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Is nurse staffing associated with critical deterioration events on acute and critical care pediatric wards? A literature review

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A CORRESPONDENCE to this article was published on 23 May 2023

Abstract

Pediatric and neonatal patients admitted to acute and critical care wards may experience critical deterioration events that may lead to unexpected deaths if unrecognized and untreated promptly. Adequate levels and skill-mix of nurse staffing are essential for the quality of patient monitoring and response to deteriorating patients. Insufficient staffing may have an impact on the occurrence of missed care and consequently on critical deterioration events, increasing the risk of mortality and failure-to-rescue. To review the literature to explore the association between nurse staffing levels or skill-mix and pediatric and neonatal critical deterioration events, such as mortality, pediatric intensive care unit (PICU)/neonatal intensive care unit (NICU) unplanned admissions, cardiac arrests, and failure-to-rescue. A structured narrative literature review was performed. Pubmed, Cinhal, and Web of Science were searched from January 2010 to September 2022. Four independent reviewers conducted the study screening and data extraction. The quality of the studies included was evaluated using the Joanna Briggs Institute critical appraisal tools. Out of a total of 2319 studies, 15 met the inclusion criteria. A total of seven studies were performed in PICU, six in NICU, and two in general pediatric wards. Nurse staffing measures and outcomes definitions used were heterogeneous. Most studies suggested nursing skill-mix, increased working experience, or higher nursing degrees were associated with increased survival in PICU. Decreased nursing staffing levels were associated with increased mortality in NICU and mechanically ventilated patients in PICU.

Conclusion: Evidence on the association of nurse staffing and critical deterioration events in PICU and NICU is limited, while there is no evidence reported for pediatric wards. Future research is needed to determine adequate levels of nurse/patient ratios and proportion of registered nurses in the skill-mix for pediatric acute and critical care nursing to improve outcomes on in-patient wards.

What is Known:

• Adult nursing skill-mix, staffing ratios, and level of education are associated with patient mortality and failure to rescue.

• In children, nurse staffing levels are associated with clinical outcomes.

What is New:

• Evidence on the association of nurse staffing levels or skill-mix with pediatric or neonatal mortality is limited.

• There is some evidence regarding the association of nursing work experience, certification, higher level degree with in-hospital survival in PICU.

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Abbreviations

NICU:

Neonatal intensive care unit

CICU:

Cardiac intensive care unit

PICU:

Pediatric intensive care unit

RNs:

Registered nurses

FTEs:

Full time equivalents

N:

Number

BSN:

Bachelor of Science in Nursing

NHS:

National Health Service

OR:

Odds ratio

RR:

Relative risk

CI:

Confidence interval

aRR:

Adjusted risk ratio

References

  1. American Nurses Association (2012) ANA’s principles for nurse staffing [Internet]. Nurses book’s.org THE PUBLISHING PROGRAM OF ANA. Available from: https://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principles-of-nurse--staffing--2nd-edition.pdf. Accessed 29 Dec 2022

  2. Savitz LA, Jones CB, Bernard S (2005) Quality indicators sensitive to nurse staffing in acute care settings. In: Henriksen K, Battles JB, Marks ES, Lewin DI, editors. Advances in patient safety: from research to implementation (Volume 4: Programs, tools, and products) [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US). Available from: http://www.ncbi.nlm.nih.gov/books/NBK20600/. Accessed 29 Dec 2022

  3. Burston S, Chaboyer W, Gillespie B (2014) Nurse-sensitive indicators suitable to reflect nursing care quality: a review and discussion of issues. J Clin Nurs 23(13–14):1785–1795

    Article  PubMed  Google Scholar 

  4. Seago JA, Williamson A, Atwood C (2006) Longitudinal analyses of nurse staffing and patient outcomes: more about failure to rescue. JONA J Nurs Adm 36(1):13–21

    Article  Google Scholar 

  5. Wilson S, Bremner A, Hauck Y, Finn J (2011) The effect of nurse staffing on clinical outcomes of children in hospital: a systematic review. Int J Evid Based Healthc 9(2):97–121

    Article  PubMed  Google Scholar 

  6. Tume L (2007) The deterioration of children in ward areas in a specialist children’s hospital. Nurs Crit Care 12(1):12–19

    Article  PubMed  Google Scholar 

  7. Padilla RM, Mayo AM (2018) Clinical deterioration: a concept analysis. J Clin Nurs 27(7–8):1360–1368

    Article  PubMed  Google Scholar 

  8. Institute for Healthcare Improvement (2022) Rapid Response Teams [Internet]. IHI - Institute for Healthcare Improvement. Available from: https://www.ihi.org:443/Topics/RapidResponseTeams/Pages/default.aspx. Accessed 9 Nov 2022

  9. Donaldson LJ, Panesar SS, Darzi A (2014) Patient-safety-related hospital deaths in England: thematic analysis of incidents reported to a national database, 2010–2012. Schiff G, editor. PLoS Med 11(6):e1001667

  10. Pearson GA, Ward-Platt M, Harnden A, Kelly D (2011) Why children die: avoidable factors associated with child deaths. Arch Dis Child 96(10):927–931

    Article  CAS  PubMed  Google Scholar 

  11. Griffiths P, Recio-Saucedo A, Dall’Ora C, Briggs J, Maruotti A, Meredith P et al (2018) The association between nurse staffing and omissions in nursing care: A systematic review. J Adv Nurs 74(7):1474–87

  12. Haegdorens F, Van Bogaert P, De Meester K, Monsieurs KG (2019) The impact of nurse staffing levels and nurse’s education on patient mortality in medical and surgical wards: an observational multicentre study. BMC Health Serv Res 19(1):864

    Article  PubMed  PubMed Central  Google Scholar 

  13. The Royal College of Nursing (2013) Mandatory nurse staffing levels [Internet]. The Royal College of Nursing. Policy & International Department. Cavendish Square, London. Available from: https://www.rcn.org.uk/About-us/Our-Influencing-work/Policy-briefings/pol-0312. Accessed 28 Sept 2022

  14. Sasso L, Bagnasco A, Petralia P, Scelsi S, Zanini M, Catania G et al (2018) RN4CAST@IT-Ped: Nurse staffing and children’s safety. J Adv Nurs 74(6):1223–1225

    Article  PubMed  Google Scholar 

  15. National Nurses United (2022) RN staffing ratios. A necessary solution to the patient safety crisis in U.S. hospitals [Internet]. National Nurses United. Available from: https://www.nationalnursesunited.org/sites/default/files/nnu/documents/0322_Ratios_Booklet_NNU.pdf. Accessed 28 Sept 2022

  16. American Nurses Association (2022) Advocating for safe staffing [Internet]. American Nurses Association. Available from: https://www.nursingworld.org/practice-policy/nurse-staffing/nurse-staffing-advocacy/. Accessed 9 Nov 2022

  17. Van den Heede K, Cornelis J, Bouckaert N, Bruyneel L, Van de Voorde C, Sermeus W (2020) Safe nurse staffing policies for hospitals in England, Ireland, California, Victoria and Queensland: A discussion paper. Health Policy 124(10):1064–1073

    Article  PubMed  Google Scholar 

  18. Società Italiana per la Direzione e il Management delle Professioni Infermieristiche (2021) Raccomandazioni per la determinazione dello “staff” per l’assistenza infermieristica [Internet]. SIDMI. Available from: https://www.sidmi.it/wp-content/uploads/2021/05/RACCOMANDAZIONI-STAFF-Professioni-Infermieristiche-MAGGIO-2021-SIDMI-rev-1.0.docx-DEF.pdf. Accessed 5 Dec 2022

  19. Care Quality Commission (2014) Regulation 18: Staffing [Internet]. Care Quality Commission. Available from: https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-18-staffing#full-regulation. Accessed 28 Sept 2022

  20. Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine (2011) The Future of Nursing: Leading Change, Advancing Health [Internet]. Washington, D.C.: National Academies Press. Available from: https://www.nap.edu/catalog/12956. Accessed 5 Dec 2022

  21. Aiken LH, Sloane D, Griffiths P, Rafferty AM, Bruyneel L, McHugh M et al (2017) Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care. BMJ Qual Saf 26(7):559–568

    Article  PubMed  Google Scholar 

  22. Jarman B, Gault S, Alves B, Hider A, Dolan S, Cook A et al (1999) Explaining differences in English hospital death rates using routinely collected data. BMJ 318(7197):1515–1520

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Griffiths P, Ball J, Murrells T, Jones S, Rafferty AM (2016) Registered nurse, healthcare support worker, medical staffing levels and mortality in English hospital trusts: a cross-sectional study. BMJ Open 6(2):e008751

    Article  PubMed  PubMed Central  Google Scholar 

  24. Harrison JM, Aiken LH, Sloane DM, Brooks Carthon JM, Merchant RM, Berg RA et al (2019) In hospitals with more nurses who have baccalaureate degrees, better outcomes for patients after cardiac arrest. Health Aff (Millwood) 38(7):1087–1094

    Article  PubMed  Google Scholar 

  25. Hickey PA, Gauvreau K, Porter C, Connor JA (2018) The impact of critical care nursing certification on pediatric patient outcomes: Pediatr Crit Care Med 19(8):718–24

  26. Van Allen K (2012) The Society of Pediatric Nurses Safe Staffing for Pediatric Patients Literature Review. J Pediatr Nurs 27(5):598–601

    Article  Google Scholar 

  27. Kim CG, Kim JS (2018) The association between nurse staffing levels and paediatric nursing-sensitive outcomes in tertiary hospitals. J Nurs Manag 26(8):1002–1014

    Article  PubMed  Google Scholar 

  28. Brenner M, Kidston C, Hilliard C, Coyne I, Eustace-Cook J, Doyle C et al (2018) Children’s complex care needs: a systematic concept analysis of multidisciplinary language. Eur J Pediatr 177(11):1641–1652

    Article  PubMed  Google Scholar 

  29. Clancy A, Olaso EM, Larkin P, Brenner M (2021) Education on childrens complex care needs in general nursing curricula in Europe: an inductive content analysis. Nurse Educ Pract 52:103034

    Article  PubMed  Google Scholar 

  30. Betz CL, Cowell JM, Craft-Rosenberg MJ, Krajicek MJ, Lobo ML (2007) Health care quality and outcome guidelines for nursing of children and families: implications for pediatric nurse practitioner practice, research, and policy. J Pediatr Health Care Off Publ Natl Assoc Pediatr Nurse Assoc Pract 21(1):64–66

    Google Scholar 

  31. Audet LA, Bourgault P, Rochefort CM (2018) Associations between nurse education and experience and the risk of mortality and adverse events in acute care hospitals: a systematic review of observational studies. Int J Nurs Stud 80:128–146

    Article  PubMed  Google Scholar 

  32. Moher D, Liberati A, Tetzlaff J, Altman DG (2009) The PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement. PLoS Med 6(7):e1000097

  33. The Joanna Briggs Institute (2017) The Joanna Briggs Institute Critical Appraisal tools. The Joanna Briggs Institute. Available from: https://jbi.global/critical-appraisal-tools. Accessed 29 Dec 2022

  34. Hickey P, Gauvreau K, Connor J, Sporing E, Jenkins K (2010) The relationship of nurse staffing, skill mix, and Magnet recognition to institutional volume and mortality for congenital heart surgery. J Nurs Adm 40(5):226–232

    Article  PubMed  Google Scholar 

  35. Hickey PA, Gauvreau K, Jenkins K, Fawcett J, Hayman L (2011) Statewide and national impact of California’s Staffing Law on pediatric cardiac surgery outcomes. J Nurs Adm 41(5):218–225

    Article  PubMed  Google Scholar 

  36. Gaies MG, Clarke NS, Donohue JE, Gurney JG, Charpie JR, Hirsch JC (2012) Personnel and unit factors impacting outcome after cardiac arrest in a dedicated pediatric cardiac intensive care unit: Pediatr Crit Care Med 13(5):583–8

  37. Hickey PA, Gauvreau K, Curley MAQ, Connor JA (2013) The effect of critical care nursing and organizational characteristics on pediatric cardiac surgery mortality in the United States. J Nurs Adm 43(12):637–644

    Article  PubMed  Google Scholar 

  38. Hickey PA, Pasquali SK, Gaynor JW, He X, Hill KD, Connor JA et al (2016) Critical care nursing’s impact on pediatric patient outcomes. Ann Thorac Surg 102(4):1375–1380

    Article  PubMed  Google Scholar 

  39. Jung M, Park H, Kang D, Park E, Jeon K, Chung CR et al (2020) The effect of bed-to-nurse ratio on hospital mortality of critically ill children on mechanical ventilation: a nationwide population-based study. Ann Intensive Care 10(1):159

    Article  PubMed  PubMed Central  Google Scholar 

  40. Lasa JJ, Banerjee M, Zhang W, Bailly DK, Sasaki J, Bertrandt R et al (2022) Critical care unit organizational and personnel factors impact cardiac arrest prevention and rescue in the pediatric cardiac population. Pediatr Crit Care Med 23(4):255–267

    Article  PubMed  Google Scholar 

  41. Mark BA, Harless DW, Berman WF (2017) Nurse staffing and adverse events in hospitalized children. Policy Polit Nurs Pract 8(2)

  42. Watson SI, Arulampalam W, Petrou S, Marlow N, Morgan AS, Draper E et al (2016) The effects of a one-to-one nurse-to-patient ratio on the mortality rate in neonatal intensive care: a retrospective, longitudinal, population-based study. Arch Dis Child - Fetal Neonatal Ed 101(3):F195-200

    Article  CAS  PubMed  Google Scholar 

  43. Beltempo M, Lacroix G, Cabot M, Blais R, Piedboeuf B (2018) Association of nursing overtime, nurse staffing and unit occupancy with medical incidents and outcomes of very preterm infants. J Perinatol Off J Calif Perinat Assoc 38(2):175–180

    CAS  Google Scholar 

  44. Lemieux-Bourque C, Piedboeuf B, Gignac S, Taylor-Ducharme S, Julien AS, Beltempo M (2022) Comparison of three nursing workload assessment tools in the neonatal intensive care unit and their association with outcomes of very preterm infants. Am J Perinatol 39(06):640–645

    Article  PubMed  Google Scholar 

  45. The UK Neonatal Staffing Study Group (2002) Patient volume, staffing, and workload in relation to risk-adjusted outcomes in a random stratified sample of UK neonatal intensive care units: a prospective evaluation. The Lancet 359(9301):99–107

    Article  Google Scholar 

  46. StC Hamilton KE, Redshaw ME, Tarnow-Mordi W (2007) Nurse staffing in relation to risk-adjusted mortality in neonatal care. Arch Dis Child Fetal Neonatal Ed 92(2):F99-103

    Article  Google Scholar 

  47. Tawfik DS, Profit J, Lake ET, Liu JB, Sanders LM, Phibbs CS (2020) Development and use of an adjusted nurse staffing metric in the neonatal intensive care unit. Health Serv Res 55(2):190–200

    Article  PubMed  Google Scholar 

  48. West E, Barron DN, Harrison D, Rafferty AM, Rowan K, Sanderson C (2014) Nurse staffing, medical staffing and mortality in Intensive Care: An observational study. Int J Nurs Stud 51(5):781–794

    Article  PubMed  Google Scholar 

  49. Lee A, Cheung YSL, Joynt GM, Leung CCH, Wong WT, Gomersall CD (2017) Are high nurse workload/staffing ratios associated with decreased survival in critically ill patients? A cohort study. Ann Intensive Care 7(1):46

    Article  PubMed  PubMed Central  Google Scholar 

  50. Fagerström L, Kinnunen M, Saarela J (2018) Nursing workload, patient safety incidents and mortality: an observational study from Finland. BMJ Open 8(4):e016367

    Article  PubMed  PubMed Central  Google Scholar 

  51. Needleman J, Shekelle PG (2019) More ward nursing staff improves inpatient outcomes, but how much is enough? BMJ Qual Saf 28(8):603–605

    Article  PubMed  Google Scholar 

  52. Jansson MM, Syrjälä HP, Ala-Kokko TI (2019) Association of nurse staffing and nursing workload with ventilator-associated pneumonia and mortality: a prospective, single-center cohort study. J Hosp Infect 101(3):257–263

    Article  PubMed  Google Scholar 

  53. District of Columbia Hospital Association (2016) Studies show that mandatory nurse ratios are not the answer. DCHA. Available from: https://www.mnhospitals.org/Portals/0/Documents/policy-advocacy/nursestaffing/130219%20DCHA_FactSheets.pdf. Accessed 5 Dec 2022

  54. Racy S, Davidson PM, Peeler A, Hager DN, Street L, Koirala B (2021) A review of inpatient nursing workload measures. J Clin Nurs 30(13–14):1799–1809

    Article  PubMed  Google Scholar 

  55. McCormick MC (1985) The contribution of low birth weight to infant mortality and childhood morbidity. N Engl J Med 312(2):82–90

    Article  CAS  PubMed  Google Scholar 

  56. Watkins WJ, Kotecha SJ, Kotecha S (2016) All-cause mortality of low birthweight infants in infancy, childhood, and adolescence: population study of England and Wales. Myers JE, editor. PLOS Med 13(5):e1002018

  57. Roland D, Stilwell PA, Fortune PM, Alexander J, Clark SJ, Kenny S (2021) Case for change: a standardised inpatient paediatric early warning system in England. Arch Dis Child 106(7):648–651

    Article  PubMed  Google Scholar 

  58. Bonafide CP, Localio AR, Roberts KE, Nadkarni VM, Weirich CM, Keren R (2014) Impact of rapid response system implementation on critical deterioration events in children. JAMA Pediatr 168(1):25

    Article  PubMed  Google Scholar 

  59. Liao LM, Sun XY, Yu H, Li JW (2016) The association of nurse educational preparation and patient outcomes: systematic review and meta-analysis. Nurse Educ Today 42:9–16

    Article  PubMed  Google Scholar 

  60. Needleman J, Buerhaus PI, Stewart M, Zelevinsky K, Mattke S (2006) Nurse staffing in hospitals: is there a business case for quality? Health Aff (Millwood) 25(1):204–211

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Professional Development, Continuing Education and Research Unit, Medical Directorate, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy

    Catia Genna, Kiara Ros Thekkan & Orsola Gawronski

  2. Department of Pediatric Intensive Care, Wilhelmina Children’s Hospital/University Medical Center Utrecht, Utrecht, The Netherlands

    Paulien A. M. A. Raymakers-Janssen

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  1. Catia Genna
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  2. Kiara Ros Thekkan
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  3. Paulien A. M. A. Raymakers-Janssen
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  4. Orsola Gawronski
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Contributions

Orsola Gawronski and Pauline Raymakers-Jannsen conceived the study protocol and planned the work. Catia Genna, Kiara Ros Thekkan, Orsola Gawronski and Pauline Raymakers-Jannsen performed the literature search, data analysis and interpretation. Orsola Gawronski, Catia Genna, and Paulien Raymakers-Jannsen drafted the article. All authors provided a critical revision of the article and provided the final approval of the version to be published.

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Correspondence to Orsola Gawronski.

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Communicated by Daniele De Luca.

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Genna, C., Thekkan, K.R., Raymakers-Janssen, P.A.M.A. et al. Is nurse staffing associated with critical deterioration events on acute and critical care pediatric wards? A literature review. Eur J Pediatr 182, 1755–1770 (2023). https://doi.org/10.1007/s00431-022-04803-2

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