title: The effect of nurse staffing on clinical outcomes of children in hospital: a systematic review.
abstract: OBJECTIVE
  The aim of the present study was to identify any association between nurse staffing and clinical outcomes in hospitalised children.
  
  
  METHODS
  Quantitative studies that evaluated the effect of nurse staffing on clinical outcomes of hospitalised children aged from 0-18 years. Measures of nurse staffing included nursing hours per patient day, nurse-to-patient ratio, skill mix and nurse characteristics such as level of education and years of experience. The clinical outcomes were those believed to be potentially sensitive to nursing care. Specifically, where the provision, or lack, of competent nursing care have made a difference to the outcome for the child (a nursing-sensitive outcome). Examples included mortality, healthcare-associated infections, failure to rescue, medication administration errors, postoperative complications and pressure ulcers.
  
  
  METHODS
  The search strategy aimed to find published and unpublished studies written in English between 1993 and 2010. Following an initial search of the Cochrane and Joanna Briggs Institute Libraries of Systematic Reviews, a three-step search strategy was utilised. First, a limited search of MEDLINE and CINAHL using keywords was undertaken and the words contained in the titles, abstracts and the index terms used to describe each article were analysed. A second search using all identified keywords and index terms was done. Third, the reference lists of all identified reports and articles were searched for additional relevant studies.
  
  
  METHODS
  Using the critical appraisal instrument from the Joanna Briggs Institute, each article was assessed by two independent reviewers for methodological quality before inclusion.
  
  
  RESULTS
  Eight studies were included of which six were cohort, one case-control and one cross-sectional. Comparison across studies was limited as few clinical outcomes were the same; similarly there was a lack of consistency in the measures of nurse staffing. Fourteen different healthcare-associated infections and ten further clinical outcomes, of which eight were adverse events, were reported. Predictor variables were 10 different definitions of nurse staffing. Measures of Registered Nurse staffing were used most frequently. Increased Registered Nurse nursing hours per patient day was associated with decreases in eight adverse events. Similarly, higher Registered Nurse skill mix contributed positively to three clinical outcomes in children. However, there appears to be a level where increasing Registered Nurse hours no longer has a significant effect on decreasing adverse events. Results reporting association between children's outcomes and casual/agency nurses are equivocal.
  
  
  CONCLUSIONS
  There is evidence that levels of nurse staffing are associated with clinical outcomes of children. Standardisation of nurse-sensitive indicators and measures of nurse staffing will enable empirical research. Further research to find the levels of Registered Nurse hours per patient day and proportion of Registered Nurse in the skill mix that maximises children's clinical outcomes is still required.
authors: School of Population Health, The University of Western Australia, Perth, Australia. swilson@meddent.uwa.edu.au
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