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Aims: To explore key factors related to nursing unit instability, complexity and patient and system outcomes., Background: The relationship between nurse staffing and quality of patient outcomes is well known. The nursing unit is an important but different aspect that links to complexity and to system and patient outcomes. The relationship between the instability, complexity and outcomes needs further exploration., Design: Descriptive., Methods: Data were collected via a nurse survey, unit profile and review of patient records on 62 nursing units (wards) across three states of Australia between 2008-2010. Two units with contrasting levels of patient and nurse instability and negative system and patient outcomes, were profiled in detail from the larger sample., Results: Ward A presented with greater patient stability (low occupancy, high planned admissions, few ICU transfers, fewer changes to patient acuity/work re-sequencing) and greater nurse instability (nurses changing units, fewer full-time staff, more temporary/casual staff) impacting system outcomes negatively (high staff turnover). In contrast, Ward B had greater patient instability, however, more nurse stability (greater experienced and permanent staff, fewer casuals), resulting in high rates for falls, medication errors and other adverse patient outcomes with lower rates for system outcomes (lower intention to leave)., Conclusion: Instability in patient and nurse factors can contribute to ward complexity with potentially negative patient outcomes. The findings highlight the variation of many aspects of the system where nurses work and the importance of nursing unit managers and senior nurse executives in managing ward complexity., (© 2014 John Wiley & Sons Ltd.)

Nurse turnover is a critical issue facing workforce planners across the globe, particularly in light of protracted and continuing workforce shortages. An ageing population coupled with the rise in complex and chronic diseases, have contributed to increased demands placed on the health system and importantly, nurses who themselves are ageing. Costs associated with nurse turnover are attracting more attention; however, existing measurements of turnover show inconsistent findings, which can be attributed to differences in study design, metrics used to calculate turnover and variations in definitions for turnover. This paper will report the rates and costs of nurse turnover across three States in Australia.

Aims: To compare nurse turnover rates and costs from four studies in four countries (US, Canada, Australia, New Zealand) that have used the same costing methodology; the original Nursing Turnover Cost Calculation Methodology., Background: Measuring and comparing the costs and rates of turnover is difficult because of differences in definitions and methodologies., Design: Comparative review., Data Sources: Searches were carried out within CINAHL, Business Source Complete and Medline for studies that used the original Nursing Turnover Cost Calculation Methodology and reported on both costs and rates of nurse turnover, published from 2014 and prior., Methods: A comparative review of turnover data was conducted using four studies that employed the original Nursing Turnover Cost Calculation Methodology. Costing data items were converted to percentages, while total turnover costs were converted to US 2014 dollars and adjusted according to inflation rates, to permit cross-country comparisons., Results: Despite using the same methodology, Australia reported significantly higher turnover costs ($48,790) due to higher termination (~50% of indirect costs) and temporary replacement costs (~90% of direct costs). Costs were almost 50% lower in the US ($20,561), Canada ($26,652) and New Zealand ($23,711). Turnover rates also varied significantly across countries with the highest rate reported in New Zealand (44·3%) followed by the US (26·8%), Canada (19·9%) and Australia (15·1%)., Conclusion: A significant proportion of turnover costs are attributed to temporary replacement, highlighting the importance of nurse retention. The authors suggest a minimum dataset is also required to eliminate potential variability across countries, states, hospitals and departments., (© 2014 John Wiley & Sons Ltd.)

Patients in hospital are increasingly being moved between clinical units and between bedspaces; however, the impact of patient transfers and bedspace moves on nurses' workload is not known. Time studies are an established observational research method that can be used to determine the duration of time taken to perform an activity or process. This review systematically searched four databases for literature published between 2000 and 2013 for observational time study techniques and patient transfers as a nurse activity. Eleven publications from three countries were included in the review. All studies used timing techniques to explore nurse work associated with the transfer process. The review highlights the duration of time spent by nurses on certain aspects of the transfer process. However, as few studies published results from timings, the impact on nurse time is likely to be higher than indicated. Further research is recommended., (© 2014 Wiley Publishing Asia Pty Ltd.)

Objective: To explore the association between patient volume in intensive care units (ICUs) and risk-adjusted mortality., Background: Large multi-speciality ICUs are emerging in response to increasing demand for critical care. Consolidation of resources through regionalisation of services aims to contain costs and optimise demand management and operational synergies. Higher patient volumes in ICU have been associated with improved outcomes. Limited evidence exists, however, to suggest an optimal volume of patients in terms of risk-adjusted mortality., Review Method: Retrospective integrative literature review., Data Sources: EMBASE, PubMed and Cumulative Index to Nursing and Allied Health Literature electronic databases., Inclusion Criteria: Primary studies of risk adjusted mortality in adult ICU patients published between 1995 and 2012., Exclusion Criteria: Studies of admissions following elective procedures., Results: Twenty quantitative observational studies were included in this review. Studies were primarily retrospective with three conducted prospectively. Nine studied mechanically ventilated patients, six included all admissions to ICU, three reported on patients with sepsis and one study each on patients post cardiac arrest and those receiving renal replacement therapy. A significant association was evident in sixteen studies suggesting a lower risk of adjusted mortality in higher-volume units. The association was not consistent across all diagnosis. A non-linear relationship observed in two studies noted no mortality benefit occurring above a volume threshold of 450 cases annually per diagnostic category and above 711 cases not specific to a diagnostic group., Conclusion: Patient mortality may be improved in large capacity ICUs. However, the association is not consistent across all diagnostic groups. Risk adjusted mortality is increased in low volume ICUs. There appears to be a high volume threshold at which point the risk adjusted mortality benefit is also lost suggesting a window of optimal ICU organisational performance exists between low and high volumes. Further prospective research is recommended into clinical outcomes in high volume ICUs to explore association between organisational efficiency and quality of care., (Copyright © 2014 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Aim: To critically review the work sampling technique used in nursing workload research., Background: Work sampling is a technique frequently used by researchers and managers to explore and measure nursing activities. However, work sampling methods used are diverse making comparisons of results between studies difficult., Design: Methodological integrative review., Data Sources: Four electronic databases were systematically searched for peer-reviewed articles published between 2002-2012. Manual scanning of reference lists and Rich Site Summary feeds from contemporary nursing journals were other sources of data., Review Methods: Articles published in the English language between 2002-2012 reporting on research which used work sampling to examine nursing workload., Results: Eighteen articles were reviewed. The review identified that the work sampling technique lacks a standardized approach, which may have an impact on the sharing or comparison of results. Specific areas needing a shared understanding included the training of observers and subjects who self-report, standardization of the techniques used to assess observer inter-rater reliability, sampling methods and reporting of outcomes., Conclusion: Work sampling is a technique that can be used to explore the many facets of nursing work. Standardized reporting measures would enable greater comparison between studies and contribute to knowledge more effectively. Author suggestions for the reporting of results may act as guidelines for researchers considering work sampling as a research method., (© 2014 John Wiley & Sons Ltd.)

Internationally, shortages in the nursing workforce, escalating patient demands, and financial constraints within the health system have led to the growth of unlicensed nursing support workers. Recently, in relation to the largest publicly funded health system (National Health Service), it was reported that extensive substitution of registered nurses with unskilled nursing support workers resulted in inadequate patient care, increased morbidity and mortality rates, and negative nurse outcomes. We argue that it is timely to consider regulation of nursing support workers with their role and scope of practice clearly defined. Further, the addition of these workers in a complementary model of care (rather than substitutive model) should also be explored in future research, in terms of impact on patient and nurse outcomes., (© The Author(s) 2014 Reprints and permissions:]br]sagepub.co.uk/journalsPermissions.nav.)

Aim: To assess the economic impact of increased nursing hours of care on health outcomes in adult teaching hospitals in Perth, Western Australia., Background: Advancing technology and increased availability of treatment interventions are increasing demand for health care while the downturn in world economies has increased demand for greater efficiency. Nurse managers must balance nurse staffing to optimize care and provide efficiencies., Design: This longitudinal study involved the retrospective analysis of a cohort of multi-day stay patients admitted to adult teaching hospitals., Methods: Hospital morbidity and staffing data from September 2000 until June 2004, obtained in 2010 from a previous study, were used to analyse nursing-sensitive outcomes pre- and post-implementation of the Nurse Hours per Patient Day staffing method, which remains in place today. The cost of the intervention comprised increased nursing hours following implementation of the staffing method., Results: The number of nursing-sensitive outcomes was 1357 less than expected post-implementation and included 155 fewer 'failure to rescue' events. The 1202 other nursing-sensitive outcomes prevented were 'surgical wound infection', 'pulmonary failure', 'ulcer, gastritis', 'upper gastrointestinal bleed', and 'cardiac arrest'. One outcome, pneumonia, showed an increase of 493. Analysis of life years gained was based on the failure to rescue events prevented and the total life years gained was 1088. The cost per life year gained was AUD$8907., Conclusion: The implementation of the Nurse Hours per Patient Day staffing method was cost-effective when compared with thresholds of interventions commonly accepted in Australia., (© 2013 Blackwell Publishing Ltd.)

Background: The NSW Health Policy Directive (NSW Department of Health, 2000) lists clinical service and consultancy; clinical leadership; research; education; clinical services planning and management as the five domains of practice for nurses appointed as Clinical Nurse Consultants (CNCs), an Australian advanced practice nurse (APN) role. However, there is no clear definition of what is meant by advanced practice in the Australian nursing context. Nowhere is this more evident than in differentiating between the roles of Clinical Nurse Consultants (CNCs) and Nurse Practitioners (NP) in NSW. To date, limited empirical research has been done to characterise or delineate CNC role activity and responsibility., Objectives: To investigate (i) the nature of CNC roles, activities and responsibilities, (ii) differentiate between CNCs by their work patterns and activities, and (iii) empirically conceptualize and differentiate ways CNCs practice in terms of an APN typology., Participants: The study sample was 56 CNCs at one tertiary level public hospital in Australia., Methods: A descriptive exploratory cohort study was conducted to explore CNC role characteristics and patterns of activity. Data were triangulated using an online survey, a follow-up survey, and semi-structured interviews. The data were analysed using descriptive statistics to examine differences between CNC work patterns and role activities. The survey data and the individual reports were thematically analysed to investigate for difference across the population of CNCs., Results: Interpretation of survey and interview data led to an analyst-developed CNC typology of four CNC categories based on the work patterns and activities of Sole Practitioner, Clinic Coordinator, Clinical Team Coordinator and Clinical Leader. The typology was based on the themes interprofessional, role focus, clinical focus and setting as these themes distinguished and differentiated CNC roles., Conclusions: The study provides evidence of great diversity and prioritization within CNC roles. The CNC typology identified in this study is similar to the categorisation of the roles of APNs reported by other researchers. With further testing, the CNC typology could be useful to service managers and policy makers in making decision on the category of CNC required for a position and may also be able to be applied to other APN roles., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Aim: To discuss the impact of patient transfers on patient outcomes and nursing workload., Background: Many patient transfers are essential and occur in response to patients' clinical changes. However, increasingly within Australia transfers are performed in response to reductions in bed numbers, resulting in 'bed block'., Evaluation: A discussion of the literature related to inpatient transfers, nursing workload and patient safety., Key Issues: Measures to increase patient flow such as short-stay units may result in an increase in patient transfers and nursing workload. Frequent patient transfers may also increase the risk of medication incidents, health-care acquired infections and patient falls., Conclusions: The continuing demand for health care has led to a reactionary bed management system that, in an attempt to accommodate patients, has resulted in increased transfers between wards. This can have a negative effect on nursing workload and affect patient outcomes., Implications for Nursing Management: High nursing workload is cited as one reason for nurses leaving the profession. Reductions in non-essential transfers may reduce nurse workload, improve patient outcomes and enhance continuity of patient care., (© 2011 Blackwell Publishing Ltd.)

This discursive paper examines recent research on career progression for nurse executives in Australia. In particular, it focuses on the personal, work-related and professional factors which influence progression. The role of gender, location and the provision of mentoring are also considered. It is suggested that family friendly policies (such as the option to job share or to perform an executive role on a part-time basis), the availability of a mentor, and the opportunity to pursue further education/training are vital in assisting nurses to progress in their executive careers.

Aim and Objective: This paper examined the impact of leadership characteristics of nursing unit managers, as perceived by staff nurses, on staff satisfaction and retention., Background: A positive work environment will increase levels of job satisfaction and staff retention. Nurse leaders play a critical role in creating a positive work environment. Important leadership characteristics of the front-line nurse manager include visibility, accessibility, consultation, recognition and support., Design: Secondary analysis of data collected on 94 randomly selected wards in 21 public hospitals across two Australian states between 2004-2006., Methods: All nurses (n = 2488, 80·3% response rate) on the selected wards were asked to complete a survey that included the 49-item Nursing Work Index-Revised [NWI-R] together with measures of job satisfaction, satisfaction with nursing and intention to leave. Subscales of the NWI-R were calculated. Leadership, the domain of interest, consisted of 12 items. Wards were divided into those reporting either positive or negative leadership. Data were analysed at the nurse level using spss version 16., Results: A nursing manager who was perceived to be a good leader, was visible, consulted with staff, provided praise and recognition and where flexible work schedules were available was found to distinguish the positive and negative wards. However, for a ward to be rated as positive overall, nurse leaders need to perform well on all the leadership items., Conclusion: An effective nursing unit manager who consults with staff and provides positive feedback and who is rated highly on a broad range of leadership items is instrumental in increasing job satisfaction and satisfaction with nursing., Relevance to Clinical Practice: Good nurse managers play an important role in staff retention and satisfaction. Improved retention will lead to savings for the organisation, which may be allocated to activities such as training and mentorship to assist nurse leaders in developing these critical leadership skills. Strategies also need to be put in place to ensure that nurse leaders receive adequate organisational support from nursing executives., (© 2010 Blackwell Publishing Ltd.)

Background: The past few years has seen a growth in the number of new nursing roles and position titles in many countries, including Australia. The Australian situation is unique due to the lack of professional engagement and debate in determining the purpose of some of these new positions. Often these new roles have been poorly defined, and there is no national consistency in nomenclature. The recent move to a national nursing registration system provides an opportunity for change., Method: Discursive paper., Results: New roles arise for a number of reasons, including a change in function or title for a preexisting role or in response to the establishment a completely new position. However, the lack of a co-ordinated approach to introduction of new roles may lead to role proliferation (the rapid increase or spread of new positions and position titles), role blurring (where the boundaries of different positions become less distinct) and role confusion (where both nurses and health system clients experience a lack of clarity regarding the precise scope of roles)., Conclusion: Professional nursing practice is defined by the impact on patient outcomes, not by position titles. As such, the potential positive impact of a new role on patient outcomes should be the primary consideration when considering its introduction. National regulation of the profession provides an opportunity for the profession to debate and determine some consistency in position titles, responsibilities and areas of specialty practice.

Purpose: To examine the differences between characteristics of the work environment of nurses working in mental health and general acute inpatient nursing settings., Design: Secondary analysis of data collected on 96 randomly selected medical and surgical (general) wards and six mental health wards in 24 public acute general hospitals across two Australian states between 2004 and 2006., Methods: All nurses on the participating wards were asked to complete a survey that included the Practice Environment Scale of the Nursing Work Index (NWI-PES). Responses were received from 2,556 nurses (76.3% response rate). Using the five-domain structure, comparisons were made between mental health and general nurses., Findings: Across the entire sample of nurses, those working in mental health settings scored more highly in regard to nurse-doctor relationships and staffing adequacy. Nurses in general wards reported more participation in hospital affairs, stronger leadership, and the presence of more of the foundations of nursing quality care such as access to continued education. Differences between the groups on each of the domains was statistically significant at p=.05 or greater, but not for the composite practice environment scale. A wide range of responses was seen when data were aggregated to the ward level., Conclusions: The work environment of mental health nurses is different from that of their colleagues working in general settings. Specific areas of the mental health environment, such as participation in the hospital, leadership, and the foundations of quality, may be enhanced to improve nurses' job satisfaction and, potentially, other nurse and patient outcomes., Clinical Relevance: Factors in the medical and surgical nursing practice environment have been established as significant influences on nurse and patient outcomes. It is important to understand the existence and potential impact of these factors in mental health inpatient settings.

The role of nurse managers at all levels is the subject of much debate in Australia. It has been argued that their role is not essential and increasingly new organisational structures are being implemented which do not include nurse managers. This paper describes reasons why nurses, who are mainly female, face conflict when making the transition to the role of manager in the male dominated health care system of today. It argues that the values which nurses are able to bring to these positions are those increasingly valued by the community they serve. It is not nurses who should change, but the values held by the organisations in which they are employed if society's needs are to be well served.