Critical Appraisal

Nurse Staffing and Inpatient

Hospital Mortality

Sari Agustine Lisano

101414453005
1. Judul Jurnal : Nurse Staffing and Inpatient
Hospital Mortality
2. Penulis : Jack Needleman, Ph.D., Peter
Buerhaus, Ph.D., R.N., V. Shane
Pankratz, Ph.D., Cynthia L. Leibson,
Ph.D., Susanna R. Stevens, M.S., and
Marcelline Harris, Ph.D., R.N.
3. Jurnal : N Engl J Med 2011;364:1037-45.
Copyright © 2011 Massachusetts Medical
Society.
4. Published : March 17, 2011
I. ABSTRAK PENELITIAN
Introduction
1. Evidence from an increasing number of studies has
shown an association between the level of in-hospital
staffing by registered nurses (RNs) and patient mortality,
adverse patient outcomes, and other quality measures.
2. The strength of the evidence underpinning the
association between nurse staffing and patient outcomes
has been challenged because studies are typically cross-
sectional in design, use hospital- level administrative
data that imprecisely allocate staffing to individual
patients, and do not account for differences in patients’
requirements for nursing care
Aim of the Study
• In this study, we address these concerns by
examining the association between mortality and
day-to-day, shift-to-shift variations in staffing at
the unit level in a single institution that has
lower-than-expected mortality and high average
nurse staffing levels and has been recognized
for high quality by the Dartmouth Atlas, rankings
in U.S. News and World Report, and Magnet
hospital designation.
• In addition, our analysis includes extensive
controls for potential sources of an increased
risk of death other than nurse staffing.
Subjects and Methods

1. Research design : retrospective observational

study
2. Setting: We used data from a large tertiary
academic medical center involving 197,961
admissions and 176,696 nursing shifts of 8
hours each in 43 hospital units to examine the
association between mortality and patient
exposure to nursing shifts during which staffing
by RNs was 8 hours or more below the staffing
target.
3. Subjects :

a. We retrieved data for 2003 through 2006 from

electronic data systems of the medical center.

We excluded pediatric, labor and delivery, behavioral

health, and inpatient rehabilitation units.

We classified the remaining 43 hospital units according

to unit type (intensive care, step-down care [i.e., with
monitored beds but not intensive care], and general
care) and service type (medical or surgical).

For each unit, we obtained data on patient census,

admissions, transfers, and discharges and on staffing
levels for each nursing shift.
• We excluded data for patients who declined to
authorize the use of their data for research
purposes (3.1% of patients)
• The final sample included 197,961 admissions
• On a shift-by-shift basis, we identified the unit on
which each patient was located and then
merged unit characteristics and staffing data for
the shift with the patient data.
• This process resulted in 3,227,457 separate
records with information for each patient for
each shift during which they were hospitalized
(which we have called patient unit-shifts); these
records included measures of patient-level and
unit-level characteristics, nurse staffing, and
other shift-specific measures

• we considered only the first admission of

possibl multiple admissions for any specific
patient during the study period, there were
1,897,424 unit-shifts for patients.
Tools of data collection:

1. Data were obtained from a tertiary

academic medical center with trained
local data specialists who constructed the
analytic data set
Statistical Analysis

1. To assess the association between mortality

and nurse staffing, we conducted a survival
analysis using Cox proportional-hazards
regression models with the time from hospital
admission as the time scale and in-hospital death
as the outcome.
2. We analyzed associations between mortality,
levels of RN staffing, and other variables using
Cox proportional-hazards regression models
1. We used regression models that included
these variables to estimate hazard ratios
and 95% confidence intervals.
2. Hazard ratios were tested for significance
with the use of two-sided Wald tests.
3. All statistical analyses were conducted
with the use of SAS software, version 9.1.
Results
• Staffing by RNs was within 8 hours of the target level for
84% of shifts, and patient turnover was within 1 SD of
the day-shift mean for 93% of shifts.
• Overall mortality was 61% of the expected rate for
similar patients on the basis of modified diagnosisrelated
groups.
• There was a significant association between increased
mortality and increased exposure to unit shifts during
which staffing by RNs was 8 hours or more below the
target level (hazard ratio per shift 8 hours or more below
target, 1.02; 95% confidence interval [CI], 1.01 to 1.03;
P<0.001).
• The association between increased mortality and high
patient turnover was also significant (hazard ratio per
high-turnover shift, 1.04; 95% CI, 1.02 to 1.06; P<0.001).
Conclusion

In this retrospective observational study,

staffing of RNs below target levels was
associated with increased mortality, which
reinforces the need to match staffing
with patients’ needs for nursing care
LIMITATION
• We did not explicitly include information on care delivery
models, the availability of staff members aside from RNs, or
differences in physical characteristics of units, although the
inclusion of unit fixed effects implicitly controlled for many of
these differences.
• Although we studied the risk of death through the first 90
shifts (approximately 30 days) after admission, we did not
study factors influencing mortality after this time or outside
the hospital.
• Our data did not allow us to identify patients who had do-not-
resuscitate orders, a factor that influences the interpretatio of
overall mortality and may influence staffing decisions.
• Additional research is needed to understand the complex
interplay among nurse staffing patient preferences, and other
factors, includin staffing levels for physicians and other non-
nursing personnel, technology, work processes, and clinical
outcomes.
Recommendation
The results of our study can be used to shift the national
dialogue from questions about whether nurse staffing levels
have a significant effect on patient outcomes to a focus on
how current and emerging payment systems can reward
hospitals’ efforts to ensure adequate staffing.

In addition, providing sufficient resources to ensure that

staffing is adequate and paying close attention to patient
transfers and other factors that have a major effect on
workload should become an active part of daily
conversations among nurses, physicians, and hospital
leaders in planning for the care of their patients.
II. CRITICAL APPRAISAL
 Ciri-ciri penelitian kuantitatif

1. Metode penelitian kuantitatif dilakukan untuk

mengukur satu atau lebih variable penelitian.
Lebih dari itu penelitian kuantitatif dilakukan
untuk mengukur hubungan atau korelasi atau
pengaruh antara dua variabel atau lebih

PADA JURNAL INI MEMPELAJARI HUBUNGAN ANTARA

JUMLAH PERAWAT JAGA PERSHIFT DENGAN
ANGKA KEMATIAN PASIEN.
DIMANA VARIABEL PENELITIAN LEBIH DARI SATU
DAN DILAKUKAN UJI REGRESI
Ciri-ciri penelitian kuantitatif

Penelitian kuantitatif dilakukan untuk menguji

teori yang sudah ada yang dipilih oleh peneliti
dan metode penelitian kuantitatif memfungsikan
teori sebagai titik tolak menemukan konsep yang
terdapat dalam teori tersebut, yang kemudian
dijadikan variabel.

TEORI YANG DIPAKAI ADALAH ADANYA HUBUNGAN ANTARA

RENDAHNYA JUMLAH PERAWAT DAN MENINGKATNYA
ANGKA KEMATIAN PASIEN. SEBAGAIMANA YANG TAMPAK
DALAM REFERENCES DI JURNAL TERSEBUT, SUDAH BANYAK
DITELITI OLEH PENELITI LAIN.
Ciri-ciri penelitian kuantitatif

• Penelitian kuantitatif menggunakan hipotesis

sejak awal ketika peneliti telah menetapkan teori
yang digunakan. Hipotesis Komparatif

• Penelitian kuantitatif lebih mengutamakan teknik

pengumpulan dokumen

• Data penelitian merupakan data primer berupa

data dari electronic data system yang berupa
sensus pasien, jumlah pasien masuk, jumlah
pasien transfer ruangan, jumlah pasien KRS dan
jumlah perawat di tiap shift jaga
Ciri-ciri Penelitian Restropective
Observasional/Cohort dalam Artikel
1. Adalah suatu penelitian (survey) analitik yang
menyangkut bagaimana faktor risiko dipelajari dengan
menggunakan pendekatan retrospektif. Dengan kata
lain efek (penyakit atau status kesehatan) diidentifikasi
pada saat ini, kemudian faktor risiko diidentifikasi
adanya atau terjadinya pada waktu yang lalu.

PADA PENELITIAN INI DAPAT DILIHAT BAHWA PENELITI

MENGAMBIL DATA DARI ELECTRONIC DATA SYSTEM
TAHUN 2003 - 2006
• Pengambilan studi ini sudah tepat karena
peneliti mencoba meneliti pengaruh suatu
sebab karena sebab tertentu
Adapun tahap-tahap penelitian case control ini adalah
sebagai berikut :

1. Identifikasi variabel-variabel penelitian (faktor risiko

atau efek)
2. Menetapkan objek penelitian (populasi dan sampel)
3. Identifikasi kasus
4. Pemilihan subyek sebagai kontrol
5. Melakukan pengukuran retrospektif (melihat
kebelakang) untuk melihat faktor risiko
6. Melakukan analisis dengan membandingkan
proporsi antara variabel-variabel objek penelitian
dengan variabel-variabel objek kontrol.
Identifikasi variable-variabel penelitian
(faktor risiko dan efek)
• Variabel yang diteliti adalah
– inpatient mortality (dependent)
– jumlah perawat per unit shift
– patient turnover
– other unit and shift measures
– patient level measures (to adjust for the risk of death,
including age, sex, payment source, type of
admission, whether the patient was a local resident or
out-of-area referral, and the 29 coexisting conditions
included in the Elixhauser algorithm.)
1. objek penelitian
- Inpatient mortality at 43 hospital between 2003 -
2006
- excluded pediatric, labor and delivery, behavioral
health, and inpatient rehabilitation units.
- We classified the remaining 43 hospital units
according to unit type (intensive care, step-down
care [i.e., with monitored beds but not intensive
care], and general care) and service type (medical
or surgical).
• We excluded data for patients who
declined to authorize the use of their data
for research purposes (3.1% of patients).
The final sample included 197,961
admissions.

• we considered only the first admission of

possibly multiple admissions for any
specific patient during the study period,
there were 1,897,424 unit-shifts for
patients
• tidak dijelaskan teknik pengambilan
sample
IDENTIFIKASI KASUS

• an association between the level of in-

hospital staffing by registered nurses
(RNs) and patient mortality,adverse
patient outcomes, and other quality
measures.
subjek penelitian

• inpatient at 43 hospital between 2003 -

2006, without pediatric, labor and delivery,
behavioral health, and inpatient
rehabilitation units
• secara spesifik jumlah pasien meninggal
pada tahun 2003 - 2006 pada 43 rs
penelitian
Pengukuran “retrospektif” (melihat ke
belakang) untuk melihat faktor resiko

• pengambilan data pasien pada tahun 2003

- 2006
• data on patient census, admissions,
transfers, and discharges and on staffing
levels for each nursing shift.
• If we want to describe the relationship
between the values of two or more
variables we can use a statistical
technique called regression
 UJI STATISTIK
uji statistik yang digunakan ialah
cox proportion regression models

The Cox model is based on a modelling

approach to the analysis of survival data.
The purpose of the model is to
simultaneously explore the effects of several
variables on survival.

sudah tepat karena study ini mecari tahu hubungan antara

jumlah pasien pershift dengan tingginya angka kematian
• The regression method introduced by Cox
is used to investigate several variables at a time.
It is also known as proportional hazards
regression analysis.

The hazard function is the probability that

an individual will experience an event (for
example, death) within a small time interval,give
that the individual has survived up to the
beginning of the interval. It can therefore be
interpreted as the risk of dying at time t.
Kritik :
1. Tidak dijelaskan juga teknik pengambilan
sample