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A systematic review of the effectiveness of different nursing staff models on patient, staff and organisational outcomes in Day Surgery Units

JBI Database of Systematic Reviews and Implementation Reports: Volume 5 - Issue 10 - p 1–13
doi: 10.11124/jbisrir-2007-778
Systematic Review Protocol
Free

Review Team:

Kim Graham

Information Scientist - Evidence Review

Joanna Briggs Institute

Margaret Graham Building

Royal Adelaide Hospital

North Terrace

ADELAIDE SA 5000

Cindy Stern

Coordinator - JBI COnNECT

Joanna Briggs Institute

Margaret Graham Building

Royal Adelaide Hospital

North Terrace

ADELAIDE SA 5000

Contact Reviewer:

Kim Graham

Information Scientist - Evidence Review

Joanna Briggs Institute

Margaret Graham Building

Royal Adelaide Hospital

North Terrace

ADELAIDE SA 5000

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BACKGROUND

Day surgery (also referred to as ambulatory surgery) refers to surgical procedures conducted in specialised, “stand-alone” day surgery centres or in units attached to a hospital with discharge from hospital usually occurring within the same working day.1 The definition of day surgery differs between countries but the International Association for Ambulatory Surgery (IAAS)1 believes that it is important to maintain a list of common terms for day/ambulatory surgery to allow collection and comparison of data in this area. Millar also states

“A clearer definition of ‘ambulatory surgery’ is needed, as well as some consensus on the reasons why we keep patients in hospital, and on what constitutes acceptable and safe care”2

A wide variety of procedures are performed as day surgery and this includes, but is not limited to, orthopaedic surgery, gynaecological procedures, ophthalmic procedures and plastic surgery.3,4 Traditionally operating theatres have been staffed by medical and nursing personnel, however new roles have emerged over the past thirty years in response to advances in surgical and procedural techniques, increased expectations of patients and societal demands for cost containment.

Some of the new roles encompass para-medical tasks5,6 such as medical history taking6; an increased number of nurse managerial roles and organisational roles7; preoperative assessment; anxiety management roles and patient education roles.5 Secondary to this refinement and expansion, roles such as that of certified ambulatory peri-anaesthesia (CAPA) nurses have been created.8

The conduct of surgical procedures on a day-stay basis has occurred for some time and the approach has accelerated in the past few decades. It evolved in the late 1800s when Glaswegian surgeon James Nicholl commenced ambulatory surgery in children, performing 7000 surgeries outside of the hospital.4,7,8,9 Observations made and reported at this time suggested that surgery appeared to be less traumatic for children if they recovered at home in the arms of their mother.9 The first purpose-built hospital based ambulatory surgery unit was established at the Butterworth Hospital in Grand Rapids, Michigan, USA in 1961 and a freestanding ambulatory surgi-centre facility was opened in Phoenix, Arizona in 1970.7,8,9

In the past two to three decades the rapid growth in day surgery has been prompted by innovations in anaesthetic medication and instrumentation, advances in surgical technique and instrumentation, economic pressure and innovative thinking.4,8,10,11 As a result of these changes to practice, 60% of elective operative procedures in the USA and UK are now carried out in day surgery facilities2,5 and in some surgical specialities this figure has reached 80%.5 With appropriate selection some acute surgical operations including trauma may also be undertaken in ambulatory surgery centres.1

The benefit of day surgery to patients presents as the convenience of outpatient surgery and recovery within their own home.4,7 Further benefit is gained in the surgical treatment of children by minimising parental separation12 and in reducing exposure to hospital-acquired infections.7,12

Advantages are not only limited to day surgery patients. Day surgery allows a greater volume of patients to receive surgical treatment at less cost than those receiving inpatient treatment, with free-standing centres achieving this cost containment to its fullest extent.3,9 Cost savings are achieved as fewer staff are required and costly shift entitlements on weekends, public holidays and night duty are avoided. Millar states that:

“…the cost benefits of true ‘day’ surgery are due to the ability to reduce hospital beds and expensive out of hours nursing costs.”2

This cost saving has resulted in a high level of acceptance of this form of surgery by funding bodies and administrators.4,11 However, the rapid increase in day surgery is not without controversy. Millar2 and Mitchell5 suggest that this rapid move towards day-stays for surgical patients has implications for both patients and staff. Implications include but are not limited to nurses undertaking para-medical tasks,5,6 extended nursing roles, multiskilling/tasking of all aspects of ambulatory surgery (admission, preparation of the patient both physical and psychological, recovery and discharge), pre-operative assessment clinics, anxiety management5 and post-operative telephone follow-up of recovery.11 Implications for patients, their families and communities include shifting the burden of further post-operative care to the home or community and readmissions for complications.2,7

Regarding the growth of ambulatory surgery, Poole states:

“The growth of this industry has provided multiple challenges and opportunities for nursing in nursing management, nursing care, and advanced practice.”7

Ambulatory surgery has required the development of new staffing patterns, staffing mixes and cross-training.7 The skill mix required for this industry includes nurse managers, nurse anaesthetists, clinical specialists and nurse practitioners. Clinical specialists and nurse practitioners need to be educated in critical care or associated specialties.7 The first specific certification of nurses caring for patients undergoing ambulatory surgery was the introduction of the Certified Ambulatory Perianesthesia (CAPA) nurses program, with the first graduating nurses certified in 1994.8

The rapid expansion of day surgery has affected decision-making related to the appropriate mix of skills, competencies and qualifications of nursing staff. A number of investigators have developed systems to measure and determine nursing workload and appropriate staffing levels (the number of staff on duty at a given time),10,13 but the resulting workload measurement scales do not always take into account specific skills and knowledge required to meet patient and organisational needs. Mitchell5 notes that there is a misconception in the minds of some planners that day surgeries only deal with minor surgery, when the figures indicate more complex surgery is commonly performed and this requires nursing staff to be well educated in the care of patients from a multitude of surgical disciplines. With this in mind, facilities are increasingly aware of the need to ensure that they employ and roster sufficient, appropriately skilled and qualified personnel to provide a high level of quality care.

There has been past research into the area of day surgery. Mitchell5 writes that there is a plethora of nursing research addressing how patients perceive their experience of day surgery. There is also past research into telephone follow-up after ambulatory surgery.11 However, Rushworth, Bliss, Burge and Glasper6 state there is a paucity of evidence to underpin the safety of nurse led clerking in regard to designating medical history taking to nursing staff. There is also a paucity of research into an appropriate staff mix for the day surgery unit.

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OBJECTIVES

The primary objective of this systematic review will be to:

Determine the relationship (if any) between nursing skill-mix, staffing levels and the achievement of patient, staff and organisational outcomes in day surgery units.

The specific questions to be addressed are:

  • What mix and professional level of nursing staff is the most effective to achieve desired patient outcomes in day surgery units?
  • What mix and professional level of nursing staff is the most effective to achieve desired staff outcomes in day surgery units?
  • What mix and professional level of nursing staff is the most effective to achieve desired organisational outcomes in day surgery units?
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CRITERIA FOR REVIEW

Types of studies

This review will consider any systematic reviews or randomised controlled trials (RCTs) that evaluate the effectiveness of nursing skill-mix and staffing levels in day surgery units. However, in the absence of any RCTs, other research methods such as non-RCTs, longitudinal studies, cohort or case-control studies, or descriptive studies will be used. Government reports, economic analysis and cost vs. benefit studies will also be examined to explore the feasibility of findings. All studies will be categorized according to the JBI Level of Evidence (Appendix I).

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Participants

The review will consider all studies that include:

  • Nurses: Registered Nurses RN (AU), Staff Nurses (UK), Licenced Practical Nurses LPN (US), Enrolled Nurses EN (AU), Certified Ambulatory PeriAnaesthesia Nurses CAPA (US), Nurses Aides, Nurse Technicians

The review will exclude all studies that include:

  • Surgeons, anaesthetists, clerical and ancillary staff (domestic staff - cleaners, kitchen staff) working in day surgery facilities.

Note: Terms for various professional levels of nursing staff differ from country to country and this difference will be demonstrated where relevant.

Definition of Nurse:

Nursing is the use of clinical judgement in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems, and to achieve the best possible quality of life, whatever their disease or disability, until death.14 A nurse is a licensed agent who provides nursing care as defined above. Licensing requirements vary from State to State and country to country.

Variants: as listed under participants.

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Interventions

The interventions of interest are:

  • skills mix including the professional level of nurses
  • staffing levels (number on duty)
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Outcomes

Outcomes of interest will be any measure that attempts to capture health and psychosocial factors relating to patient, staff and organisational outcomes including:

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Patient

Clinical

  • infection rates
  • relapse/re-admission
  • healing
  • post-operative nausea and vomiting
  • pain levels
  • patient safety
  • use of community nursing resources post discharge
  • GP visits for complications of day-surgery post discharge

Psychosocial

  • patient satisfaction
  • patient knowledge
  • anxiety levels
  • perceived independence
  • activity of daily living scale;

Staff

  • staff turnover
  • staff satisfaction
  • staff sick leave
  • staff burnout
  • absenteeism

Organisational

  • unplanned admission rates
  • transfer rates
  • procedure cancellation rates
  • length of stay
  • vacancy rate
  • regular staff to ‘transient’ staff
  • use of agency staff
  • cost
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SEARCH STRATEGY

The search seeks to find both published and unpublished studies in the English language from 1960 to March 2007 inclusive and utilising a three-step search strategy. An initial limited search of MEDLINE and CINAHL databases will be conducted to identify keywords contained in the title or abstract. A second extensive search will be undertaken using the identified key words and index terms The third step will be to search the reference lists and bibliographies of all relevant articles.

Databases to be searched include:

  • MEDLINE, CINAHL, EMBASE, The Cochrane Central Register of Controlled Trials, Australian Medical Index (AMI), AUSThealth, AGELINE, Expanded Academic Index, and Current Contents

Databases to be searched for unpublished studies include:

  • Dissertation Abstracts International, Proceedings First

Initial search terms will be:

Participants:

Nurse or nurs*or technician or staff*or personnel or scheduling or rostering.

and

Environment:

Day surgery or ambulatory or same-day surgery or fast tracking or day case or day only or day clinic or day surgery unit or day surgery centre/center or ambulatory centre/center/unit or extended recovery or 23 hour overnight stay or 23 hour admission unit or overnight stay or single night or outpatient surgery.

and

Studies:

RCT or controlled trial or study

and

Outcome:

Satisfaction/staff/client/patient or standards or re-admission

All studies identified by the search will be assessed by two independent reviewers for relevance based on the information provided in the title, abstract and descriptor/MESH terms and a full report will be retrieved for all studies that appear to meet the inclusion criteria (Appendix II). Studies identified from reference list searches will be assessed for relevance based on the study title.

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METHODS FOR REVIEW

Assessment of methodological quality

Methodological quality will be assessed by two independent reviewers using a checklist developed by the Joanna Briggs Institute based on the work of the Cochrane Collaboration15 and Centre for Reviews and Dissemination16 (Appendix III). Any disagreements that arise between the reviewers will be resolved through discussion and if necessary with a third reviewer.

Data collection/extraction

Data will be extracted independently by two reviewers using appropriate data extraction tools based on the work of the Cochrane Collaboration15 and the Centre for Reviews and Dissemination16 (Appendix IV).

Data synthesis

Where possible, odds ratio (OR; for categorical data) or weighted mean difference (WMD; for continuous data) and their 95% confidence intervals (CI) will be calculated for each analysis. Where statistical pooling is not appropriate or possible, the findings will be summarised in narrative form.

Potential Conflicts of Interest

None

Acknowledgements

This protocol is an extension of a previously unpublished report.17

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References:

1. International Association for Ambulatory Surgery IAAS. Ambulatory (day) surgery: suggested international terminology and definitions. Paris: International Association for Ambulatory Surgery; 2003 [cited 2007 Feb 19]. Available from: http://www.iaas-med.com/modules/content/index.php?id=24.
2. Millar JM. US ambulatory surgery projections are inappropriate. Ambul Surg. 1997;5(3):121-4.
3. Roberts L. Day Surgery: the future [monograph on the Internet. Melbourne: Royal Australasian College of Surgeons; 2007 [cited 2007 Feb 19]. Available from: www.surgeons.org/Content/NavigationMenu/FellowshipandStandards/AustraliaDaySurgeryCouncil/Day_Surgery_The_Futu.htm. NB. Website states that this article was reproduced with permission from another journal.
4. Pandit SK. Ambulatory anesthesia and surgery in America: a historical background and recent innovations. J Perianesth Nurs. 1999 Oct;14(5):270-4.
5. Mitchell M. Anxiety management: A distinct nursing role in day surgery. Ambul Surg. 2000;8(3):119-27.
6. Rushforth H, Bliss A, Burge D, Glasper EA. A pilot randomised controlled trial of medical versus nurse clerking for minor surgery. Arch Dis Child. 2000;83(3):223-6.
7. Poole EL. Ambulatory surgery: The growth of an industry. J Perianesth Nurs. 1999;14(4):201-6.
8. Burden N. Outpatient surgery: a view through history. J Perianesth Nurs.2005 Dec;20(6):435-7.
9. Brokelmann J. Ambulatory surgery in Germany 2004 and historical aspects. Ambul Surg. 2006;12:173-6.
10. Song D, Chung F, Ronayne M, Ward B, Yogendran S, Sibbick C. Fast-tracking (bypassing the PACU) does not reduce nursing workload after ambulatory surgery. Br J Anaesth. 2004;93(6):768-74.
11. Kleinpell RM. Improving telephone follow-up after ambulatory surgery. J Perianesth Nurs. 1997 Oct;12(5):336-40.
12. Hannallah RS. Anaesthetic considerations for paediatric ambulatory surgery. Ambul Surg. 1997;5:53-9.
13. AORN Guidance Statement. Postoperative patient care in the ambulatory surgery setting. AORN J. 2005 Apr;81(4):881-8.
14. Royal College of Nursing. Defining Nursing. [monograph on the Internet]. London: Royal College of Nursing; 2003 Apr [cited 2007 Mar 13]. Available from: http://www.rcn.org.uk
15. Mulrow CD, Oxman AD. Cochrane collaboration handbook [CD-ROM]. Oxford: The Cochrane Collaboration; 1997
    16. NHS Centre for Reviews and Dissemination. Undertaking Systematic Reviews of Research on Effectiveness: CRD Guidelines for Those Carrying Out of Commissioning Reviews. York: University of York Publishing Services; 1996.
      17. Pearson A, Richardson M, Brown S, Cairns M. (In Press) Appropriate staffing models to achieve desirable health outcomes in day surgery units: A systematic review. HCR.
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      Appendix I: JBI Levels of Evidence

      Table

      Table

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      Appendix II: Inclusion Criteria

      Types of participants:

      • Nurses: Registered Nurses RN (AU), Staff Nurses (UK), Licenced Practical Nurses LPN (US), Enrolled Nurses EN (AU), Certified Ambulatory PeriAnaesthesia Nurses CAPA (US), Nurses Aides, Nurse Technicians

      Types of intervention:

      • skills mix including the professional level of nurses
      • staffing levels (number on duty)

      Types of outcome measures:

      • Any measure that attempts to capture health and psychosocial factors relating to patient, staff and organisational outcomes

      Types of studies:

      • Systematic reviews or randomised controlled trials (RCTs)
      • In their absence, other research methods such as non-RCTs, longitudinal studies, cohort or case-control studies, or descriptive studies
      • Government reports, economic analysis and cost vs. benefit studies will also be examined to explore the feasibility of findings
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      Appendix III Critical Appraisal Form

      Figure

      Figure

      Figure

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      Appendix IV: Data Extraction Form

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      © 2007 by Lippincott Williams & Wilkins, Inc.