Park, Suin
(College of Nursing, Kosin University)
,
Park, Sohee
(Department of Biostatistics, Graduate School of Public Health, Yonsei University)
,
Lee, Young Joo
(College of Nursing, Daegu Catholic University)
,
Park, Choon-Seon
(Department of Quality Assessment Administration, Health Insurance Review and Assessment Service)
,
Jung, Young-Chul
(Department of Psychiatry, College of Medicine, Yonsei University)
,
Kim, Sunah
(College of Nursing, Yonsei University)
Purpose: The present study investigated the association between nurse staffing and health outcomes among psychiatric inpatients in Korea by assessing National Health Insurance claims data. Methods: The dataset included 70,136 patients aged 19 years who were inpatients in psychiatric wards for at lea...
Purpose: The present study investigated the association between nurse staffing and health outcomes among psychiatric inpatients in Korea by assessing National Health Insurance claims data. Methods: The dataset included 70,136 patients aged 19 years who were inpatients in psychiatric wards for at least two days in 2016 and treated for mental and behavioral disorders due to use of alcohol; schizophrenia, schizotypal and delusional disorders; and mood disorders across 453 hospitals. Nurse staffing levels were measured in three ways: registered nurse-to-inpatient ratio, registered nurse-to-adjusted inpatient ratio, and nursing staff-to-adjusted inpatient ratio. Patient outcomes included length of stay, readmission within 30 days, psychiatric emergency treatment, use of injected psycholeptics for chemical restraint, and hypnotics use. Relationships between nurse staffing levels and patient outcomes were analyzed considering both patient and system characteristics using multilevel modeling. Results: Multilevel analyses revealed that more inpatients per registered nurse, adjusted inpatients per registered nurse, and adjusted inpatients per nursing staff were associated with longer lengths of stay as well as a higher risk of readmission. More adjusted inpatients per registered nurse and adjusted inpatients per nursing staff were also associated with increased hypnotics use but a lower risk of psychiatric emergency treatment. Nurse staffing levels were not significantly associated with the use of injected psycholeptics for chemical restraint. Conclusion: Lower nurse staffing levels are associated with negative health outcomes of psychiatric inpatients. Policies for improving nurse staffing toward an optimal level should be enacted to facilitate better outcomes for psychiatric inpatients in Korea.
Purpose: The present study investigated the association between nurse staffing and health outcomes among psychiatric inpatients in Korea by assessing National Health Insurance claims data. Methods: The dataset included 70,136 patients aged 19 years who were inpatients in psychiatric wards for at least two days in 2016 and treated for mental and behavioral disorders due to use of alcohol; schizophrenia, schizotypal and delusional disorders; and mood disorders across 453 hospitals. Nurse staffing levels were measured in three ways: registered nurse-to-inpatient ratio, registered nurse-to-adjusted inpatient ratio, and nursing staff-to-adjusted inpatient ratio. Patient outcomes included length of stay, readmission within 30 days, psychiatric emergency treatment, use of injected psycholeptics for chemical restraint, and hypnotics use. Relationships between nurse staffing levels and patient outcomes were analyzed considering both patient and system characteristics using multilevel modeling. Results: Multilevel analyses revealed that more inpatients per registered nurse, adjusted inpatients per registered nurse, and adjusted inpatients per nursing staff were associated with longer lengths of stay as well as a higher risk of readmission. More adjusted inpatients per registered nurse and adjusted inpatients per nursing staff were also associated with increased hypnotics use but a lower risk of psychiatric emergency treatment. Nurse staffing levels were not significantly associated with the use of injected psycholeptics for chemical restraint. Conclusion: Lower nurse staffing levels are associated with negative health outcomes of psychiatric inpatients. Policies for improving nurse staffing toward an optimal level should be enacted to facilitate better outcomes for psychiatric inpatients in Korea.
* AI 자동 식별 결과로 적합하지 않은 문장이 있을 수 있으니, 이용에 유의하시기 바랍니다.
문제 정의
This study examined the relationship between nurse staffing level and psychiatric health outcomes based on PCDM thus contributing to the body of knowledge on the importance of nurse staffing in meeting patient needs and achieving positive health outcomes. The current findings also provided evidence that can be used for reviewing domestic legal standards and establishing policies on the nurse staffing in psychiatric wards.
This study investigated the association between nurse staffing level and psychiatric health outcomes based on PCDM. The current study found that nurse staffing levels were associated with health outcomes of psychiatric inpatients.
This study was a secondary analysis of National Health Insurance claims data aiming to examine the relationships between nurse staffing level and health outcomes of psychiatric inpatients.
제안 방법
The conceptual framework for this study was based on the Patient Care Delivery Model (PCDM) which conceptualizes the delivery of nursing care services to a patient care unit within a hospital [30]. It focused on the interdependent and dynamic interactions among inputs (characteristics of patients, nurses, systems, and system behaviors), throughputs (interventions, perceived work environment, and environmental complexity), intermediate outputs (staffing utilization level), and distal outputs (patient, nurse, and system outputs). PCDM proposed that the inputs yield distal outputs through the throughput processes which are influenced by throughput factors in the patient care delivery subsystem and affect the intermediate outputs.
PCDM proposed that the inputs yield distal outputs through the throughput processes which are influenced by throughput factors in the patient care delivery subsystem and affect the intermediate outputs. This study focused on the relationship between input factors, especially system behaviors such as nurse staffing levels, and output factors which are finally obtained from input factors as the intermediate variables that could be included in the throughput processes but were not available in the National Health Insurance claims data. Input factors consist of patient and system characteristics as well as system behaviors, such as nurse staffing level.
The dataset did not include any information on the individuals or hospitals and did not allow for data export. To construct a dataset for the analyses in the current study, we selected all claims data submitted to the HIRA for psychiatric inpatient care in 2016 and combined it with hospital data (medical resource information data and estimation reports on differentiating policies for hospitalization fees in medical aid psychiatric departments) from the same year. As this study was a secondary analysis of public access data, it did not require informed consent.
We adjusted our multilevel analyses for both patient and system characteristics (selected from within the dataset and based on previous studies) to examine the associations between nurse staffing levels and patient outcomes. Patient characteristics included age, gender, type of insurance, diagnosis, previous psychiatric hospitalization within the last year, number of psychiatric sub-diagnoses, number of physical sub-diagnoses, and Elixhauser Comorbidity Measures (ECM) score for the last year [34- 37].
001), indicating that multilevel analyses were appropriate for the data. We tested three models which included each nurse staffing variable separately: RN-to-inpatient ratio (model A), RN-to-adjusted inpatient ratio (model B), and nursing staff-to-adjusted inpatient ratio(model C). RN proportion, one of the system characteristics, was only adjusted in the multilevel Model C.
대상 데이터
003, respectively). Data from 65,433 patients were used for the readmission analysis. Having more inpatients per RN, adjusted inpatients per RN, and adjusted inpatients per nursing staff was associated with a higher risk of readmission within 30 days (OR 1.
We used the National Health Insurance claims data submitted to the Health Insurance Review and Assessment Service (HIRA). Data were submitted by psychiatric wards from tertiary and general hospitals, hospitals (see below), psychiatric hospitals, and clinics. In Korea, based on the Enforcement Rule of the Act on the Improvement of Mental Health and the Support for Welfare Services for Mental Patients, psychiatric clinics were allowed to have 49 or fewer beds for inpatient care.
The data were derived from claims of 70,136 patients across 453 institutions. Table 1 showed patient and system characteristics, and nurse staffing as system behaviors.
The final data comprised 70,136 inpatients from 453 hospitals after screening for inclusion and exclusion criteria. Figure 1 showed the process of the data construction.
데이터처리
We used χ2 tests, independent t-tests, and one-way ANOVAs to examine differences in patient outcomes according to patient and system characteristics and system behaviors.
이론/모형
The conceptual framework for this study was based on the Patient Care Delivery Model (PCDM) which conceptualizes the delivery of nursing care services to a patient care unit within a hospital [30]. It focused on the interdependent and dynamic interactions among inputs (characteristics of patients, nurses, systems, and system behaviors), throughputs (interventions, perceived work environment, and environmental complexity), intermediate outputs (staffing utilization level), and distal outputs (patient, nurse, and system outputs).
성능/효과
The current result could be interpreted in two ways. First, patient characteristics, such as diagnosis and symptom severity, may have greater effects on the use of injected psycholeptics than do nurse staffing levels. Alternatively, the nurse staffing level may affect the use of injected psycholeptics, but significant relationship was not confirmed when not accounting for the qualitative aspects of the nursing staff present.
Data from 65,433 patients were used for the readmission analysis. Having more inpatients per RN, adjusted inpatients per RN, and adjusted inpatients per nursing staff was associated with a higher risk of readmission within 30 days (OR 1.01, 95% CI 1.00~1.02; OR 1.01, 95% CI 1.00~1.02; OR 1.02, 95% CI 1.00~1.04, respectively). Having more adjusted inpatients per RN and more adjusted inpatients per nursing staff was associated with lower risk of psychiatric emergency treatment (OR 0.
The fourth outcome of the present study found that the relationship between the nurse staffing level and injected psycholeptics for chemical restraint was not significant. Although the influence of nurse staffing on the use of chemical restraints has rarely been investigated, it is expected that mental health nurses could help patients stabilize and reduce the use of chemical restraints [22,25].
The second significant finding was that more inpatients per RN, adjusted inpatients per RN, and adjusted inpatients per nursing staff were also associated with a higher risk of readmission within 30 days. The current results are similar to a previous finding, which reported that the number of nurses had an inverse association with readmission risk within 30 days [18].
Thus, the nurse staffing level presented in this study might not be the same as the actual level in practice. Third, adjusting for patient severity while using National Health Insurance claims data was insufficient given that we were limited in our access to the available information and variables. Fourth, some hospitalizations and readmissions due primarily to the lack of family and social support systems may have been included, because it is not possible to screen hospitalization episodes using administrative data.
후속연구
Alternatively, the nurse staffing level may affect the use of injected psycholeptics, but significant relationship was not confirmed when not accounting for the qualitative aspects of the nursing staff present. Further studies should consider proper adjustments based on patient severity and measurement of both quantitative and qualitative aspects of nurse staffing levels. Moreover, we suggest that a longitudinal study is needed to analyze the influence of the nurse staffing level on changes to the number of mechanical and chemical restraints simultaneously employed.
Therefore, future research is needed to investigate the differences in the influences of number of patients per RN and number of patients per nursing staff on nursing-sensitive outcomes in psychiatric wards. Further, research is needed to identify the optimal nurse staffing levels and nursing skill mix to improve psychiatric health outcomes.
These results might suggest that patient outcomes in this study were not closely related to nursing interventions for conditions such as urinary tract infection and pneumonia [49,50]. Therefore, future research is needed to investigate the differences in the influences of number of patients per RN and number of patients per nursing staff on nursing-sensitive outcomes in psychiatric wards. Further, research is needed to identify the optimal nurse staffing levels and nursing skill mix to improve psychiatric health outcomes.
Previous studies reported that nurse staffing, nursing work environments, and nurse education were all associated with patient outcomes [19,46]. Thus, the development of a measurement tool that can properly adjust for inpatient severity is necessary and further studies are needed to investigate the relationship between nurse staffing and the use of seclusion and restraints.
참고문헌 (50)
Organisation for Economic Co-operation and Development (OECD). Hospital average length of stay by diagnostic categories [Internet]. Paris: OECD; c2020 [cited 2020 May 14]. Available from: http://stats.oecd.org/.
Health Insurance Review & Assessment Service (HIRA). OECD health statistics comparison database in 2014 [Internet]. Wonju: HIRA; c2014 [cited 2020 May 14]. Available from: http://www.hira.or.kr/bbsDummy.do?pgmidHIRAA020045010000&brdScnBltNo4&brdBlt-No2274&pageIndex1#none.
Health Insurance Review & Assessment Service (HIRA). Psychiatric emergency treatment [Internet]. Wonju: HIRA; c2020 [cited 2020 May 14]. Available from: http://opendata.hira.or.kr/op/opc/olapDiagBhvInfo.do.
Health Insurance Review & Assessment Service (HIRA). Hypnotics and sedatives use [Internet]. Wonju: HIRA; c2020 [cited 2020 May 14]. Available from: http://opendata.hira.or.kr/op/opc/olapMeftDiv.do.
Health Insurance Review & Assessment Service (HIRA). Behavior definition of relative value score - psychiatric emergency treatment [Internet]. Wonju: HIRA; c2020 [cited 2020 May 14]. Available from: https://biz.hira.or.kr/index.do?ssook.
Ministry of Health and Welfare. Enforcement rule of the act on the improvement of mental health and the support for welfare services for mental patients, article 11, paragraph 2 [Internet]. Sejong: Ministry of Government Legislation; c2017 [cited 2020 May 14]. Available from: http://www.law.go.kr/lsInfoP.do?lsiSeq206272&efYd20190101#0000.
California Office of Administrative Law. Nursing service staff, 22 CA ADC ${\S}$ 70217 [Internet]. Toronto: Thomson Reuters Westlaw; c2004 [cited 2020 May 14]. Available from: https://govt.westlaw.com/calregs/Document/I8612C-410941F11E29091E6B951DDF6CE?viewTypeFullText&originationContextdocumenttoc&transitionTypeCategoryPage-Item&contextData(sc.Default).
Morioka N, Tomio J, Seto T, Kobayashi Y. The association between higher nurse staffing standards in the fee schedules and the geographic distribution of hospital nurses: A cross-sectional study using nationwide administrative data. BMC Nursing. 2017;16:25. https://doi.org/10.1186/s12912-017-0219-1
You SJ. Policy implications of nurse staffing legislation. The Journal of the Korea Contents Association. 2013;13(6):380-389. https://doi.org/10.5392/JKCA.2013.13.06.380
Pitkaaho T, Partanen P, Miettinen MH, Vehvilainen-Julkunen K. The relationship between nurse staffing and length of stay in acute-care: A one-year time-series data. Journal of Nursing Management. 2016;24(5):571-579. https://doi.org/10.1111/jonm.12359
Cho E, Park J, Choi M, Lee HS, Kim EY. Associations of nurse staffing and education with the length of stay of surgical patients. Journal of Nursing Scholarship. 2018;50(2):210-218. https://doi.org/10.1111/jnu.12366
Lasater KB, Mchugh MD. Nurse staffing and the work environment linked to readmissions among older adults following elective total hip and knee replacement. International Journal for Quality in Health Care. 2016;28(2):253-258. https://doi.org/10.1093/intqhc/mzw007
Kim SJ, Park EC, Han KT, Kim SJ, Kim TH. Nurse staffing and 30-day readmission of chronic obstructive pulmonary disease patients: A 10-year retrospective study of patient hospitalization. Asian Nursing Research. 2016;10(4):283-288. https://doi.org/10.1016/j.anr.2016.09.003
Driscoll A, Grant MJ, Carroll D, Dalton S, Deaton C, Jones I, et al. The effect of nurse-to-patient ratios on nurse-sensitive patient outcomes in acute specialist units: A systematic review and meta-analysis. European Journal of Cardiovascular Nursing. 2018;17(1):6-22. https://doi.org/10.1177/1474515117721561
Cho E, Chin DL, Kim S, Hong O. The relationships of nurse staffing level and work environment with patient adverse events. Journal of Nursing Scholarship. 2016;48(1):74-82. https://doi.org/10.1111/jnu.12183
Pertile R, Donisi V, Grigoletti L, Angelozzi A, Zamengo G, Zulian G, et al. DRGs and other patient-, service- and area- level factors influencing length of stay in acute psychiatric wards: The Veneto region experience. Social Psychiatry and Psychiatric Epidemiology. 2011;46(7):651-660. https://doi.org/10.1007/s00127-010-0231-1
Kim GH, Kim SJ, Kim SS. Nurse staffing, inpatient's length of stay and safety accidents in psychiatric hospital settings. Journal of the Korean Data Analysis Society. 2017;19(1):503-511.
Han KT, Kim SJ, Jang SI, Hahm MI, Kim SJ, Lee SY, et al. The outcomes of psychiatric inpatients by proportion of experienced psychiatrists and nurse staffing in hospital: New findings on improving the quality of mental health care in South Korea. Psychiatry Research. 2015;229(3):880-886. https://doi.org/10.1016/j.psychres.2015.07.051
Janssen W, Noorthoorn E, van Linge R, Lendemeijer B. The influence of staffing levels on the use of seclusion. International Journal of Law and Psychiatry. 2007;30(2):118-126. https://doi.org/10.1016/j.ijlp.2006.04.005
Donat DC. Impact of improved staffing on seclusion/restraint reliance in a public psychiatric hospital. Psychiatric Rehabilitation Journal. 2002;25(4):413-416. https://doi.org/10.1037/h0094994
Fukasawa M, Miyake M, Suzuki Y, Fukuda Y, Yamanouchi Y. Relationship between the use of seclusion and mechanical restraint and the nurse-bed ratio in psychiatric wards in Japan. International Journal of Law and Psychiatry. 2018;60:57-63. https://doi.org/10.1016/j.ijlp.2018.08.001
De Lacy LC. The influence of nursing staff numbers and skill mix on seclusion and restraint use in public psychiatric hospitals [dissertation]. Fairfax (VA): George Mason University; 2006. p. 1-157.
McHugh MD, Ma C. Hospital nursing and 30-day readmissions among medicare patients with heart failure, acute myocardial infarction, and pneumonia. Medical Care. 2013;51(1):52-59. https://doi.org/10.1097/MLR.0b013e3182763284
Kutney-Lee A, Lake ET, Aiken LH. Development of the hospital nurse surveillance capacity profile. Research in Nursing & Health. 2009;32(2):217-228. https://doi.org/10.1002/nur.20316
Cusack P, Cusack FP, McAndrew S, McKeown M, Duxbury J. An integrative review exploring the physical and psychological harm inherent in using restraint in mental health inpatient settings. International Journal of Mental Health Nursing. 2018;27(3):1162-1176. https://doi.org/10.1111/inm.12432
Masters KJ, Bellonci C, Bernet W, Arnold V, Beitchman J, Benson RS, et al. Practice parameter for the prevention and management of aggressive behavior in child and adolescent psychiatric institutions, with special reference to seclusion and restraint. Journal of the American Academy of Child and Adolescent Psychiatry. 2002;41(2 Suppl):4S-25S. https://doi.org/10.1097/00004583-200202001-00002
Muller MJ, Olschinski C, Kundermann B, Cabanel N. Subjective sleep quality and sleep duration of patients in a psychiatric hospital. Sleep Science. 2016;9(3):202-206. https://doi.org/10.1016/j.slsci.2016.08.004
Lee MJ, Hah YS. The effect of relaxation training applied to psychiatric inpatients complaining of insomnia. Journal of Korean Academy of Psychiatric Mental Health Nursing. 2008;17(1):35-45.
Pellatt GC. The nurse's role in promoting a good night's sleep for patients. British Journal of Nursing. 2007;16(10):602-605. https://doi.org/10.12968/bjon.2007.16.10.23507
O'Brien-Pallas L, Meyer RM, Hayes LJ, Wang S. The patient care delivery model--an open system framework: Conceptualisation, literature review and analytical strategy. Journal of Clinical Nursing. 2011;20(11-12):1640-1650. https://doi.org/10.1111/j.1365-2702.2010.03391.x
Reitan SK, Helvik AS, Iversen V. Use of mechanical and pharmacological restraint over an eight-year period and its relation to clinical factors. Nordic Journal of Psychiatry. 2018;72(1):24-30. https://doi.org/10.1080/08039488.2017.1373854
WHO Collaborating Centre for Drug Statistics Methodology. Guidelines for ATC classification and DDD assignment 2018. Oslo: WHO Collaborating Centre for Drug Statistics Methodology; 2017. p. 22-30, 223-226.
Ministry of Food and Drug Safety. Regulation on codes for classification of drugs and other products [Internet]. Cheongju: Sejong: Ministry of Government Legislation; c2009 [cited 2020 May 14]. Available from: http://www.law.go.kr/admRul-LsInfoP.do?admRulSeq2100000038481.
Okumura Y, Sugiyama N, Noda T, Sakata N. Association of high psychiatrist staffing with prolonged hospitalization, follow-up visits, and readmission in acute psychiatric units: A retrospective cohort study using a nationwide claims database. Neuropsychiatric Disease and Treatment. 2018;14:893-902. https://doi.org/10.2147/NDT.S160176
Sprah L, Dernovsek MZ, Wahlbeck K, Haaramo P. Psychiatric readmissions and their association with physical comorbidity: A systematic literature review. BMC Psychiatry. 2017;17(1):2. https://doi.org/10.1186/s12888-016-1172-3
Cha SK, Kim SS. The determinant of the length of stay in hospital for schizophrenic patients: Using data from the in-depth injury patient surveillance system. Journal of Digital Convergence. 2013;11(4):351-359. https://doi.org/10.14400/JDPM.2013.11.4.351
Knutzen M, Bjorkly S, Eidhammer G, Lorentzen S, Mjosund NH, Opjordsmoen S, et al. Characteristics of patients frequently subjected to pharmacological and mechanical restraint--a register study in three Norwegian acute psychiatric wards. Psychiatry Research. 2014;215(1):127-133. https://doi.org/10.1016/j.psychres.2013.10.024
Walsh JK. Pharmacologic management of insomnia. The Journal of Clinical Psychiatry. 2004;65 Suppl 16:41-45.
Chung W, Cho WH, Yoon CW. The influence of institutional characteristics on length of stay for psychiatric patients: A national database study in South Korea. Social Science & Medicine. 2009;68(6):1137-1144. https://doi.org/10.1016/j.socscimed.2008.12.045
Clarke SP, Aiken LH. Failure to rescue: Needless deaths are prime examples of the need for more nurses at the bedside. The American Journal of Nursing. 2003;103(1):42-47. https://doi.org/10.1097/00000446-200301000-00020
Aiken LH, Clarke SP, Sloane DM. Hospital staffing, organization, and quality of care: Cross-national findings. International Journal for Quality in Health Care. 2002;14(1):5-13. https://doi.org/10.1093/intqhc/14.1.5
Cleary M, Horsfall J, O'Hara-Aarons M, Hunt GE. Mental health nurses' views of recovery within an acute setting. International Journal of Mental Health Nursing. 2013;22(3):205-212. https://doi.org/10.1111/j.1447-0349.2012.00867.x
Boden R, Brandt L, Kieler H, Andersen M, Reutfors J. Early non-adherence to medication and other risk factors for rehospitalization in schizophrenia and schizoaffective disorder. Schizophrenia Research. 2011;133(1-3):36-41. https://doi.org/10.1016/j.schres.2011.08.024
You SJ, Chang HS, Kim MK, Choi YK, Sung YH, Kim ES, et al. Study of the utilization strategy of nursing personnel by types of medical institutions. Journal of Korean Clinical Nursing Research. 2007;13(1):157-172.
Cho E, Sloane DM, Kim EY, Kim S, Choi M, Yoo IY, et al. Effects of nurse staffing, work environments, and education on patient mortality: An observational study. International Journal of Nursing Studies. 2015;52(2):535-542. https://doi.org/10.1016/j.ijnurstu.2014.08.006
Laguna-Parras JM, Jerez-Rojas MR, Garcia-Fernandez FP, Carrasco-Rodriguez MD, Nogales-Vargas-Machuca I. Effectiveness of the 'sleep enhancement' nursing intervention in hospitalized mental health patients. Journal of Advanced Nursing. 2013;69(6):1279-1288. https://doi.org/10.1111/j.1365-2648.2012.06116.x
Butcher HK, Bulechek GM, Dochterman JMM, Wagner CM. Nursing interventions classification (NIC). 7th ed. St. Louis (MO): Elsevier; 2018. p. 349.
Twigg DE, Myers H, Duffield C, Pugh JD, Gelder L, Roche M. The impact of adding assistants in nursing to acute care hospital ward nurse staffing on adverse patient outcomes: An analysis of administrative health data. International Journal of Nursing Studies. 2016;63:189-200. https://doi.org/10.1016/j.ijnurstu.2016.09.008
※ AI-Helper는 부적절한 답변을 할 수 있습니다.