Research on nurse to patient ratio impact on medication errors in acute care settings
Research problem
According to the available data, it is estimated that about 44,000 Americans die in various hospital settings as a result of medical errors which are preventable (Kohn, et al., 2000). It is also estimated that up t 17 billion dollars is required as a national cost on preventable adverse events while another estimate of 37.6 billion dollars is needed as national costs for adverse events. (Konh, et. Al, 2000). One of the most important elements in acute care setting is the physical environment because it has a direct impact on the safety of patients in terms of medication and nursing errors and also errors resulting from burnout, stresses and staff fatigue.
Literature analysis and review provide a clear demonstration of various environmental variables which are the causative elements of workplace errors, noise place errors, micro-environmental design, air condition, heating, color, ventilation, noise levels. The other non –environmental variable such as staffing, age, levels and their health is also associated with errors in the acute care setting. Both the environmental and the non environmental variables which result to errors is as a result of the workers, ration to the number of patients they handle while on duty. This results to them being stressed, disrupted, fatigue and other related mediating errors. Finding a balance between the ratios of nurses to patients is one of the recommendations that can be used in preventing medical errors in the acute care setting.
This research study will examine the critical issue on the impact of nurse to patient ratio in relation to the various errors caused in the acute care setting. This topic will be dealt with in multiple ways which are:
- Literature analysis and Review
- carry out a survey on the Nursing staff from four different hospitals found in the Pacific North west region
- Focus Groups with the pharmacy, administration and Nursing staff members
- Visit to the selected three facilities which have strategies and design on the reduction of errors and on enhancing patient safety.
This paper will be critical in assisting various heath organizations in establishing the relationship between the imbalances of nurse to patient ratio with the various medication errors occurring in the acute care setting. The paper will provide evidence of the positive results associated with this balance which have positively reduced the chances of errors as seen in some of the selected areas which have implemented designs for ensuring patients safety. This is with the aim of establishing if the nurse to patient ratio has impact on medication errors in acute care settings.
Research purpose
The synthesis of the research examines the impact on ratio of nursing staff in four different hospitals in the Pacific North west region which are Auburn Regional Medical Center, cascade, valley Hospital , Children’s Hospital & Regional Medical Center and Enumclaw Regional Hospital. This ratio will be weighed against the quality of care provided to patients, quality of services , cost and outcomes in the acute care setting, of these hospitals the key finding from the research synthesis is to determine if the implementation of a minimum patient to nurse ratio reduces the rate of medical errors another key finding from the research is that there is no major impact in the improvement of staffing measures on reducing nursing associated errors, patient safety and nursing quality indicators in the four hospitals.
Another critical observation the research aims in finding out is that the adverse outcomes in terms of medical errors did not increases with the increase of the severity of patients based on the reflections given by the case mix index. It will then be possible to careful posit the claim that the research findings suggest that the impact on staffing ratio is essential in adverse events prevention in cases where the patients face an increased risk.
research question:
- What is the impact on mandated ratio on safety of patients, quality of services, cost and outcomes of patient care in the acute care departs of the hospitals
- what has been the impact on the nursing ration legislation in selected settings which have implemented designs on work force ration as for the case of California hospitals?
- What has been the impact of nursing staffing ration on relation to the operations of the hospitals?
- What are the other reported and studied aspects related to the impact of the mandatory ratio on nurses.
Hypotheses:
There will be no impact on rate of medication errors as a result of nurse to patient ratio
Literature review
Through the exclusion and inclusion criteria, it became possible to evaluate the abstracts ion the various literature materials related to the topic under research. out of the thirty materials, the method allowed the researchers to thoroughly review and analyze eight articles selected thoroughly through evidence appraisal and reviews of the full texts. Among the eight t articles, studied based on the data bases and search on grey literature to help in validation of the review process.
Through the survey of the available literature materials It is observable that Donaldson, et. Al (2005) is a preliminary report on the impacts of pre-post rations. the findings from this article were the extended and replicated by the research by Bolton et. Al (2007). The other studies by Cook (2009), Spats. 2008 and Spetz et. Al 2009 is distinct studies from those by Donaldson and Bolton. Despite the articles by Bolton and Donaldson being superficially seen as duplicated study, it was important to treat them separately.
All the sources provide an overlap view on the impact of on nurse to patient ratios in the patient care deployment, patients safety and the effects of the staffing sensitive measures on patients safety and care quality to patients and also the effect of these measures on the overall consequences to hospitals in terms of finances. The unit of analyses and sources of data varied from one study to another but the main theme of the studies is the examination on the impact of outcomes in relation to nurse staffing . the studies also provide potential error in there measurement as well as other aspects the investigators have used to critique their work (Clarke & Donaldson, 2008).
The three out of the twelve studies for this synthesis indicate the independent variable showing medication errors is the hospital acquires pressure ulcers while the data sources and operational definitions differed from one study to another depending on the data prevalence got from direct observations of the patients (Bolton et al., 2007). Other data used by the selected material are the codes on pressure ulcers in relation to diagnostic records from the Office of state wide Health Planning and Development and the discharge dataset of hospital (Spetz ET. Al, 2009: Cook, 2009). this shows that there is a possibility of coming up with a different variable all together.
The studies reviewed in this study mainly explore the mandated ratios and the impact it has on a wide range of outcome, structure, financials, workforce and outcome variables and also measures on nursing sensitivity implemented by the National Quality Forum (National Quality Forum, 2009). These measures are used for the measurement of outcome and structure in the hospital studies (Spertz, ET. Al, 2009, Donaldson et al, 2005, Bolton, et al, 2007 and Cook, 2009). the study by Mitchell, (2008) is a one single study on hospital a unit.
The Nursing Sensitive Core measures given by which were initially endorsed in 2004 and the 2009 endorsement. the endorsed measures include the hours of care a registered nurse is supposed to provide and the percentage of nurse staff. Through the data provided on annual report of hospitals, Serratt(2009), Cook, (2009) and Spetz eat al,(2009), computed and oparationalized the various variables on nurse staffing based on accounting data and later were bale to create an approximation which is financially derived for patient care ratio on. Despite the studies sharing the concept of measure, they give different definitions.
The studies by Bolton et al (2007) and Donaldson et al.(2005) and other researches dealing with the study of a single unit like Mitchell, (2008), Armstrong, 2004 and Wiesenthal & Hendy, 2009) have successfully captured the variables of staffing in a direct way from the staffing system of the hospitals. Due to this the investigators were able to clearly differentiate the care productive hours and the direct care separate from other paid hours for example the on productive hours and activities which not directly clinical. The researchers were also keen on indicating the risks associated with this method requiring measurement precision by the use of large data sets from the hospital administration.
The studied materials also showed variation in the analyses levels through the use of the design of a single case unit per level (Armstrong, 2004, Wiesenthal & Hendy, 2009, Mitchell, 2008. This single unit is used to match level of design using pre-post multihospital init (Donaldson, et al. 2005: Bolton ET a, 2007). Based on the level designs of the hospital which outcomes and staffing are separated from the public database (Serratt, 2009; Cook, 2009, Spetz, et al, 2009 and Spetz, 2008). Due to the use of different samples size from a single unit of a hospital (Weinchenthal & Hendey, 2009; Mitchell 2008) to the use of a sample which is convenient of matched pre-post hospitals to self reporting (Donaldson
20005; Bolton et al, 2007). Spratt, 2009 notability uses the national data provided by OSHPD administrative and carefully notes and matches the pre-post datasets which makes him to note the challenge caused by the hospital attrition from a wide range of time derived from the post line to the baseline analysis. In determining the impact of intervention like the mandate given by the legislative laws, it has to address the concepts of time in relation to post implementation and pre implementation of measures.
The hospitals in California State were put on demand in 1999 after the passing of AB 39A legislation. This mandate is on the nursing staffing ratio. The baseline measures precision clearly show the various methodological concerns. Four of the studies used in the research recorded a baseline in 2004 of n= I and 3003 to be n- 3. These results are more likely to be confounded before the passing of legislation on nursing standards in finding the data for the beginning of 2002. With this in mind several of the investigators began to establish the 2002 pre-ratio collection data but prior to the passing of legislation, statistics indicated a anticipatory staffing shift ( Donaldson, et al, 2005, Bolton et al 2007; Serratt, 2009).
Two of the studies which utilizes large administrative data which include changes transcend, longitudinal historical data in the main variable of the 1990s to the implementation of the rations recently (Anti et al , 2099; Spetz et al, 2009 ). Other investigators in contrast utilized the baseline measures of six months the requirement implementation in 20004( Mitchell, 2008 and Armstrong , 2004) this methods is likely to have biased findings because the a hospitals b y then were expecting an increase in their staffing and moving towards accommodating the mandated ratios.
Another aspect on the topic concern is the tapping measurement timing with the effects of the post implementation of the required ratios. The early impacts of this mandate are purposely measured by Donaldson et al (2005). They the go ahead to give a report of the initial findings of the first six months which is the implementation’s first phase. Armstrong (2004) limited his study period of study to only four months after the implementation of the legislative mandate. The cumulative impacts are traced during the first and second phase of implementation. As for the other investigators they have focused on the effects of the ratios during the period of 2005 and 2008 after the complete implementation of the date on ratios by most of the hospitals. The capture of pre-post data on timing show a design factor forms the main body of literary text which were not represented and used in the study.
Variables and Definitions
The variables in this synthesis include the financial variables which incorporate the nation wide database and other metrics computed from COSHPD (2009) through reducing heterogeneity measurements and potential of error. the research also used case Mix index to indicate the clinical acuity and patient complexity example of the patient acuity variable include hospital acquired pressure ulcers which leads to greater acuity of patients. Through the measure of the various challenges it was concluded that there is no any notable after the implementation of standards for improving staff measures. Financial ratio was determined from the statistics given by the national data
Methodology
Research method.
The research method used in this study include the collection of literature search strategies a critical evaluation of evidence and synthesizing of information which are all guided by the methods and standards of Jonna Briggs Institute(2008) show highly regards search of evidence evaluation in health care and nursing around the globe the main steps required to be adhered to in the JBI literature synthesis method is the focus on selecting citation , coming up with a research search strategy and choosing citations to for review purposes on which is based on the exclusion and explicit criteria. The selected citation were then critically evaluated by the investigators and later developed and evidence based findings of the meta- analyses in the evaluation of both the external and internal validity. Meta analyses are used in the absence of each permitting Mata- analyses to be computed. To analyze both the qualitative and quantitative were synthesized from studies provided in the study. The resulting synthesis comprises o f quantitative studies, qualitative studies and mixed methods for economic analysis other studies used were on historical longitudinal studies and explicit data on post and pre ratios.
Research design.
The research design used is a non experimental research design. The study does not require nay manipulation of circumstances, situations and the experiences of the sample. the design is a correlation al studies which compares a similar variables among the four hospitals based on the impact of nurse patient ratio on medical errors in the acute care unit. Thorough the study it is possible to conclude that there was no significant impact on measures of improvement for staff members on the quality of patient’s safety and on nursing quality in the hospitals.
Sample
The research targeted the staff in four different hospitals in the Pacific North west region which are Auburn Regional Medical Center, cascade, valley Hospital , Children’s Hospital & Regional MEDICAL Center and Enumclaw Regional Hospital. The selection of the literature was carried out through the exclusion and inclusion criteria.
Setting
The setting staff in four different hospitals in the Pacific North west region which are Auburn Regional Medical Center, cascade, valley Hospital , Children’s Hospital & Regional medical Center and Enumclaw Regional Hospital.
Data collection
The data used in this synthesis were those showing the impact of ratios provided by the patient care staff, the effect on measure of nurse sensitivity over patient safety and care and on the finances consequences the hospitals face. Units of analysis and sources of data varied from one study to another but studies focusing one the outcomes of the impact of nurse staffing are aggregated in the narrative summary.
Data Analysis
The analyses levels also varied among the studies used in the research, it ranges from the study on a single case unit design to the Reports of multi hospitals level unit of designs. Other analyses of data were based on hospital level of design to show the outcomes and staffing were separated from the large baseline measures as shown in the methodological concerns.
Ethical Considerations
The authors of the various literature sources were contacted and asked for permission to utilize their work in coming up with the stylish of this paper. The research was also conducted with full awareness to avoid any form of biasness and providing opinions with no outright evidence.
Implication for practice
From this synthesis shows that the policy of the mandated on minimum nurse to patient ratio achieved in reducing the number required to be handled by each nurse and at the same time increased the number of nursing hours at each given day in the acute care setting. Another finding from this research is that there is no significant influence in the improvement of measures on staffing on the quality of services and on safety of patients. From the study it is important for public policy makers to come up with initiative which can help to improve the costs of health care, outcomes of health care and quality so as to integrate and evaluate methods needed before coming up with final regulations. This is possible when the stakeholders are sensitized to evaluate the mandates of patients care delivery and its outcome.
Reference
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Declaration of Conflicting Interests Chapter 845/Statutes of 1999 AB 394, State of California, Assembly
The author(s) declared that they had no conflicts of interest with (1999).
Respect to their authorship or the publication of this article
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The author(s) disclosed that they received the following support for nurses . Washington, DC: Agency for Healthcare Research
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