Systematic review of evidence on the impact of nursing workload and staffing on establishing healthy work environments.

UNLABELLED: Background This systematic review set out to examine the impact, if any, of nursing workload and staffing on creating and maintaining healthy work environments. For the purposes of this review, the term 'healthy work environment' was defined as '. . . a practice setting that maximizes the health and well-being of nurses, quality patient outcomes and organizational performance'. This definition identifies nurse, patient and organisational outcomes as indicators of the establishment and maintenance of a healthy work environment. Objectives The review sought to determine the impact of: • Patient characteristics, nurse characteristics, system characteristics and system processes on workload, scheduling and concepts of productivity and utilisation • Workload, scheduling and concepts of productivity and utilisation on the quality of outcomes for clients, nurses and the system/organisation Search strategy The search strategy sought to find both published and unpublished studies and papers written in the English language. A three-step search strategy approach was used. An initial limited search of MEDLINE and CINAHL databases was undertaken to identify optimal search terms followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second extensive search using all identified keywords and index terms was then undertaken. The third step consisted of a search of the reference lists of all identified reports and articles for additional studies. Selection criteria Types of studies: This review considered research papers that addressed the appropriateness and effectiveness of workload and staffing concepts in fostering a healthy work environment in healthcare. The types of papers to be considered included: meta-analysis, randomised controlled trials, quasi-randomised controlled trials, cohort studies, case-control studies, descriptive studies and correlational studies. TYPES OF PARTICIPANTS: The review considered all participants involved or affected by workload and staffing concepts within the nursing workforce in a healthcare environment, including staff and patients. System and policy issues were also considered. Types of interventions: All workload and staffing strategies that impact on the work environment, patient and nurse outcomes were considered in this review. Types of outcome measures: Outcomes of interest were categorised into four groups: nursing staff outcomes, patient outcomes, organisational outcomes and system outcomes. Data collection and analysis Following assessment of methodological quality, data were extracted using data extraction tools based on the work of the Cochrane Collaboration and the Centre for Reviews and Dissemination. Statistical pooling was not possible and findings were presented in narrative form. Results Of the 2162 papers identified in the search, 171 were selected for full paper retrieval and assessed independently by two reviewers for methodological quality. A total of 40 papers were included in the review: one systematic review; one cohort study; and 38 correlational descriptive studies. Results were summarised in narrative form. The evidence suggests strong correlations between patient characteristics and work environments; and workload and staffing and the quality of outcomes for clients, nurses and the system/organisation. This gave rise to a number of recommendations for practice and for further research, such as: • A greater proportion of regulated staffing (i.e. registered nurses, enrolled nurses, practical or vocational nurses) is associated with improved outcomes related to the Functional Independence Measure score, the Short Form Health Survey (SF-36) vitality score, patient satisfaction with nursing care, patient adverse events (including atelectasis, decubitus ulcers, falls, pneumonia, postsurgical and treatment infection and urinary tract infections) • An increase in the number of registered nurse hours available is associated with improved patient outcomes in relation to falls, pneumonia, pressure ulcers, urinary tract infection, length of stay and postoperative infection rates.

Nurses who work outside nursing.

BACKGROUND: The desire to care for people, a family history of professional health care work, and security in career choice are documented reasons for entering nursing. Reasons for leaving include workload, unsafe work environments and harassment. The relationship between these factors and the time nurses spend in the profession has not been explored. AIM: This paper reports a study with people who have left nursing, to investigate why they became a nurse, how long they stayed in nursing, and their reasons for leaving. METHOD: A questionnaire was mailed to Registered Nurses currently working outside nursing, seeking respondents' reasons for entering and leaving nursing, and perceptions of the skills gained from nursing and the ease of adjustment to working in a non-nursing environment. Data analysis included descriptive statistics, exploratory and confirmatory factor analysis, correlational analysis and linear and multiple regression analysis. RESULTS: A model incorporating the factors 'altruistic reasons', 'default choice' and 'stepping stone' explained 36.2% of the variance in reasons for becoming a nurse. A model incorporating the factors 'legal and employer', 'external values and beliefs about nursing', 'professional practice', 'work life/home life' and 'contract requirements' explained 55.4% of the variance in reasons for leaving nursing. Forty-eight per cent of the variance in tenure in nursing practice was explained through personal characteristics of nurses (36%), reasons for becoming a nurse (7%) and reasons for leaving (6%). CONCLUSION: The reasons why nurses entered or left the profession were varied and complex. While personal characteristics accounted for a large component of tenure in nursing, those managing the nursing workforce should consider professional practice issues and the balance between work life and home life.