There are growing worries about the quality of care provided to patients in hospitals and nursing homes. This has sparked a debate on the elements that influence this quality from both policy and scientific perspectives. To make the topic more understandable, studies comparing various components of care with patient outcomes are needed. According to Horn et al. (2005), the evidence linking nurse staffing and results is frequently equivocal, particularly in nursing homes. In hospitals, however, there is a clear relationship between these two categories of variables. The study's goal is to determine this association in long-term care institutions. The researcher notes that most studies tend to combine multiple factors such as urinary incontinence, ulcers, pain, malnutrition and pressure as the dependent variables without considering multiple dependent independent variables such as demographics, severity of illness, nutritional and incontinence interventions, medications, and nurse staffing time. This study not only considers staffing time but also chooses only those cases where other independent factors are relatively comparable.
Description of the Participants
This study entailed a secondary analysis of a subset of data retrieved from the National Pressure Ulcer Long-Term Study. In the study, nursing hours could only be considered as the independent variable if they are provided by Registered Nurses, Certified Nursing Assistants and Licensed Practical Nurses. The database contained information on 1524 residents who had attended 95 different facilities. Residents who qualified to join the study sample were only those who had entered the facility without pressure ulcer and had all their nurse staffing information available. 148 residents who lived in 13 different facilities had 40 or more minutes of Registered Nurse care. These individuals were excluded because the researchers wanted patients who had less than 40 minutes of RN direct car. The mean age of the study residents was 81.6 years. 75.3% of the sample were female. The average stay duration of the sample in the respective nursing homes was 78.6 days. For individuals to qualify under the general NPULS criteria, they had to 18 years or older, residents in the facility for at least 2 continuous weeks and have been at risk of developing ulcers.
Sampling
This study entailed non-probability sampling. The researcher settled for convenience sampling. The NPULS database was chosen as a source of data because it contained information that is relevant to the topic of interest. However, since the researchers did not collect the data themselves, no issues regarding sampling are discussed in the article.
Study Setting
The data used in this study was collected from 82 facilities spread across 19 states. Nursing services in each of the facilities was provided by Registered Nurses, Certified Nursing Assistants and Licensed Practical Nurses. The individuals who received more than 40 minutes of care stayed in the facilities for fewer days than the rest of the sample. Therefore, the former group was expunged from the research.
Ethical Considerations
One key ethical consideration entailed respecting the residents’ privacy. This was done by discarding most of the identifiers from the NPULS database. Only those identifiers permitted by the privacy rule under the Health Insurance Portability and Accountability Act of 1996 were included in this study. The Declaration of Helsinki was also applied in determining the rules for human experimentation that were adhered to by the researchers. The researchers also indicate that the process of collecting and analyzing data met the expedited review standards by the respective institutional review boards.
Hypothesis
The researchers propose that adverse outcomes such as pressure ulcers become less likely to occur as registered nurses spend more time on direct patient care.
Research Design
This study is non-experimental where researchers neither manipulate any of the independent variables nor control any extraneous variables. The variables of interest in this case are measured in order to determine the relationship between them without an effort to manipulate the nurse staffing levels to fit. The researchers expanded the residents and institutions that they felt do not meet the conditions set.
According to Horn et al. (2005), the relationship between nurse staffing and adverse patient outcomes is unclear. An effort to study this relationship makes this study exploratory. An exploratory study is carried out on a problem that has few or little prior researches referring to it.
Research Variables
The independent variable in this study is the number of minutes that registered nurses spend on a resident per day. The dependent variables are development of pressure ulcers, urinary tract infection, weight loss, deterioration in the client’s ability to independently perform activities of daily living, hospitalization, catheterization and nutritional supplements. The independent variable is divided into four categories based on the duration; less than ten minutes, between ten and twenty minutes, between twenty and thirty minutes and between thirty and forty minutes of direct care time.
Review of Literature
This article does not have the literature review section. This denies the reader an opportunity to understand the foundation of the study and what gaps necessitated it. However, statistics that are related to the inquiry are discussed at the beginning of the article. This part also highlights how the concern on the quality of care in hospitals and nursing homes have stimulated research. Horn et al. (2005) acknowledges that studies that consider a large number of nursing outcomes as dependent variables lead to mixed results. Giving a detailed description of these studies in a literature review part would have provided a clearer picture to the reader.
Results of The Study and Appropriateness of the Methods Used
The mean registered nurse time in the 82 facilities was 16 minutes, that of the LPN time was 30.6 minutes while that of CNA time was 1.7 hours per day. 38.1% of individuals who received less than 10 minutes of direct RN care developed pressure ulcers. This number kept reducing with an increase of RN hours with only 31.8% of those who received between 10 and 20 minutes, 25.1% of those who received between 20 and 30 minutes and 9.4% of those receiving between 20 and 40 of RN nursing minutes developing the condition.
20.7% of individuals who received less than 10 minutes of direct RN care developed urinary tract infection. 21.1% of those who received between 10 and 20 minutes, 20% of those who received between 20 and 30 minutes and 10% of those receiving between 20 and 40 of RN nursing minutes developing the condition.
29% of individuals who received less than 10 minutes of direct RN care experienced weight loss. 26.6% of those who received between 10 and 20 minutes, 26.8% of those who received between 20 and 30 minutes and 15.6% of those receiving between 20 and 40 of RN nursing minutes developing the condition.
32.3% of individuals who received less than 10 minutes of direct RN care experienced deterioration in their ability to perform activities of daily living. 35% of those who received between 10 and 20 minutes, 39.4% of those who received between 20 and 30 minutes and 15% of those receiving between 20 and 40 of RN nursing minutes developing the condition.
18.4% of individuals who received less than 10 minutes of direct RN care were hospitalized in the course of their stay. This number kept reducing with an increase of RN hours with only 11.1% of those who received between 10 and 20 minutes, 9.6% of those who received between 20 and 30 minutes and 6.1% of those receiving between 20 and 40 of RN nursing minutes developing the condition.
14.5% of individuals who received less than 10 minutes of direct RN care underwent catheterization. 13.9% of those who received between 10 and 20 minutes, 15.2% of those who received between 20 and 30 minutes and 5.2% of those receiving between 20 and 40 of RN nursing minutes developing the condition.
8.7% of individuals who received less than 10 minutes of direct RN care required nutritional supplements in the course of their stay. 8.3% of those who received between 10 and 20 minutes, 8.2% of those who received between 20 and 30 minutes and 21.7% of those receiving between 20 and 40 of RN nursing minutes developing the condition. For each outcome, there was either a diminishing percentage of patients with complications or a threshold effect where better outcomes were experienced with 30-40 minutes of RN care. Data on Urinary tract infection and Hospitalization was the most consistent in confirming the hypothesis.
Collection of the data described in this study can be a long, tedious and expensive process.
Therefore, using secondary analysis was the most appropriate for this study. However, it is important to note that this data was collected in the 1990s, about 10 years before the article was published. The nursing sector is a dynamic one and there was need for data from a more recent study.
Nursing outcomes are affected by a number of factors, including resident characteristics such as age and medical history.
There were no criteria for factoring these other aspects into the results to determine their effect in the dependent variables. The fact that the NPULS data may also be a limitation since dynamics in the nursing profession have changed and it is likely that the data does not apply to contemporary conditions.
Level of Evidence Used, Nursing Theory, And Implications for Nursing Research
The number of subjects used in this study are sufficient to validate the results. The number of variables also provides an opportunity for the reader to comprehensively asses the association of average nursing time and clinical outcomes in nursing homes. In the article, the researchers do not mention the link between the findings and the nursing theory. There was no clear-cut consistency in the relationship between RN hours and some of the nursing outcomes. There is need for more research to facilitate better understanding on the relationship between RN hours and intake of nutritional supplements since this did not come out clearly in this research.
Discuss How the Research Findings Can Be Applied to The Clinical Area
The research findings are important for nurse employers, administrators and the individual practitioners. There is need to increase the amount of time that each nursing home resident spends in contact with a registered nurse. The nursing homes should target employing a sufficient workforce. The administrators should come up with ways of encouraging nurses to stay close to the residents while the nurses should be motivated to spend more hours with the patients in order to improve the clinical outcomes.
Reference
Horn, S. D., Buerhaus, P., Bergstrom, N., & Smout, R. J. (2005). RN staffing time and outcomes of long-stay nursing home residents: pressure ulcers and other adverse outcomes are less likely as RNs spend more time on direct patient care. AJN The American Journal of Nursing, 105(11), 58-70.
