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. |
Similar content being viewed by others
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
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
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
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
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
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
Tume L (2007) The deterioration of children in ward areas in a specialist children’s hospital. Nurs Crit Care 12(1):12–19
Padilla RM, Mayo AM (2018) Clinical deterioration: a concept analysis. J Clin Nurs 27(7–8):1360–1368
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
Van Allen K (2012) The Society of Pediatric Nurses Safe Staffing for Pediatric Patients Literature Review. J Pediatr Nurs 27(5):598–601
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
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
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
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
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
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
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
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
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
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
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
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
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
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
Mark BA, Harless DW, Berman WF (2017) Nurse staffing and adverse events in hospitalized children. Policy Polit Nurs Pract 8(2)
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
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
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
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
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
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
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
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
Fagerström L, Kinnunen M, Saarela J (2018) Nursing workload, patient safety incidents and mortality: an observational study from Finland. BMJ Open 8(4):e016367
Needleman J, Shekelle PG (2019) More ward nursing staff improves inpatient outcomes, but how much is enough? BMJ Qual Saf 28(8):603–605
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
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
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
McCormick MC (1985) The contribution of low birth weight to infant mortality and childhood morbidity. N Engl J Med 312(2):82–90
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
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
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
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
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
Author information
Authors and Affiliations
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.
Corresponding author
Ethics declarations
Ethics approval
This article does not contain any studies with human participants performed by any of the authors.
Consent to participate
Not applicable to this manuscript.
Competing interests
The authors declare no competing interests.
Additional information
Communicated by Daniele De Luca.
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary Information
Below is the link to the electronic supplementary material.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
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
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00431-022-04803-2