice is strongly recommended. The development of general non-disease-specific assessment tools could facilitate the evaluation of complex patients, especially those with multiple co-morbidities. Although self-care has been recognized as a vital intermediate outcome, further large-scale studies clarifying the association between self-care and patients' and health systems' outcomes are needed.

Nursing Team Composition and Mortality Following Acute Hospital Admission.

Importance: Many studies show the adverse consequences of insufficient nurse staffing in hospitals, but safe and effective staffing is unlikely to be just about staff numbers. There are considerable areas of uncertainty, including whether temporary staff can safely make up shortfalls in permanent staff and whether using experienced staff can mitigate the effect of staff shortages. Objective: To explore the association of the composition of the nursing team with the risk of patient deaths. Design, Setting, and Participants: This patient-level longitudinal observational study was conducted in 185 wards in 4 acute hospital trusts in England between April 2015 and March 2020. Eligible participants were patients with an overnight stay and nursing staff on adult inpatient wards. Data analysis was conducted from month April 2022 to June 2023. Exposure: Naturally occurring variation during the first 5 days of hospital admission in exposure to days of low staffing from registered nurses (RNs) and nursing support (NS) staff, the proportion of RNs, proportion of senior staff, and proportion of hospital-employed (bank) and agency temporary staff. Main Outcomes and Measures: The primary outcome was death within 30 days of admission. Mixed-effect Cox proportional hazards survival models were used. Results: Data from 626 313 admissions (319 518 aged ≥65 years [51.0%]; 348 464 female [55.6%]) were included. Risk of death was increased when patients were exposed to low staffing from RNs (adjusted hazard ratio [aHR], 1.08; 95% CI 1.07-1.09) and NS staff (aHR, 1.07; 95% CI, 1.06-1.08). A 10% increase in the proportion of temporary RNs was associated with a 2.3% increase in the risk of death, with no difference between agency (aHR, 1.023; 95% CI, 1.01-1.04) and bank staff (aHR, 1.02; 95% CI, 1.01-1.04). A 10% increase in the proportion of agency NS was associated with a 4% increase in risk of death (aHR, 1.04; 95% CI, 1.02-1.06). Evidence on the seniority of staff was mixed. Model coefficients were used to estimate the association of using temporary staff to avoid low staffing and found that risk was reduced but remained elevated compared with baseline. Conclusions and Relevance: This cohort study found that having senior nurses in the nursing team did not mitigate the adverse outcomes associated with low nurse staffing. These findings indicate that while the benefits of avoiding low staffing may be greater than the harms associated with using temporary staff, particularly for RNs, risk remains elevated if temporary staff are used to fill staffing shortages, which challenges the assumption that temporary staff are a cost-effective long-term solution to maintaining patient safety.

Inpatient midwifery staffing levels and postpartum readmissions: a retrospective multicentre longitudinal study.

BACKGROUND: Preventing readmission to hospital after giving birth is a key priority, as rates have been rising along with associated costs. There are many contributing factors to readmission, and some are thought to be preventable. Nurse and midwife understaffing has been linked to deficits in care quality. This study explores the relationship between staffing levels and readmission rates in maternity settings. METHODS: We conducted a retrospective longitudinal study using routinely collected individual patient data in three maternity services in England from 2015 to 2020. Data on admissions, discharges and case-mix were extracted from hospital administration systems. Staffing and workload were calculated in Hours Per Patient day per shift in the first two 12-hour shifts of the index (birth) admission. Postpartum readmissions and staffing exposures for all birthing admissions were entered into a hierarchical multivariable logistic regression model to estimate the odds of readmission when staffing was below the mean level for the maternity service. RESULTS: 64 250 maternal admissions resulted in birth and 2903 mothers were readmitted within 30 days of discharge (4.5%). Absolute levels of staffing ranged between 2.3 and 4.1 individuals per midwife in the three services. Below average midwifery staffing was associated with higher rates of postpartum readmissions within 7 days of discharge (adjusted OR (aOR) 1.108, 95% CI 1.003 to 1.223). The effect was smaller and not statistically significant for readmissions within 30 days of discharge (aOR 1.080, 95% CI 0.994 to 1.174). Below average maternity assistant staffing was associated with lower rates of postpartum readmissions (7 days, aOR 0.957, 95% CI 0.867 to 1.057; 30 days aOR 0.965, 95% CI 0.887 to 1.049, both not statistically significant). CONCLUSION: We found evidence that lower than expected midwifery staffing levels is associated with more postpartum readmissions. The nature of the relationship requires further investigation including examining potential mediating factors and reasons for readmission in maternity populations.

Safer and more efficient vital signs monitoring protocols to identify the deteriorating patients in the general hospital ward: an observational study.

Background: The frequency at which patients should have their vital signs (e.g. blood pressure, pulse, oxygen saturation) measured on hospital wards is currently unknown. Current National Health Service monitoring protocols are based on expert opinion but supported by little empirical evidence. The challenge is finding the balance between insufficient monitoring (risking missing early signs of deterioration and delays in treatment) and over-observation of stable patients (wasting resources needed in other aspects of care). Objective: Provide an evidence-based approach to creating monitoring protocols based on a patient's risk of deterioration and link these to nursing workload and economic impact. Design: Our study consisted of two parts: (1) an observational study of nursing staff to ascertain the time to perform vital sign observations; and (2) a retrospective study of historic data on patient admissions exploring the relationships between National Early Warning Score and risk of outcome over time. These were underpinned by opinions and experiences from stakeholders. Setting and participants: Observational study: observed nursing staff on 16 randomly selected adult general wards at four acute National Health Service hospitals. Retrospective study: extracted, linked and analysed routinely collected data from two large National Health Service acute trusts; data from over 400,000 patient admissions and 9,000,000 vital sign observations. Results: Observational study found a variety of practices, with two hospitals having registered nurses take the majority of vital sign observations and two favouring healthcare assistants or student nurses. However, whoever took the observations spent roughly the same length of time. The average was 5:01 minutes per observation over a 'round', including time to locate and prepare the equipment and travel to the patient area. Retrospective study created survival models predicting the risk of outcomes over time since the patient was last observed. For low-risk patients, there was little difference in risk between 4 hours and 24 hours post observation. Conclusions: We explored several different scenarios with our stakeholders (clinicians and patients), based on how 'risk' could be managed in different ways. Vital sign observations are often done more frequently than necessary from a bald assessment of the patient's risk, and we show that a maximum threshold of risk could theoretically be achieved with less resource. Existing resources could therefore be redeployed within a changed protocol to achieve better outcomes for some patients without compromising the safety of the rest. Our work supports the approach of the current monitoring protocol, whereby patients' National Early Warning Score 2 guides observation frequency. Existing practice is to observe higher-risk patients more frequently and our findings have shown that this is objectively justified. It is worth noting that important nurse-patient interactions take place during vital sign monitoring and should not be eliminated under new monitoring processes. Our study contributes to the existing evidence on how vital sign observations should be scheduled. However, ultimately, it is for the relevant professionals to decide how our work should be used. Study registration: This study is registered as ISRCTN10863045. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/05/03) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 6. See the NIHR Funding and Awards website for further award information.

Patient recovery in hospital is tracked by measuring heart rate, blood pressure and other 'vital signs' and converting them into a score. These are 'observed' regularly by nursing staff so that deterioration can be spotted early. However, taking observations can disturb patients, and taking them too often causes extra work for staff. More frequent monitoring is recommended for higher scores, but evidence is lacking. To work out how often patients should be monitored, we needed to know how likely it is for patients to become more unwell between observations. We analysed over 400,000 patient records from two hospitals to understand how scores change with time. We looked at three of the most serious risks for patients in hospital. These risks are dying, needing intensive care or having a cardiac arrest. We also looked at the risk that a patient's condition would deteriorate significantly before their measurements were taken again. We identified early signs of deterioration and how changes in vital signs affected the risk of a patient's condition becoming worse. From this we calculated a maximum risk of deterioration. We then calculated different monitoring schedules that keep individual patients below this risk level. Some of those would consume less staff time than current National Health Service guidelines suggest. We also watched staff record patients' vital signs. We learnt it takes about 5 minutes to take these measurements from each patient. This information helped us calculate how costs would change if patients' vital signs were taken more or less often. We found that patients with a low overall score could have their vital signs monitored less often without being in danger of serious harm. This frees up nursing time so that patients with a higher score can be monitored more often. Importantly, this can be achieved without employing more staff.