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Running head: REGISTERED NURSES REDUCE HOSPITAL-ACQUIRED INFECTIONS 1 Does the educational level of the nurse - registered versus licensed practical or licensed vocational - positively promote a decrease in hospital-acquired infections? Larkin Virden Western Governors University SkT2 Literature Review February 6, 2013

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Page 1: APA editing sample - final version

Running head: REGISTERED NURSES REDUCE HOSPITAL-ACQUIRED INFECTIONS1

Does the educational level of the nurse - registered versus licensed practical or licensed

vocational - positively promote a decrease in hospital-acquired infections?

Larkin Virden

Western Governors University

SkT2 Literature Review

February 6, 2013

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2REGISTERED NURSES REDUCE HOSPITAL-ACQUIRED INFECTIONS

Does the educational level of the nurse - registered versus licensed practical or licensed

vocational - positively promote a decrease in hospital-acquired infections?

Problem statement

The Center for Disease Control and Prevention has reported that almost 1.7 million

patients acquire infections while being hospitalized for non-susceptible illness or injury, with

nearly 88,000 dying from these infections (Miller, 2013). These infections are classified as

hospital-acquired infections (HAIs), and are responsible for a significant amount of harm, and

contribute to the high cost of health care (Hassan, Tuckman, Patrick, Kountz, & Kohn, 2010).

Several studies have indicated registered nurses (RNs) have lower incidence of hospital-acquired

infections versus licensed or practical nurses (LVNs/LPNs), and a landmark study conducted by

the New England Journal of Medicine indicated that hospitals with a higher number of RNs had

fewer serious complications (Needleman, Buerhaus, Pankratz, Leibson, Stevens, & Harris,

2011). Another study conducted by the same group indicated that hospitals with higher RN

staffing levels had lower mortality rates than hospitals with lower RN staffing levels (Needleman

et al., 2011). Researchers reconfirmed these results in 2002 at Harvard and Vanderbilt

Universities. (Costello, 2002) This literature review will explore research studies to determine if

the educational level of the nurse - registered versus licensed practice or licensed vocational -

positively promotes a decrease in hospital-acquired infections.

Organizational headings

In this literature review 10 studies were reviewed. Seven articles were studied, focusing

on the impact the staffing levels of the nursing workforce, educational and RNs had on patient

outcomes. The remaining three articles discussed the cost of HAIs on hospitalized patients,

evidence-based practices to reduce HAIs, and nurse staffing levels in for-profit (FPs) hospitals

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3REGISTERED NURSES REDUCE HOSPITAL-ACQUIRED INFECTIONS

compared to not-for-profits (NFPs) hospitals. These articles were sorted into six groups for

further review.

RN staffing levels impact on patient outcomes

Debates have been ongoing for many years on the outcomes of RNs versus LPN/LVNs,

and there are multiple studies that associate RNs with better outcomes for hospitalized patients.

In 2004, a study was conducted in collaboration with the California Nursing Outcomes Coalition

(CalNOC) database project. The study goals were to improve evidence-based clinical and

administrative decision-making and resolve public policy and clinical dilemmas (Aydin, Bolton,

Donaldson, Brown, Buffum, Elashoff, & Sandhu, 2004). Studies like this develop platforms for

further research, but other studies do indeed associate, and in some cases validate, RNs having

fewer incidents of adverse events and lower mortality (Aydin et al., 2004). Another study of

nurse staffing levels and inpatient hospital mortality associated higher incidence of mortality

with fewer RNs (Needleman et al., 2011).

Factors influencing RN staffing levels.

Cost is a major factor influencing higher staffing levels of RNs because a hospital's

upfront expense doesn’t immediately show a net gain in overall expense to justify the added

expense. However, this is controversial as one study indicates that hospitals would see a benefit

of decreases in length of stay and fewer adverse events (Shamliyan, Kane, Mueller, Duval, &

Wilt, 2009). Length of stay is a key financial performance metric for most hospitals, but the

initial expense will need to be analyzed to determine the return on investment. This thought

process could cause heartburn but the reality is hospitals are businesses and most have positive

profit margins to serve the public, whereas society is concerned with the philosophy of lives

saved and adverse events avoided. (Shamliyan et al., 2009).

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4REGISTERED NURSES REDUCE HOSPITAL-ACQUIRED INFECTIONS

Barriers to successful RN staffing levels.

The barriers to successful RN staffing levels are numerous. Whereas cost was a

influencing factor not to increase RN staffing it is also a barrier. Role ambiguity is a barrier in

determining the function of the RN in staffing models since other unlicensed and licensed nurses

like vocational and practical have assumed some of the roles that RNs have delegated to them

(McGillis Hall, 2003).

Best practices to successful RN staffing levels.

The best-practice models for successful RN staffing encompasses the hospital's

characteristics, acuity level of patients and the commitment to quality patient outcomes (Kane,

Shamliyan, Mueller, Duval, & Wilt, 2007). One study examined staffing levels, patient

outcomes and the RNs perception to these models. Perception is a key factor in a best-practice

RN staffing model as it demonstrates lower staff turn-over and increased job satisfaction, which

is pivotal in implementing changes and to improving patient outcomes (McGillis Hall, 2003).

Nursing workforce staffing levels impact on patient outcomes

The relationship between the nursing workforce and patient outcomes was reviewed

systematically with international studies of acute hospital care from 1990. These studies review

not only RN impact on patient outcomes, but the entire nursing workforce that includes

registered nurses, practical or vocational nurses and unlicensed caregivers (Lankshear, Sheldon,

& Maynard, 2005). These studies shed light on the overall staffing mix or nursing hours

allocated to direct patient care and its association to better patient outcomes.

Factors influencing nursing workforce staffing levels.

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5REGISTERED NURSES REDUCE HOSPITAL-ACQUIRED INFECTIONS

Common factors influencing nursing workforce-staffing levels are patient characteristics,

and hospital structures. Nurse-to-patient ratios are fundamental in the evaluation of improved

outcomes, and are usually weighted by skill mix and nursing hours per patient, per day. This

ratio may include only RNs or both RNs and LPN/LVNs known as “licensed nurses” (Lankshear

et al., 2005).

Barriers to successful nursing workforce staffing levels.

There are many barriers to a successful nursing workforce, but one in particular identified

was the hospital administration's willingness to evaluate its nursing workforce when results from

similar studies have shown that work completed by RNs could be completed equally by less

qualified staff (Lankshear et al 2005).

Best practices for a successful nursing workforce through staffing levels.

Studies have identified that the best practice for a successful nursing workforce is to

move away from correlational studies which tend to show causality and move to theoretically

based research (Lankshear et al., 2005). The advancement of research that examines the effects

of nursing care on patient outcomes is fundamental to answering the hypothesis that RNs

improve patient outcomes. These types of studies will also have implications for resource

allocation and its long-term benefits.

The impact of nursing educational levels on patient outcomes

This integrative study assesses the relationship between patient safety and nurse

educational levels. Although there are studies that indicate that increasing RN staffing levels and

skill mix are associated with improved patient outcome, specifically mortality, there is little

evidence linking RN educational levels such as ADN, diploma or BSN (Ridley, 2008). The

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6REGISTERED NURSES REDUCE HOSPITAL-ACQUIRED INFECTIONS

purpose of this study was further defined by its use of empirical findings of patient safety

indicators (PSIs) defined by the Agency for Health Care Research and Quality (AHRQ). The

PSIs encompass more than mortality; they also include decubitus ulcer, failure to rescue,

postoperative sepsis, and others (Ridley, 2008).

Factors influencing the impact of nursing educational levels on patient outcomes.

Patient safety is a key influencing factor when examining patient outcomes and their

relationship to nursing educational levels, specifically in the use of empiric patient-safety

indicators to evaluate the difference in patient outcomes when LPNs, ADNs, BSNs, MSNs and

student nurses deliver care (Ridley, 2008).

Barriers to determining if successful nursing educational levels impact on patient

outcomes.

The limited number of credible studies is a barrier to determining if nursing educational

levels impact patient outcomes. In the literature review Ridley highlights that only three studies

included variables of educational levels more specific than RNs or LPNs, thus exemplifying this

as a barrier (Ridley, 2008).

Best practices in determining the relationship between nurse staffing and patient

outcomes.

This use of AHRQ PSIs to analyze empirical data in determining the relationship between

nurse staffing and patient outcomes are a best practice in the validation of this hypothesis

(Ridley, 2008).

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Nursing staffing levels in for-profit hospitals compared to not-for-profit hospitals

In the 1990s hospitals were faced with changing their operations to adjust to the changes

in the industry, and reimbursement for Medicare patients became more stringent along with the

emergence of managed-care plans. Hospitals reacted by introducing new structures, such as

reducing labor cost and improving efficiency, to reduce cost and adhere to new regulations which

frequently resulted in changes to nurse staffing levels (Mark & Harless, 2007). These changes

transformed FP and NFP hospitals, and new incentives were established such as tax exemptions

for NFPs (Mark & Harless, 2007). This study reviews data from 626 hospitals, Medicare

reports, and the America Hospital Association (AHA) annual reports to determine differentials in

quality in FP and NFP hospitals (Mark & Harless, 2007). The study found that FP hospitals had

lower staffing levels than in NFP hospitals and showed a higher distribution of patient outcomes,

as well as lower mortality and length of stay.

Factors influencing nursing staffing levels in FP and NFP hospitals.

Factors influencing nursing staffing levels in FP and NFP hospitals are the tax-exempt

status for NFP hospitals, and possible disparities in quality in both (Mark & Harless, 2007).

However, the researchers do report that NFP hospitals on average have a higher skill mix of RNs,

but the FP hospitals reported higher pay for RNs (Mark & Harless, 2007). However, paying

more does not necessarily equate to better care.

Barriers influencing nursing staffing levels in FP and NFP hospitals.

The limited research is a barrier to influencing nursing staffing levels in the two types of

studies. In fact, one study discussed in the article is inconclusive on quality differences between

the two types of hospitals (Mark & Harless, 2007).

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Best practices in evaluating nursing staffing levels in FP and NFP hospitals.

The study used a large data source for data collection in establishing a best practice in

evaluating the nursing staffing levels in FP and NFP hospitals and its relationship to quality

outcomes. Another best practice is the statistical data evaluation by using a parametric model of

quality and staffing levels in the comparison rate, rather than estimates, making this study more

credible and valid (Mark & Harless, 2007).

The cost of hospital-acquired infections

This study assessed the cost of HAIs by examining data from the AHA, Medicare cost

reports and UB-92s from New Jersey (Hassan, Tuckman, Patrick, Kountz, & Kohn, 2010). The

incidence of HAIs has increased, despite better implementation of infection control practices

(Hassan et al., 2010).

Factors influencing the cost of hospital-acquired infections.

The sheer cost of HAIs is an influencing factor for reviewing this topic. Studies estimate

that the United States' annual cost of HAIs is between $5 to $10 billion (Hassan et al., 2010).

This is a staggering amount and could be detrimental to the health-care system and the public.

Barriers to successful evaluation of the cost of HAIs.

There are many barriers to the successful reduction of the cost of HAIs. One is

establishing a solid database that will allow for monitoring and collection of data that isn’t

restricted by the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (Hassan

et al., 2010). HIPAA restricts researchers from conducting studies to measure data related to

HAIs and the cost of these infections.

Best practice for evaluating the cost of HAIs.

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Establishment of a centralized database to collect data for HAIs was described as the

purpose of this study. However, the researcher concluded that their model using billing data like

UB-92s can be helpful in estimating the cost of HAIs with fairly moderate accuracy (Hassan et

al., 2010). This data can be shared with healthcare organizations and insurance providers and the

general public to make consumer-driven decisions in choosing healthcare providers.

Reducing HAIs with collaborative, evidence-based infection control practices

This study deployed a collaborative approach to achieve sustained reductions in HAIs

over a 2-year period in a large university hospital. Although the hospital was in compliance with

national compliance standards (called “bundles”) released by the Institute for Healthcare

Improvement, they were still above national benchmarks (Henderson et al., 2012). Their goal

was to eliminate four types of HAIs: methicillin-resistant Staphylococcus aureus (MRSA),

CLABSI, ventilator-associated pneumonia (VAP), and respiratory virus infections (Henderson et

al., 2012). The researchers concluded that HAIs were reduced with the use of a collaborative

system approach.

Factors influencing the reduction of HAIs.

There were several factors influencing the reduction to include the cost associated with

these infections, compliance with national benchmarks for similar hospitals and the support of

senior leadership with the project. One of the initiatives was infection prevention because the

hospital served a large population of patients that were “severely immunocompromised patients

who are especially vulnerable to the consequences of HAIs” (Henderson et al., 2012, p. 40).

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10REGISTERED NURSES REDUCE HOSPITAL-ACQUIRED INFECTIONS

Barriers to the reduction of HAIs.

Barriers to the reduction of HAIs were minimal in this study outside of non-controllable

variables such as patient population, change in senior leadership, or resource allocation.

Best practices in the reduction of HAIs.

Collaboration is the identified best practice in this study, with a system-wide initiative

alongside the support of senior leadership and multidisciplinary teams. This was evident in the

results, with a 50% reduction in healthcare-associated CLABSI and MRSA rates in 2 years. The

hospital VAP rate dropped to zero and cost reductions were estimated to be in excess of $2

million during the reporting period (Henderson et al., 2012).

Conclusion

In conclusion, this literature review supports contentions that increased nursing staffing levels

are associated with improvements in patient outcomes and quality care. However, there is

limited research on the determining if the educational levels of the nurse; registered versus

licensed practice or licensed vocational, positively promote a decrease in HAIs. Although one

study does evaluate the educational levels of nursing, the breakdown of specific nursing levels

(ADN, BSN and MSN) is almost nonexistent. So, further research is needed to explore and

strengthen what is already published and known about nurse staffing and patient outcomes.

Future research can determine the best way to enhance the care of nursing by utilizing skills sets

of the nursing workforce so that nurses can provide the best care possible to their patients.

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Sandhu, M. (2004). Creating and analyzing a statewide nursing quality measurement

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