Interprofessional Care Team, Staffing, and Setting Characteristics that Impact Patient Outcomes: A Review of Reviews

Key findings in this review reinforce the reliance on nursing in existing research assessing the impact of staffing on patient outcomes. Our results also indicate a lack of attention to the contexts in which acute care occurs within organizations and the community, and which may impact patient needs and equitable care delivery. These findings suggest several critical areas for future research on staffing and patient outcomes, including interprofessional care team composition and characteristics of communities, hospitals, and patients that may influence staffing and/or patient outcomes. In particular, a lack of attention to patients’ SDOH limits our ability to understand implications of staffing on health equity. Findings also point to a need for clearly defined, consistently used variables and appropriate analytic strategies in healthcare workforce research. Care team composition A key finding from this review was that interprofessional acute care team composition is undertheorized and underrepresented in current scientific literature. Because studies that included interprofessional team members occurred in specific areas outside of acute care or focused on a specific event such as discharge, we found no evidence describing the effects of a comprehensive, interprofessional care team on patient outcomes in acute care. Furthermore, studies predominantly focus . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 7, 2024. ; https://doi.org/10.1101/2024.01.04.24300868doi: medRxiv preprint 15 on the effects of nurse staffing and infrequently consider the influence of non-nursing staff or indirect care providers such as environmental services on patient outcomes. These findings reinforce trends in current workforce analysis to focus exclusively on nursing personnel without acknowledgement of associated factors that impact the RN workload.(7) While a focus on nursing is warranted due to their essential role in acute care, research that fails to account for other factors and team members impacting RN work will miss important elements that influence the relationship between staffing and patient outcomes. For example, in the absence of other care team members, RNs often take on non-nursing roles, diluting time that could be spent on activities that optimize their full scope of practice and increasing frustration and burnout.(9) Understanding the impacts of other types of staffing is therefore essential to understanding how outcomes are affected in settings where RNs are able to exclusively focus on RN work and settings where they routinely take on other tasks. A national workplace-focused survey in the United States found that among 5,461 acute care RN respondents, 27% rated availability of appropriate ancillary staff as ‘seldom’ or ‘never’, 39% indicated availability as ‘sometimes’, and only 29% rated availability as ‘often’ or ‘always’.(28) In the context of staffing shortages and nursing burnout, organizations need to understand the optimal care team composition for both patient and worker outcomes. Community, hospital, and patient characteristics Nearly half of the reviews included in the study did not address community, hospital or organizational, or patient characteristics. When hospital characteristics were included in reviews, there was little consensus on how to best define and control for characteristics that may influence the provision of high-quality care. For example, hospitals equipped to perform open heart surgeries were used as proxy for more advanced equipment and technological capacity than those who do not perform open heart surgery, but it is unclear whether this denotes a substantive difference in organizational capacity or resources compared to a hospital that does not perform open heart surgeries. Data suggests that community level factors such as urbanicity, county socioeconomic status, and housing type may shape the patient population served by the organization, which impacts both care delivery and outcomes,(10) so these factors need to be considered when examining the impacts of staffing and workforce issues. . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 7, 2024. ; https://doi.org/10.1101/2024.01.04.24300868doi: medRxiv preprint 16 None of the included reviews addressed SDOH as patient characteristics, nor did they use the term ‘health equity’ in describing patient outcomes. This may have occurred in part because of the temporality of the reviews and the papers they sourced, but is nonetheless a gap in our understanding of relationships between staffing and patient outcomes. In general, patient characteristics such as demographics were not consistently included in staffing models, and more nuanced patient-level metrics such as insurance status or admission type were even less commonly included. Measures intended to reflect patient acuity, such as an adjustment for comorbidities or severity of illness, were similarly sparse. In the existing literature, some studies reported diagnostic codes or acuity ratings to quantify workload related to patient care, but even these measures failed to identify patients requiring extra time and personnel resources to achieve similar outcomes.(29) This implies an over-reliance on patient demographics such as age, sex, and race as proxies for SDOH and therefore limits the interpretation of

and their impact on health equity. This pattern may be related to a lack of available data in primary research studies endeavoring to quantify these relationships. In Washington State, House Bill 1272 requires hospitals to begin reporting additional patient demographic information in 2023. This data should improve future researchers’ ability to assess health equity as a critical outcome. Variable definition and analytic strategy Definitions of staffing metrics used by primary studies were rarely provided in the systematic reviews, suggesting that these variables were not consistently defined in workforce research. The lack of clear definitions or consistent measures makes further analysis and application of findings difficult. For example, the most common staffing metric used in the study was nurse-to-patient ratio. This ratio does not overtly reflect patient acuity as well as measurements such as Nursing Hours Per Patient Day, and therefore hinders the comparison of staffing ratios and patient outcomes among different populations and in different acute care settings. Along with inconsistent variable definitions, we found a lack of consensus regarding the analytic strategy or model type used in studies exploring the impacts of healthcare staffing on patient outcomes. Most included reviews did not report the methods of quantitative analysis used by primary workforce . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 7, 2024. ; https://doi.org/10.1101/2024.01.04.24300868doi: medRxiv preprint 17 studies. Of those reporting analytic strategies, multivariate logistic regression was the most common

of analysis. Future studies in this field could explore which model types and methods best reflect the relationship between healthcare staffing and patient outcomes, particularly when examining the influence of community, hospital, or patient characteristics.

A review has inherent limitations, since findings generally rely on the accuracy and completeness of the review, and quality may vary across studies. For example, reviews may have poorly specified inclusion and exclusion criteria or an inadequate search process. This study relied on the information presented in the papers we reviewed, which may have missing information from primary studies or may be interpreted differently in our findings. Additionally, despite careful development of a systematic search strategy, we may have missed some relevant systematic reviews. Despite the various limitations, a key strength of this report is the sheer volume of primary studies assessed. More than 575 studies were represented in the included reviews. Examination of reference lists showed that 13 primary studies were represented in multiple reviews, with 9/13 in 2 reviews, 3/13 in 3 reviews, and 1/13 in 4 reviews. However, assessment of each review showed that findings were not exclusively drawn from duplicated studies. Altogether, this review offers a comprehensive overview of current studies about interprofessional team composition and staffing and their impacts on patient outcomes in the hospital setting.

This review revealed that contextual factors such as healthcare team composition or hospital setting were largely unexamined in current health services literature. Further research is needed to better understand how these factors impact hospital function, work environment, care quality, and staff and patient outcomes. Given the pervasive and ongoing shortages of workers in healthcare, we need to build on our understanding of nurse staffing by examining how the availability of interprofessional care team members impact clinician workload and patient outcomes, and how hospitals in different settings and those serving diverse patient populations may require different care team composition. This work can . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 7, 2024. ; https://doi.org/10.1101/2024.01.04.24300868doi: medRxiv preprint 18 inform strategies to optimize team composition with the goal of improving patient outcomes and furthering health equity. In addition, to promote comparability across studies, future workforce research should include a comprehensive analytic approach that includes clearly defined variables representing interprofessional care teams, community factors, and staffing and patient characteristics. More comprehensive and applicable research can better inform practice and policy, improving outcomes for patients, workers, and communities. Abbreviations SDOH: Social determinants of health RN: Registered nurse PRISMA-ScR: Preferred Reporting Items for Systematic Reviews and Meta-Analysis PICOS: Population, Intervention, Comparison, Outcome, and Study type MeSH: Medical Subject Heading CINAHL: Cumulated Index to Nursing and Allied Health Literature NPR: Nurse-to-patient ratio NHPPD: Nurse Hours Per Patient Day NAS: Nursing Activities Score TISS: Therapeutic Intervention Scoring System Declarations Ethics approval and consent to participate Not applicable Consent for publication Not applicable Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 7, 2024. ; https://doi.org/10.1101/2024.01.04.24300868doi: medRxiv preprint 19 The authors declare that they have no competing interests. Funding The study was funded by the Washington State Department of Health through a contract (HED26380) with the University of Washington’s School of Nursing. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Washington State Department of Health or the University of Washington. This work was also supported, in part, by the National Institutes of Health, National Institute of Nursing Research Training Program in Global Health Nursing at the University of Washington (T32 NR019761). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Authors’ contributions AP is the corresponding author for this study. AP and ZG designed and performed the literature extraction. CM executed the literature search. AP and KW drafted the manuscript and designed the figures. NBS, NH, PL, AF, and SI were involved in planning and supervising the work. All authors reviewed and contributed to editing the manuscript. Acknowledgments Not applicable.

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