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Amid the Covid-19 Pandemic, there are increasing reports of the health workforce experiencing adverse outcomes including fatigue, presenteeism and burnout, which have serious safety implications. In this paper we discuss issues of measurement around the phenomena of fatigue, burnout and presenteeism and burnout, and propose a way forward to assess and reduce the negative impact of these on systems’ safety.

BackgroundExtensive research shows associations between increased nurse staffing, skill mix and patient outcomes. However, showing that improved staffing levels are linked to improved outcomes is not sufficient to provide a case for increasing them. This review of economic studies in acute hospitals aims to identify costs and consequences associated with different nurse staffing configurations in hospitals.MethodsWe included economic studies exploring the effect of variation in nurse staffing. We searched PubMed, CINAHL, Embase Econlit, Cochrane library, DARE, NHS EED and the INAHTA website. Risk of bias was assessed using a framework based on the NICE guidance for public health reviews and Henrikson’s framework for economic evaluations. Inclusion, data extraction and critical appraisal were undertaken by pairs of reviewers with disagreements resolved by a third. Results were synthesised using a hierarchical matrix to summarise findings of economic evaluationsResultsWe found 22 observational studies conducted in the USA (15), Australia, Belgium, China, South Korea and the United Kingdom (3). Fourteen had high risk of bias and eight moderate. Six studies clearly favoured increased registered nurse staffing with improved outcomes and reduced or unchanged net costs, but most showed increased costs and outcomes. Studies undertaken outside the USA showed that increased nurse staffing was likely to be cost-effective at a per capita GDP threshold or lower. Three studies of skill mix favoured increased registered nurse skill mix, with reduced net cost and similar or improved outcomes.DiscussionDespite the risk of bias, evidence is largely consistent and strongly favours increased skill mix. Evidence for the cost-effectiveness of increases in registered nurse staffing is less certain although it is likely to be cost-effective. In an era of registered nurse scarcity, the results strongly favour investment in registered nurse supply as opposed to using lesser qualified staff as substitutes.What is already known?Higher registered nurse staffing levels and skill mix in acute hospitals are associated with improved care quality and patient outcomes, most notably reduced risk of deathPrevious reviews of evidence strongly support a causal interpretation, but reviews of economic evidence have failed to reach firm conclusions.What is study addsDespite limitations in the evidence, results favour a richer registered nurse skill mix in the nursing workforce as an economically dominant strategy and increases in registered nurse staffing could be cost effective at a low thresholdHow this study might affect research practice or policyWorkforce substitution is unlikely to provide a cost-effective solution to registered nurse shortages.More incremental cost effectiveness studies are required to guide decision making in context as specific results do not generaliseCREDiT (author contributions)Jane Ball, Chiara Dall’Ora, Peter Griffiths, Jeremy Jones, Paul Meredith acquired funding for the study Peter Griffiths, Jeremy Jones, Christina Saville designed the review and wrote the protocolChristina Saville undertook the searchesJane Ball, Jeremy Jones, Paul Meredith, Lesley Turner, Christina Saville undertook screening and application of the inclusion criteriaJane Ball, Chiara Dall’Ora, Peter Griffiths, Jeremy Jones, Paul Meredith, Lesley Turner, Christina Saville undertook data extraction and critical appraisal of included studiesChristina Saville and Peter Griffiths prepared the first draft of the paperPeter Griffiths undertook data synthesis and drafted resultsJane Ball, Chiara Dall’Ora, Peter Griffiths, Jeremy Jones, Paul Meredith, Lesley Turner, Christina Saville reviewed the first draft and provided critical comment and contribution to the discussion / suggested revisions.All reviewed the final draftRegistrationPROSPERO (CRD42021281202).

The risk of adverse patient outcomes,including death, is lower in hospitals thatprovide more registered nurses to carefor patients on inpatient wards. The association has been demonstrated in a bodyof evidence comprising several hundredstudies, involving hundreds of hospitals andmillions of patients from around the world.The association has been shown at hospitallevel in large cross-sectional studies and ina growing number of longitudinal studiesexamining the effect of variation in staffingexperienced by individuals.1–3 In the contextof such an extensive body of evidence, onemight ask what could possibly be left todiscover?

ObjectivesExamine the association between multiple clinical staff levels and case-mix adjusted patient mortality in English hospitals. Most studies investigating the association between hospital staffing levels and mortality have focused on single professional groups, in particular nursing. However, single staff group studies might overestimate effects or neglect important contributions to patient safety from other staff groups.DesignRetrospective observational study of routinely available data.Setting and participants138 National Health Service hospital trusts that provided general acute adult services in England between 2015 and 2019.Outcome measureStandardised mortality rates were derived from the Summary Hospital level Mortality Indicator data set, with observed deaths as outcome in our models and expected deaths as offset. Staffing levels were calculated as the ratio of occupied beds per staff group. We developed negative binomial random-effects models with trust as random effects.ResultsHospitals with lower levels of medical and allied healthcare professional (AHP) staff (e.g, occupational therapy, physiotherapy, radiography, speech and language therapy) had significantly higher mortality rates (rate ratio: 1.04, 95% CI 1.02 to 1.06, and 1.04, 95% CI 1.02 to 1.06, respectively), while those with lower support staff had lower mortality rates (0.85, 95% CI 0.79 to 0.91 for nurse support, and 1.00, 95% CI 0.99 to 1.00 for AHP support). Estimates of the association between staffing levels and mortality were stronger between-hospitals than within-hospitals, which were not statistically significant in a within–between random effects model.ConclusionsIn additional to medicine and nursing, AHP staffing levels may influence hospital mortality rates. Considering multiple staff groups simultaneously when examining the association between hospital mortality and clinical staffing levels is crucial.Trial registration numberNCT04374812.

AimsTo examine the organisation of the nursing workforce in intensive care units and identify factors that influence how the workforce operates.BackgroundPre-pandemic UK survey data show that up to 60% of intensive care units (ICUs) 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 ICUs 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.MethodsFocus groups with health care professionals working in ICUs (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.FindingsThree themes were identified: the constraining or enabling nature of ICU and hospital structures; whole team processes to mitigate nurse staffing shortfalls; and the impact of nurse staffing on patient, staff and ICU flow outcomes. Staff made decisions about staffing throughout a shift and were influenced by a combination of factors illuminated in the three themes.ConclusionsWhilst 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 wellbeing, ICU layout and the experience, and availability, of other members of the multi-professional team. This has important implications for future planning for ICU nurse staffing and highlights important factors to be accounted for in future research studies.Implications for Nursing ManagementThe potential opportunities for different staffing models are likely to be highly dependent on other professions. Hence, any change to staffing models needs to take into account how different professions work together.Factors such as ICU layout, reported to influence nurse staffing decisions, suggest that patient safety in ICU may not be best served by blanket ‘ratio’ approaches to nurse staffing, intended to apply uniformly across health services.The findings have the potential to feed into discussions about funding tariffs for critical care and quality metrics to be included in commissioning contracts.

The contribution of registered nurses towards safe patient care has been demonstrated in many studies. However, most of the evidence linking staffing levels to outcomes is cross-sectional with intrinsic limitations including an inability to establish that presumed cause (staffing) precedes the effect. No reviews have summarised longitudinal studies considering nurse staffing and patient outcomes.To identify and assess the evidence for an association between nurse staffing levels, including the composition of the nursing team, and patient outcomes in acute care settings from longitudinal studies.We undertook a systematic review of studies where the association between nurse staffing with patient outcomes was assessed in a longitudinal design. Studies with repeated cross-sectional analyses were excluded unless a difference-in-difference design was used. We searched Medline, CINAHL, Embase and the Cochrane Library up to February 2022. We used the ROBINS-I tool to assess risk of bias. We synthesised results in a tabular form and a narrative grouped by outcome.27 papers were included. Studies were conducted in a variety of settings and populations, including adult general medical/surgical wards and adult and neonatal intensive care units. Staffing measures were operationalised in a variety of different ways, making direct comparisons between studies difficult and pooled estimates impossible. Most studies were either at serious (n = 12) or critical (n = 5) risk of bias, with only 3 studies at low risk of bias. Studies with the most risk of bias were judged as likely to underestimate the effect of higher registered nurse staffing. Findings are consistent with an overall picture of a beneficial effect from higher registered nurse staffing on preventing patient death. The evidence is less clear for other patient outcomes with a higher risk of bias, but in general the proposition that higher registered nurse staffing is likely to lead to better patient outcomes is supported. Evidence about the contribution of other nursing staff groups is unclear.The causal relationship between low registered nurse staffing and mortality is plausible and these estimates of relationships from longitudinal studies provide further support. To address residual uncertainties, future studies should be conducted in more than one hospital and using standardised measures when reporting staffing levels.Having more registered nurses on hospital wards is causally linked to reduced mortality - new review shows there is little room for doubt @ora_dall @workforcesoton @turnel.

AimTo understand student nurses’ views around shift patterns.DesignQualitative studyMethodWe held a Tweetchat in May 2019, where we asked questions around the frequency of 12-hour shifts working on placement; schedule flexibility while on placement; which shift patterns they preferred and why. Data from the Tweetchat were analysed to identify emerging themes and inductively develop a coding frame.ResultsSeventy-three nursing students participated in the Tweetchat. The majority (68%) of respondents reported that they work 12-hour shifts on placements. We identified three main overarching themes: “Achieving a personal equilibrium”; “Meeting the needs of the care environment”, “Factors affecting negotiation capacity”. Data highlighted a conflict for most students, where they preferred 12-hour shifts because of more time off for study, paid work, and leisure, while acknowledging 12-hour shifts had a negative effect on fatigue, exhaustion, and their ability to achieve self-care (i.e. poor diet, no exercise).

ObjectiveTo determine the association between daily levels of registered nurse (RN) and nursing assistant staffing and hospital mortality.DesignThis is a retrospective longitudinal observational study using routinely collected data. We used multilevel/hierarchical mixed-effects regression models to explore the association between patient outcomes and daily variation in RN and nursing assistant staffing, measured as hours per patient per day relative to ward mean. Analyses were controlled for ward and patient risk.Participants138 133 adult patients spending >1 days on general wards between 1 April 2012 and 31 March 2015.OutcomesIn-hospital deaths.ResultsHospital mortality was 4.1%. The hazard of death was increased by 3% for every day a patient experienced RN staffing below ward mean (adjusted HR (aHR) 1.03, 95% CI 1.01 to 1.05). Relative to ward mean, each additional hour of RN care available over the first 5 days of a patient’s stay was associated with 3% reduction in the hazard of death (aHR 0.97, 95% CI 0.94 to 1.0). Days where admissions per RN exceeded 125% of the ward mean were associated with an increased hazard of death (aHR 1.05, 95% CI 1.01 1.09). Although low nursing assistant staffing was associated with increases in mortality, high nursing assistant staffing was also associated with increased mortality.ConclusionLower RN staffing and higher levels of admissions per RN are associated with increased risk of death during an admission to hospital. These findings highlight the possible consequences of reduced nurse staffing and do not give support to policies that encourage the use of nursing assistants to compensate for shortages of RNs.

Background Due to worldwide nursing shortages and difficulty retaining staff, long shifts for nursing staff (both registered nurses and nursing assistants) working in hospitals have been adopted widely. Because long shifts reduce the daily number of shifts from three to two, many assume that long shifts improve productivity by removing one handover and staff overlap. However, it is unclear whether staffing levels are more likely to be perceived as adequate when more long shifts are used. Objectives To investigate the association between the proportion of long (≥12‐hour) shifts worked on a ward and nurses-in-charge's perceptions that the staffing level was sufficient to meet patient need. Methods A retrospective cross-sectional study using routinely collected data (patient administrative data and rosters) linked to nurses-in-charge's reports from 81 wards within four English hospitals across 1 year (2017). Hierarchical logistic regression models were used to determine associations between the proportion of long shifts and nurses-in-charge's reports of having enough staff for quality or leaving necessary nursing care undone, after controlling for the staffing level relative to demand (shortfall). We tested for interactions between staffing shortfall and the proportion of long shifts. Results The sample comprised 19648 ward days. On average across wards, 72% of shifts were long. With mixed short and long shifts, the odds of nurses-in-charge reporting that there were enough staff for quality were 14-17% lower than when all shifts were long. For example, the odds of reporting enough staff for quality with between 60-80% long shifts was 15% lower (95% confidence interval 2% to 27%) than with all long shifts. Associations with nursing care left undone were consistent with this pattern. Although including interactions between staffing shortfalls and the proportion of long shifts did not improve model fit, the effect of long shifts did appear to differ according to shortfall, with lower proportions of long shifts associated with benefits when staffing levels were high relative to current norms. Conclusions Rather than a clear distinction between wards using short and long shifts, we found that a mixed pattern operated on most days and wards, with no wards using all short shifts. We found that when wards use exclusively long shifts rather than a mixture, nurses-in-charge are more likely to judge that they have enough staff. However, the adverse effects of mixed shifts on perceptions of staffing adequacy may be reduced or eliminated by higher staffing levels. ISRCTN 12307968. Tweetable abstract 12-hour shifts in nursing: a mix of short and long shifts may be worse than all long shifts.

Background & Objectives Previous research demonstrates the impact of workforce organisation variables on quality of care and nurse wellbeing. However, the extent to which these variables influence completion of important “ancillary” nursing work is unexplored. This type of work can include discussion of care information between colleagues, promoting continuity of care during shift changes, and participating in continuing professional development programs. Although ancillary work is not usually classified as direct nursing care, it remains critical to the delivery of safe and effective care, as well as for building nurse resiliency and workforce capacity. Our aim was to examine the relationship between ≥12-hour shifts, overtime, and lower staffing levels and opportunities for completing ancillary work. Design & Methods Cross-sectional survey of 2990 registered nurses in 48 hospitals in England. Relationships were estimated through generalised linear mixed models. Results When compared to ≤8 hour shifts, nurses working ≥12-hour shifts were less likely to report having staff education programs (OR=0.58, 95% CI [0.43, 0.76]) and enough opportunity to discuss patient care with other nurses (OR=0.72, 95% CI [0.56, 0.92]). When compared to working overtime, nurses working only scheduled hours reported more opportunities these activities (OR=1.31, 95% CI [1.07, 1.61] and OR=2.06, 95% CI [1.72, 2.47] respectively), and reported fewer cases of losing care information during handovers (OR=0.72, 95% CI [0.60, 0.86]). Furthermore, with each additional patient per nurse (i.e., higher workloads), poorer outcomes for all variables of interest were observed. Conclusion Long shifts, overtime, and lower staffing levels are associated with fewer reported opportunities for completing ancillary work. Our findings contribute to the large body of literature exploring the drawbacks of implementing short-term solutions for nurse shortages and warrant careful consideration when establishing nursing shift rotas and staffing policies.

There is conflicting evidence on the effect of night work on sickness absence. Most previous studies used self-reporting to identify shift patterns and measure levels of sickness absence. In contrast, this study used objective data from electronic rosters to explore the association of nurses’ patterns of night work and sickness absence. This was a retrospective longitudinal study of nurse roster data from 32 general medical and surgical wards in a large acute hospital in England. We used data from 3 years and included both registered nurses and unregistered nursing assistants. We used generalized linear-mixed models to explore the association between night work and the subsequent occurrence of sickness absence. Of 601,282 shifts worked by 1944 nursing staff, 38,051 shifts were lost due to sickness absence. After controlling for potential confounders including proportion of long (≥12 h) shifts worked, proportion of overtime shifts, proportion of shifts worked in the past 7 days, and staff grade, we found that staff working more than 75% of their shifts in the past 7 days as night shifts were more likely to experience sickness absence (aOR = 1.12; 95% CI: 1.03–1.21), compared to staff working on day only schedules. Sub-group analysis found that an association between a high proportion of night shifts worked and long-term sickness (aOR = 1.31; 95% CI: 1.15–1.50), but not short-term sickness. Working high proportions of night shifts, likely representing permanent night work schedules, is associated with a higher risk of long-term sickness absence for nurses working in inpatient adult wards in acute hospitals. The higher sickness absence rates associated with permanent night shifts could result in additional costs or loss of productivity for hospitals. This study challenges the assumption that permanent night schedules maximize circadian adjustment and, therefore, reduce health problems.

PurposeTo 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.DesignA 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.MethodsWe 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.FindingsUse 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).ConclusionsDays 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 RelevanceHeavy 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.

BACKGROUND: Several time and motion studies have sought to quantify the nursing work involved in observing patients' vital signs. However, none of these studies offered a validated methodology that can be replicated. This is reflected in the high variation between these studies in the mean times for measuring and recording observations. AIM: To describe the development and inter-rater reliability of a methodology for observing the nursing time and workload involved in measuring and recording patients' vital signs. DISCUSSION: The authors developed a methodology that used the quality of interactions (QI) tool ( Bridges et al 2018 ) to measure and record the start and finish times of the rounds of nurses observing vital signs and individual observations clustered in rounds. Two raters concurrently documented their observations of nurses undertaking patient observations in a simulated setting. The tool and associated documentation were found to be easy to use, and there was a high level of agreement in measurements by different observers. CONCLUSION: The authors' methodology can be used to reliably measure the time involved in taking vital signs. IMPLICATIONS FOR PRACTICE: Using the QI tool may increase precision when timing and classifying nursing activities concerning observing vital signs. The authors anticipate that it could be adapted effectively to measure several other nursing activities and so support researchers interested in capturing different aspects of nurses' work.

AimTo 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.BackgroundNurses working long shifts may become less productive and no research has investigated whether potential cost savings are realized.MethodA 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.ResultsCompared 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).ConclusionsWe 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 ManagementIncreases in resource use could result in additional costs or loss of productivity for hospitals. Implementation of long shifts should be questioned.

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.

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 ( 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.

Aims: To identify nursing care most frequently missed in acute adult inpatient wards and 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 reviewData Sources: We searched the Cochrane Library, CINAHL, Embase and Medline (2006-2016) 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 was abstracted on study design, missed care prevalence and measures of association. Synthesis was narrative.Results: Eighteen studies gave subjective reports of missed care. 75% 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.

Objective:\ud To determine associations between variations in registered nurse staffing levels in adult critical care units and outcomes such as patient, nurse, organisational and family outcomes.\ud \ud Methods:\ud We published and adhered to a protocol, stored in an open access repository and searched for quantitative studies written in the English language and held in CINAHL Plus, MEDLINE, PsycINFO, SCOPUS and NDLTD databases up to July 2020.\ud \ud Three authors independently extracted data and critically appraised papers meeting the inclusion criteria. Results are summarised in tables and discussed in terms of strength of internal validity. A detailed review of the two most commonly measured outcomes, patient mortality and nosocomial infection, is also presented.\ud \ud Results:\ud Our search returned 7960 titles after duplicates were removed; 55 studies met the inclusion criteria. Studies with strong internal validity report significant associations between lower levels of critical care nurse staffing and increased odds of both patient mortality (1.24–3.50 times greater) and nosocomial infection (3.28–3.60 times greater), increased hospital costs, lower nurse-perceived quality of care and lower family satisfaction. Meta-analysis was not feasible because of the wide variation in how both staffing and outcomes were measured.\ud \ud Conclusions:\ud A large number of studies including several with high internal validity provide evidence that higher levels of critical care nurse staffing are beneficial to patients, staff and health services. However, inconsistent approaches to measurement and aggregation of staffing levels reported makes it hard to translate findings into recommendation for safe staffing in critical care.

IntroductionMonitoring vital signs in hospital is an important part of safe patient care. However, there are no robust estimates of the workload it generates for nursing staff. This makes it difficult to plan adequate staffing to ensure current monitoring protocols can be delivered.ObjectiveTo estimate the time taken to measure and record one set of patient’s vital signs observations; and to identify factors associated with time to measure and record one set of patient’s vital signs observations.MethodsWe undertook a time-and-motion study of 16 acute medical or surgical wards across four hospitals in England. One hospital recorded vital signs on paper, while three recorded measurements on electronic devices. Two trained observers followed a standard operating procedure to record the time taken to measure and record vital sign observations. We used mixed-effects models to estimate the mean time using whole observation rounds, which included preparation time, or time spent taking observations at the bedside. We tested whether our estimates were influenced by nurse, ward and hospital factors.ResultsAfter excluding non-vital signs related interruptions, dividing the length of an observation round by the number of observations in that round yielded an estimated time per observation set of 5 minutes and 1 second (95% Confidence Interval (CI) = 4:39-5:24). If interruptions within the round were included, the estimated time was 6:26 (95% CI = 6:01-6:50). If only time taking each patient’s observations at the bedside was considered, after excluding non-vital signs related interruptions the estimated time was 3:45 (95% CI = 3:32-3:58). We found no substantial differences by hospital, ward or nurse characteristics, despite different systems for recording observations being used across the hospitals.DiscussionThe time taken to observe and record a patient’s vital signs is considerable, so changes to recommended observation frequency could have major workload implications. Variation in estimates derived from previous studies may, in part, arise from a lack of clarity about what was included in the reported times. We found no evidence that nurses save time when using electronic vital signs recording, or that the grade of staff taking the observation influenced the time taken.ConclusionsTaking and recording vital signs observations is time consuming and the impact of interruptions and preparation away from the bedside is considerable. When considering the nursing workload around vital signs observations, no assumption of relative efficiency should be made if different technologies or staff groups are deployed.

BACKGROUND: Shift work is recognised as a component of work organisation that may affect the balance between employee’s efficiency, effectiveness and wellbeing. Shift work is frequent in healthcare and for nurses in particular, as they typically comprise a large proportion of the workforce in healthcare AIM: To identify the characteristics of shift work that have an effect on employee’s performance (including job performance, productivity, safety, quality of care delivered, errors, adverse events and client satisfaction) and wellbeing (including burnout, job satisfaction, absenteeism, intention to leave the job) in all sectors including healthcareMETHODS: A search of electronic databases (CINAHL, MEDLINE, PsychINFO, SCOPUS) to identify primary quantitative studies was conducted between January and March 2015. Studies were drawn from all occupational sectors (i.e. health and non health), meeting the inclusion criteria: involved participants aged ?18 who have been working shifts or serve as control group for others working shifts, exploring the association of characteristics of shift work with at least one of the selected outcomes. Reference lists from retrieved studies were checked to identify any further studiesRESULTS: 35 studies were included in the review; 25 studies were performed in the health sector. A variety of shift work characteristics are associated with compromised employee’s performance and wellbeing. Findings from large multicentre studies highlight that shifts of 12 hours or longer are associated with jeopardised outcomes. Working more than 40 hours per week is associated with adverse events, while no conclusive evidence was found regarding working a ‘Compressed Working Week’; working overtime was associated with decreased job performance. Working rotating shifts was associated with worse job performance outcomes, whilst fixed night shifts appeared to enable resynchronisation. However, job satisfaction of employees working fixed nights was reduced. Timely breaks had a positive impact on employee fatigue and alertness, whilst quick returns between shifts appeared to increase pathologic fatigue. The effect of shift work characteristics on outcomes in the studies reviewed is consistent across occupational sectorsCONCLUSIONS: This review highlighted the complexity that encompasses shift work, but many studies do not account for this complexity. While some consistent associations emerge (e.g. 12 hour shifts and jeopardised outcomes), it is not always possible to conclude that results are not confounded by unmeasured factors

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 support the hypothesis that lower levels of registered nurses on duty increases 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 reviewMethods: 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 (UTIs), 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. In order 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, re-admissions, 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.

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.

A large and increasing number of studies have reported a relationship between low nurse staffing levels and adverse outcomes, including higher mortality rates. Despite the evidence being extensive in size, and having been sometimes described as "compelling" and "overwhelming", there are limitations that existing studies have not yet been able to address. One result of these weaknesses can be observed in the guidelines on safe staffing in acute hospital wards issued by the influential body that sets standards for the National Health Service in England, the National Institute for Health and Care Excellence, which concluded there is insufficient good quality evidence available to fully inform practice. In this paper we explore this apparent contradiction. After summarising the evidence review that informed the National Institute for Health and Care Excellence guideline on safe staffing and related evidence, we move on to discussing the complex challenges that arise when attempting to apply this evidence to practice. Among these, we introduce the concept of endogeneity, a form of bias in the estimation of causal effects. Although current evidence is broadly consistent with a cause and effect relationship, endogeneity means that estimates of the size of effect, essential for building an economic case, may be biased and in some cases qualitatively wrong. We expand on three limitations that are likely to lead to endogeneity in many previous studies: omitted variables, which refers to the absence of control for variables such as medical staffing and patient case mix; simultaneity, which occurs when the outcome can influence the level of staffing just as staffing influences outcome; and common-method variance, which may be present when both outcomes and staffing levels variables are derived from the same survey. Thus while current evidence is important and has influenced policy because it illustrates the potential risks and benefits associated with changes in nurse staffing, it may not provide operational solutions. We conclude by posing a series of questions about design and methods for future researchers who intend to further explore this complex relationship between nurse staffing levels and outcomes. These questions are intended to reflect on the potential added value of new research given what is already known, and to encourage those conducting research to take opportunities to produce research that fills gaps in the existing knowledge for practice. By doing this we hope that future studies can better quantify both the benefits and costs of changes in nurse staffing levels and, therefore, serve as a more useful tool for those delivering services.

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.

Objectives 12 h shifts are becoming increasingly common for hospital nurses but there is concern that long shifts adversely affect nurses’ well-being, job satisfaction and intention to leave their job. The aim of this study is to examine the association between working long shifts and burnout, job dissatisfaction, dissatisfaction with work schedule flexibility and intention to leave current job among hospital nurses.Methods Cross-sectional survey of 31 627 registered nurses in 2170 general medical/surgical units within 488 hospitals across 12 European countries.Results Nurses working shifts of ≥12 h were more likely than nurses working shorter hours (≤8) to experience burnout, in terms of emotional exhaustion (adjusted OR (aOR)=1.26; 95% CI 1.09 to 1.46), depersonalisation (aOR=1.21; 95% CI 1.01 to 1.47) and low personal accomplishment (aOR=1.39; 95% CI 1.20 to 1.62). Nurses working shifts of ≥12 h were more likely to experience job dissatisfaction (aOR=1.40; 95% CI 1.20 to 1.62), dissatisfaction with work schedule flexibility (aOR=1.15; 95% CI 1.00 to 1.35) and report intention to leave their job due to dissatisfaction (aOR=1.29; 95% CI 1.12 to 1.48).Conclusions Longer working hours for hospital nurses are associated with adverse outcomes for nurses. Some of these adverse outcomes, such as high burnout, may pose safety risks for patients as well as nurses.

The aim of this project was to find out the priorities for research that could improve fundamental care. ‘Fundamental care’ covers all aspects of basic care in hospital wards, such as helping with core physical needs, building positive relationships and keeping patients safe. By setting the priorities with patients, carers, the public and health care professionals, research can look at the issues that really matter to people who are receiving or delivering care in hospital wards. Previously, prioritisation exercises have started with a menu of options and asked people to choose from that list. They have also been focused on specific health conditions. Traditionally, there has been little opportunity for patients, carers and the public to contribute to identifying the issues to be prioritised. To develop the priorities for research, we started by exploring what is meant by ‘fundamental care’, looking at patient and carer accounts and academic and policy reports. Patients, carers, staff, and members of the public were consulted via surveys, interviews and group discussions to share experiences and issues. A list of 15 topics was identified based on what was most commonly mentioned by patients, carers and healthcare professionals as well as what was practical for the CLAHRC Wessex team to research. A workshop with patients, carers and healthcare professionals was held, to decide the top 5 areas. The five priority areas identified were: Background The provision of high quality fundamental care in hospitals is a top priority for the NHS. Recent reports and investigations highlight that at times care has fallen below standard. It is unclear what research should be prioritised to improve care. The aim of this work is to involve patients/carers/public, clinicians and other stakeholders to identify issues that are priorities for research which could improve fundamental care in hospital. Methods Patient and public involvement was integral to this project, with a patient leader/service user being a member of the core team who designed and executed this research. After consideration of existing priority setting approaches, we developed an inclusive approach which consisted of six main phases: 1) Development of a conceptual framework of fundamental care, based on reports and literature 2) Consultation with a wide range of stakeholders through a survey, focus groups and interviews 3) Identifying themes from the responses to the consultation phase (76 themes identified) 4) Analysis to identify the 15 topics most frequently cited 5) Prioritisation of the top 15 themes through a half day workshop, which led to a shortlist of five themes 6) Development of the top 5 themes into research areas. Results Three hundred forty stakeholders (29 % of whom were patients/carers/public) completed the consultation survey. Analysis of the survey responses and of focus groups and interviews led us to identify 15 high scoring themes. We presented these at the prioritisation workshop, attended by 39 participants (23 of whom patients/carers/public). After a voting exercise, the 5 top research priorities which emerged were: nurse staffing; individualised patient care; staff communication; staff attitudes and relationships with patients; and information about care. Conclusions We involved a range of stakeholders in identifying topics for research to improve fundamental care and asked them to prioritise these. The process provided a means of reaching consensus as to the important issues for future research to focus on to improve fundamental care on hospital wards.