Background
Nurse staffing levels
Skill mix of baccalaureate-prepared registered nurses
Nursing practice environment
Methods/design
Aims
Objectives
Hypotheses
Design and sample
Measures and source of data
A. Measures of individual nurse characteristics and their perceptions of the practice environment
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Demographic characteristics: Age, sex, work experience as a RN (months), position (RN, advanced practice nurse, nurse specialist, nurse consultant, ward manager, nursing officer) in the study ward, and whether full time or part time.
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Education level and attainment.
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Certification: year of certification, place, type (general/psychiatric/midwife registration).
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Entry-level education to RN: Diploma, pre-registration Bachelor of Nursing degree, pre-registration for Master of Nursing degree.
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Highest credential in nursing: Diploma, pre-registration Bachelor of Nursing degree, pre-registration for Master of Nursing degree, Master degree, Master of Philosophy, Doctor of Nursing, Doctor of Philosophy.
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Measure of practice environment: The Practice Environment Scale-Nursing Work Index (PES-NWI) [24] will be used to measure the quality of the professional nursing practice environment in each ward. The PES-NWI is a 31-item scale. Respondents rate each item on a scale of 1 (strongly disagree) to 4 (strongly agree) to indicate whether the feature is ‘present in the current job’. The five subscales include nurse participation in hospital affairs; staffing and resource adequacy; nursing foundations for quality of care; nurse manager ability, leadership, and support for nurses; and collegial nurse-physician relations. The PES-NWI is a nationally endorsed nursing care performance standard and has been adopted by the NQF as a nursing-sensitive care performance measure [23]. Cronbach’s alphas for the subscales range from 0.71 to 0.84 based on Lake’s five-factor structure [24]. The Chinese version of the PES-NWI was tested by Chiang and Lin [25] in a study of 842 nurses. The alpha coefficient for the total scale was 0.9, and the alpha for the subscales ranged from 0.65 to 0.87.
B. Measures of nurse staffing
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RN staffing per unit- shift.
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Number of RNs with a baccalaureate level or higher upon entry to the profession staffing per unit- shift.
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Skill mix information, including the number of full-time and part-time RNs, enrolled nurses and patient care assistants/healthcare assistants working on each shift.
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Nursing care hours per patient day: number of RNs per patient day and number of nursing staff hours (RNs, enrolled nurses, patient care assistants/healthcare assistants) per patient day.
C. Measures of nurse-sensitive patient outcomes
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Pressure ulcers prevalence (hospital acquired); falls prevalence (inpatient falls); falls with injury; restraint prevalence; infection rates (hospital acquired): CAUTI; and CLCABI.
D. Risk-adjustment
Data collection procedures
Ethical considerations
Statistical analyses
Variables enter in the multilevel Cox Regression models | Data Level |
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Nurse-sensitive patient outcomes | |
Pressure ulcers (hospital acquired) | Patient |
Falls (inpatient falls) | Patient |
Falls with injury | Patient |
Restraints | Patient |
Urinary catheter-associated urinary tract infection | Patient |
Central line catheter-associated blood stream infection | Patient |
Explanatory nursing factors | |
Education composition of registered nurses: the proportion of registered nurses educated to baccalaureate level or higher upon entry to the profession | Ward |
Registered nurses staffing level: full-time equivalent employment | Ward |
Practice environment: | Ward |
Nurse participation in hospital affairs (mean subscale score) | |
Staffing and resource adequacy (mean subscale score) | |
Nursing foundations for quality of care (mean subscale score) | |
Nurse manager ability, leadership, and support of nurses (mean subscale score) | |
Collegial nurse-physician relations (mean subscale score) | |
Potential confounding variables | |
Patients’ characteristics: age, sex, diagnosis, comorbidities, level of surgical invasiveness, mortality, length of stay and type of admission. | Patient |
Characteristics of the wards and patient turnover: types of wards, number of beds, patient bed-days and patient turnover for each shift and patient days | Ward |
Characteristics of the hospitals: type of hospital, number of beds, teaching status, region, and technology. | Hospital |