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• W2904296486 abstract "The recent position statement published by the International Council of Nurses (ICN) on evidence-based nurse staffing is important and timely and provides an action agenda for nurses globally. Rigorous studies are now available from many parts of the world documenting the association between nurses caring for fewer patients each (better nurse staffing) and better outcomes for hospitalized patients (International Council of Nurses 2018). Moreover, there is evidence of a business case for increased investments in nursing showing that when there are too few nurses in hospitals, the overall costs of care rise because of high expenses of treating patients with preventable complications like healthcare-associated infections. ICN is an influential global health organization representing the largest group of health professionals in the world – nurses. Its position statements carry weight with decision-makers. As I discussed in my keynote address on safe nursing staffing at the 2017 ICN Conference in Barcelona, good evidence is now available on the impact of safe nurse staffing on improved patient outcomes in over 30 countries. That large body of research, reviewed in ICN's position statement, is more than sufficient for nurses everywhere to use the position statement to advocate for evidence-based investments in safe nurse staffing. Research does not need to be replicated in every country. There is sufficient evidence, as ICN concluded, to act now. A strategy I have found effective in advocacy is to use the publication of a new position statement from an important organization like ICN's position statement on evidence-based safe nurse staffing as the occasion to brief decision-makers and the media in your locale or country on the particulars of nurse staffing challenges and ICN's recommended strategies. I have found that it is also helpful to give decision-makers and the media physical examples (via email and hard copy) of a couple of research papers published in high profile international journals where the journal's prestige helps bolster the legitimacy of the research findings. ICN's position statement has excellent references, although it is not meant to be a systematic review of all of the global research on safe nurse staffing. I have a few suggestions below for papers that I have found particularly useful with decision-makers and the media because they are in high profile interdisciplinary scientific journals and include multiple countries. A programme of research that has been an effective resource for staffing advocacy is the RN4CAST study of 12 European countries that has produced over 70 scientific papers on the link between nursing and patient and workforce outcomes. Several papers have been particularly influential because the scientific journals in which they were published are known around the world. If I were to choose one paper for advocacy, it would be the 2014 RN4CAST paper published in The Lancet showing in nine European countries that each additional patient added to professional nurses’ workloads was associated with a 7% increase in inpatient mortality following common surgical procedures (Aiken et al. 2014). The difference in postoperative mortality between hospitals in the nine countries if nurses cared for 5 patients each compared to 10 patients each could account for many thousands of potentially preventable deaths. Similarly, another RN4CAST analysis in BMJ Quality and Safety is also useful in demonstrating that changing the nursing skill mix in hospitals, an intervention often supported by decision-makers on the assumption that it will save money by adding non-nurses rather than fully qualified professional nurses, results in worse patient outcomes that increase rather than decrease hospital expenditures (Aiken et al. 2016). Large-scale studies documenting the association of better nurse staffing with better patient outcomes have also been conducted across a wide variety of countries including China (You et al. 2013), South Korea (Cho et al. 2014), Thailand (Nantsupawat et al. 2011), South Africa (Coetzee et al. 2013), Chile (Aiken et al. 2018a), in addition to many studies in North America (Aiken et al. 2011). The guidance given by the ICN position statement is comprehensive and specific. Commenting on each recommendation is beyond the scope of this paper. However, I would like to emphasize the evidence base underlying some of the recommendations including giving examples of evidence that is in the published literature. ICN's (2018) first recommendation that ‘decisions concerning nurse staffing must respond to clients’ healthcare needs’ seems obvious and not in need of evidence. However, there is considerable evidence that is perhaps unappreciated by decision-makers. A growing body of evidence shows that nurse staffing is one of the most important factors associated with patients’ global assessments including whether they rate their hospitals favourably, and whether they would recommend the hospital in which they received care to family and friends who need care. Research from the United States (Kutney Lee et al. 2009), Europe (Aiken et al. 2012), England (Aiken et al. 2018bb) and China (You et al. 2013) all show the essential contributions of adequate nurse staffing to favourable patient ratings of their care. Many countries are now conducting mandatory patient satisfaction surveys in healthcare facilities. Nurses should make more use of these national data to conduct analyses documenting within countries that nurse workloads are driving patient satisfaction, since the public's evaluation of health services is increasingly salient to decision-makers and of interest to national media. International Council of Nurses guidance on safe nurse staffing makes several recommendations regarding nurse work environments and the organization of nursing that have been shown by research to be highly related to good patient outcomes. One relates to the need for direct care nurses and nursing management being involved and engaged in organizational decision-making. There is a large and growing literature showing that greater engagement of clinical nurses is associated with better patient outcomes as well as improved nurse retention and reduction in the high costs of nurse turnover (Kutney Lee et al. 2016). ICN's recommendation that organizations should have a nurse at the executive level is supported by good evidence of the excellent patient and workforce outcomes of Magnet hospitals in which a qualified chief nurse officer is required. Unfortunately, policies in some countries have removed chief nurse positions in their efforts to save money through reducing administrative layers; there is good evidence to challenge these policies (McHugh et al. 2013). ICN's policy statement encourages national nurses’ associations, in collaboration with their respective government, to make nurse staffing in healthcare facilities more transparent. While there is a large evidence base supporting the importance of evidence-based safe nurse staffing, most countries require little to no transparency from healthcare organizations in their actual nurse staffing. Thus, it is very difficult to evaluate and improve nurse staffing if little information is publicly available. Our research shows that even in countries with large public national health services where it is assumed that nurse staffing is roughly similar across institutions, large variations in staffing exist between hospitals with adverse implications for patient outcomes and nurse retention (Aiken et al. 2013, 2014). Transparency about health care, especially in publicly funded institutions, is often a popular topic for the advancement of progress in achieving evidence-based staffing. One ICN recommendation that I fear may be premature is calling on individual nurses to report unsafe nurse staffing situations. I base this on large-scale research in Europe and the United States where we find, on average, across 13 countries that from one-third to two-thirds of hospital nurses report that they do not feel free to question the decisions or actions of those in authority. Moreover, over 20% of nurses in some countries to more than two-thirds of nurses in other countries do not believe that management in their hospital listens to and responds to employee concerns (Aiken et al. 2013). Given the lack of nurses’ trust in organization management, it may be unrealistic to expect individual nurses to report unsafe staffing situations. Thus, it is all the more important to institute the other ICN recommendations that are feasible and hold promise for moving closer to evidence-based nurse staffing. Nurses globally should take the ICN position statement and its recommendations along with a few of the key international studies published in high profile scientific journals to their country's policymakers and medical and hospital leaders to educate them that investing in evidence-based safe nurse staffing is in the public's interest and in the interest of efficient and affordable health care. As an adjunct activity, nurses should develop more capacity to effectively communicate newsworthy stories to the press and use social media which the press often monitors to communicate evidence of the importance of investments in safe nurse staffing. Frame the nurse staffing issue in terms of better patient outcomes. Those that have the numbers often prevail in policy debates, and nursing now has valuable research findings that can be compelling if communicated effectively." @default.
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• W2904296486 title "Evidence‐based Nurse Staffing: ICN’s New Position Statement" @default.
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