Background

Unlike the work of physicians, the work of registered nurses (RNs) in hospitals is rarely organized around disease-specific populations. Rather, patients are generally grouped by age and/or intensity of nursing care (eg, pediatrics or intensive care). Adult patients who require the least amount of nursing care (the largest proportion of hospitalized patients), may be separated into medical or surgical units but may also be combined on one unit. Because the work of RNs and other nurses is organized differently than the work of physicians, this chapter explores the literature related to nursing structure and process variables that may affect outcomes that relate to patient safety.

Investigations of patient outcomes in relationship to nurses and their professional responsibilities in hospitals commonly involve structural measures of care^1-4 including numbers of nurses, number of nurse hours, percentage or ratios of nurses to patients, organization of nursing care delivery or organizational culture, nurse workload, nurse stress, or qualification of nurses. Less commonly, studies involve intervention or process measures of care including studies based on the science of nursing and others using nurses as the intervention.^1-5 The use of structural variables rather than process measures to study the impact of nursing activities reflects the greater availability of data relating to the former (often obtainable from administrative sources) compared with the latter (typically requiring chart review of direct observation). A number of structural measures have received considerable attention, specifically measures of staffing levels in the face of major cost cutting and other changes in health care over the past 15-20 years. In 1996, the Institute of Medicine ⁶ reported that there were insufficient data to draw conclusions about the relationship between nurse staffing and inpatient outcomes. However later studies have revisited this issue, allowing us to review the literature relating patient outcomes to various measures of nurse staffing levels, such as full time equivalents (FTEs), skill mix (proportion of RN hours to total hours), or RN hours per patient day.

This chapter does not address patient outcomes as they relate to various "patient classification systems" (PCSs), although the prevalence of the use of such systems deserves mention. PCSs predict nursing care requirements at the individual patient level in order to determine unit staffing, project budgets, define an objective measure for costing out nursing services, and to maintain quality standards. ⁸ Although PCSs are used for multiple purposes, they are an inadequate tool for determining unit staffing on a daily or shift basis.^9-11 In addition, there are numerous patient classification systems^12-14 and most are specific to one hospital or one nursing unit. The validity and reliability of PCSs are inconsistent and the systems cannot be compared with each other.^8-10,15-28 Thus, rather than reviewing studies that analyze various PCS scores to patient outcomes, we review studies addressing the question of whether or not "safe thresholds" exist for levels of nursing care.

Practice Description

The availability of nurses, the organization of nursing care, and the types of nursing interventions vary by institution. Structuring nurse staffing (eg, availability of nurses, organizational models of nursing care) and care interventions to meet "safe thresholds" could be considered a patient safety practice. However, no studies have evaluated thresholds explicitly. This chapter reviews the precursor evidence from observational studies about the strength of the relationship between nursing variables and patient outcomes, so that possible safe thresholds may be inferred. We assess evidence that relates patient outcomes to: 1) specific numbers, proportions, or ratios of nurses to patients (nurse staffing); Nurse availability variables generally characterize the number of hours nurses spend with patients. Typically, the time is not measured for each patient, but rather averages are measured based on the census of nurses to patients at a particular point in time. There are several common ways of accounting for this nurse staffing and no standardized way to measure it (Table 39.1).2) specific organization of nursing care delivery, nursing models of care, or organizational culture; Organization of nursing care variables (Table 39.2) may also include various nursing care delivery models, nursing unit or hospital culture, or governance structures. An issue of governance that has been studied by Aiken ²⁹ and others ³⁰ includes how much autonomy a nurse has to make practice decisions, how much control she has over practice decisions, how much collaboration occurs between physicians and nurse in the organization, and communication patterns; and3) specific nursing interventions; Although nursing interventions are frequently studied in outpatient setting,^31,32-39 perhaps because these venues provide nurses more flexibility to make independent decisions,^40-42 studies in the inpatient setting have included measures of education, training. or retraining of nurses, providing audit data to nurses, and capturing nurse assessment of patient outcomes.

Table

Table 39.1. Measures of nurse staffing.

Table

Table 39.2. Models of nursing care delivery.

The varieties of intevention studies require some comment. Education interventions are popular in nursing research because they involve less risk than interventions that directly involve patients and are more readily approved by hospitals and physicians.^43-51 Unfortunately, some investigators have made the assumption (which led to the failure to measure clinical outcomes) that increasing nursing knowledge or changing a practice, such as handwashing, automatically improves outcomes.^52,46,48,53

Because a large part of a nurse's job is assessment, investigators have used various nursing assessments as interventions, such as fall risk assessment, pressure ulcer risk assessment, or identification of patients at high risk for malnutrition,^55-60 to reduce adverse events. In multidisciplinary protocols, the nursing activity is often assessment, rather than a nursing process or procedure. ⁴⁹

Other process-oriented interventions that lack sufficiently rigorous data to evaluate here, include specialty nurses,^61,62-65 and interventions based on nursing science in the realm of nurse decision making in acute care hospitals (eg, mouth care to reduce mucositis, nonpharmacutical interventions to reduce pain, nausea and vomiting, increase sleep, and improve wound healing).^31,66-73

Prevalence and Severity of the Target Safety Problem

The target safety problems are patient adverse events such as mortality and morbidity. The challenge is to create an optimum practice environment so that nurses can ideally reduce safety problems.

Commonly studied adverse hospital events such as falls (Chapter 26), medication errors (Part III, Section A), and pressure ulcers (Chapter 27), are often used as outcome indicators for nursing practice.^83-90 Less commonly studied are issues related to improving basic symptom management (eg, symptoms related to poor sleep, nutrition, or physical activity, or anxiety, pain, distress and discomfort caused by symptoms, or distress caused by diagnostic tests). In the last decade there has been increasing public and legislative pressure to improve hospital environments and address some of the heretofore ignored issues.^91-93

Opportunities for Impact

Unfortunately, there is no definitive evidence as to specific thresholds for RN or total nursing staff hours per patient day, or nursing skill mix for various patient populations or nursing unit types. The lack of empirical evidence has been problematic for politicians, the public and the nursing community. Because decisions about nurse staffing do not have a scientific basis and are instead based on economics and anecdotes, nurse executives and managers are frequently at odds with staff nurses; especially those represented by labor unions, over staffing. Nurse executives are charged with providing safe patient care at a responsible cost. The need to constrain budgets by reducing nursing hours is in conflict with the needs of the unions and, some allege, in conflict with the needs of patients.

Based in part on some limited data, New York and Massachusetts have passed legislation requiring formulae to be developed that ensure safe patient care.^95,96 New Jersey has regulations which state that licensed nurses shall provide at least 65% of the direct care hours and requires an acuity system for patient classification. ⁹⁷ California Assembly Bill 394 directs the California Department of Health Services to establish nurse-to-patient staffing ratios for acute care hospitals by January 1, 2002. Sixteen states other than California have nurse staffing legislation on the calendar but have not implemented ratios. ⁹⁴

Staffing and ratios are items for collective bargaining and contract negotiations in some areas.^98-104 Registering complains about "unsafe staffing" may be the nurses' only recourse unless there is a negotiated agreement between the union and the hospital.

Current utilization of practices using nursing interventions to make an impact on adverse hospital events is most likely limited due to uncertainty about effectiveness of specific interventions. Resources necessary for conducting systematic studies of nursing care provided in hospitals and then implementing the practices found to be helpful are scarce.^105-109

Study Designs

Searches of MEDLINE from 1990, CINHAL from 1966, documents published by the American Nurses Association, and the Cochrane Collaboration Library identified no randomized clinical trials or non-randomized controlled trials analyzing nurse staffing and adverse events. The study designs for nurse availability (Table 39.3) and organization of care (Table 39.4) are Level 2 or 3 designs. Mitchell et al ¹¹¹ references several randomized trials in her review article. However, the articles mentioned used advanced practice nurses such as clinical nurse specialists, or home care visits as the intervention.^62,112,113 The study by Jorgensen et al ¹¹⁴ was set in a hospital but the comparison was between a specialty stroke unit and a regular care unit. The difference was between the different organization of stroke treatment, not nurse skill mix. The studies abstracted are observational studies that are case control, cohort, before-after, or health services research using data from large public databases.

Table

Table 39.3 Structural measures: availability of nurses and patient outcomes (First 11 studies showed positive associations; final 5 studies detected no significant effect).

Table

Table 39.4 Structural variables: nursing organization models and patient outcomes.

The study designs for nurse interventions (Table 39.5) vary from Level 1 to 3. Five studies use education of nurses as the intervention, and an additional 3 studies cover enhancements to education efforts (ie, providing data to nurses about adverse events in their units).

Table

Table 39.5 Process measures: nurse intervention and patient outcomes.

Study Outcomes

The studies of structural measures reported Level 1 or 2 outcomes, along with various other outcomes such as length of stay, patient satisfaction or nurse satisfaction. Most of the studies corrected for potential confounders and most adjusted outcomes based on patient acuity. The process measure studies vary between Level 2 and 3 outcomes. The studies also often included Level 4 outcomes, such as nurse knowledge, but these did not meet inclusion criteria. Most of the studies used adverse events such as falls, nosocomial infection, pain, phlebitis, medication errors or pressure ulcers as outcomes.

Evidence for Effectiveness of the Practice

Potential for Harm

The potential for harm of patients associated with structural interventions such as too few nurses has been documented.^{83-85,124,125} Studies involving process interventions such as using education of nurses, providing data to nurses, and interventions based on nursing science, seem to have a low probability of harm, but that is as yet unknown.

Costs and Implementation

Few of the abstracted studies mentioned cost, although several measured length of stay as an outcome variable. Pratt et al ⁶³ found no difference in quality of care measures using a 100% RN skill mix and an 80% RN skill mix in 2 wards in one hospital in the United Kingdom. The cost was less with the 80% skill mix but the nurses who worked with less experienced staff reported an increase in workload and increase in stress. California is faced with impending legislated minimum nurse staffing ratios in the acute care hospitals. Based on early studies, ¹⁴⁹ at least 40% of California hospitals may see a negative financial effect because of the need to increase staffing. Additionally, based on a number of predictions,^150,151 there is now, and there will continue to be, a significant shortage of registered nurses in the US. Thus, implementing any increase in RN staffing may be very difficult.

One investigator who provided data to nurses as the intervention related to urinary catheter infection reported an estimated cost savings of $403,000. ⁵⁵ Another investigator who also provided data to nurses related to nosocomial pressure ulcer rates estimated implementation costs but not cost saving. ⁵⁷ The investigator who studied adding an IV team (specialty nurses) reported a savings of $53,000/saved life and $14,000/bloodstream infection. Using clean rather than sterile dressings on open postoperative wounds saved $9.59/dressing with no change in rate of wound healing. Based on these studies, it is likely that some nursing interventions can save costs.

Comment

The studies evaluated in this review include only medical, surgical and ICU nursing units. Other data from more specialized units, the outpatient setting, and those pertaining to subsets of patients tend to mirror the findings of the evidence evaluation, and are cited in this section alongside those abstracted and presented in the evidence tables.

The relationship of hospital environment to patient outcomes is still being debated. However, evidence using hospital-level data indicates increasing the percentage of RNs in the skill mix, increasing RN FTEs or hours per patient day or average daily census is associated with decreased risk-adjusted mortality.^{116,131,152,153} Other studies, also aggregating data to the hospital level, found that increasing RN hours per patient day is associated with decreased nosocomial infection rates,^121,154 decreased urinary tract infections, thrombosis and pulmonary complications in surgical patients, ¹²⁴ decreased pressure ulcers, pneumonia, postoperative infection and urinary tract infection.^122,125 Hunt ¹¹⁷ found that decreasing ratios were related to increasing readmission rates but were not related to mortality rates.

The cost of primary data collection has limited the number of studies using data aggregated to the individual nursing unit. There is some evidence that decreased nurse-to-patient ratios in the ICU was associated with an increase in blood stream infections associated with central venous catheter, ¹²⁶ while an increase in agency nurses was related to other negative patient outcomes. ¹⁵⁶ A study in the NICU setting found understaffing and overcrowding of patients led to an outbreak of Enterobactor cloacae. ¹⁵⁵ In 42 ICUs Shortell et al. found that low nurse turnover was related to shorter length of stay ³⁰ ; in 65 units an increase in nurse absenteeism was related to an increase in urinary tract infection and other patient infections but not to other adverse events. ¹⁵⁷ Amaravadi et al ¹⁵⁸ found that night nurse-to-patient ratio in ICUs in 9 hospitals for a select group of patients who had undergone esophagectomy was not associated with mortality but was associated with a 39% increase in length of stay and higher pneumonia rates, reintubation rates, and septicimia rates. As noted previously, Blegan et al found that as the percentage of RNs per total staff (skill mix) increased there was a decrease in medication errors, decubitus ulcers, and patient complaints up to a skill mix of 85-87% RNs.^83,84

In several studies, increasing skill mix was associated with decreasing falls, length of stay, postoperative complications, nosocomial pneumonia, pressure ulcer rates, urinary tract infection, and postoperative infection.^122-125,130 Several studies with varying sample sizes have found skill mix to be unrelated to mortality.^{111,118,159,160} Others have found skill mix to be unrelated to treatment problems, postoperative complications, unexpected death rates, or unstable condition at discharge ¹²⁹ and found no relationship between skill mix or nursing hours per patient day and medication errors, falls, patient injuries, and treatment errors. ¹⁶¹ In an early study of primary (all RN) and team (skill mix) nursing care delivery models, there was no relationship between percent of RNs and quality of care as measured by nurse report ¹⁶² and in 23 hospitals in the Netherlands, there was no relationship between RN-to-patient ratio and incidence of falls. ⁸⁹

Although mixed, the overall evidence seems to indicate that proportion of RN hours per total hours and richer RN-to-patient ratios likely do not affect 30-day mortality, may be associated with in-hospital mortality, and are probably associated with adverse events such as postoperative complications, nosocomial infection, medication errors, falls, and decubitus ulcers.

Based on recent work, nurse staffing was examined in "best practices" hospitals. This included hospitals recognized by the American Nurses Association's Magnet Hospital program, those commended by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), those listed in USA Today's Top 100 Hospitals, those listed in US News and World Report's set of high-quality hospitals, those noted for having better than expected mortality for heart attacks and newborn readmission rates by the Pacific Business Group on Health (PBGH), and those recognized by the Bay Area Consumer Checkbook for high quality. There is significant variation in nurse staffing among these best practices hospitals. The staffing data for best practices hospitals do not consistently demonstrate that hospitals rated highly for quality of patient care have uniformly richer staffing than do other hospitals. ⁷⁴ Because units within hospitals vary widely in nurse staffing and outcomes, results from data aggregated to the hospital level are difficult to interpret.

At present the literature is insufficient to make a reasoned judgment about organization of the work environment of nurses. Further work is needed in the area of nurse interventions. If there truly is to be an emphasis on reducing adverse events in hospitals and creating hospital environments that promote health and healing, resources for research related to nurses and nursing interventions must be found.

References

1.

Brook RH, McGlynn EA, Cleary PD Quality of health care. Part 2: measuring quality of care. N Engl J Med . 1996;335:966–970. [PubMed: 8782507]

2.

Donabedian A Evaluating the quality of medical care. Milbank Memorial Fund Quarterly . 1966;44:166–203. [PubMed: 5338568]

3.

Donabedian A Promoting quality through evaluating the process of patient care. Med Care . 1968;6:181–202.

4.

Donabedian A Explorations in Quality Assessment and Monitoring. The definition of quality and approaches to its assessment. Ann Arbor, MI: Health Administration Press; 1980.

5.

Donabedian A The quality of care: How can it be assessed? JAMA . 1988;260:1743–1748. [PubMed: 3045356]

6.

Wunderlich GS, Sloan FA, Davis CK Nursing staff in hospitals and nursing homes: Is it adequate? Washington, D.C.: National Academy Press; 1996. [PubMed: 25121200]

7.

Cullum N Identification and analysis of randomised controlled trials in nursing: a preliminary study. Qual Health Care . 1997;6:2–6. [PMC free article: PMC1055436] [PubMed: 10166598]

8.

DeGroot HA Patient Classification System Evaluation: Part 1: Essential System Elements. J of Nurs Admin . 1989;19:30–35. [PubMed: 2723792]

9.

Finnigan S When patient classification systems fail. Aspens Advis Nurse Exec . 1993;8:1–3. [PubMed: 8343303]

10.

Finnigan SA, Abel M, Dobler T, Hudon L, Terry B Automated patient acuity. Linking nursing systems and quality measurement with patient outcomes. J Nurs Adm . 1993;23:62–71. [PubMed: 8509882]

11.

Lawson KO, Formella NM, Smeltzer CH, Walters RM Redefining the purpose of patient classification [published erratum appears in Nurs Econ 1993 Nov-Dec;11(6):382] Nurs Econ . 1993;11:298–302. [PubMed: 8232651]

12.

Cohen MM, O'Brien-Pallas LL, Copplestone C, Wall R, Porter J, Rose DK Nursing workload associated with adverse events in the postanesthesia care unit. Anesthesiology . 1999;91:1882–1890. [PubMed: 10598633]

13.

Garfield M, Jeffrey R, Ridley S An assessment of the staffing level required for a high-dependency unit. Anaesthesia . 2000;55:137–143. [PubMed: 10651674]

14.

Moreno R, Reis Miranda D Nursing staff in intensive care in Europe: the mismatch between planning and practice. Chest . 1998;113:752–758. [PubMed: 9515853]

15.

DeGroot HA Patient classification systems and staffing. Part 2, Practice and process. J Nurs Adm . 1994;24:17–23. [PubMed: 7931682]

16.

DeGroot HA Patient Classification System Evaluation: Part 2, System Selection and Implemention. J of Nurs Admin . 1989;19:24–30. [PubMed: 2760676]

17.

DeGroot HA Patient classification systems and staffing. Part 1, Problems and promise. J Nurs Adm . 1994;24:43–51. [PubMed: 8089717]

18.

Davidhizar R, Mallow GE, Bechtel GA, Giger JN A patient classification system for the chronic psychiatric patient. Aust N Z J Ment Health Nurs . 1998;7:126–133. [PubMed: 10095462]

19.

Detwiler C, Clark MJ Acuity classification in the urgent care setting. J Nurs Adm . 1995;25:53–61. [PubMed: 7844633]

20.

Dunbar LJ, Diehl BC Developing a patient classification system for the pediatric rehabilitation setting. Rehabil Nurs . 1995;20:328–332. [PubMed: 7494947]

21.

Freund L, Burrows-Hudson S, Preisig P Development of a patient classification system for chronic hemodialysis patients. Am J Kidney Dis . 1998;31:818–829. [PubMed: 9590192]

22.

Giovannetti P, Johnson JM A new generation of patient classification system. JONA . 1990;20:33–40. [PubMed: 2335788]

23.

Godin M A patient classification system for the hemodialysis setting. Nurs Manage . 1995;26:66–67. [PubMed: 7478373]

24.

Lovett RB, Reardon MB, Gordon BK, McMillan S Validity and reliability of medical and surgical oncology patient acuity tools. Oncol Nurs Forum . 1994;21:1709–1717. [PubMed: 7854933]

25.

Lovett RB, Wagner L, McMillan S Validity and reliability of a pediatric hematology oncology patient acuity tool. J Pediatr Oncol Nurs . 1991;8:122–130. [PubMed: 1930802]

26.

O'Brien-Pallas L, Irvine D, Peereboom E, Murray M Measuring nursing workload: understanding the variability. Nursing Economics . 1997;15:171–182. [PubMed: 9282029]

27.

O'Brien-Pallas LL, Cockerill RW Satisfaction with nursing workload systems: report of a survey of Canadian hospitals. Part B. Can J Nurs Adm. . 1990;3:23–26. [PubMed: 2268658]

28.

Walts LM, Kapadia AS Patient classification system: an optimization approach. Health Care Manage Rev . 1996;21:75–82. [PubMed: 8922967]

29.

Aiken LH, Smith HL, Lake ET Lower Medicare mortality among a set of hospitals known for good nursing care. Med Care . 1994;32:771–787. [PubMed: 8057694]

30.

Shortell SM, Zimmerman JE, Rousseau DM, et al The performance of intensive care units: does good management make a difference? Medical Care . 1994;32:508–525. [PubMed: 8182978]

31.

Dodd MJ, Dibble SL, Miaskowski C, et al Randomized clinical trial of the effectiveness of 3 commonly used mouthwashes to treat chemotherapy-induced mucositis. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics . 2000;90:39–47. [PubMed: 10884634]

32.

Robertson R, Samuelson C Should nurse patient ratios be legislated? - Pros and cons - Georgia Nursing . 1996;56:–.

33.

Shoemake A Solutions to the home healthcare nursing shortage. Home Healthc Nurse . 1994;12:35–39. [PubMed: 7960869]

34.

Davis MA, Freeman JW Excess demand and cost relationships among Kentucky nursing homes. Health Care Financ Rev . 1994;15:137–152. [PMC free article: PMC4193438] [PubMed: 10138482]

35.

Carr EC Talking on the telephone with people who have experienced pain in hospital: clinical audit or research? J Adv Nurs . 1999;29:194–200. [PubMed: 10064299]

36.

Waterman H, Waterman C Trends in ophthalmology services, nursing skill-mix and education: 2nd national survey. J Adv Nurs . 1999;30:942–949. [PubMed: 10520108]

37.

Miskella C, Avis M Care of the dying person in the nursing home: exploring the care assistants' contribution including commentary by Froggatt K and Sale DNT. European Journal of Oncology Nursing . 1998;2:80–88.

38.

Eliopoulos C Nurse staffing in long-term care facilities: the case against a high ratio of RNs. J Nurs Adm . 1983;13:29–31. [PubMed: 6413664]

39.

Gagnon AJ, Edgar L, Kramer MS, Papageorgiou A, Waghorn K, Klein MC A randomized trial of a program of early postpartum discharge with nurse visitation. Am J Obstet Gynecol . 1997;176:205–211. [PubMed: 9024115]

40.

Cumbey DA, Alexander JW The relationship of job satisfaction with organizational variables in public health nursing. J Nurs Adm . 1998;28:39–46. [PubMed: 9601492]

41.

Schmidt CE, Gillies DA, Biordi D, Child DA Marketing the home healthcare agency. Do nurses and physicians agree? J Nurs Adm . 1990;20:9–17. [PubMed: 2231016]

42.

Jansen PGM, Kerkstra A, Abu-Saad HH, van der Zee J Models of differentiated practice and specialization in community nursing: a review of the literature. J Adv Nurs . 1996;24:968–980. [PubMed: 8933257]

43.

Carey RG, Teeters JL CQI case study: reducing medication errors. Jt Comm J Qual Improv . 1995;21:232–237. [PubMed: 7663629]

44.

Dinc L, Erdil F The effectiveness of an educational intervention in changing nursing practice and preventing catheter-related infection for patients receiving total parenteral nutrition. Int J Nurs Stud . 2000;37:371–379. [PubMed: 10785528]

45.

Cohran J, Larson E, Roach H, Blane C, Pierce P Effect of intravascular surveillance and education program on rates of nosocomial bloodstream infections. Heart Lung . 1996;25:161–164. [PubMed: 8682688]

46.

Flynn ER, Wolf ZR, McGoldrick TB, Jablonski RA, Dean LM, McKee EP Effect of three teaching methods on a nursing staff's knowledge of medication error risk reduction strategies. J Nurs Staff Dev . 1996;12:19–26. [PubMed: 8699272]

47.

Lundgren A, Wahren LK Effect of education on evidence-based care and handling of peripheral intravenous lines. J Clin Nurs . 1999;8:577–585. [PubMed: 10786531]

48.

Gould D, Chamberlain A The use of a ward-based educational teaching package to enhance nurses' compliance with infection control procedures. J Clin Nurs . 1997;6:55–67. [PubMed: 9052110]

49.

Hendryx MS, Fieselmann JF, Bock MJ, Wakefield DS, Helms CM, Bentler SE Outreach education to improve quality of rural ICU care. Results of a randomized trial. Am J Respir Crit Care Med . 1998;158:418–23. [PubMed: 9700115]

50.

Kite K Changing mouth care practice in intensive care: implications of the clinical setting context. Intensive Crit Care Nurs . 1995;11:203–209. [PubMed: 7670288]

51.

Knoblauch SC, Wilson CJ Clinical outcomes of educating nurses about pediatric pain management. Outcomes Manag Nurs Pract . 1999;3:87–89. [PubMed: 10427245]

52.

Spetz J, Coffman J Maintaining an adequate supply of registered nurses in California: the case for increased public investment in nursing education [abstract] Abstract Book / Association for Health Services Research . 1999:426–427.

53.

Barnason S, Merboth M, Pozehl B, Tietjen MJ Utilizing an outcomes approach to improve pain management by nurses: a pilot study. Clin Nurse Spec . 1998;12:28–36. [PubMed: 9481262]

54.

Fernandez-Perez C, Tejada J, Carrasco M Multivariate time series analysis in nosocomial infection surveillance: a case study. Int J Epidemiol . 1998;27:282–288. [PubMed: 9602411]

55.

Goetz AM, Kedzuf S, Wagener M, Muder RR Feedback to nursing staff as an intervention to reduce catheter-associated urinary tract infections. Am J Infect Control . 1999;27:402–404. [PubMed: 10511486]

56.

Huda A, Wise LC Evolution of compliance within a fall prevention program. J Nurs Care Qual . 1998;12:55–63. [PubMed: 9447803]

57.

Moore SM, Wise L Reducing nosocomial pressure ulcers. J Nurs Adm . 1997;27:28–34. [PubMed: 9379238]

58.

Frykberg RG The team approach in diabetic foot management. Adv Wound Care . 1998;11:71–77. [PubMed: 9729937]

59.

Gunningberg L, Lindholm C, Carlsson M, Sjoden PO Implementation of risk assessment and classification of pressure ulcers as quality indicators for patients with hip fractures. J Clin Nurs . 1999;8:396–406. [PubMed: 10624256]

60.

Rubenstein LZ, Robbins AS, Josephson KR, Schulman BL, Osterweil D The value of assessing falls in an elderly population. A randomized clinical trial. Ann Intern Med . 1990;113:308–316. [PubMed: 2115755]

61.

Meier PA, Fredrickson M, Catney M, Nettleman MD Impact of a dedicated intravenous therapy team on nosocomial bloodstream infection rates. Am J Infect Control . 1998;26:388–392. [PubMed: 9721390]

62.

Naylor M, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, Pauly M Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. Ann Intern Med . 1994;120:999–1006. [PubMed: 8185149]

63.

Pratt R, Burr G, Leelarthaepin B, Blizard P, Walsh S The effects of All-RN and RN-EN staffing on the quality and cost of patient care. Aust J Adv Nurs . 1993;10:27–39. [PubMed: 8240762]

64.

Ridsdale L, Kwan I, Cryer C Newly diagnosed epilepsy: can nurse specialists help? A randomized controlled trial. Epilepsy Care Evaluation Group. Epilepsia . 2000;41:1014–1019. [PubMed: 10961629]

65.

York R, Brown LP, Samuels P, et al A randomized trial of early discharge and nurse specialist transitional follow-up care of high-risk childbearing women. Nursing Research . 1997;46:254–261. [PubMed: 9316597]

66.

Evans ML, Dick MJ, Shields DR, Shook DM, Smith MB Postpartum sleep in the hospital. Relationship to taking-in and taking-hold. Clin Nurs Res . 1998;7:379–389. [PubMed: 9919094]

67.

Mock V, Dow KH, Meares CJ, et al Effects of exercise on fatigue, physical functioning, and emotional distress during radiation therapy for breast cancer. Oncol Nurs Forum . 1997;24:991–1000. [PubMed: 9243585]

68.

Sheely LC Sleep disturbances in hospitalized patients with cancer. Oncol Nurs Forum . 1996;23:109–111. [PubMed: 8628701]

69.

ter Riet G, Kessels AG, Knipschild PG Randomized clinical trial of ascorbic acid in the treatment of pressure ulcers. J Clin Epidemiol . 1995;48:1453–1460. [PubMed: 8543959]

70.

Hardyck C, Petrinovich L Reducing urinary tract infections in catheterized patients. Ostomy/Wound Management . 1998;44:36–8, 40, 42-43. [PubMed: 10026547]

71.

Stotts NA, Barbour S, Griggs K, et al Sterile versus clean technique in postoperative wound care of patients with open surgical wounds: a pilot study. J Wound Ostomy Continence Nurs . 1997;24:10–18. [PubMed: 9204846]

72.

Wipke-Tevis DD, Stotts NA Effect of dressings on saphenous vein harvest incision pain, distress and cosmetic result. Prog Cardiovasc Nurs . 1998;13:3–13. [PubMed: 9950019]

73.

Gilcreast DM, Stotts NA, Froelicher ES, Baker LL, Moss KM Effect of electrical stimulation on foot skin perfusion in persons with or at risk for diabetic foot ulcers. Wound Repair Regen . 1998;6:434–441. [PubMed: 9844163]

74.

Spetz J, Seago JA, Coffman J, Rosenoff E, O'Neil E Minimum Nurse Staffing Ratios in California Acute Care Hosptials. San Francisco, CA: University of California, San Francisco Center for the Health Professions; 2000.

75.

Rogut L, Hudson A Meeting patients' needs: quality care in a changing environment. Pap Ser United Hosp Fund N Y . 1995:1–33. [PubMed: 10164376]

76.

Minion M, Ogden C, Brune D Patient and staff needs drive changes on a postsurgical unit. Nurs Adm Q . 1994;18:18–28. [PubMed: 8196854]

77.

[No authors listed.] Managed care and nursing: a view from the front lines. Massachusetts Nurse . 1995;65:4, 10–11.

78.

Seago JA, Faucett J Job strain among registered nurses and other hospital workers. J Nurs Adm . 1997;27:19–25. [PubMed: 9159610]

79.

Seago JA Evaluation of work redesign: Patient focused care. J Nurs Adm . 1999;29:31–38. [PubMed: 10565318]

80.

Sochalski J, Aiken LH, Fagin C Hospital Restructuring in the United States, Canada, and Western Europe: An Outcomes Research Agenda. Med Care . 1997;35:OS13–25. [PubMed: 9339773]

81.

Sochalski J, Boulis A, Shamian J, Buchan J, Muller-Mundt G Lessons for restructuring the nursing workforce in North American and European hospitals [abstract] Abstract Book / Association for Health Services Research . 1997;14:207–208.

82.

Weinberg DB Why aare the nurses crying? Restructuring, power, an dcontrol in an American hospital. Boston, MA: Harvard; 2000.

83.

Blegen MA, Goode CJ, Reed L Nurse staffing and patient outcomes. Nurs Res . 1998;47:43–50. [PubMed: 9478183]

84.

Blegen MA, Vaughn T A multisite study of nurse staffing and patient occurrences. Nursing Economics . 1998;16:196–203. [PubMed: 9748985]

85.

McCloskey JM Nurse staffing and patient outcomes. Nursing Outlook . 1998;46:199–200. [PubMed: 9805336]

86.

Reed L, Blegen MA, Goode CS Adverse patient occurrences as a measure of nursing care quality. J Nurs Adm . 1998;28:62–69. [PubMed: 9601494]

87.

Stevenson B, Mills EM, Welin L, Beal KG Falls risk factors in an acute-care setting: a retrospective study. Can J Nurs Res . 1998;30:97–111. [PubMed: 9726185]

88.

Sutton JC, Standen PJ, Wallace WA Patient accidents in hospital: incidence, documentation and significance. Br J Clin Pract . 1994;48:63–66. [PubMed: 8024991]

89.

Tutuarima JA, de Haan RJ, Limburg M Number of nursing staff and falls: a case-control study on falls by stroke patients in acute-care settings. J Adv Nurs . 1993;18:1101–1105. [PubMed: 8370900]

90.

Wolf ZR, McGoldrick TB, Flynn ER, Warwick F Factors associated with a perceived harmful outcome from medication errors: a pilot study. J Contin Educ Nurs . 1996;27:65–74. [PubMed: 8698929]

91.

Medicare. Available at: www.state.ia.us/ins/shiip/resources.html. Accessed June 23, 2001.

92.

Available at: http://www​.health.state.ri.us//. Accessed June, 23 2001.

93.

Available at: www.healthscope.org/hospital/where.asp. Accessed June 30, 2001.

94.

Denby C, Hogan N Retaining Nursing Talent. In: Company TAB, ed. The Journey Begins. Atlanta, GA; 1999.

95.

Ballard K Legislating Patient Advocacy: Nurse Staffing Ratios. In: Curtin L, ed. A Staffing Crisis: Nurse/Patient Ratios. Washington, DC; 2000.

96.

Ober S Legislating Patient Advocacy: Nurse Staffing Ratios. In: Curtin L, ed. Staffing Crisis: Nurse/Patient Ratios. Washington, DC; 2000.

97.

[No authors listed.] 1997 NJSNA annual survey. New Jersey Nurse . 1997;27:–.

98.

[No authors listed.] Staffing is the top prioirty for MNA bargaining units. Massachusetts Nurse . 1999;69:–.

99.

[No authors listed.] MNA members take to the streets for safe patient care. Massachusetts Nurse . 1999;69:–.

100.

[No authors listed.] Staffing is the top priority for MNA bargaining units. Massachusetts Nurse . 1999;69:–.

101.

[No authors listed.] New study confirms critical role of low nurse-to-patient ratio. Massachusetts Nurse . 1999;69:–.

102.

[No authors listed.] Maryland RNs win big in a pact that sets patient-load lilmits. Am J Nurs . 1990;127:–.

103.

[No authors listed.] Cape Cod Hospital RNs ratify landmark agreement. Massachusetts Nurse . 1997;67:1–2.

104.

[No authors listed.] Ratio ruckus. Modern Healthcare . 1998;28:–. [PubMed: 10187320]

105.

Alexander JW, Bauerschmidt AD Implications for nursing administration of the relationship of technology and structure to quality of care. Nurs Adm Q . 1987;11:1–10. [PubMed: 3649587]

106.

Currell R, Wainwright P, Urquhart C Nursing record systems: effects on nursing practice and health care outcomes (Cochrane Review). In: The Cochrane Library, Issue 4, 2000. Oxford. [PubMed: 10796679]

107.

Curtin LL Nursing productivity: from data to definition. Nurs Manag . 1995;26:25, 28–29, 32-36. [PubMed: 7731592]

108.

Kovner C, Rosenfeld P Practice and employment trends among nurse practitioners in New York State. J N Y State Nurses Assoc . 1997;28:4–8. [PubMed: 9564356]

109.

Park HA, Park JH Development of a computerized patient classification and staffing system. Stud Health Technol Inform . 1997;46:508–511. [PubMed: 10175451]

110.

Spetz J The measurement of technology in studies of the hospital industry [abstract] Ahsr and Fhsr Annual Meeting Abstract Book . 1996;13:–.

111.

Mitchell PH, Shortell SM Adverse outcomes and variations in organization of care delivery. Med Care . 1997;35:NS19–32. [PubMed: 9366876]

112.

Brooten D, Roncoli M, Finkler S, Arnold L, Cohen A, Mennuti M A randomized trial of early hospital discharge and home follow-up of women having cesarean birth. Obstet Gynecol . 1994;84:832–838. [PMC free article: PMC3694422] [PubMed: 7936522]

113.

Alexander JS, Younger RE, Cohen RM, Crawford LV Effectiveness of a nurse-managed program for children with chronic asthma. J Pediatr Nurs . 1988;3:312–317. [PubMed: 3171895]

114.

Jorgensen HS, Kammersgaard LP, Houth J, et al Who benefits from treatment and rehabilitation in a stroke Unit? A community-based study. Stroke . 2000;31:434–439. [PubMed: 10657419]

115.

Aiken LH, Sloane DM, Lake ET, Sochalski J, Weber AL Organization and outcomes of inpatient AIDS care. Med Care . 1999;37:760–772. [PubMed: 10448719]

116.

Hartz AJ, Krakauer H, Kuhn EM, et al Hospital characteristics and mortality rates. N Engl J Med . 1989;321(25):1720–1725. [PubMed: 2594031]

117.

Hunt J, Hagen S Nurse to patient ratios and patient outcomes. Nursing Times . 1998;94:63–66. [PubMed: 9919285]

118.

Robertson RH, Hassan M Staffing intensity, skill mix and mortality outcomes: the case of chronic obstructive lung disease. Health Services Management Research . 1999;12:258–268. [PubMed: 10622804]

119.

Hagen S, Hunt J Investigating the relationship between nurse: patient ratios and patient outcomes using nationally collected data [abstract] Abstract Book / Association for Health Services Research . 1998;15:–.

120.

Hunt J, Hagen S Nurse to patient ratios and patient outcomes. Nurs Times . 1998;94:63–66. [PubMed: 9919285]

121.

Needleman J, Buerhaus PI, Mattke S, Stewart M, Zelevinsky K Nurse Staffing and Patient Outcomes in Hospitals. Boston, MA: US Department of Health and Human Services, Health Resources and Service Administration; 2001.

122.

Implementing nursing's report card: A study of RN staffing, length of stay, and patient outcomes. Washington, DC: American Nurses Publishing; 1997:32.

123.

Nurse Staffing and Patient Outcomes in the Inpatient Hospital Setting. Washington, DC: American Nurses Publishing; 2000:53.

124.

Kovner C, Gergen PJ Nurse staffing levels and adverse events following surgery in U.S. hospitals. Image J Nurs Sch . 1998;30:315–321. [PubMed: 9866290]

125.

Lichtig LK, Knauf RA, Milholland DK Some impacts of nursing on acute care hospital outcomes. J Nurs Adm . 1999;29:25–33. [PubMed: 10029799]

126.

Fridkin SK, Pear SM, Williamson TH, Galgiani JN, Jarvis WR The role of understaffing in central venous catheter-associated bloodstream infections. Infect Control Hosp Epidemiol . 1996;17:150–158. [PubMed: 8708352]

127.

Flood SD, Diers D Nurse staffing, patient outcome and cost. Nurs Manag . 1988;19:34–35, 38-39, 42-43. [PubMed: 3368147]

128.

Kuhn EM, Hartz AJ, Gottlieb MS, Rimm AA The relationship of hospital characteristics and the results of peer review in six large states. Med Care . 1991;29:1028–1038. [PubMed: 1921522]

129.

Wan TT, Shukla RK Contextual and organizational correlates of the quality of hospital nursing care. QRB Qual Rev Bull . 1987;13:61–64. [PubMed: 3104860]

130.

Grillo-Peck AM, Risner PB The Effect of a Partnership Model on Quality and Length of Stay. Nursing Economics . 1995;13:367–374. [PubMed: 8538811]

131.

Pierce SF Nurse-sensitive health care outcomes in acute care settings: an integrative analysis of the literature. Journal of Nursing Care Quality . 1997;11(4):60–72. [PubMed: 9097521]

132.

Czaplinski C, Diers D The effect of staff nursing on length of stay and mortality. Med Care . 1998;36:1626–1638. [PubMed: 9860053]

133.

Aiken LH, Sloane DM Effects of specialization and client differentiation on the status of nurses: the case of AIDS. J Health Soc Behav . 1997;38:203–222. [PubMed: 9343961]

134.

Aubert RE, Herman WH, Waters J, et al Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization. A randomized, controlled trial. Ann Intern Med . 1998;129:605–612. [PubMed: 9786807]

135.

Borkowski V Implementation of a managed care model in an acute care setting. J Healthc Qual . 1994;16:25–27, 30. [PubMed: 10132202]

136.

Clark JM, Maben J Health promotion in primary health care nursing: the development of quality indicators. Health Educ J . 1999;58:99–119.

137.

Dring R, Hiott B, Elliott K Case management: a case study. J Neurosci Nurs . 1994;26:166–169. [PubMed: 7963822]

138.

Jones J, Rowan K Is there a relationship between the volume of work carried out in intensive care and its outcome? Int J Technol Assess Health Care . 1995;11:762–769. [PubMed: 8567208]

139.

Strzalka A, Havens DS Nursing care quality: comparison of unit-hired, hospital float pool, and agency nurses. J Nurs Care Qual . 1996;10:59–65. [PubMed: 8783546]

140.

Westcott E, Dunn V An exploration of the value of specialist neurosurgical nurses... including commentary by Northcott N. NT Research . 1998;3:421–431. [PubMed: 9866582]

141.

Gilbert M, Counsell C Planned change to implement a restraint reduction program. Published erratum appears in J Nurs Care Qual 1999;13. J Nurs Care Qual . 1999;13:57–64. [PubMed: 10343480]

142.

von Koch L, Widen Holmqvist L, Kostulas V, Almazan J, de Pedro-Cuesta J A randomized controlled trial of rehabilitation at home after stroke in Southwest Stockholm: outcome at six months. Scand J Rehabil Med . 2000;32:80–86. [PubMed: 10853722]

143.

Wagner EH, LaCroix AZ, Grothaus L, et al Preventing disability and falls in older adults: a population-based randomized trial. Am J Public Health . 1994;84:1800–1806. [PMC free article: PMC1615188] [PubMed: 7977921]

144.

Day G, Hindmarsh J, Hojna C, Roy G, Ventimiglia N Improving medication administration through an enhanced occurrence reporting system. J Nurs Care Qual . 1994;9:51–56. [PubMed: 7994071]

145.

Mendelson MH, Short LJ, Schechter CB, et al Study of a needleless intermittent intravenous-access system for peripheral infusions: analysis of staff, patient, and institutional outcomes. Infect Control Hosp Epidemiol . 1998;19:401–406. [PubMed: 9669621]

146.

Rush J, Fiorino-Chiovitti R, Kaufman K, Mitchell A A randomized controlled trial of a nursery ritual: wearing cover gowns to care for healthy newborns. Birth . 1990;17:25–30. [PubMed: 2189428]

147.

Gilbert B Facts, not myths. Study shows for-profit hospital conversions help communities by injecting capital. Mod Healthc . 1997:–. [PubMed: 10174122]

148.

Moore MM, Nguyen D, Nolan SP, et al Interventions to reduce decibel levels on patient care units. Am Surg . 1998;64:894–899. [PubMed: 9731822]

149.

Spetz J Hospital use of nursing personnel: holding steady through the 1990s. J Nurs Adm . 2000;30:344–346. [PubMed: 10953691]

150.

Coffman J, Spetz J Maintaining an adequate supply of RNs in California. Image J Nurs Sch . 1999;31:389–393. [PubMed: 10628107]

151.

Coffman J, Spetz J, Seago JA, Rosenoff E, O;Neil E Nursing in California: A Workforce in Crisis. San Francisco, CA: UCSF Center for the Health Professions; 2001:91.

152.

Aiken LH, Smith HL, Lake ET Lower medicare mortality among a set of hospitals known for good nursing care. Med Care . 1994;32:771–787. [PubMed: 8057694]

153.

Aiken LH, Clarke SP, Sloane DM Hospital Restructuring: Does it Adversely Affect Care and Outcomes? J Nurs Adm. 2000. pp. 457–65. [PMC free article: PMC436279] [PubMed: 11045104]

154.

Archibald LK, Manning ML, Bell LM, Banerjee S, Jarvis WR Patient density, nurse-to-patient ratio and nosocomial infection risk in a pediatric cardiac intensive care unit. Pediatr Infect Dis J . 1997;16:1045–1048. [PubMed: 9384337]

155.

Harbarth S, Sudre P, Dharan S, Cadenas M, Pittet D Outbreak of Enterobacter cloacae related to understaffing, overcrowding, and poor hygiene practices. Infect Control Hosp Epidemiol . 1999;20:598–603. [PubMed: 10501256]

156.

Robert J, Fridkin SK, Blumberg HM, et al The influence of the composition of the nursing staff on primary bloodstream infection rates in a surgical intensive care unit. Infect Control Hosp Epidemiol . 2000;21:12–17. [PubMed: 10656348]

157.

Taunton RL, Kleinbeck SV, Stafford R, Woods CQ, Bott MJ Patient outcomes. Are they linked to registered nurse absenteeism, separation, or work load? J Nurs Adm . 1994;24:48–55. [PubMed: 8068081]

158.

Amaravadi RK, Dimick JB, Pronovost PJ, Lipsett PA ICU nurse-to-patient ratio is associated with complications and resource use after esophagectomy. Intensive Care Med . 2000;26:1857–1862. [PubMed: 11271096]

159.

Silber JH, Rosenbaum PR, Ross RN Comparing the contributions of groups of predictors: which outcomes vary with hospital rather than patient characteristics? Journalof the American Statistical Association . 1995;90:7–18.

160.

Zimmerman JE, Shortell SM, Knaus WA, et al Value and cost of teaching hospitals: a prospective, multicenter, inception cohort study. Crit Care Med . 1993;21:1432–1442. [PubMed: 8403950]

161.

Wan TT Hospital variations in adverse patient outcomes. Qual Assur Util Rev . 1992;7:50–53. [PubMed: 1530718]

162.

Shukla R Structure vs. people in primary nursing: An inquiry. Nursing Research . 1981;30:236–241. [PubMed: 6909733]