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Numerous research studies have been completed in the last ten years linking higher nurse – patient ratios to improved patient outcomes. A consequence of mandating nurse staffing levels is the use of mandatory and voluntary overtime which can lead to increased fatigue and adverse events. The use of overtime is not a solution to maintaining adequate nurse staffing levels and can have detrimental, unwanted consequences. The potential risk to nurses and patients must be explored through quality research.
In an attempt to meet staffing ratios many organizations rely on the use of mandatory and voluntary overtime which leads to fatigue and adverse outcomes.
- P: Overtime
- I: Limit hours worked by RN’s to 12 per 24 hours
- C: No limit on hours worked
- O: Decreased fatigue and adverse outcomes
Search Strategies with Medline, CINAHL and Google Scholar
Using the Medline database the key words RN staffing and hour worked were entered. This resulted in 21,214 articles. To narrow this search the following limits were applied: publication years 2004-2009, English language, patient safety and medical errors. This resulted in 407 articles. To narrow to a manageable number of relevant articles the subheading of ‘staffing: supply and distribution’, and’ personnel staffing and scheduling’ were added to the previous search terms resulting in 26 current articles. A systematic review was completed using the terms RN staffing, overtime and patent safety, which provided similar results and articles. Final articles chosen were: ‘International Experts’ Perspectives on the State of the Nurse Staffing and Patient Outcomes Literature’ by Van den Heede, et al published in the January 2007 issue of Journal of Nursing Scholarship and ‘Correlates of medication error in hospitals by Wilkins and Shields published in the June 2008 issue of Health Reports.
Keywords entered into the CINAHL database included mandatory overtime in nursing and patient safety which resulted in 1,597 articles. By setting the parameters to articles published between 2004 and 2009 in the English language and adding the subheading of personnel staffing and scheduling and adverse outcomes a total of 31 articles were provided. Adding the subheading of quality of nursing care along with the keywords ‘systematic review’ resulted in 17 final articles. The two articles chosen were: ‘Nurse Staffing and Healthcare Outcomes: A systematic review of the International Research Evidence’ by Lankshear, Sheldon and Maynard published in the 2005 issue of Advances in Nursing Science and ‘Factors Influencing the use of Registered Nurse Overtime in Hospitals, 1995-200 published by Berney, Needleman and Kovner in the second quarter 2005 issue of Journal of Nursing Scholarship.
Keywords nurse staffing, medical errors, patient outcomes and hours worked were entered into the Google Scholar database. This search resulted in 1782 articles. Adding the parameters of articles published between 2004 and 2009 and medical, pharmacological and veterinary only yielded 442 articles. The addition of the terms mandatory overtime to the above selections resulted in 180 articles. Other variations of search terms did not yield less than 180 relevant articles. Many of these 180 articles were also found in the final Medline and CINAHL searches. The two chosen from this search included: ‘The working hours of hospital staff nurses and patient safety’ published by Rogers et al in the July / August 2004 edition of Health Watch. The second article Scott et. al ‘Effects of critical care nurses’ work hours on vigilance and patients’ safety published in the January 2006 issue of American Journal of Critical Care.
Analysis of Articles from each Database
International Experts’ Perspectives on the State of the Nurse Staffing and Patient Outcomes Literature by Van den Heede et al., published in the fourth quarter 2007 issue of Journal of Nursing Scholarship is an article written to assess the variables used in research on nurse staffing and patient outcomes from the perspective of an international panel. A Delphi survey (November 2005-February 2006) of a selected expert panel from 10 countries consisting of 24 researchers specializing in nurse staffing and quality of care and 8 nurse administrators were sent a review of evidence related to 30 patient outcomes, 14 nurse staffing and 31 background variables and asked to rate the importance or usefulness of each variable for research on nurse staffing and patient outcomes. In subsequent rounds the group median, mode, frequencies, and earlier responses were sent to each respondent. The conclusions of this study provided a picture of the science on nurse staffing and patient outcomes research as of 2006. The findings showed a connection between human resource issues and healthcare quality based on empirical findings and opinion. While the article did focus on quality of care and nurse – patient ratios, it did not provide relevant information regarding the effects of extended work hours on patient care outcomes.
‘Correlates of medication error in hospitals’ by Wilkins and Shields published in the June 2008 issue of Health Reports examined associations between medication error and selected factors in the workplace of hospital employed registered nurses in Canada. Data was derived from the 2005 National Survey of the Work and Health of Nurses in Canada who deliver direct care to hospital patients. Correlates of medication error were considered in bivariate and multivariate analyses. Multiple logistic regression modeling was used to examine medication error in relation to work organization and workplace environment, while controlling for personal factors, including nurses general and mental health, job satisfaction, education years of experience, and clinical area of employment. The results of this study showed that nearly one-fifth of nurses reported medication error involving patients had occurred occasionally or frequently in the past year. In the fully adjusted multivariate model, medication error was positively associated with working overtime, role overload, perceived staffing or resource inadequacy. Working a 12 hour shift, compared with shorter shifts was negatively associated with medication errors. This article provided relevant information pertaining to the initial PICO question of hours worked and adverse outcomes.
The 2005 issue of Advances in Nursing Science contained the article ‘Nurse staffing and healthcare outcomes: A systematic review of international research evidence’ by Lankshear et. al. The authors performed a systematic review of the literature and policy analysis and conducted interviews with key researchers in the filed in both the Untied States and the United Kingdom. The goal was to retrieve research on nurse staffing and healthcare outcomes published since 1990. A combination of electronic databases, internet and organizational web sites, and contacted researchers were queried. For each relevant study data were extracted systematically using a predesigned table to describe the type and feature of the workforce, the setting, the outcomes, the methods used, the results found, the quality of the studies and the limitations. A formal meta-analysis of the results was not able to be conducted due to the studies reporting different outcomes and use of different measure of staffing and ways of summarizing the association between staffing and outcome. Instead, a qualitative synthesis to explore patterns in the data and possible explanations for inconsistencies such as study design, analysis, context and setting was used. The systematic review found that many of the studies were of poor quality, using data from only one unit or hospital or failing to control for case mix variations. Overall, there was found to be accumulating evidence of a relationship between nurse staffing, especially higher skill mix, and patient outcomes. However, the estimates of the nurse staffing effects are likely to be unreliable. There is emerging evidence of a curvilinear relationship that suggests that the cost effectiveness of using registered nurse levels as a quality improvement tool will gradually become less cost effective. This article addressed staffing issues and quality of care but focused little on the issue of increased work hours of nurses and patient care outcomes.
‘Factors Influencing the Use of Registered Nurse Overtime in Hospital, 1995-2000’ by Berney et al published in the second quarter 2005 issue of Journal of Nursing Scholarship, aimed to assess nurse overtime in acute care general hospitals and the factors that influenced overtime among various hospitals. Staffing data from 1995-2000 from 193 acute general hospitals in New York State were used to examine hospital characteristics to determine whether they were associated with nurse overtime. The study concluded that hospitals varied dramatically in their overtime use. Some categories, for example Government owned, used little overtime indicating that management can find substitutes for overtime to meet fluctuating staffing needs. Unionized hospitals worked slightly more overtime than did nurses in nonunionized hospitals. The finding that hospitals with similar characteristics varied greatly in their number of overtime hours also supported this conclusion. Statistical analysis was completed with bivariate associations between nurse overtime and each hospital characteristic and independent nursing variables. The article provided valuable information on the various uses of overtime by hospitals, but did not specifically address the correlation between hour’s worked and adverse events.
The July 2004 issue of Health Watch contained an article by Rogers et al, “The working hours of hospital staff nurses and patient safety’. A letter explaining the study and eligibility criteria was mailed to a random nationwide sample of 4,320 members of the American Nurses Association during the winter of 2002. 1.725 nurses expressed interest by returning the completed demographic questionnaire. The final sample consisted of 393 registered nurses working full time as unit based hospital staff nurses. Logbooks were completed by these participants who revealed they usually worked longer than originally schedule and that 40% of 5,317 work shifts logged exceeded 12 hours. The risk of making an error were increased when shifts were longer than 12 hours, nurses worked overtime, or when they worked more than 40 hours per week. The data from demographic questionnaires and logbooks were then summarized using descriptive statistics and frequency tables. The long and unpredictable hours documented suggest a link between poor working conditions and treats to patient safety. This article provided relevant information pertaining to the initial PICO question.
Scott et. al published “Effects of Critical Care nurses’ work hours on vigilance and patients safety’ in the January 2006 issue of American Journal of Critical Care. The objectives were to describe the work patterns of critical care nurses, determine if an association existed between the occurrence of errors and the hours worked, and explore whether these work hours have adverse effects on the nurses vigilance. Data were obtained from a random sample of critical care nurses in the Untied States. Nurses eligible for the study were mailed two 14 day logbooks to fill out. Information collected included the hours worked, the time of day worked, overtime hours, days off and sleep wake patterns. On days worked, the respondents completed all work related questions and questions about difficulties in remained awake while on duty. The 502 respondents consistently worked longer than scheduled and for extended periods. Longer work duration increased the risk of errors and near errors and decreased nurses’ vigilance. The findings support the Institute of Medicine recommendations to minimize the use of 12 hours shifts and limit work hours to no more than 12 consecutive hours during a 24 hour period. This article contained information pertinent to the original PICO question.
Article best addressing PICO Question
‘Effects of Critical Care Nurse’s’ Work Hours on Vigilance and Patients’ Safety’ (Scott et. al., 2006) and ‘Correlates of Medication Errors in Hospitals’ (Wilkins & Shields, 2008) were found to be two articles that provided quality information regarding nursing hours worked and adverse patient outcomes. While the use of subjective measure of drowsiness, self report of errors and the relatively small sample of nurses used in the studies may limit the generalize-ability of the findings, the anonymity provided lends to more truthful responses. The methods allowed the nurses to disclose information that might have been unattainable if the use of standard categories for error reporting had been used. Although 12 hour shifts are popular among nurses, the findings in this study are congruent with previous reports that recommend minimizing the use of 12 hour shifts or at least limiting nurses’ work hours to more than 12 consecutive hours during a 24 hour period. Experience and extensive research in other industries has shown that accident rates increase when workers work 12 hours or longer. However, research pertaining to nurses has been relatively recent and data on accidents in healthcare facilities are not widely available.
Each database provided relevant articles containing research on the issue of the number hours worked by nurses and the effect of hours worked on patient care outcomes. Keywords nursing hours worked and patient outcomes delivered a large number of results. The methods to narrow results by placing additional parameters can be used across all databases. While there are minute differences among databases, basic search skills are universal by utilizing keywords developed in the PICO question.
The final articles chosen provided data on the effects of hours worked by nurses and the potential effect on patient outcomes. While the articles addressed the limitations of the studies, the methods, data analysis and results were presented in a logical, reproducible format. The issue of the effects of long work hours has been studied extensively in other industries, such as air traffic controllers, leading to changes in work environment. Further research needs to be completed in the area of nursing regarding the effects of the long hours. These articles provide a solid basis for other researchers to build upon. The use of nursing informatics can provide databases with universal quality measures to provide more consistent, reliable data across healthcare facilities.
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