Electronic Health Record Adoption and Nurse Reports of Usability and Quality of Care: The Role of Work Environment

BACKGROUND

Despite evidence suggesting higher quality and safer care in hospitals with comprehensive electronic health record (EHR) systems, factors related to advanced system usability remain largely unknown, particularly among nurses. Little empirical research has examined sociotechnical factors, such as the work environment, that may shape the relationship between advanced EHR adoption and quality of care.

OBJECTIVE

The objective of this study was to examine the independent and joint effects of comprehensive EHR adoption and the hospital work environment on nurse reports of EHR usability and nurse-reported quality of care and safety.

METHODS

This study was a secondary analysis of nurse and hospital survey data. Unadjusted and adjusted logistic regression models were used to assess the relationship between EHR adoption level, work environment, and a set of EHR usability and quality/safety outcomes. The sample included 12,377 nurses working in 353 hospitals.

RESULTS

In fully adjusted models, comprehensive EHR adoption was associated with lower odds of nurses reporting poor usability outcomes, such as dissatisfaction with the system (odds ratio [OR]: 0.75; 95% confidence interval [CI]: 0.61-0.92). The work environment was associated with all usability outcomes with nurses in better environments being less likely to report negatively. Comprehensive EHRs (OR: 0.83; 95% CI: 0.71-0.96) and better work environments (OR: 0.47; 95% CI: 0.42-0.52) were associated with lower odds of nurses reporting fair/poor quality of care, while poor patient safety grade was associated with the work environment (OR: 0.50; 95% CI: 0.46-0.54), but not EHR adoption level.

CONCLUSION

Our findings suggest that adoption of a comprehensive EHR is associated with more positive usability ratings and higher quality of care. We also found that-independent of EHR adoption level-the hospital work environment plays a significant role in how nurses evaluate EHR usability and whether EHRs have their intended effects on improving quality and safety of care.

Quality of End-of-Life Care and Its Association with Nurse Practice Environments in U.S. Hospitals

OBJECTIVES

The purpose of this study is twofold: (1) to describe the quality of end-of-life care in US hospitals from the perspective of hospital nurses; and (2) to evaluate the relationship between the nurse practice environment and end-of-life care quality.

DESIGN

Cross-sectional analysis of multiple linked secondary data sources.

PARTICIPANTS AND SETTING

A total of 12,870 direct care registered nurses in 491 acute-care hospitals.

MEASUREMENTS

Measures of end-of-life care quality and nurse practice environment were derived from the 2016 RN4CAST-US survey of nurses. Nurses reported on end-of-life care quality for patients for whom death within a year would not be surprising. Nurse practice environment was measured using the Practice Environment Scale of the Nursing Work Index, a National Quality Forum validated scale.

RESULTS

Most nurses gave their hospitals an unfavorable evaluation of end-of-life care overall (58%) and said patients often experience painful procedures that were unlikely to change their outcome (53%). The best predictor of poor quality was the nurse practice environment. Nurses in the best environments were 55% less likely than nurses in poor environments to rate their hospital's overall end-of-life care quality unfavorably (odds ratio = 0.45; 95% confidence interval = 0.39-0.52; P < .001).

CONCLUSION

Quality of end-of-life care in US hospitals is imperfect and is significantly worse in hospitals with poor nurse practice environments than in hospitals with the best environments. This study reinforces the importance of nurses in providing high-quality end-of-life care. J Am Geriatr Soc 67:302-308, 2019.

Effect of Changes in Hospital Nursing Resources on Improvements in Patient Safety and Quality of Care: A Panel Study

BACKGROUND

Evidence shows hospitals with better nursing resources have better outcomes but few studies have shown that outcomes change over time within hospitals as nursing resources change.

OBJECTIVES

To determine whether changes in nursing resources over time within hospitals are related to changes in quality of care and patient safety.

RESEARCH DESIGN

Multilevel logistic response models, using data from a panel of 737 hospitals in which cross-sections of nurse informants surveyed in 2006 and 2016, were used to simultaneously estimate longitudinal and cross-sectional associations between nursing resources, quality of care, and patient safety.

MEASURES

Nursing resources included hospital-level measures of work environments, nurse staffing, and nurse education. Care quality was measured by overall rating of care quality, confidence in patients managing care after discharge, confidence in management resolving patient care problems; patient safety was measured by patient safety grade, concern with mistakes, and freedom to question authority.

RESULTS

After taking into account cross-sectional differences between hospitals, differences among nurses within hospitals, and potential confounding variables, changes within hospitals in nursing resources were associated with significant changes in quality of care and patient safety. Improvements in work environment of 1 SD decrease odds of unfavorable quality care and patient safety by factors ranging from 0.82 to 0.97.

CONCLUSIONS

Improvements within hospitals in work environments, nurse staffing, and educational composition of nurses coincide with improvements in quality of care and patient safety. Cross-sectional results closely approximate longitudinal panel results.

Patient satisfaction with hospital care and nurses in England: an observational study

OBJECTIVES

To inform healthcare workforce policy decisions by showing how patient perceptions of hospital care are associated with confidence in nurses and doctors, nurse staffing levels and hospital work environments.

DESIGN

Cross-sectional surveys of 66 348 hospital patients and 2963 inpatient nurses.

SETTING

Patients surveyed were discharged in 2010 from 161 National Health Service (NHS) trusts in England. Inpatient nurses were surveyed in 2010 in a sample of 46 hospitals in 31 of the same 161 trusts.

PARTICIPANTS

The 2010 NHS Survey of Inpatients obtained information from 50% of all patients discharged between June and August. The 2010 RN4CAST England Nurse Survey gathered information from inpatient medical and surgical nurses.

MAIN OUTCOME MEASURES

Patient ratings of their hospital care, their confidence in nurses and doctors and other indicators of their satisfaction. Missed nursing care was treated as both an outcome measure and explanatory factor.

RESULTS

Patients' perceptions of care are significantly eroded by lack of confidence in either nurses or doctors, and by increases in missed nursing care. The average number of types of missed care was negatively related to six of the eight outcomes-ORs ranged from 0.78 (95% CI 0.68 to 0.90) for excellent care ratings to 0.86 (95% CI 0.77 to 0.95) for medications completely explained-positively associated with higher patient-to-nurse ratios (b=0.15, 95% CI 0.10 to 0.19), and negatively associated with better work environments (b=-0.26, 95% CI -0.48 to -0.04).

CONCLUSIONS

Patients' perceptions of hospital care are strongly associated with missed nursing care, which in turn is related to poor professional nurse (RN) staffing and poor hospital work environments. Improving RN staffing in NHS hospitals holds promise for enhancing patient satisfaction.

U.S. Hospital Employment of Foreign-Educated Nurses and Patient Experience: A Cross-Sectional Study

INTRODUCTION

For over half a century, hospitals in the United States have actively recruited foreign-educated nurses (FENs) in response to nurse shortages in hospitals and nursing homes. Little attention has been paid to the quality of care in the United States related to employment of FENs.

AIMS

The purpose of this retrospective study was to determine whether employment of FENs in U.S. hospitals is associated with patient care experience.

METHOD

This study used cross-sectional data from three sources in 425 hospitals in four large states to evaluate the relationship between patient perceptions of care and hospital employment of FENs. The study linked data from publicly reported patient experience of care surveys, nurse surveys, and administrative data using unique hospital identifiers common across the data sets.

RESULTS

Patient-reported care experience was found to be more negative in hospitals employing more FENs, after controls for other possible explanations. Each 10% increase in FENs was associated with a decrease in the percentage of patients who would recommend their hospital and a decrease in the percentage of patients giving favorable reports on five nursing-specific aspects of patient experience.

CONCLUSIONS

The results of this study suggest that employment of substantial numbers of nurses educated outside the United States may have implications for quality of care. The findings suggest that research on the outcomes of transition programs for FENs would be useful to inform regulatory policies.

Post-operative mortality, missed care and nurse staffing in nine countries: A cross-sectional study

Background

Variation in post-operative mortality rates has been associated with differences in registered nurse staffing levels. When nurse staffing levels are lower there is also a higher incidence of necessary but missed nursing care. Missed nursing care may be a significant predictor of patient mortality following surgery.

Aim

Examine if missed nursing care mediates the observed association between nurse staffing levels and mortality.

Method

Data from the RN4CAST study (2009–2011) combined routinely collected data on 422,730 surgical patients from 300 general acute hospitals in 9 countries, with survey data from 26,516 registered nurses, to examine associations between nurses’ staffing, missed care and 30-day in-patient mortality. Staffing and missed care measures were derived from the nurse survey. A generalized estimation approach was used to examine the relationship between first staffing, and then missed care, on mortality. Bayesian methods were used to test for mediation.

Results

Nurse staffing and missed nursing care were significantly associated with 30-day case-mix adjusted mortality. An increase in a nurse’s workload by one patient and a 10% increase in the percent of missed nursing care were associated with a 7% (OR 1.068, 95% CI 1.031–1.106) and 16% (OR 1.159 95% CI 1.039–1.294) increase in the odds of a patient dying within 30 days of admission respectively. Mediation analysis shows an association between nurse staffing and missed care and a subsequent association between missed care and mortality.

Conclusion

Missed nursing care, which is highly related to nurse staffing, is associated with increased odds of patients dying in hospital following common surgical procedures. The analyses support the hypothesis that missed nursing care mediates the relationship between registered nurse staffing and risk of patient mortality. Measuring missed care may provide an ‘early warning’ indicator of higher risk for poor patient outcomes.

Unmet Nursing Care Linked to Rehospitalizations Among Older Black AMI Patients: A Cross-Sectional Study of US Hospitals

BACKGROUND

Recent studies suggest that nurses may be unable to complete all aspects of necessary care due to a lack of time. Research is needed to determine whether unmet nursing care contributes to disparities in readmissions for vulnerable populations.

OBJECTIVES

To examine differences in the relationship between nursing care left undone and acute myocardial infarction readmissions among older black patients compared with older white patients.

RESEARCH DESIGN

Cross-sectional analysis of multiple datasets, including: 2006 to 2007 administrative discharge data, a survey of registered nurses, and the American Hospital Association Annual Survey. Risk-adjusted logistic regression models were used to estimate the association between care left undone and 30-day readmission. Interactions were used to examine the moderating effect of care left undone on readmission by race.

RESULTS

The sample included 69,065 patients in 253 hospitals in California, New Jersey, and Pennsylvania. Older black patients were 18% more likely to experience a readmission after adjusting for patient and hospital characteristics and more likely to be in hospitals where nursing care was often left undone. Black patients were more likely to be readmitted when nurses were unable to talk/comfort patients [odds ratio (OR), 1.09; 95% confidence interval (CI), 1.01-1.19], complete documentation (OR, 1.16; 95% CI, 1.01-1.32), or administer medications in a timely manner (OR, 1.26; 95% CI, 1.09-1.46).

CONCLUSIONS

Unmet nursing care is associated with readmissions for older black patients following acute myocardial infarction. Investment in nursing resources to improve the delivery of nursing care may decrease disparities in readmission.

Patient satisfaction and non-UK educated nurses: a cross-sectional observational study of English National Health Service Hospitals

OBJECTIVES

To examine whether patient satisfaction with nursing care in National Health Service (NHS) hospitals in England is associated with the proportion of non-UK educated nurses providing care.

DESIGN

Cross-sectional analysis using data from the 2010 NHS Adult Inpatient Survey merged with data from nurse and hospital administrator surveys. Logistic regression models with corrections for clustering were used to determine whether the proportions of non-UK educated nurses were significantly related to patient satisfaction before and after taking account of other hospital, nursing and patient characteristics.

SETTING

31 English NHS trusts.

PARTICIPANTS

12,506 patients 16 years of age and older with at least one overnight stay that completed a satisfaction survey; 2962 bedside care nurses who completed a nurse survey; and 31 NHS trusts.

MAIN OUTCOME MEASURE

Patient satisfaction.

RESULTS

The percentage of non-UK educated nurses providing bedside hospital care, which ranged from 1% to 52% of nurses, was significantly associated with patient satisfaction. After controlling for potential confounding factors, each 10-point increase in the percentage of non-UK educated nurses diminished the odds of patients reporting good or excellent care by 12% (OR=0.88), and decreased the odds of patients agreeing that they always had confidence and trust in nurses by 13% (OR=0.87). Other indicators of patient satisfaction also revealed lower satisfaction in hospitals with higher percentages of non-UK educated nurses.

CONCLUSIONS

Use of non-UK educated nurses in English NHS hospitals is associated with lower patient satisfaction. Importing nurses from abroad to substitute for domestically educated nurses may negatively impact quality of care.

Hospitals Known for Nursing Excellence Associated with Better Hospital Experience for Patients

OBJECTIVE

To examine the relationship between Magnet recognition, an indicator of nursing excellence, and patients' experience with their hospitalization reported in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.

DATA SOURCES

This secondary analysis includes cross-sectional data from the 2010 HCAHPS survey, the American Hospital Association, and the American Nurses Credentialing Center.

STUDY DESIGN

We conducted a retrospective observational study.

DATA COLLECTION

Using common hospital identifiers, we created a matched set of 212 Magnet hospitals and 212 non-Magnet hospitals.

PRINCIPAL FINDINGS

Patients in Magnet hospitals gave their hospitals higher overall ratings, were more likely to recommend their hospital, and reported more positive care experiences with nurse communication.

CONCLUSIONS

Magnet recognition is associated with better patient care experiences, which may positively enhance reimbursement for hospitals.

Organization of Hospital Nursing, Provision of Nursing Care, and Patient Experiences With Care in Europe

This study integrates previously isolated findings of nursing outcomes research into an explanatory framework in which care left undone and nurse education levels are of key importance. A moderated mediation analysis of survey data from 11,549 patients and 10,733 nurses in 217 hospitals in eight European countries shows that patient care experience is better in hospitals with better nurse staffing and a more favorable work environment in which less clinical care is left undone. Clinical care left undone is a mediator in this relationship. Clinical care is left undone less frequently in hospitals with better nurse staffing and more favorable nurse work environments, and in which nurses work less overtime and are more experienced. Higher proportions of nurses with a bachelor's degree reduce the effect of worse nurse staffing on more clinical care left undone.

The quality of hospital work environments and missed nursing care is linked to heart failure readmissions: a cross-sectional study of US hospitals

INTRODUCTION

Threats to quality and patient safety may exist when necessary nursing care is omitted. Empirical research is needed to determine how missed nursing care is associated with patient outcomes.

AIM

The aim of this study was to examine the relationship between missed nursing care and hospital readmissions.

METHODS

Cross-sectional examination, using three linked data sources-(1) nurse survey, (2) patient discharge data from three states (California, New Jersey and Pennsylvania) and (3) administrative hospital data- from 2005 to 2006. We explored the incidence of 30-day readmission for 160 930 patients with heart failure in 419 acute care hospitals in the USA. Logistic regression was used to assess the effect of missed care on the odds of readmission, adjusting for patient and hospital characteristics.

RESULTS

The most frequently missed nursing care activities across all hospitals in our sample included talking to and comforting patients (42.0%), developing and updating care plans (35.8%) and educating patients and families (31.5%). For 4 of the 10 studied care activities, each 10 percentage-point increase in the number of nurses reporting having missed the activity was associated with an increase in the odds of readmission by 2-8% after adjusting for patient and hospital characteristics. However, missed nursing care was no longer a significant predictor of readmission once adjusting for the nurse work environment, except in the case of the delivery of treatments and procedures (OR 1.08, 95% CI 1.02 to 1.14).

CONCLUSIONS

Missed care is an independent predictor of heart failure readmissions. However, once adjusting for the quality of the nurse work environment, this relationship is attenuated. Improvements in nurses' working conditions may be one strategy to reduce care omissions and improve patient outcomes.

Effects of nurse staffing, work environments, and education on patient mortality: an observational study

BACKGROUND

While considerable evidence has been produced showing a link between nursing characteristics and patient outcomes in the U.S. and Europe, little is known about whether similar associations are present in South Korea.

OBJECTIVE

To examine the effects of nurse staffing, work environment, and education on patient mortality.

METHODS

This study linked hospital facility data with staff nurse survey data (N=1024) and surgical patient discharge data (N=76,036) from 14 high-technology teaching hospitals with 700 or more beds in South Korea, collected between January 1, 2008 and December 31, 2008. Logistic regression models that corrected for the clustering of patients in hospitals were used to estimate the effects of the three nursing characteristics on risk-adjusted patient mortality within 30 days of admission.

RESULTS

Risk-adjusted models reveal that nurse staffing, nurse work environments, and nurse education were significantly associated with patient mortality (OR 1.05, 95% CI 1.00-1.10; OR 0.52, 95% CI 0.31-0.88; and OR 0.91, CI 0.83-0.99; respectively). These odds ratios imply that each additional patient per nurse is associated with an 5% increase in the odds of patient death within 30 days of admission, that the odds of patient mortality are nearly 50% lower in the hospitals with better nurse work environments than in hospitals with mixed or poor nurse work environments, and that each 10% increase in nurses having Bachelor of Science in Nursing Degree is associated with a 9% decrease in patient deaths.

CONCLUSIONS

Nurse staffing, nurse work environments, and percentages of nurses having Bachelor of Science in Nursing Degree in South Korea are associated with patient mortality. Improving hospital nurse staffing and work environments and increasing the percentages of nurses having Bachelor of Science in Nursing Degree would help reduce the number of preventable in-hospital deaths.

Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study

BACKGROUND

Austerity measures and health-system redesign to minimise hospital expenditures risk adversely affecting patient outcomes. The RN4CAST study was designed to inform decision making about nursing, one of the largest components of hospital operating expenses. We aimed to assess whether differences in patient to nurse ratios and nurses' educational qualifications in nine of the 12 RN4CAST countries with similar patient discharge data were associated with variation in hospital mortality after common surgical procedures.

METHODS

For this observational study, we obtained discharge data for 422,730 patients aged 50 years or older who underwent common surgeries in 300 hospitals in nine European countries. Administrative data were coded with a standard protocol (variants of the ninth or tenth versions of the International Classification of Diseases) to estimate 30 day in-hospital mortality by use of risk adjustment measures including age, sex, admission type, 43 dummy variables suggesting surgery type, and 17 dummy variables suggesting comorbidities present at admission. Surveys of 26,516 nurses practising in study hospitals were used to measure nurse staffing and nurse education. We used generalised estimating equations to assess the effects of nursing factors on the likelihood of surgical patients dying within 30 days of admission, before and after adjusting for other hospital and patient characteristics.

FINDINGS

An increase in a nurses' workload by one patient increased the likelihood of an inpatient dying within 30 days of admission by 7% (odds ratio 1·068, 95% CI 1·031-1·106), and every 10% increase in bachelor's degree nurses was associated with a decrease in this likelihood by 7% (0·929, 0·886-0·973). These associations imply that patients in hospitals in which 60% of nurses had bachelor's degrees and nurses cared for an average of six patients would have almost 30% lower mortality than patients in hospitals in which only 30% of nurses had bachelor's degrees and nurses cared for an average of eight patients.

INTERPRETATION

Nurse staffing cuts to save money might adversely affect patient outcomes. An increased emphasis on bachelor's education for nurses could reduce preventable hospital deaths.

FUNDING

European Union's Seventh Framework Programme, National Institute of Nursing Research, National Institutes of Health, the Norwegian Nurses Organisation and the Norwegian Knowledge Centre for the Health Services, Swedish Association of Health Professionals, the regional agreement on medical training and clinical research between Stockholm County Council and Karolinska Institutet, Committee for Health and Caring Sciences and Strategic Research Program in Care Sciences at Karolinska Institutet, Spanish Ministry of Science and Innovation.

Nurse employment contracts in Chinese hospitals: impact of inequitable benefit structures on nurse and patient satisfaction

PURPOSE

Ongoing economic and health system reforms in China have transformed nurse employment in Chinese hospitals. Employment of 'bianzhi' nurses, a type of position with state-guaranteed lifetime employment that has been customary since 1949, is decreasing while there is an increase in the contract-based nurse employment with limited job security and reduced benefits. The consequences of inequities between the two types of nurses in terms of wages and job-related benefits are unknown. This study examined current rates of contract-based nurse employment and the effects of the new nurse contract employment strategy on nurse and patient outcomes in Chinese hospitals.

METHODS

This cross-sectional study used geographically representative survey data collected from 2008 to 2010 from 181 hospitals in six provinces, two municipalities, and one autonomous region in China. Logistic regression models were used to estimate the association between contract-based nurse utilization, dissatisfaction among contract-based nurses, nurse intentions to leave their positions, and patient satisfaction, controlling for nurse, patient, and hospital characteristics.

PRINCIPAL RESULTS

Hospital-level utilization of contract-based nurses varies greatly from 0 to 91%, with an average of 51%. Contract-based nurses were significantly more dissatisfied with their remuneration and benefits than 'bianzhi' nurses who have more job security (P <0.01). Contract-based nurses who were dissatisfied with their salary and benefits were more likely to intend to leave their current positions (P <0.01). Hospitals with high levels of dissatisfaction with salary and benefits among contract-based nurses were rated lower and less likely to be recommended by patients (P < 0.05).

CONCLUSIONS

Our results suggest a high utilization of contract-based nurses in Chinese hospitals, and that the inequities in benefits between contract-based nurses and 'bianzhi' nurses may adversely affect both nurse and patient satisfaction in hospitals. Our study provides empirical support for the 'equal pay for equal work' policy emphasized by the China Ministry of Health's recent regulations, and calls for efforts in Chinese hospitals to eliminate the disparities between 'bianzhi' and contract-based nurses.

Utilization of non-US educated nurses in US hospitals: implications for hospital mortality

OBJECTIVE

To determine whether, and under what circumstance, US hospital employment of non-US-educated nurses is associated with patient outcomes.

DESIGN

Observational study of primary data from 2006 to 2007 surveys of hospital nurses in four states (California, Florida, New Jersey and Pennsylvania). The direct and interacting effects of hospital nurse staffing and the percentage of non-US-educated nurses on 30-day surgical patient mortality and failure-to-rescue were estimated before and after controlling for patient and hospital characteristics.

PARTICIPANTS

Data from registered nurse respondents practicing in 665 hospitals were pooled with patient discharge data from state agencies.

MAIN OUTCOMES MEASURE(S)

Thirty-day surgical patient mortality and failure-to-rescue.

RESULTS

The effect of non-US-educated nurses on both mortality and failure-to-rescue is nil in hospitals with lower than average patient to nurse ratios, but pronounced in hospitals with average and poor nurse to patient ratios. In hospitals in which patient-to-nurse ratios are 5:1 or higher, mortality is higher when 25% or more nurses are educated outside of the USA than when <25% of nurses are non-US-educated. Moreover, the effect of having >25% non-US-educated nurses becomes increasingly deleterious as patient-to-nurse ratios increase beyond 5:1.

CONCLUSIONS

Employing non-US-educated nurses has a negative impact on patient mortality except where patient-to-nurse ratios are lower than average. Thus, US hospitals should give priority to achieving adequate nurse staffing levels, and be wary of hiring large percentages of non-US-educated nurses unless patient-to-nurse ratios are low.

An observational study of nurse staffing ratios and hospital readmission among children admitted for common conditions

Background

Hospital patient-to-nurse staffing ratios are associated with quality outcomes in adult patient populations but little is known about how these factors affect paediatric care. We examined the relationship between staffing ratios and all-cause readmission (within 14 days, 15–30 days) among children admitted for common medical and surgical conditions.

Methods

We conducted an observational cross-sectional study of readmissions of children in 225 hospitals by linking nurse surveys, inpatient discharge data and information from the American Hospital Association Annual Survey. Registered Nurses (N=14 194) providing direct patient care in study hospitals (N=225) and children hospitalised for common conditions (N=90 459) were included.

Results

Each one patient increase in a hospital's average paediatric staffing ratio increased a medical child's odds of readmission within 15–30 days by a factor of 1.11, or by 11% (95% CI 1.02 to 1.20) and a surgical child's likelihood of readmission within 15–30 days by a factor of 1.48, or by 48% (95% CI 1.27 to 1.73). Children treated in hospitals with paediatric staffing ratios of 1 : 4 or less were significantly less likely to be readmitted within 15–30 days. There were no significant effects of nurse staffing ratios on readmissions within 14 days.

Discussion

Children with common conditions treated in hospitals in which nurses care for fewer patients each are significantly less likely to experience readmission between 15 and 30 days after discharge. Lower patient-to-nurse ratios hold promise for preventing unnecessary hospital readmissions for children through more effective predischarge monitoring of patient conditions, improved discharge preparation and enhanced quality improvement success.

An increase in the number of nurses with baccalaureate degrees is linked to lower rates of postsurgery mortality

An Institute of Medicine report has called for registered nurses to achieve higher levels of education, but health care policy makers and others have limited evidence to support a substantial increase in the number of nurses with baccalaureate degrees. Using Pennsylvania nurse survey and patient discharge data from 1999 and 2006, we found that a ten-point increase in the percentage of nurses holding a baccalaureate degree in nursing within a hospital was associated with an average reduction of 2.12 deaths for every 1,000 patients--and for a subset of patients with complications, an average reduction of 7.47 deaths per 1,000 patients. We estimate that if all 134 hospitals in our study had increased the percentage of their nurses with baccalaureates by ten points during our study's time period, some 500 deaths among general, orthopedic, and vascular surgery patients might have been prevented. The findings provide support for efforts to increase the production and employment of baccalaureate nurses.

Changes in hospital nurse work environments and nurse job outcomes: an analysis of panel data

BACKGROUND

One strategy proposed to alleviate nursing shortages is the promotion of organizational efforts that will improve nurse recruitment and retention. Cross-sectional studies have shown that the quality of the nurse work environment is associated with nurse outcomes related to retention, but there have been very few longitudinal studies undertaken to examine this relationship.

OBJECTIVES

To demonstrate how rates of burnout, intention to leave, and job dissatisfaction changed in a panel of hospitals over time, and to explore whether these outcomes were associated with changes in nurse work environments.

METHODS

A retrospective, two-stage panel design was chosen for this study. Survey data collected from large random samples of registered nurses employed in Pennsylvania hospitals in 1999 and 2006 were used to derive hospital-level rates of burnout, intention to leave current position, and job dissatisfaction, and to classify the quality of nurses' work environments at both points in time. A two-period difference model was used to estimate the dependence of changes in rates of nurse burnout, intention to leave, and job dissatisfaction on changes in nurse work environments between 1999 and 2006 in 137 hospitals, accounting for concurrent changes in nurse staffing levels.

RESULTS

In general, nurse outcomes improved between 1999 and 2006, with fewer nurses reporting burnout, intention to leave, and job dissatisfaction in 2006 as compared to 1999. Our difference models showed that improvements in work environment had a strong negative association with changes in rates of burnout (β=-6.42%, p<0.01) intention to leave (β=-4.10%, p<0.01), and job dissatisfaction (β=-8.00%, p<0.01).

CONCLUSIONS

Improvements in nurse work environments over time are associated with lower rates of nurse burnout, intention to leave current position, and job dissatisfaction.

Hospital use of agency-employed supplemental nurses and patient mortality and failure to rescue

OBJECTIVE

To determine the association between the use of agency-employed supplemental registered nurses (SRNs) to staff hospitals and patient mortality and failure to rescue (FTR).

DATA SOURCES

Primary survey data from 40,356 registered nurses in 665 hospitals in four states in 2006 were linked with American Hospital Association and inpatient mortality data from state agencies for approximately 1.3 million patients.

STUDY DESIGN

Logistic regression models were used to examine the association between SRN use and 30-day in-hospital mortality and FTR, controlling for patient and hospital characteristics, nurse staffing, the proportion of nurses with bachelor's degrees, and quality of the work environment.

PRINCIPAL FINDINGS

Before controlling for multiple nurse characteristics of hospitals, higher proportions of agency-employed SRNs in hospitals appeared to be associated with higher mortality (OR = 1.06) and FTR (OR = 1.05). Hospitals with higher proportions of SRNs have poorer work environments, however, and the significant relationships between SRNs and mortality outcomes were rendered insignificant when work environments were taken into account.

CONCLUSIONS

Higher use of SRNs does not appear to have deleterious consequences for patient mortality and may alleviate nurse staffing problems that could produce higher mortality.

The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction

Extended work shifts of twelve hours or longer are common and even popular with hospital staff nurses, but little is known about how such extended hours affect the care that patients receive or the well-being of nurses. Survey data from nurses in four states showed that more than 80 percent of the nurses were satisfied with scheduling practices at their hospital. However, as the proportion of hospital nurses working shifts of more than thirteen hours increased, patients' dissatisfaction with care increased. Furthermore, nurses working shifts of ten hours or longer were up to two and a half times more likely than nurses working shorter shifts to experience burnout and job dissatisfaction and to intend to leave the job. Extended shifts undermine nurses' well-being, may result in expensive job turnover, and can negatively affect patient care. Policies regulating work hours for nurses, similar to those set for resident physicians, may be warranted. Nursing leaders should also encourage workplace cultures that respect nurses' days off and vacation time, promote nurses' prompt departure at the end of a shift, and allow nurses to refuse to work overtime without retribution.

Lower mortality for abdominal aortic aneurysm repair in high-volume hospitals is contingent upon nurse staffing

OBJECTIVE

To determine whether and to what extent the lower mortality rates for patients undergoing abdominal aortic aneurysm (AAA) repair in high-volume hospitals is explained by better nursing.

DATA SOURCES

State hospital discharge data, Multi-State Nursing Care and Patient Safety Survey, and hospital characteristics from the AHA Annual Survey.

STUDY DESIGN

Cross-sectional analysis of linked patient outcomes for individuals undergoing AAA repair in four states.

DATA COLLECTION

Secondary data sources.

PRINCIPAL FINDINGS

Favorable nursing practice environments and higher hospital volumes of AAA repair are associated with lower mortality and fewer failures-to-rescue in main-effects models. Furthermore, nurse staffing interacts with volume such that there is no mortality advantage observed in high-volume hospitals with poor nurse staffing. When hospitals have good nurse staffing, patients in low-volume hospitals are 3.4 times as likely to die and 2.6 times as likely to die from complications as patients in high-volume hospitals (p < .001).

CONCLUSIONS

Nursing is part of the explanation for lower mortality after AAA repair in high-volume hospitals. Importantly, lower mortality is not found in high-volume hospitals if nurse staffing is poor.