COVID-19 and Ontario’s Long-Term Care Homes

Ontario long-term care (LTC) home residents have experienced disproportionately high morbidity and mortality, both from COVID-19 and from the conditions associated with the COVID-19 pandemic. There are several measures that could be effective in preventing COVID-19 outbreaks, hospitalizations, and deaths in Ontario’s LTC homes, if implemented. First, temporary staffing could be minimized by improving staff working conditions. Second, homes could be further decrowded by a continued disallowance of three- and four-resident rooms and additional temporary housing for the most crowded homes. Third, the risk of SARS-CoV-2 infection in staff could be minimized by approaches that reduce the risk of transmission in communities with a high burden of COVID-19.

The Association between Care Left Undone and Temporary Nursing Staff ratios in Acute Settings: A cross- sectional survey of registered nurses

Background: The shortage of health workers is a global phenomenon. To meet increasing patient demands on UK health services, providers are increasingly relying on temporary staff to fill permanent posts. This study examines the occurrence of ‘care left undone’, understaffing and temporary staffing across acute sector settings. Methods: “Secondary data analysis from an RCN administered online survey covering nurses from hospitals and trusts across all four UK countries. Staffing and ‘care left undone’ measures were derived from the responses of 8,841 registered nurses across the UK. A locally smoothed scatterplot smoothing regression analysis (Loess) was used to model the relationship between any ‘care left undone’ events and full complement, modest and severely understaffed shifts, and proportions of temporary staff. Results: Occurrence of ‘care left undone’ was highest in Emergency Departments (48.4%) and lowest in Theatre settings (21%). The odds of ‘care left undone’ increase with increasing proportion of temporary staff. This trend is the same in all understaffing categories. On shifts with a full quota of nursing staff, an increase in the proportion of temporary staff from 0 to 10 per cent increases the odds of care left undone by 6 per cent (OR= 1.06, 95 % CI, 1.04-1.09). Within the full quota staffing category, the difference becomes statistically significant (p<0.05) on shifts with a proportion of temporary nursing staff of 40 per cent or more. On shifts with a full quota of nursing staff the odds of a ‘care left undone’ event is 10 per cent more with the proportion of temporary nursing staff at 50 per cent, compared to shifts with modest understaffing of 25 per cent or less with no temporary nursing staff (OR=1.1, 95%CI, 0.96-1.25). Conclusion: The odds of a ‘care left undone’ event are similar for fully staffed shifts with a high temporary nursing staff ratio compared to severely understaffed shifts with no temporary nursing staff. Increasing the proportion of temporary nurse staff is associated with higher rates of self-reported care left undone by nursing staff. This has significant implications for nurse managers and policy makers.

Relational Expectations and Transactional Obligations: Incompatible Psychological Contracts and Triadic Employment Relationships

This research investigated the triangular employment relationship between organizations, temporary staffing agencies, and clerical temporary workers using the conceptual framework of the psychological contract. The rapid growth in triadic employment relationships is well documented; however, there is limited research into the interlocking psychological contracts between the three parties. This research advances our understanding of the mechanisms underlying triangular psychological contracts by drawing attention to the ways in which people’s beliefs concerning their own obligations toward others may be incommensurate with their expectations of other parties. Findings are based on semistructured interviews with 10 client organization representatives, 10 staffing agency consultants, and 20 female clerical temporaries working in Auckland, New Zealand. The interviews revealed that the three sets of participants held mutually incompatible expectations, which were shaped by their differing positions and power bases within the temporary labor market. Each group expected, or wanted, the other parties to behave toward them as if a relational psychological contract existed but perceived their obligations toward others in more transactional terms. In consequence, the expectations, goals, and actions of the three sets of participants often conflicted, creating a range of adverse outcomes, which were unintended by, and problematic for, each group within the triangular employment relationship.

Costs and consequences of using average demand to plan baseline nurse staffing levels: a computer simulation study

BackgroundPlanning numbers of nursing staff allocated to each hospital ward (the ‘staffing establishment’) is challenging because both demand for and supply of staff vary. Having low numbers of registered nurses working on a shift is associated with worse quality of care and adverse patient outcomes, including higher risk of patient safety incidents. Most nurse staffing tools recommend setting staffing levels at the average needed but modelling studies suggest that this may not lead to optimal levels.ObjectiveUsing computer simulation to estimate the costs and understaffing/overstaffing rates delivered/caused by different approaches to setting staffing establishments.MethodsWe used patient and roster data from 81 inpatient wards in four English hospital Trusts to develop a simulation of nurse staffing. Outcome measures were understaffed/overstaffed patient shifts and the cost per patient-day. We compared staffing establishments based on average demand with higher and lower baseline levels, using an evidence-based tool to assess daily demand and to guide flexible staff redeployments and temporary staffing hires to make up any shortfalls.ResultsWhen baseline staffing was set to meet the average demand, 32% of patient shifts were understaffed by more than 15% after redeployment and hiring from a limited pool of temporary staff. Higher baseline staffing reduced understaffing rates to 21% of patient shifts. Flexible staffing reduced both overstaffing and understaffing but when used with low staffing establishments, the risk of critical understaffing was high, unless temporary staff were unlimited, which was associated with high costs.ConclusionWhile it is common practice to base staffing establishments on average demand, our results suggest that this may lead to more understaffing than setting establishments at higher levels. Flexible staffing, while an important adjunct to the baseline staffing, was most effective at avoiding understaffing when high numbers of permanent staff were employed. Low staffing establishments with flexible staffing saved money because shifts were unfilled rather than due to efficiencies. Thus, employing low numbers of permanent staff (and relying on temporary staff and redeployments) risks quality of care and patient safety.

The Association between Care Left Undone and Temporary Nursing Staff ratios in Acute Settings: A cross- sectional survey of registered nurses

Background The shortage of health workers is a global phenomenon. To meet increasing patient demands on UK health services, providers are increasingly relying on temporary staff to fill permanent posts. This study examines the occurrence of ‘care left undone’, understaffing and temporary staffing across acute sector settings. Methods Staffing and ‘care left undone’ measures were derived from the responses of 13, 218 registered nurses across the UK. A locally smoothed scatterplot smoothing regression analysis (Loess) was used to model the relationship between any ‘care left undone’ events and full complement, modest and severely understaffed shifts, and proportions of temporary staff. Results Occurrence of ‘care left undone’ was highest in Emergency Departments and lowest in Theatre settings. The odds of ‘care left undone’ increase with increasing proportion of temporary staff. This trend is the same in all understaffing categories. On shifts with a full quota of nursing staff, an increase in the proportion of temporary staff from 0 to 10 per cent increases the odds of care left undone by 6 per cent (OR= 1.06,95% CI, 1.04-1.09 ). Within the full quota staffing category, the difference becomes statistically significant (p<0.05) on shifts with a proportion of temporary nursing staff of 40 per cent or more. On shifts with a full quota of nursing staff the odds of a ‘care left undone’ event is 10 per cent more with the proportion of temporary nursing staff at 50 per cent, compared to shifts with modest understaffing of 25 per cent or less with no temporary nursing staff (OR=1.1, 95%CI, 0.96-1.25). Conclusion The odds of a ‘care left undone’ event is similar for fully staffed shifts with a high temporary nursing staff ratio compared to severely understaffed shifts with no temporary nursing staff. Increasing the proportion of temporary nurse staff is associated with higher rates of self-reported care left undone by nursing staff. This has significant implications for nurse managers and policy makers.

Lithuanian Temporary Workers in Iceland in Another Economic Boom: Expectations and Experiences

Economic changes and a booming tourism industry in Iceland have triggered a rise in temporary workforce, where employees are brought to Iceland from Eastern Europe and other less economically developed countries. Major societal and economic shifts are evidenced by a doubled number of temporary staffing agencies and a ten-fold increase in foreign temporary agency workers. However, limited research exists regarding the phenomenon. Furthermore, the expectations of temporary work force in Iceland have not been researched. The study employed field survey methods to investigate pre-arrival expectations and post-arrival experiences of temporary agency workers regarding temporary agencies and Icelandic society. The findings indicate that the employees had relatively high expectations towards the temporary staffing agency and Icelandic society before arriving in Iceland. However, the findings also indicated unmet expectations in these respects. The study provides empirical data that serves as catalyst for both expectation management and better integration of foreign temporary workforce.

Nurse staffing levels, missed vital signs and mortality in hospitals: retrospective longitudinal observational study

Background Low nurse staffing levels are associated with adverse patient outcomes from hospital care, but the causal relationship is unclear. Limited capacity to observe patients has been hypothesised as a causal mechanism. Objectives This study determines whether or not adverse outcomes are more likely to occur after patients experience low nurse staffing levels, and whether or not missed vital signs observations mediate any relationship. Design Retrospective longitudinal observational study. Multilevel/hierarchical mixed-effects regression models were used to explore the association between registered nurse (RN) and health-care assistant (HCA) staffing levels and outcomes, controlling for ward and patient factors. Setting and participants A total of 138,133 admissions to 32 general adult wards of an acute hospital from 2012 to 2015. Main outcomes Death in hospital, adverse event (death, cardiac arrest or unplanned intensive care unit admission), length of stay and missed vital signs observations. Data sources Patient administration system, cardiac arrest database, eRoster, temporary staff bookings and the Vitalpac system (System C Healthcare Ltd, Maidstone, Kent; formerly The Learning Clinic Limited) for observations. Results Over the first 5 days of stay, each additional hour of RN care was associated with a 3% reduction in the hazard of death [hazard ratio (HR) 0.97, 95% confidence interval (CI) 0.94 to 1.0]. Days on which the HCA staffing level fell below the mean were associated with an increased hazard of death (HR 1.04, 95% CI 1.02 to 1.07), but the hazard of death increased as cumulative staffing exposures varied from the mean in either direction. Higher levels of temporary staffing were associated with increased mortality. Adverse events and length of stay were reduced with higher RN staffing. Overall, 16% of observations were missed. Higher RN staffing was associated with fewer missed observations in high-acuity patients (incidence rate ratio 0.98, 95% CI 0.97 to 0.99), whereas the overall rate of missed observations was related to overall care hours (RN + HCA) but not to skill mix. The relationship between low RN staffing and mortality was mediated by missed observations, but other relationships between staffing and mortality were not. Changing average skill mix and staffing levels to the levels planned by the Trust, involving an increase of 0.32 RN hours per patient day (HPPD) and a similar decrease in HCA HPPD, would be associated with reduced mortality, an increase in staffing costs of £28 per patient and a saving of £0.52 per patient per hospital stay, after accounting for the value of reduced stays. Limitations This was an observational study in a single site. Evidence of cause is not definitive. Variation in staffing could be influenced by variation in the assessed need for staff. Our economic analysis did not consider quality or length of life. Conclusions Higher RN staffing levels are associated with lower mortality, and this study provides evidence of a causal mechanism. There may be several causal pathways and the absolute rate of missed observations cannot be used to guide staffing decisions. Increases in nursing skill mix may be cost-effective for improving patient safety. Future work More evidence is required to validate approaches to setting staffing levels. Other aspects of missed nursing care should be explored using objective data. The implications of findings about both costs and temporary staffing need further exploration. Trial registration This study is registered as ISRCTN17930973. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 6, No. 38. See the NIHR Journals Library website for further project information.