Hospital staffing, organization, and quality of care: Cross-national findings

Relationships Between Stressors, Work Supports, and Burnout Among Cancer Nurses

This pilot study investigated the relationships between stressors, work supports, and burnout among cancer nurses. One hundred and one registered nurses, employed at a major specialist oncology, metropolitan Australian hospital, completed self-report questionnaires measuring these constructs and provided responses to open-ended questions. The 50 listed stressors were experienced as sources of stress by more than 50% of the sample; most work support came from peers, rather than supervisor and organizational supports; and the overall level of burnout for the sample was moderate to low. Significant positive correlations were found between Stressors and the Emotional Exhaustion and Depersonalization subscales of the Maslach Burnout Inventory and a significant weak positive correlation between Peer Support and Personal Accomplishment (intensity). Findings are discussed in relation to developing strategies for reducing stress and burnout among cancer nurses, and directions for further study are suggested.

Does money really matter? A review of the literature on the relationships between healthcare organization finances and quality

The authors review empirical literature from 1980 to 2005 on relationships between healthcare organizations' finances and quality of care. They found only 16 studies of this topic that employed statistical methods. This research indicates cumulatively that expenses, fiscal margin, and asset and liability management all affect healthcare outcome quality. There is less evidence about how organizational finance factors affect structural or process quality, and there is no information about how structural or process quality mediates between finances and outcomes. The authors note what patterns have emerged from previous studies and make specific suggestions about what future research is necessary and why.

Impact of nursing overtime on nurse-sensitive patient outcomes in New York hospitals, 1995-2000

During the past several years, nurses and their advocates have expressed concern about heavy use of overtime in hospitals and claimed that it undermines the quality of nursing care. Using staffing and discharge data covering 1995 to 2000 from 161 acute general hospitals in New York State, this study uses multi variate regression to analyze the relationship between overtime and the rates of six nurse-sensitive patient outcomes and mortality. We find an association of overtime with lower rates of mortality in medical and surgical patients but do not consider these findings definitive. Because overtime use is episodic and unit specific, further study of these issues using data that examines the occurrence of adverse events by unit during periods of heavy nurse overtime is recommended.

Advancing practice inquiry: Research foundations of the practice doctorate in nursing

The University of Washington Doctor of Nursing Practice program entails 3 curricular dimensions: advanced practice, leadership, and practice inquiry. In this article, the practice inquiry dimension is discussed and defined as a type of clinical investigation that closely aligns with the realities and complexities of everyday practice by advanced practice nurses (APNs). The advancement of APNs' practice inquiry competencies is timely for its interfaces with the national scientific agenda's emphasis on translating science to clinical practice, health care delivery systems and policy. A framework for conceptualizing a practice inquiry curriculum and competencies is proposed. In addition, the divergent and convergent comparisons with Doctor of Philosophy (PhD) nursing programs are discussed, with emphasis placed on potential collaborative clinical research endeavors.

Nurses in cancer care—coping strategies when encountering existential issues

This paper is a presentation of general/secular coping strategies and strategies related to the caritas orientation that nurses in cancer care use when encountering stress. As a concept, caritas indicates the will to do good. The paper tries to provide an answer to the question of which functional and dysfunctional coping strategies nurses use when coping with work-related stress. The study is qualitative and hypothesis-generating. The material analysed consists of 15 interviews with Swedish registered nurses and is based on a life-story approach. Pargament's coping theory related to the psychology of religion has been applied for interpretation purposes. The nurses use several coping strategies with the dominant strategy being a general boundary demarcation. Other strategies that were used for coping included emotional outlets, caritas--oblivion and periodically changing activity. The strategies can be used in a functional or dysfunctional way; e.g. dysfunctional coping was present when there was a lack of human support and boundary demarcation.

Framing Patient Safety Initiatives

The authors describe an original patient Safety Platform Model. The model identifies the broad components involved in patient safety initiatives and outlines their relationship to one another. A case example of how the model can be used is given as the authors describe a falls-prevention program.

A model of nursing care microsystems for a large neonatal intensive care unit

Nationally the number and size of neonatal intensive care units (NICUs) continues to grow. Today, NICUs with >40 beds, often referred to as "megaunits," are not uncommon. Staff in large units find it challenging to maintain teamwork, communication, and continuity of nursing care for patients. Families find large units overwhelming. In large NICUs, nurse leaders struggle to achieve a balance between parent satisfaction with care provided and nursing job satisfaction. This article describes the development of a new model of nursing practice, a nursing team microsystem. This innovative model has the unique effect of creating smaller units within the larger one, using highly skilled nursing teams, that are geographically grouped to provide care for infants and their families. The model supports teamwork, communication, continuity of care, and has shown a positive impact on both family and nurses' job satisfaction.

Nurse turnover: a literature review

Ongoing instability in the nursing workforce is raising questions globally about the issue of nurse turnover. A comprehensive literature review was undertaken to examine the current state of knowledge about the scope of the nurse turnover problem, definitions of turnover, factors considered to be determinants of nurse turnover, turnover costs and the impact of turnover on patient, and nurse and system outcomes. Much of the research to date has focused on turnover determinants, and recent studies have provided cost estimations at the organizational level. Further research is needed to examine the impact of turnover on health system cost, and how nurse turnover influences patient and nurse outcomes.

New graduate nurse self-concept and retention: A longitudinal survey

Graduate nurse attrition is an increasing phenomenon within a world of decreasing nursing numbers. The newly developed nursing self-concept of the graduate nurse may provide a key indicator for predicting graduate retention. This study explores the development of multiple dimensions of nursing self-concept and examines their relationship to graduate nurse retention plans. A descriptive survey design with repeated measures was utilised to assess nurse self-concept and retention plans. The key findings suggest that multiple dimensions of graduate nurse self-concepts rise significantly in the second half of their graduate year and that nurse general self-concept is a strong predictor of graduate nurse retention. The implications of this study are that monitoring of self-concept throughout the transitional period for new nurses can lead to early detection and appropriate intervention strategies thereby improving retention rates for new nurses.

Systematic review of evidence on the impact of nursing workload and staffing on establishing healthy work environments

BACKGROUND

This systematic review set out to examine the impact, if any, of nursing workload and staffing on creating and maintaining healthy work environments. For the purposes of this review, the term 'healthy work environment' was defined as '… a practice setting that maximizes the health and well-being of nurses, quality patient outcomes and organizational performance'. This definition identifies nurse, patient and organisational outcomes as indicators of the establishment and maintenance of a healthy work environment.

OBJECTIVES

The review sought to determine the impact of: SEARCH STRATEGY: The search strategy sought to find both published and unpublished studies and papers written in the English language. A three-step search strategy approach was used. An initial limited search of MEDLINE and CINAHL databases was undertaken to identify optimal search terms followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second extensive search using all identified keywords and index terms was then undertaken. The third step consisted of a search of the reference lists of all identified reports and articles for additional studies.

SELECTION CRITERIA

Types of studies: This review considered research papers that addressed the appropriateness and effectiveness of workload and staffing concepts in fostering a healthy work environment in healthcare. The types of papers to be considered included: meta-analysis, randomised controlled trials, quasi-randomised controlled trials, cohort studies, case-control studies, descriptive studies and correlational studies.

TYPES OF PARTICIPANTS

The review considered all participants involved or affected by workload and staffing concepts within the nursing workforce in a healthcare environment, including staff and patients. System and policy issues were also considered. Types of interventions: All workload and staffing strategies that impact on the work environment, patient and nurse outcomes were considered in this review. Types of outcome measures: Outcomes of interest were categorised into four groups: nursing staff outcomes, patient outcomes, organisational outcomes and system outcomes.

DATA COLLECTION AND ANALYSIS

Following assessment of methodological quality, data were extracted using data extraction tools based on the work of the Cochrane Collaboration and the Centre for Reviews and Dissemination. Statistical pooling was not possible and findings were presented in narrative form.

RESULTS

Of the 2162 papers identified in the search, 171 were selected for full paper retrieval and assessed independently by two reviewers for methodological quality. A total of 40 papers were included in the review: one systematic review; one cohort study; and 38 correlational descriptive studies. Results were summarised in narrative form. The evidence suggests strong correlations between patient characteristics and work environments; and workload and staffing and the quality of outcomes for clients, nurses and the system/organisation. This gave rise to a number of recommendations for practice and for further research, such as.

The contribution of organization theory to nursing health services research

We review nursing and health services research on health care organizations over the period 1950 through 2004 to reveal the contribution of nursing to this field. Notwithstanding this rich tradition and the unique perspective of nursing researchers grounded in patient care production processes, the following gaps in nursing research remain: (1) the lack of theoretical frameworks about organizational factors relating to internal work processes; (2) the need for sophisticated methodologies to guide empirical investigations; (3) the difficulty in understanding how organizations adapt models for patient care delivery in response to market forces; (4) the paucity of attention to the impact of new technologies on the organization of patient care work processes. Given nurses' deep understanding of the inner workings of health care facilities, we hope to see an increasing number of research programs that tackle these deficiencies.

Facilitating Role Transition for New Graduate RNs in a Semi-Rural Healthcare Setting

This study describes and evaluates a structured program for orientation of new graduate registered nurses in a setting that has increased the number of new graduate RNs hired in recent years. It describes the elements of a supportive environment for new RNs and brings attention to the need to develop support and recognition of nurse preceptors, who are noted to be the cornerstone of support for new RNs as they make the transition from student to accomplished professional.

Nurse Staffing and Patient Outcomes in Veterans Affairs Hospitals

OBJECTIVE

To assess characteristics and perceptions of nurses working in the Veterans Health Administration (VHA), comparing types of nursing personnel, to benchmark to prior studies across healthcare systems.

BACKGROUND

Prior studies have shown relationships between positive registered nurse (RN) perceptions of the practice environment and patient outcomes. To date, no study has reported the comparison of RN perceptions of the practice environment in hospital nursing with those of non-RN nursing personnel. This study is the first to offer a more comprehensive look at perceptions of practice environment from the full range of the nursing work force and may shed light on issues such as the relationship of skill mix to nurse and patient outcomes.

METHODS

Cross-sectional observational study with a mailed survey administered to all nursing personnel in 125 VA Medical Centers between February and June 2003.

RESULTS

Compared with other types of nursing personnel in the VHA, RNs are generally less positive about their practice environments. However, compared with RNs in other countries and particularly with other RNs in the United States (Pennsylvania), VHA RNs are generally more positive about their practice environment and express more job satisfaction.

CONCLUSIONS

The nursing work force of the VHA has some unique characteristics. The practice environment for nurses in the VHA is relatively positive, and may indicate that the VHA, as a system, provides an environment that is more like magnet hospitals. This is significant for a public sector hospital system.

Hospital Nurse Staffing and Patient Mortality, Emotional Exhaustion, and Job Dissatisfaction

OBJECTIVE

To conduct an investigation similar to a landmark study that investigated the association between nurse-to-patient ratio and patient mortality, failure-to-rescue, emotional exhaustion and job satisfaction of nurses.

METHODS

Cross-sectional analysis of 2709 general, orthopedic, and vascular surgery patients, and 140 staff nurses (42% response rate) caring for these patients in a large Midwestern institution. The main outcome measures were mortality, failure-to-rescue, emotional exhaustion, and job dissatisfaction.

RESULTS AND CONCLUSIONS

Staffing was not a significant predictor of mortality or failure-to-rescue, nor did clinical specialty predict emotional exhaustion or job dissatisfaction. Although these findings reinforce adequate staffing ratios at this institution, programs that support nurses in their daily practice and positively impact job satisfaction need to be explored. The Nursing Research Council not only has heightened awareness of how staffing ratios affect patient and nurse outcomes, but also a broader understanding of how the research process can be used to effectively shape nurse's practice and work environments.

Nurses' working conditions: implications for infectious disease

Staffing patterns and nurses' working conditions are risk factors for healthcare-associated infections as well as occupational injuries and infections. Staffing shortages, especially of nurses, have been identified as one of the major factors expected to constrain hospitals' ability to deal with future outbreaks of emerging infections. These problems are compounded by a global nursing shortage. Understanding and improving nurses' working conditions can potentially decrease the incidence of many infectious diseases. Relevant research is reviewed, and policy options are discussed.

Patient preferences and cost-utility analysis

This column discusses patient preference measures and their application in cost utility analysis. A variety of methods of eliciting patient preferences by use of generic utility measures are described. Practical issues in the use of utility measures are discussed.

The pull of magnetism: a look at the standards and the experience of a western academic medical center hospital in achieving and sustaining Magnet status

Many hospitals are working to improve the work environment for their staff. Research has indicated a linkage between work environment characteristics and patient outcomes and this research along with the nursing shortage has been the impetus for focusing on improving the work environment. The authors described the experience of an academic medical center hospital in achieving Magnet hospital status. The process and the required resources and support are discussed. Outcome data from staff nurses regarding their perception of the work environment in a Magnet hospital are presented.

Factors Influencing the Use of Registered Nurse Overtime in Hospitals, 1995-2000

PURPOSE

To assess nurse overtime in acute care general hospitals and the factors that influence overtime among various hospitals and in the same hospitals from year to year.

METHODS

Staffing data from 1995 to 2000 from 193 acute general hospitals in New York State were used to examine hospital characteristics (size, location, RN unionization, hospital ownership, and teaching status) to determine whether they were associated with nurse overtime.

RESULTS

The average weekly overtime RNs worked was 4.5% of total hours, varying from almost none to 16.6%. At mean overtime levels, nurses were working less overtime than the mean for manufacturing workers, but, at the extreme, nurses were working more than 6 hours overtime per week. Significant differences were observed in the use of overtime by hospital ownership and by union status. Nurses in government hospitals worked less overtime than did those in nongovernment hospitals. Nurses in unionized hospitals worked slightly more overtime than did nurses in nonunionized hospitals.

CONCLUSIONS

Hospitals varied dramatically in their overtime use. That some categories of hospitals (e.g., government-owned) used little overtime indicates that hospital management can find substitutes for overtime to meet fluctuating staffing needs. The finding that hospitals with similar characteristics varied greatly in their number of overtime hours also supported this conclusion.

Health and safety of older nurses

The nursing workforce is aging at an unprecedented rate yet little is known about the health and safety of older registered nurses (RNs). The survey reported here examined the relationships between demographic variables, job attributes (job satisfaction, control over practice, and job demands) and the physical and mental health and job-related injuries and health disorders of 308 nurses over the age of 50. Findings indicate that nurses with higher job satisfaction, higher control over practice, and lower job demands experienced increased physical health. Increasing age was positively correlated with mental health. Almost a quarter of older RNs experienced a job-related injury within the past 5 years, and over a third experienced job-related health problems. Nurses with higher job demands and those employed in hospital settings were more likely to have an injury. Overall, older RNs reported higher levels of physical and mental health than the national norm. Efforts must be made to keep older RNs healthy so we can retain them in the workforce.

Perceived nursing work environment of critical care nurses

BACKGROUND

Different concepts and measures have been used to evaluate the work environment of nurses in hospital settings. There is increasing need for updated measurement tools that reflect the evolving nature of the work environment.

OBJECTIVES

To report the psychometric properties of the Perceived Nursing Work Environment (PNWE) instrument, and to compare these results with those of other scales derived from the same background instrument: the Nursing Work Index-Revised.

METHODS

The Nursing Work Index-Revised was used in a national survey of critical care nurses. Exploratory principal component analysis with orthogonal rotation was conducted. Psychometric properties were examined. Construct validity was evaluated by comparing the scores for a subsample of nurses in magnet and nonmagnet hospitals.

RESULTS

Surveys obtained from 68 hospitals across the nation had a mean response rate of 41%, resulting in a sample of 2,324 participants. The PNWE, with its seven subscales and 42 items, explained 53% of the total variance of the Nursing Work Index-Revised. The subscales exhibited moderate to high reliabilities ranging from .70 to .91, except for one subscale (.56), and generally low intercorrelation. A similar version of the nurse-physician collaboration subscale was found in three of the other four scales compared. The positive scheduling climate subscale was a unique finding. Nurses employed at magnet hospitals had more positive perceived work environments than those employed at nonmagnet hospitals, and showed higher mean scores in four of the seven subscales (p < .05).

CONCLUSIONS

The PNWE, a measure of the work environment as perceived by nurses, represents the latest version of the Nursing Work Index-Revised based on current practice. In this study, it exhibited sound psychometric properties. Further application and testing of the PNWE in various patient care settings is recommended.

Cross-cultural comparison of workplace stressors, ways of coping and demographic characteristics as predictors of physical and mental health among hospital nurses in Japan, Thailand, South Korea and the USA (Hawaii)

In an attempt to cross-culturally compare factors that may contribute to the nursing shortage within countries that have produced a limited number of research findings on role stress in nurses, this research examined work stressors, ways of coping and demographic characteristics as predictors of physical and mental health among hospital nurses from Japan, South Korea, Thailand and the USA (Hawaii). Subjects (n = 1554 hospital-based nurses) were administered four self-report questionnaires: Demographic Questionnaire, "Nursing Stress Scale", "Ways of Coping Questionnaire" and "SF-36 Health Survey". Findings suggested that nurses indicated similar workplace stressors, ways of coping, and levels of physical and mental health. While subjects, across countries, demonstrated a variety of predictors of physical and mental health, several predictors were found to be the same. Cross-culturally the role of nurses may vary; however, certain factors are predictive of the status of hospital nurses' physical health and mental health.

An invitation to Magnet accreditation

Review Magnet program basics and eligibility requirements to determine your organization's readiness for undergoing certification.

Healing Ourselves, Healing Others

A review of the literature (Part 1 in this series) revealed the power and pitfalls of being female and being a healer. A qualitative study of medical-surgical nurses (Part 2) gave a glimpse of the satisfaction, frustration, and confusion nurses experience as healers. In particular, participants did not engage in regular self-care behaviors and did not articulate ways to create healing environments that would support nurses as well as patients. In this third and final article, implications and recommendations beyond the study will be shared. Education, clinical practice, leadership, and research are aspects of professional nursing that may benefit from these interpretations.

The future of the nurse shortage: will wage increases close the gap?

In recent years the U.S. media have been reporting a shortage of registered nurses (RNs). In theory, labor-market shortages are self-correcting; wage increases will bring labor markets into equilibrium, and policy intervention is not necessary. In this paper we develop a simple forecasting model and ask the question: How high must RN wages rise in the future to end the RN shortage? We find that inflation-adjusted wages must increase 3.2-3.8 percent per year between 2002 and 2016, with wages cumulatively rising up to 69 percent, to end the shortage. Total RN expenditures would more than double by 2016.

Use of physician extenders in surgical pathology practice

CONTEXT

Use of a variety of nonphysician personnel for surgical pathology gross examination is generally known to be increasing, although detailed information regarding nonphysician use is currently unavailable.

OBJECTIVE

To measure and describe the use of nonphysician personnel for surgical pathology gross examination in order to gain a better understanding of the current surgical pathology workforce.

DESIGN

A voluntary, mailed questionnaire containing items related to the use of multiple nonphysician personnel types in surgical pathology was distributed to (1) a cross-sectional sample (n = 968) of US pathologists and (2) a purposive sample of pathologist directors of surgical and/or anatomic pathology (n = 77) located at teaching institutions. Responses were analyzed using descriptive statistics, correlation analyses, the chi2 test, and 1-way analysis of variance. Staffing ratios were calculated for multiple nonphysician personnel types.

RESULTS

The overall response rate was 22% (n = 225). Of the US sample, 56% of respondents reported using nonphysician laboratory personnel to perform gross examinations, compared with 91% of the directors' sample. The most frequently reported personnel type for both samples was pathologists' assistants, but multiple other personnel types were used as well. Significant associations existed between certain practice types and personnel types used, as well as differences in the scope of responsibilities between personnel types. Calculated staffing ratios were variable across personnel types and were highest for pathologists' assistants.

CONCLUSIONS

The use of a variety of nonphysician laboratory personnel for surgical pathology gross examination is common, particularly in academic pathology practice. Further studies are needed to examine the impact of physician extenders on laboratory efficiency and quality of care.

Predictors of patient satisfaction with inpatient hospital nursing care

The purpose of this predictive nonexperimental study was to investigate the influence of registered nurse (RN) job satisfaction, context of care, structure of care, patient-perceived nurse caring, and patient characteristics on patient satisfaction with inpatient hospital nursing care in an academic medical center in north-central West Virginia. Convenience samples of patients (N = 362) and RNs (N = 90) were recruited from two medical units, two surgical units, and three intensive care step-down units. Causal modeling identified patient-perceived nurse caring as the major predictor of patient satisfaction, with nurse/physician (RN/MD) collaboration as the only other direct predictor. Age had an indirect influence on patient satisfaction. Strategies to achieve and maintain patient satisfaction should address the enhancement of patient-perceived nurse caring and RN/MD collaboration.

Reflections on quality health care

The author, a JCAHO Codman Award recipient, reflects on her professional career in the area of health care quality and describes how nurses have been leaders in the study and improvement of health care quality. Nursing's contributions to the development of quality of care measures, guidelines, and standardized languages are described and current and future opportunities for nursing are discussed.

Magnet Home Care Agencies: A Professional Way to Impact Quality and Retention

By 2009 the nursing shortage will reach a critical level with home care agencies seriously affected. Hospitals have begun to embrace one proven method for recruiting and retaining nurses: achieving magnet recognition from the American Nurses Credentialing Center. Although magnet recognition has been available to home health agencies since 2000, no agency has applied. This article outlines how agencies can take advantage of the program.