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      Nurse forecasting in Europe (RN4CAST): Rationale, design and methodology


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          Current human resources planning models in nursing are unreliable and ineffective as they consider volumes, but ignore effects on quality in patient care. The project RN4CAST aims innovative forecasting methods by addressing not only volumes, but quality of nursing staff as well as quality of patient care.


          A multi-country, multilevel cross-sectional design is used to obtain important unmeasured factors in forecasting models including how features of hospital work environments impact on nurse recruitment, retention and patient outcomes. In each of the 12 participating European countries, at least 30 general acute hospitals were sampled. Data are gathered via four data sources (nurse, patient and organizational surveys and via routinely collected hospital discharge data). All staff nurses of a random selection of medical and surgical units (at least 2 per hospital) were surveyed. The nurse survey has the purpose to measure the experiences of nurses on their job (e.g. job satisfaction, burnout) as well as to allow the creation of aggregated hospital level measures of staffing and working conditions. The patient survey is organized in a sub-sample of countries and hospitals using a one-day census approach to measure the patient experiences with medical and nursing care. In addition to conducting a patient survey, hospital discharge abstract datasets will be used to calculate additional patient outcomes like in-hospital mortality and failure-to-rescue. Via the organizational survey, information about the organizational profile (e.g. bed size, types of technology available, teaching status) is collected to control the analyses for institutional differences.

          This information will be linked via common identifiers and the relationships between different aspects of the nursing work environment and patient and nurse outcomes will be studied by using multilevel regression type analyses. These results will be used to simulate the impact of changing different aspects of the nursing work environment on quality of care and satisfaction of the nursing workforce.


          RN4CAST is one of the largest nurse workforce studies ever conducted in Europe, will add to accuracy of forecasting models and generate new approaches to more effective management of nursing resources in Europe.

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          Most cited references39

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          Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction

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            Nurse-staffing levels and the quality of care in hospitals.

            It is uncertain whether lower levels of staffing by nurses at hospitals are associated with an increased risk that patients will have complications or die. We used administrative data from 1997 for 799 hospitals in 11 states (covering 5,075,969 discharges of medical patients and 1,104,659 discharges of surgical patients) to examine the relation between the amount of care provided by nurses at the hospital and patients' outcomes. We conducted regression analyses in which we controlled for patients' risk of adverse outcomes, differences in the nursing care needed for each hospital's patients, and other variables. The mean number of hours of nursing care per patient-day was 11.4, of which 7.8 hours were provided by registered nurses, 1.2 hours by licensed practical nurses, and 2.4 hours by nurses' aides. Among medical patients, a higher proportion of hours of care per day provided by registered nurses and a greater absolute number of hours of care per day provided by registered nurses were associated with a shorter length of stay (P=0.01 and P<0.001, respectively) and lower rates of both urinary tract infections (P<0.001 and P=0.003, respectively) and upper gastrointestinal bleeding (P=0.03 and P=0.007, respectively). A higher proportion of hours of care provided by registered nurses was also associated with lower rates of pneumonia (P=0.001), shock or cardiac arrest (P=0.007), and "failure to rescue," which was defined as death from pneumonia, shock or cardiac arrest, upper gastrointestinal bleeding, sepsis, or deep venous thrombosis (P=0.05). Among surgical patients, a higher proportion of care provided by registered nurses was associated with lower rates of urinary tract infections (P=0.04), and a greater number of hours of care per day provided by registered nurses was associated with lower rates of "failure to rescue" (P=0.008). We found no associations between increased levels of staffing by registered nurses and the rate of in-hospital death or between increased staffing by licensed practical nurses or nurses' aides and the rate of adverse outcomes. A higher proportion of hours of nursing care provided by registered nurses and a greater number of hours of care by registered nurses per day are associated with better care for hospitalized patients.
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              The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis.

              To examine the association between registered nurse (RN) staffing and patient outcomes in acute care hospitals. Twenty-eight studies reported adjusted odds ratios of patient outcomes in categories of RN-to-patient ratio, and met inclusion criteria. Information was abstracted using a standardized protocol. Random effects models assessed heterogeneity and pooled data from individual studies. Increased RN staffing was associated with lower hospital related mortality in intensive care units (ICUs) [odds ratios (OR), 0.91; 95% confidence interval (CI), 0.86-0.96], in surgical (OR, 0.84; 95% CI, 0.80-0.89), and in medical patients (OR, 0.94; 95% CI, 0.94-0.95) per additional full time equivalent per patient day. An increase by 1 RN per patient day was associated with a decreased odds ratio of hospital acquired pneumonia (OR, 0.70; 95% CI, 0.56-0.88), unplanned extubation (OR, 0.49; 95% CI, 0.36-0.67), respiratory failure (OR, 0.40; 95% CI, 0.27-0.59), and cardiac arrest (OR, 0.72; 95% CI, 0.62-0.84) in ICUs, with a lower risk of failure to rescue (OR, 0.84; 95% CI, 0.79-0.90) in surgical patients. Length of stay was shorter by 24% in ICUs (OR, 0.76; 95% CI, 0.62-0.94) and by 31% in surgical patients (OR, 0.69; 95% CI, 0.55-0.86). Studies with different design show associations between increased RN staffing and lower odds of hospital related mortality and adverse patient events. Patient and hospital characteristics, including hospitals' commitment to quality of medical care, likely contribute to the actual causal pathway.

                Author and article information

                BMC Nurs
                BMC Nursing
                BioMed Central
                18 April 2011
                : 10
                : 6
                [1 ]Center for Health Services and Nursing Research, Katholieke Universiteit Leuven, Kapucijnenvoer 35/4, 3000 Leuven, Belgium
                [2 ]Center for Health Outcomes and Policy Research, University of Pennsylvania, 418 Curie Blvd. Claire M. Fagin Hall, 387R, Philadelphia, PA 19104-4217, USA
                [3 ]Florence Nightingale School of Nursing & Midwifery, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, UK
                [4 ]School of Health Sciences, University of Southampton, Building 67, Highfield Campus, Southampton 17 1BJ, UK
                [5 ]National Spanish Research Unit, Instituto de Salud Carlos III. Ministry of Science and Innovation, C/Monforte de Lemos, 5. Pabellón 13, 28029 Madrid, Spain
                [6 ]Department of Health Care Management, WHO Collaborating Centre for Health Systems Research and Management, Technische Universität Berlin, H 80, Strasse des 17. Juni 135, 10623 Berlin, Germany
                [7 ]Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, 171 77 Stockholm, Sweden
                [8 ]School of Nursing, Dublin City University, Dublin 9, Ireland
                [9 ]Department of Internal Diseases and Community Nursing, Jagiellonian University Medical College, Kopernika 25, 31-501 Krakow, Poland
                [10 ]Department of Health Policy and Management, University of Eastern Finland, POB 1627, 70211 Kuopio, Finland
                [11 ]Institute of Nursing Science, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland
                [12 ]Scientific Institute for Quality of Healthcare, UMC St Radboud, Postbus 9101, 114 IQ healthcare, 6500 HB Nijmegen, The Netherlands
                [13 ]Laboratory of Health Informatics, Faculty of Nursing, National and Kapodistrian University of Athens, Papadiamantopoulou 123, 11527 Athens, Greece
                Copyright ©2011 Sermeus et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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