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Dr. Bernard Braun SOCIUM/Zentrum für Sozialpolitik der Universität Bremen Kommentar „Verbindliche Personalbemessung – internationaler Vergleich“ EPSU-Workshop.

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Präsentation zum Thema: "Dr. Bernard Braun SOCIUM/Zentrum für Sozialpolitik der Universität Bremen Kommentar „Verbindliche Personalbemessung – internationaler Vergleich“ EPSU-Workshop."—  Präsentation transkript:

1 Dr. Bernard Braun SOCIUM/Zentrum für Sozialpolitik der Universität Bremen Kommentar „Verbindliche Personalbemessung – internationaler Vergleich“ EPSU-Workshop „Personalbemessung in Krankenhäusern im internationalen Vergleich“ am 16. November 2016 in Berlin tttt 1

2 Pflegefachkräfte und ausgebildete Pflegehilfskräfte in Krankenhäusern 2013 (VZÄ je 1.000 Einwohner)

3 Verbesserungen der patient-nurse-ratio sind prinzipiell erreichbar
Erkenntnisse über patientenbezogene Auswirkungen einer Verbesserung der patient-nurses-ratio Verbesserungen der patient-nurse-ratio sind prinzipiell erreichbar dies gilt auch für patientenbezogene Effekte dieser Verbesserungen die Evaluation der mehrjährigen Verbesserungen und ihrer Auswirkungen insbesondere in Kalifornien zeigt aber auch es kann sein, dass unter bestimmten zusätzlichen Bedingungen gewünschte qualitative Effekte für Patienten nicht oder nicht in der gewünschten oder erforderlichen Quantität eintreten es kann sein/sollte bedacht werden, dass mehr getan werden muss als die Anzahl der Pflegekräfte zu erhöhen, um die gewünschten Effekte zu erreichen tttt 3

4 Methodische Defizite in Studien über die Effekte der Personalbemessung= Grenzen der Aussagekraft
zu wenig Längsschnittanalysen (z.B. vorher-nachher) und zu viel Querschnittuntersuchungen wenig kausale Analysen viele Studien untersuchen lediglich die Personalausstattung und Outcomes in einer oder wenigen Kliniken die meisten Studien mit morbiditätsbezogenen Outcomes konzentrieren sich nur auf wenige Ereignisse/Folgen, was je nach Ereignis zu gegensätzlichen Ergebnissen führt zu wenig Konzentration auf Outcomes, die eindeutig mit der Tätigkeit von Pflegekräften zu tun haben/pflegesensitive Outcomes (z.B. Druckgeschwüre) Vernachlässigung unterschiedlicher die Wirkung des Personaleinsatzes und des Outcomes modifizierenden Bedingungen („modifiers“): Strukturmerkmale der Krankenhäuser qualitative Merkmale der Pflegekräfte (z.B. skill-mix) und ihrer Stellung im Behandlungsprozess (z.B. Autorität, Autonomie) „work environment“ soziale und gesundheitliche Merkmale der Patienten tttt 4

5 „Wieder mehr Geld und Personal allein, ist nicht die Lösung für unerwünschte Outcomes“ - Begrenzte Bedeutung von quantitativen Arbeitsbedingungen für die Versorgungsqualität am Beispiel der Personalbemessung in den USA - I Indikatoren des “Innenlebens” oder “work environment” von/für Pflegekräfte: Beteiligung an Klinikangelegenheiten, Basis für qualitätsgesicherte Arbeit, gute Führungsstrukturen/spezifische Unterstützung, Beziehungen zwischen Pflegekräften und Ärzten (nach Practice Environment Scale of the Nursing Work Index-Revised (PES-NWI): 665 Kliniken in vier großen Bundesstaaten; Daten von rund 1,2 Millionen Patienten und Pflegekräften/nurses “Results: The effect of decreasing workloads by one patient/nurse on deaths and failure-to-rescue is virtually nil in hospitals with poor work environments, but decreases the odds on both deaths and failures in hospitals with average environments by 4%, and in hospitals with the best environments by 9 and 10% respectively. The effect of 10% more BSN (Bachelor of Science nursing) nurses decreases the odds on both outcomes in all hospitals, regardless of their work environment, by roughly 4%.” Quelle: Aiken L. et al. (2011): The Effects of Nurse Staffing and Nurse Education on Patient Deaths in Hospitals With Different Nurse Work Environments. Med Care. 49(12): 1047–1053. tttt 5

6 „Wieder mehr Geld und Personal allein, ist nicht die Lösung für unerwünschte Outcomes“ - Begrenzte Bedeutung von quantitativen Arbeitsbedingungen für die Versorgungsqualität am Beispiel der Personalbemessung in den USA - II “We have shown that better staffing, better work environments, and better educated nurses all “work” to improve outcomes, at least for general surgical patients, and that the question of whether one works better than the other is, at least in one sense, less central than under what conditions they work at all. Better staffing, the most expensive option to improve care, has little effect on surgical mortality and failure-to-rescue in hospitals with poor work environments, but in hospitals with better work environments staffing has a sizable effect. Getting better value for investments in hospital nursing requires better staffing in the context of a good nurse work environment, and a more educated nurse workforce.” Quelle: Aiken L. et al. (2011): The Effects of Nurse Staffing and Nurse Education on Patient Deaths in Hospitals With Different Nurse Work Environments. Med Care. 49(12): 1047–1053. tttt 6

7 Keine empirische Evidenz für bessere Behandlungsergebnisse/Pflegequalität für „Bill 394“ Kalifornien ab 1999 – Cook et al. 2012; ähnlich Bolton et al. 2007, Donaldson et al. 2005, Greenberg 2006, Blakeman-Hodge et al. 2004 “In sum, we find no evidence of a causal impact of the patient/nurse ratio on failure to rescue (pneumonia, deep vein thrombosis/pulmonary embolism, sepsis, acute renal failure, shock/cardiac arrest, and gastrointestinal hemorrhage/acute ulcer.). … “We find persuasive evidence that AB394 did have the intended effect of decreasing patient/nurse ratios in hospitals that previously did not meet mandated standards. However, our analysis suggests that failure to rescue rates did not disproportionately improve in these same hospitals. That is, we do not find persuasive evidence that the regulation change improved patient safety in the affected hospitals.“ (Cook et al. 2012) “Thus, improved nurse staffing might be crucial in improving patient safety, but only in combination with other elements. It is important that analysts, policy-makers, and healthcare providers sort out these important issues.” (Cook et al. 2012) tttt 7

8 Unerklärliche Wirkungen oder Nichtwirkungen einer besseren Ausstattung mit Pflegekräften – Einflussfaktor Morbidität “With respect to other outcomes, lower rates of hospital-acquired pneumonia, pulmonary failure, unplanned extubation, failure to rescue, and nosocomial bloodstream infections were associated with higher RN staffing in pooled analyses of multiple studies. However, several other outcomes presumed to have strong sensitivity to nurse staffing levels did not show consistent associations; these outcomes included falls, pressure ulcers, and urinary tract infections.” (Shekelle et al – HTA-Bericht) tttt 8

9 Unerklärliche Wirkungen oder Nichtwirkungen einer besseren Ausstattung mit Pflegekräften – Einflussfaktor Klinikcharakteristika und Qualitätssicherung/-kultur “The EPC (Minnesota Evidence-Based Practice Center) review concluded that a consistent relationship has been demonstrated but identified numerous limitations in the literature with respect to establishing that this relationship is causal. Ultimately, the authors concluded that the arguments for a causal relationship are “mixed,” and they called for future research to address the role of nurse staffing and competence on the effectiveness of patient care, “taking greater cognizance of other relevant factors such as patient and hospital characteristics and quality of medical care.” (Shekelle et al – HTA-Bericht) tttt 9

10 Unerklärliche Wirkungen oder Nichtwirkungen einer besseren Ausstattung mit Pflegekräften – Einflussfaktor Outcomes “Therefore, given the consistent associations observed in multiple cross-sectional and a few longitudinal studies, the indirect “dose-response” analysis by Kane and colleagues, and the methodologically careful single-site study by Needleman and colleagues, we grade the strength of evidence for increased RN staffing and lower hospital-related mortality as moderate. The strength of evidence for other outcomes (hospital-acquired pneumonia, failure-to-rescue, falls, pressure ulcers, etc.) remains low, owing to the sparseness of data, conflicting data, and/or lack of evidence of a dose-response relationship.” (Shekelle et al – HTA-Bericht) tttt 10

11 Unerklärliche Wirkungen oder Nichtwirkungen einer besseren Ausstattung mit Pflegekräften – Einflussfaktoren Klinik-/Morbiditätsmerkmale “The results on the impact of nurse staffing levels and mortality are mixed, with three studies showing a statistically significant association with increased nurse staffing levels on reduced mortality; and four studies not finding a statistically significant association. Cho et al. found a significant association between patient—nurse ratios and mortality in secondary hospitals (secondary level of care as opposed to tertiary referral hospital) … Further, the association between patient—nurse ratio and mortality in tertiary hospitals was not significant.” (McGahan et al. 2012) tttt 11

12 Determinanten der Pflegekräfte-“Produktion“
“Our study demonstrates that the strength of political, social, and economic institutions does impact human resources for health production and lays a foundation for studying how macro-level contextual factors influence physician and nurse workforce supply. In particular, the results suggest that public and private investments in the education sector would provide the greatest rate of return to countries. The study offers a foundation from which longitudinal analyses can be conducted and identifies additional data that may help enhance the robustness of the models.” Allison Squires, S. Jennifer Uyei, Hiram Beltrán-Sánchez, Simon A. Jones. Examining the influence of country-level and health system factors on nursing and physician personnel production. Human Resources for Health, 2016; 14 (1) tttt 12

13 Unerklärliche Wirkungen oder Nichtwirkungen einer besseren Ausstattung mit Pflegekräften – Einflussfaktor qualitative Arbeitsbedingungen/work environment If the relationship between nurse staffing and mortality outcomes is causal, then the wide variety of hospital settings included in existing analyses suggests that the effect is likely to be relatively insensitive to hospital contexts. However, some of the nurse work environment factors, such as job satisfaction, burnout, teamwork, workload, and leadership, are potentially important effect modifiers, and this area merits further study. (Shekelle et al – HTA-Bericht) tttt 13

14 Unerklärliche Wirkungen oder Nichtwirkungen einer besseren Ausstattung mit Pflegekräften – Einflussfaktor „work environment“ “Our results suggest that it is probably not possible to determine perfect staffing systems or nurse–patient ratios if the quality of the working environment and workload are not considered.” (Duffield et al. 2011) tttt 14

15 Literatur Aiken L. et al. (2011): The Effects of Nurse Staffing and Nurse Education on Patient Deaths in Hospitals With Different Nurse Work Environments. Med Care. 49(12): 1047–1053 Blakeman-Hodge M. (2004). Licensed Caregiver Characteristics and Staffing in California Acute Care Hospital Units. The Journal of Nursing Administration. Volume 34(3): Bolton L, Aydin CE, Donaldson N, et al. (2007). Mandated nurse staffing ratios in California: a comparison of staffing and nursing-sensitive outcomes pre- and postregulation. Policy Polit Nurs Pract. 8(4):238–50 Cook A, Gaynor M, Stephens M, et al. (2012). The effect of a hospital nurse staffing mandate on patient health outcomes: Evidence from California's minimum staffing regulation. Journal of Health Economics. 31(2):340–8 Donaldson N, Bolton LB, Aydin C, et al. (2005). Impact of California's licensed nurse-patient ratios on unit-level nurse staffing and patient outcomes. Policy Polit Nurs Pract. 6(3):198–210 Duffield C, Diers D, O'Brien-Pallas L, et al. (2011). Nursing staffing, nursing workload, the work environment and patient outcomes. Applied Nursing Research. 24(4):244–55 Greenberg, P.B. (2006). Nurse-to-patient ratios: What do we know? Policy, Politics and nursing practice, 7(1), 14-15 McGahan M, Kucharski G, Coyer F. (2012). Nurse staffing levels and the incidence of mortality and morbidity in the adult intensive care unit: A literature review. Australian Critical Care. 25(2):64–77 Shekelle PG et al. (2013). Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices . Comparative Effectiveness Review No Rockville (Kapitel 34) Squires A., S. Jennifer Uyei, Hiram Beltrán-Sánchez, Simon A. Jones (2016). Examining the influence of country-level and health system factors on nursing and physician personnel production. Human Resources for Health, 14 (1) tttt 15

16 Danke für Ihre Aufmerksamkeit!
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