The effects of nurse staffing on hospital financial performance: competitive versus less competitive markets

Hospital-based skilled nursing facility survival: Organizational and market-level predictors

BACKGROUND

Rising health care costs and consequent increases in Medicare reimbursements have led to many payment reforms over the years. Implementation of the prospective payment system (PPS) for hospitals in 1983 incentivized hospitals to either purchase skilled nursing facilities (SNFs) or utilize their excess capacity to establish one within the hospital. With PPS reimbursement being applied to SNFs in 1998, prior monetary incentives for hospitals to own an SNF disappeared. However, despite the reduction in numbers, many hospitals continued to operate their hospital-based skilled nursing facilities (HBSNFs).

PURPOSE

This study examines the organizational and market-level factors associated with the survival of HBSNFs using the population ecology of organizations framework.

METHODOLOGY

Using American Hospital Association survey data, event histories of all U.S. acute care hospitals with an open HBSNF in 1998 were plotted to examine if a hospital closed its HBSNF during a 22-year period (1998-2020). The primary independent variables included hospital size, ownership, total margin, market competition, and Medicare Advantage penetration. The independent and control variables were lagged by 1 year. Cox regressions were conducted to estimate the hazard ratios capturing the risk of HBSNF closure.

RESULTS

The results showed that HBSNFs located in large, not-for-profit hospitals and those operating in less competitive markets had greater odds of surviving.

PRACTICE IMPLICATIONS

The HBSNF administrators of small, for-profit hospitals and those operating in highly competitive markets could utilize the findings of this study to judiciously allocate slack resources to their HBSNFs to keep those open given the current emphasis on continuity of care by regulatory bodies.

Effects of rural hospital closures on nurse staffing levels and health care utilization at nearby hospitals

Our study examines the causal effect of rural hospital closures on nearby hospitals' nurse staffing levels and health care utilization. We use data from the 2014-2019 American Hospital Association Survey on nurse staffing level outcomes including licensed practical or vocational nurses (LPNs), registered nurses (RNs), and advanced practice nurses (APNs); and health care utilization outcomes, including inpatient and outpatient surgical operations and emergency department (ED) visits. Using propensity score matching and difference-in-differences (DID) methods, we find that rural hospital closures lead to an average increase of 37.3% in the number of nurses in nearby rural hospitals during the 4 years following the closure. This increase is found across all categories of nurses, including LPNs, RNs, and APNs. We also find a substantial increase in the provision of inpatient and outpatient surgical operations but there is no change in ED visits. We do not find any effects for nearby urban hospitals. Our study suggests that a large proportion of the nursing workforce relocates to nearby hospitals after a rural hospital closure, which mitigates the negative consequences of such closures and allows these nearby hospitals to provide a larger volume of highly profitable services.

Patient-reported experience is associated with higher future revenue and lower costs of hospitals

BACKGROUND

Despite the established positive association between patient experience and patient volume, the relationship between patient experience and the financial performance of hospitals has not been studied thoroughly.

METHODS

To investigate this relationship, we used longitudinal data from 132 Swiss acute-care hospitals from 2016 to 2019 to examine the associations between patient experience and the proportion of elective patients, revenue, costs, and profits of hospitals. To account for a potential time lag effect, we utilized annual patient experience data and employed multilevel mixed-effects regression modeling to investigate its association with the aforementioned financial performance indicators for the following year.

RESULTS

Data for private and public hospitals were analyzed both separately and in combination, to account for the different proportions of elective patients in these types of hospitals. The resulting mixed models, revealed that for each year studied, the previous year's patient experience was positively associated with the current year's proportion of elective patients (β = 0.09, p = 0.004, all hospitals) and revenue (β = 1789.83, p = 0.037, private hospitals only), and negatively associated with costs (β =  - 1191.13, p = 0.017, all hospitals); but not significantly associated with future profits (β = 629.12, p = 0.240, all hospitals).

CONCLUSIONS

This analysis showed that better patient experience is associated with a higher proportion of elective patients, greater revenue, and lower costs. Our findings may assist hospital managers and regulators in identifying strategies to increase revenue and reduce costs.

On the Association Between Demographic Structural Change and the Effectiveness of Nurse Staffing Policy for Inpatient Care: Evidence from Taiwan

Purpose

This study investigates the influence of demographic changes on the effectiveness of hospital nurse staffing policy, measured by the cumulative response of inpatient care quality to adjustments in hospital nurse staffing levels in Taiwan.

Methods

The research design utilized in this study aligns with the observational time-series methodology, and a total of 99 monthly time-series observations were collected from multiple databases administered by the Taiwan government over the period from January 2015 to March 2023. Specifically, the time-varying parameter vector autoregressive and autoregressive distributed lag models were employed to investigate the association between age distribution and nurse staffing policy effectiveness.

Results

The time-varying impulse responses of the unplanned 14-day readmission rate after discharge to changes in nurse staffing levels indicate a positive association between patient-to-nurse ratios and unplanned 14-day readmission rates across various types of hospitals. Nevertheless, the effectiveness of hospitals' nurse staffing policy is observed to diminish with population aging, particularly evident in medical centers and regional hospitals.

Conclusion

Policymakers should establish lower mandated patient-to-nurse ratios, grounded in practical nurse workforce planning, to address the needs of an aging society and enhance inpatient care quality through improved nurse staffing in hospitals.

Improvement in nurse staffing ratios according to policy changes: a prospective cohort study

BACKGROUND

Since 1999, reimbursements for nursing services for inpatients have been paid differentially according to the nurse staffing ratios in Korea. However, differentiated nursing fees are insufficient for nurse staffing; thus, steps have been taken to improve the policy. This study aimed to identify the impact of a policy that changed the method of calculating nurse staffing ratios from the nurse-to-bed ratio to the nurse-to-patient ratio on improving the nurse staffing ratio in medical institutions.

METHODS

Data were collected from 1,339 medical institutions that continuously provided medical services from 2017 to of 2021, and a prospective cohort was used for analysis. A generalized estimating equation for longitudinal ordered logistic regression was used to identify the impact of this policy change on the nurse staffing ratios in medical institutions.

RESULTS

During the cohort study, 59.8% of the first-applied group of medical institutions and 65.6% of the second-applied group of medical institutions improved their nurse staffing ratios. However, only 22.6% of the medical institutions to which the revised calculation method was not applied improved their nurse staffing ratios. A statistically significant difference was found in the improved nurse staffing ratio depending on whether and when the revised calculation method was applied (χ2 = 89.830, p < .001). The analysis of nurse staffing ratios of medical institutions from 2017 to 2021 showed that the likelihood of improving the nurse staffing ratio increased gradually after the revised calculation method was adopted. Also,the likelihood of the nurse staffing ratio improving in the first-applied group was 1.41 times higher (odds ratio = 1.41, 95% confidence interval = 1.04-1.92) than in the non-applied group. The odds ratio for the improvement of nurse staffing ratio in the second-applied group was 2.35 (95% confidence interval = 1.76-3.14).

CONCLUSIONS

Financial incentives inherent in the new policy can be regarded as the driving force behind improvements in nurse staffing ratios. The revised calculation method should be extended to all medical institutions nationwide, and the law should be revised to secure the minimum number of nurses.

Effects of a disincentive policy on behavioral changes by South Korean medical institutions that do not submit official nursing grade data

AIM

This study aimed to determine whether the policy of imposing deductions on medical institutions in South Korea led to increased submission of nursing grade data.

BACKGROUND

In Korea, medical institutions are required to report data on their nursing workforce; however, many institutions did not comply with this regulation, making it difficult to gauge their level of nurse staffing. Therefore, in 2020, a nursing fee deduction policy was introduced that penalizes medical institutions financially for failing to submit nursing workforce data.

METHODS

We prospectively collected data on the characteristics, nursing grade, and data submission status of 1,200 hospitals in South Korea from 2015 to 2021. We analyzed the submission rate of data related to nursing grades according to the characteristics of the medical institutions and evaluated the effect of policy change on data submission status using multiple logistic regression.

FINDINGS

The submission rate of data increased from 50.2% in 2015 to 93.3% in 2021, and 39.3% of medical institutions that had not previously submitted data did so after the policy was introduced. The submission rate of medical institutions unaffected by the policy also increased after its introduction. Compared with 2015, the likelihood of medical institutions submitting data increased by 23.69 times in 2020 and 20.47 times in 2021.

CONCLUSION

The appropriate use of disincentive policies, such as financial deductions for medical institutions showing inappropriate behavior, was found to be effective in inducing desirable changes in the behavior of medical institutions.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Properly planned and implemented policies can contribute to improved quality of medical services and patient safety through effective administrative control.

An Exploratory Analysis of the Association between Hospital Quality Measures and Financial Performance

Hospitals are perpetually challenged by concurrently improving the quality of healthcare and maintaining financial solvency. Both issues are among the top concerns for hospital executives across the United States, yet some have questioned if the efforts to enhance quality are financially sustainable. Thus, the aim of this study is to examine if efforts to improve quality in the hospital setting have a corresponding association with hospital profitability. Recent and directly relevant research on this topic is very limited, leaving practitioners uncertain about the wisdom of their investments in interventions which enhance quality and patient safety. We assessed if eight different quality measures were associated with our targeted measure of hospital profitability: the net patient revenue per adjusted discharge. Using multivariate regression, we found that improving quality was significantly associated with our targeted measure of hospital profitability: the net patient revenue per adjusted discharge. Significant findings were reported for seven of eight quality measures tested, including the HCAHPS Summary Star Rating (p < 0.001), Hospital Compare Overall Rating (p < 0.001), All-Cause Hospital-Wide Readmission Rate (p < 0.01), Total Performance Score (p < 0.001), Safety Domain Score (p < 0.01), Person and Community Engagement Domain Score (p < 0.001), and the Efficiency and Cost Reduction Score (p < 0.001). Failing to address quality and patient safety issues is costly for US hospitals. We believe our findings support the premise that increased attention to the quality of care delivered as well as patients' perceptions of care may allow hospitals to accentuate profitability and advance a hospital's financial position.

A comparison of critical access hospitals and other rural acute care hospitals in Pennsylvania

PURPOSE

As the Flex Program celebrates its 25th anniversary, we examined changes in critical access hospital (CAH) financial performance, investigated whether CAH status has reduced hospitals' financial vulnerability, and identified factors influencing financial performance.

METHODS

We collected data on acute care hospitals in Pennsylvania's rural counties for 2000-20. Our sample contained 1,444 hospital-year observations. We used trend analysis to compare the financial performance of CAHs and rural prospective payment system (PPS) hospitals (non-CAHs). We investigated the effect of CAH status on financial performance and identified the time-variant factors impacting financial performance using fixed-effects regression analysis.

RESULTS

The median total margin of CAHs lagged behind that of non-CAHs. When compared to non-CAH costs over the same period, the median cost per patient day incurred by CAHs has increased, with the rate of increase being significantly higher in the most recent decade. Our findings show that while CAH status does not appear to have a direct impact on the total margin, it is significantly associated with a higher cost per patient day.

CONCLUSIONS

CAHs in Pennsylvania appear to be facing a double whammy of declining margins and rising costs compared to non-CAHs. Our findings demonstrate how crucial the Flex program has been in sustaining CAHs in Pennsylvania ever since its inception. Our findings have implications for rural health care delivery as well. While providing financial support and operational flexibility to CAHs should be a continuing policy priority, a long-term policy goal should be to envision an economic development strategy that capitalizes on the unique strengths of each of the rural archetypes.

The impact of Medicare shared savings program participation on hospital financial performance: An event-study analysis

OBJECTIVE

To evaluate the impact of hospitals' participation in the Medicare Shared Savings Program (MSSP) on their financial performance.

DATA SOURCES

Centers for Medicare & Medicaid Services Hospital Cost Reports and MSSP Accountable Care Organizations (ACO) Provider-Level Research Identifiable File from 2011 to 2018.

STUDY DESIGN

We used an event-study design to estimate the temporal effects of MSSP participation on hospital financial outcomes and compared within-hospital changes over time between MSSP and non-MSSP hospitals while controlling for hospital and year fixed effects and organizational and service-area characteristics. The following financial outcomes were evaluated: outpatient revenue, inpatient revenue, net patient revenue, Medicare revenue, operating margin, inpatient revenue share, Medicare revenue share, and allowance and discount rate.

DATA COLLECTION/EXTRACTION METHODS

Secondary data linked at the hospital level.

PRINCIPAL FINDINGS

Controlling for trends in non-MSSP hospitals, MSSP participation was associated with differential increases in net patient revenue by $3.28 million (p < 0.001), $3.20 million (p < 0.01), and $4.20 million (p < 0.01) in the second, third, and fourth year and beyond after joining MSSP, respectively. Medicare revenue differentially increased by $1.50 million (p < 0.05), $2.24 million (p < 0.05), and $4.47 million (p < 0.05) in the first, second, and fourth year and beyond. Inpatient revenue share differentially increased by 0.29% (p < 0.05) in the second year and 0.44% (p < 0.05) in the fourth year and beyond. Medicare revenue share differentially increased by 0.17% (p < 0.01), 0.25% (p < 0.01), 0.32% (p < 0.01), and 0.41% (p < 0.01) in consecutive years following MSSP participation. MSSP participation was associated with 0.33% (p < 0.05) and 0.39% (p < 0.05) differential reduction in allowance and discount rate in the second and third years.

CONCLUSIONS

MSSP participation was associated with differential increases in net patient revenue, Medicare revenue, inpatient revenue share, and Medicare revenue share, and a differential reduction in allowance and discount rate.

The Association Between Hospital Financial Performance and the Quality of Care - A Scoping Literature Review

BACKGROUND

Improving the quality of hospital care is an important policy objective. Hospitals operate under pressure to contain costs and might face challenges related to financial deficits. The objective of this paper was to identify and map the available evidence on the association between hospital financial performance (FP) and quality of care (Q).

METHODS

A scoping review was performed. Searches were conducted in 7 databases: Medline via PubMed, EMBASE, Web of Science, Scopus, EconLit, ABI/INFORM, and Business Source Complete. The search strategy combined multiple terms from 3 topics: hospital AND FP AND Q. The collected data were analysed using both quantitative and qualitative methods.

RESULTS

10 503 records were screened and 151 full text papers analysed. A total of 69 papers were included (60 empirical, 2 theoretical, 5 literature reviews, and 2 dissertations). The majority of identified studies were published within the last decade (2010-2021). Most empirical studies had been conducted in the United States (55/60), used cross-sectional approaches (32/60) and applied diverse regression models with FP measures as dependent variables, thus measuring the impact of Q on hospitals FP (34/60). The comparability of the studies' results is limited due to differences in applied methods and settings. Yet, the general overview shows that in almost half of the cases the association between hospital FP and Q was positive, while no study showed a clear negative association.

CONCLUSION

This scoping review provides an overview of the available literature on the association between hospital FP and Q. The results highlight numerous research gaps: (1) systematic reviews and meta-analyses of existing studies with similar measures of FP and Q are unavailable, (2) further methodological/conceptual work is needed on the metrics measuring hospital FP and Q, and (3) more empirical studies should analyse the association between FP and Q in non-US healthcare settings.

Cost-quality tradeoff in nurse staffing: an exploration of USA hospitals facing market competition

Purpose

This research aims to explore the fine-grained relationships between nurse staffing and hospital operational performance with respect to care quality and operating costs. The authors also investigate the moderation effect of competition in local hospital markets on these relationships.

Design/methodology/approach

A six-year panel data is assembled from five separate sources to obtain information of 2,524 USA hospitals. Fixed-effect (FE) models are used to test the proposed hypotheses.

Findings

First, nurse staffing is initially associated with improved care quality until nurse staffing reaches a turning point, beyond which nurse staffing is associated with worse care quality. Second, a similar pattern applies to the relationship between nurse staffing and operating costs, although the turning point is at a much lower nurse staffing level. Third, market competition moderates the relationship between nurse staffing and care quality so that the turning point of nurse staffing will be higher when the degree of competition is higher. This shift of turning point is also observed in the relationship between nurse staffing and operating costs.

Practical implications

The study identifies three ranges of nurse staffing in which hospitals will likely experience simultaneous improvements, a tradeoff or simultaneous decline of care quality and operating costs when investing in more nursing capacity. Hospitals should adjust nurse staffing levels to the right directions to achieve better care or reduce operating costs.

Originality/value

Nurses constitute the largest provider group in hospitals and profoundly impact care quality and operating costs among all health care professionals. Optimizing the level of nurse staffing, therefore, can significantly impact the care quality and operating costs of hospitals.

Qualifications of Executive Nurses for Service on Hospital Boards

OBJECTIVE

The purpose of this qualitative survey was to document executive nurse leaders' perception of their own leadership qualities in the context of the American Hospital Association (AHA) recommended membership requirements for executive hospital board appointment.

BACKGROUND

Hospital boards of trustees are increasingly responsible for the quality of care and its impact on financial performance. High-performing boards are focused on the accountability of chief executive officer for quality metrics. Nurse leaders have valuable insight into key shared governance issues such as quality of care, financial performance, legal requirements, and regulatory oversight.

METHODS

Fifty senior-level nurse executive members polled from the American Organization of Nurse Leaders, the Texas Organization of Nurse Leaders, and the Texas Nurse Practitioners Association completed an online quantitative survey using The Center for Healthcare Governance (CHG) Assessment Tool© of the AHA, which details a list of skills, experience, and personal qualities for executive hospital board placement. Respondents ranked their individual knowledge and skills on a 4-point Likert scale.

RESULTS

Participant responses indicated that senior-level nurse executives have significant expertise in the key areas of quality, patient safety and performance, healthcare administration and policy, and business management. Areas ranking lower are those associated with organizational specialties: legal, construction project management, and finance.

CONCLUSION

This information can be used to educate executive hospital boards regarding the qualifications of nurse leaders members. Nursing leaders, professional organizations, and academia can use this information to assess the skills of senior nursing leaders as it relates to potential board appointments.

(Re)defining nursing leadership: On the importance of parrhèsia and subversion

AIM

Through a review of philosophical and theoretical constructs, this paper offers insight and guidance as to ways in which nurse leaders may operationalize advocacy and an adherence to nursing's core ethical values.

BACKGROUND

The US health care system works in opposition to core nursing values. Nurse leaders are obliged to advocate for the preservation of ethical care delivery.

EVALUATION

This paper draws upon the philosophies of Fromm, Foucault, and Deleuze and Guattari to critically review the functions of nurse leaders within a capitalist paradigm.

KEY ISSUE

Key emergent issues in the paper include health care and capitalism and the nurse leader's obligations towards advocacy.

CONCLUSION

The nurse leader acts as parrhèsia in viewing truth telling as a duty critical to improving the lives of patients. Ramifications of the decisions by those in power have even greater impact in institutions that serve those with little to no political agency.

IMPLICATIONS FOR NURSING MANAGEMENT

The nurse leader has a freedom and platform that their patients do not and must take the courageous risk of choosing to speak. This paper serves as a call to action for nurse leaders to urgently address the current state of US health outcomes.

To whom health care aides report: Effect on nursing home resident outcomes

INTRODUCTION

Health care aides (personal support workers and nursing assistants) provide ~80%-90% of direct care to residents in nursing homes; it is therefore important to understand whether supervision of health care aides affects quality of care. We sought to determine whether health care aide reporting practices are associated with resident outcomes in nursing homes.

DESIGN AND METHODS

We conducted a cross-sectional secondary analysis of survey data of 3991 health care aides from 322 units in 89 nursing homes in Western Canada. We then linked resident data from the Resident Assessment Instrument-Minimum Data Set (RAI-MDS) 2.0 database to care aide surveys at the unit level. We used hierarchical mixed models to determine if the proportion of health care aides reporting to a respective nursing leader role was associated with 13 practice sensitive quality indicators of resident care.

RESULTS

Most health care aides reported to a registered nurse (RN, 44.5%) or licenced practical nurse (LPN, 53.3%). Only 2.2% of health care aides reported to a care manager and were excluded from the analysis. Resident outcomes for only declining behavioural symptoms were more favourable when a higher proportion of health care aides (on a unit) reported to RNs, β = -0.004 (95% CI -0.006, -0.001, p = .004). The remaining indicators were not affected by care aide reporting practices.

DISCUSSION AND IMPLICATIONS

Resident outcomes as evaluated by the indicators appear largely unaffected by care aide reporting practices. LPNs' increasing scope of practice and changing work roles and responsibilities in nursing homes across Western Canada may explain the findings.

Facilitators and barriers to the provision of type 1 diabetes inpatient care: An interpretive phenomenological analysis

AIM

The aim and objective of this study was to understand how non-specialized nurses understand the possible barriers and facilitators of inpatient care for type 1 diabetes.

DESIGN

An interpretative phenomenology approach was conducted.

METHODS

The sample consisted of non-specialized nurses (N = 24) working in medical, surgical and nephrology wards in the state hospitals in Cyprus. The data were collected during 2016-2018 from one focus group with nurses (N = 6) and individual semi-structured interviews with nurses (N = 18) conducted. The Standards for Reporting Qualitative Research checklist used to ensure the quality of the study.

RESULTS

It is evident from the study findings that nurses experience several barriers in diabetes inpatient care reported which are of great concern since this could have adverse effects on patients' outcomes. Only one facilitator has been reported by few nurses.

Nurse staffing practices and adverse events in acute care hospitals: The research protocol of a multisite patient-level longitudinal study

Aims

We describe an innovative research protocol to: (a) examine patient‐level longitudinal associations between nurse staffing practices and the risk of adverse events in acute care hospitals and; (b) determine possible thresholds for safe nurse staffing.

Design

A dynamic cohort of adult medical, surgical and intensive care unit patients admitted to 16 hospitals in Quebec (Canada) between January 2015–December 2019.

Methods

Patients in the cohort will be followed from admission until 30‐day postdischarge to assess exposure to selected nurse staffing practices in relation to the subsequent occurrence of adverse events. Five staffing practices will be measured for each shift of an hospitalization episode, using electronic payroll data, with the following time‐varying indicators: (a) nursing worked hours per patient; (b) skill mix; (c) overtime use; (d) education mix and; and (e) experience. Four high‐impact adverse events, presumably associated with nurse staffing practices, will be measured from electronic health record data retrieved at the participating sites: (a) failure‐to‐rescue; (b) in‐hospital falls; (c) hospital‐acquired pneumonia and; and (d) venous thromboembolism. To examine the associations between the selected nurse staffing exposures and the risk of each adverse event, separate multivariable Cox proportional hazards frailty regression models will be fitted, while adjusting for patient, nursing unit and hospital characteristics, and for clustering. To assess for possible staffing thresholds, flexible non‐linear spline functions will be fitted. Funding for the study began in October 2019 and research ethics/institutional approval was granted in February 2020.

Discussion

To our knowledge, this study is the first multisite patient‐level longitudinal investigation of the associations between common nurse staffing practices and the risk of adverse events. It is hoped that our results will assist hospital managers in making the most effective use of the scarce nursing resources and in identifying staffing practices that minimize the occurrence of adverse events.

Psychosocial Risks, Work Engagement, and Job Satisfaction of Nurses During COVID-19 Pandemic

Context: COVID-19 pandemic is a serious health emergency that has affected countries all over the world. Health emergencies are a critical psychosocial risk factor for nurses. In general, psychosocial risks constitute serious problems as they impact workers' health, productivity, and efficiency. Despite their importance, few studies analyze nurses' psychosocial risks during a health emergency caused by a pandemic or analyze their perception of the emergency and its relation to such risks. Objectives: To analyze the perception of COVID-19 by nurses, especially about measures, resources, and impact on their daily work. Also, to analyze these professionals' psychosocial risks and the relationship between perception of COVID-19 and these risks. Methods: A descriptive correlational study was performed in a convenience sample of 92 nurses from two public hospitals in the Valencian Community (Spain), (74 women, 79.1%), aged 24-63 (M = 43.37, SD = 11.58). Data were collected via an online self-completed questionnaire during the rise of the pandemic from March 29 to April 8, when the number of infections went from 78,797 to 146,690. Results: The measures and resources available about COVID-19 are relatively low, and the impact on their work is high. Similarly, the most prominent psychosocial risks appear to be emotional work and workload. In contrast, nurses' work engagement is medium, and their satisfaction is high. Finally, there seems to be a negative and significant relationship between the information available to nurses, the measures implemented, and resources with some of their psychosocial risks, and a positive one with job satisfaction and work engagement. There is also a positive and significant relationship only between the impact of COVID-19 and their work inequality, but not for other risks. Conclusions: The resources, measures, and information can be a protective factor facing nurses' psychosocial risks, especially during a pandemic. Studying the relationships between psychosocial risk and perception of a health emergency would be relevant and fundamental to protecting and caring for nurses, health professionals, and society.

Effect of Emotional Intelligence and Psychosocial Risks on Burnout, Job Satisfaction, and Nurses' Health during the COVID-19 Pandemic

Nurses are exposed to psychosocial risks that can affect both psychological and physical health through stress. Prolonged stress at work can lead to burnout syndrome. An essential protective factor against psychosocial risks is emotional intelligence, which has been related to physical and psychological health, job satisfaction, increased job commitment, and burnout reduction. The present study aimed to analyze the effect of psychosocial risks and emotional intelligence on nurses' health, well-being, burnout level, and job satisfaction during the rise and main peak of the COVID-19 pandemic in Spain. It is a cross-sectional study conducted on a convenience sample of 125 Spanish nurses. Multiple hierarchical linear regression models were calculated considering emotional intelligence levels, psychosocial demand factors (interpersonal conflict, lack of organizational justice, role conflict, and workload), social support and emotional work on burnout, job satisfaction, and nurses' health. Finally, the moderating effect of emotional intelligence levels, psychosocial factors, social support, and emotional work on burnout, job satisfaction, and nurses' health was calculated. Overall, this research data points to a protective effect of emotional intelligence against the adverse effects of psychosocial risks such as burnout, psychosomatic complaints, and a favorable effect on job satisfaction.

The Impact of Market Conditions on RN Staffing in Hospitals: Using Resource Dependence Theory and Information Uncertainty Perspective

Purpose

Due to a limited number of studies with generalizable findings on the relationships between market conditions and RN staffing levels in hospitals, this study examined such relationships employing a longitudinal design with a representative national sample.

Materials and Methods

We used longitudinal panel datasets from 2006 to 2010, drawn from various datasets including the American Hospital Association Annual Survey Database and the Area Health Resource File. A random-effects linear regression model was used to measure the influence of market conditions on RN staffing levels.

Results

The results of this study showed that market conditions were significantly associated with RN staffing levels in hospitals. First, an increase in per capita income and being located in urban rather than rural areas were associated with a greater number of RNs per 1,000 inpatient days and a higher ratio of RNs to LPNs and nursing aides. In addition, an increase in the number of physician specialists was associated with an increase in the number of RNs per 1,000 inpatient days. Second, an increase in Medicare HMO penetration in the environment was related to an increase in the RNs to LPNs and nursing aides ratio. Lastly, an increase in market competition was associated with an increase in the number RNs per 1,000 inpatient days and the ratio of RNs to LPNs and nursing aides.

Conclusion

The findings of this study suggest that staffing decision makers in hospitals should consider how to best align their RN staffing levels with their operating environment. In addition, health policy makers may improve the levels the RN supply in communities that needs more RNs by modulating external environmental forces (eg, specialist resources) that influence RN staffing levels in hospitals.

Factors influencing the recruitment and retention of registered nurses in adult community nursing services: an integrative literature review

BACKGROUND

Adult community nursing services are evolving around the world in response to government policies and changing patient demographics. Amidst these changes, recruitment and retention of community nursing staff are proving a challenge. An integrative literature review has identified multiple factors that influence nurse retention in adult community nursing with sparse information on recruitment factors. Although factors impacting retention of community nurses have been identified, their generalisability around the world is a challenge as they are context and co-dependent. Indicating the need for this area of study to be explored at a local level, as the same factors present with different findings globally.

AIM

To establish factors influencing recruitment and retention of registered nurses in adult community nursing services.

DESIGN

Integrative literature review.

DATA SOURCES

Four electronic databases were searched in August 2019 from January 2008 to December 2018: CINAHL Complete, Web of Science, MEDLINE and PROQUEST. Both qualitative and quantitative studies focusing on factors influencing community nursing recruitment and retention were included.

REVIEW METHODS

An integrative literature review methodology by Whittemore and Knafl (The integrative review: updated methodology. Journal of Advanced Nursing 52, 546-553) was followed, supported by Cochrane guidelines on data synthesis and analysis using a narrative synthesis method. The Center for Evidence-Based Management (CEBMa) critical appraisal tools were used for study quality assessment.

RESULTS

Ten papers met the study inclusion criteria. Data synthesis and analysis revealed individual and organisational factors influencing the retention of community nurses with the following three dominant themes: (1) work pressure, (2) working conditions and (3) lack of appreciation by managers.

CONCLUSION

The review identified context-dependent factors that influence adult community nurses' retention with limited generalisability. There is a lack of data on factors influencing recruitment into adult community nursing; further research is needed to explore factors affiliated to community nursing recruitment.

The Moderating Effect of Organization Culture on Competition Intensity and Hospital Quality

This study empirically tests the relationship between hospital competition intensity and its quality, and the moderating impact of hospital culture on this relationship. An emailed questionnaire collected data from 239 American hospital CEO's to validate the measures and test the hypothesized relationships. The results corroborated the importance of competition intensity as determinant of hospital quality and the positive moderating impact of hospital organization culture as measured here. Future research should expand this model to include other potential determinants of hospital quality such as economic conditions and hospital size. Also, future research should explore other potential moderators and mediators for inclusion in a more elaborate model. While hospitals administrators cannot control the intensity of their competition, and are forced to do everything they can to improve hospital quality (including establishing a helpful organization culture), understanding how to measure these constructs and manage their relationships should be very useful.

Healthcare Research and Analytics Data Infrastructure Solution: A Data Warehouse for Health Services Research

Background

Health services researchers spend a substantial amount of time performing integration, cleansing, interpretation, and aggregation of raw data from multiple public or private data sources. Often, each researcher (or someone in their team) duplicates this effort for their own project, facing the same challenges and experiencing the same pitfalls discovered by those before them.

Objective

This paper described a design process for creating a data warehouse that includes the most frequently used databases in health services research.

Methods

The design is based on a conceptual iterative process model framework that utilizes the sociotechnical systems theory approach and includes the capacity for subsequent updates of the existing data sources and the addition of new ones. We introduce the theory and the framework and then explain how they are used to inform the methodology of this study.

Results

The application of the iterative process model to the design research process of problem identification and solution design for the Healthcare Research and Analytics Data Infrastructure Solution (HRADIS) is described. Each phase of the iterative model produced end products to inform the implementation of HRADIS. The analysis phase produced the problem statement and requirements documents. The projection phase produced a list of tasks and goals for the ideal system. Finally, the synthesis phase provided the process for a plan to implement HRADIS. HRADIS structures and integrates data dictionaries provided by the data sources, allowing the creation of dimensions and measures for a multidimensional business intelligence system. We discuss how HRADIS is complemented with a set of data mining, analytics, and visualization tools to enable researchers to more efficiently apply multiple methods to a given research project. HRADIS also includes a built-in security and account management framework for data governance purposes to ensure customized authorization depending on user roles and parts of the data the roles are authorized to access.

Conclusions

To address existing inefficiencies during the obtaining, extracting, preprocessing, cleansing, and filtering stages of data processing in health services research, we envision HRADIS as a full-service data warehouse integrating frequently used data sources, processes, and methods along with a variety of data analytics and visualization tools. This paper presents the application of the iterative process model to build such a solution. It also includes a discussion on several prominent issues, lessons learned, reflections and recommendations, and future considerations, as this model was applied.

An assessment of the food safety knowledge and attitudes of food handlers in hospitals

BACKGROUND

The possession of inadequate food safety knowledge (FSK) by food handlers poses a serious threat to food safety in service establishments. The aim of this research was to investigate factors that influenced the FSK and food safety attitudes (FSA) of employees involved in the preparation and/or the serving of food from nine hospitals in the Capricorn District Municipality (CDM) in Limpopo Province, South Africa.

METHOD

Up to 210 individuals (18-65 years) who were employed in these hospitals, and who were involved in the preparation and serving of food to patients were purposefully selected. Data collection was by means of an interview using a questionnaire design for this study. The FSK and FSA scores of hospital food handlers were obtained by adding the correct response to FSK or FSA questions.

RESULTS

Only 29% of the hospital food handlers have attended a food safety-training course. Many food handlers were not knowledgeable on the correct temperature for handling foods, and on the correct minimum internal cooking temperature for poultry, seafood and egg. Only the minority of food handlers knew that Salmonella is the main foodborne bacteria pathogen mostly associated with poultry products (47.1%) and that food borne bacteria will grow quickly in food at a temperature of 37 °C (38.1%). Hospital food handlers with higher academic qualifications do not possess more FSK than those with lower academic qualifications. 51% of the hospital food handlers possessed a Satisfactory FSK while 10% possessed a Good FSK and 39% possessed an Inadequate FSK.

CONCLUSION

More than 60% of the hospital food handlers possesses either Good FSK or Satisfactory FSK. Higher levels of education, experience in food handling and job position did not lead to better FSK outcome. All the hospital food handlers possess at least a Satisfactory FSA. There was a weak positive but significant correlation between the FSK and FSA of hospital food handlers. It is recommended all employees involved in food handlers be subjected to food safety training programmes on a regular basis irrespective of their academic, employment and training details.

Physician-leaders and hospital performance revisited

Reflecting the increasing relevance of quality outcomes for hospital payments, some hospital boards have promoted physicians into top-management positions. So far, however, the literature regarding the impact of physician leadership on care quality or cost is limited. The aim of this study is to examine the link between the educational background of a hospital's CEO and its performance in terms of medical quality and financial success. Examining data of 370 German hospitals for the year 2016, this study uses the second largest sample of its kind and the largest for a single country. Multivariate regression analysis with matching is used to model the effect of the CEO's education, controlling for tenure, competition, hospital size and ownership. We find that physician-led hospitals have lower in-hospital mortality rates for pneumonia and higher patient satisfaction (at the 5% and 1% significance level, respectively). In contrast, institutions led by managers with economics or business degrees have better financial performance (at the 10% significance level) and superior outcomes for hip and knee surgeries (at the 1% and 10% significance level). Our findings support prior results regarding financial outcomes and mortality. However, including a broad spectrum of measures for clinical quality, we draw a more nuanced picture that does not point to the straightforward interpretation that physician CEOs lead to superior medical quality.

Patient-Nurse Ratio is Related to Nurses' Intention to Leave Their Job through Mediating Factors of Burnout and Job Dissatisfaction

In healthcare settings, nurses’ workload, burnout, and job satisfaction are associated to the patient–nurse ratio. Whether this ratio also affects their intention to leave the nursing profession, along with the underlying stress pathway, remains unclear. This study aimed to investigate the effects of the patient–nurse ratio on nurses’ intention to leave and considering the mediating roles of burnout and job dissatisfaction. The study analyzed the data of two pooled cross-sectional surveys collected in 2013 and 2014. Measures were obtained by a structure questionnaire, which queried the average daily patient–nurse ratio (ADPNR), nurses’ personal burnout, client-related burnout, job dissatisfaction, intention to leave, and other demographics. ADPNRs were standardized according to hospital levels. Multiple regression models examined mediation hypotheses, and a percentile bootstrap confidence interval was applied to determine the significance of indirect effects. A total of 1409 full-time registered nurses in medical and surgical wards of 24 secondary or tertiary hospitals in Taiwan completed self-administered questionnaires. Most of the participants were female (97.2%), and the mean age was 29.9 years. The association between the standardized ADPNR and intention to leave their job was significantly mediated by personal burnout, client-related burnout, and job dissatisfaction. Higher standardized ADPNRs predicted higher levels of personal burnout, client-related burnout, and job dissatisfaction, each of which resulted in higher levels of intention to leave the current job. The results highlight that appropriate patient–nurse ratio standards may be further discussed by selecting personal burnout, client-related burnout, and job dissatisfaction as indicators.

Occupational stress, quality of working life and turnover intention amongst nurses

BACKGROUND

Turnover intention is a frequent event in almost all institutions and is associated with unfavourable consequences for employees.

AIM

The aim of this study was to examine the relationship between occupational stress, quality of working life and turnover intention amongst nurses working in critical care units in Iran.

DESIGN

A cross-sectional survey design was used.

METHOD

The study was conducted in the critical care units of 10 hospitals in Tabriz, Iran, between July and November 2017 using a sample of 203 nurses. Data were obtained using a self-administered questionnaire, and multiple logistic regression analysis was performed to determine the factors impacting turnover intention.

RESULTS

Overall, 64% of nurses had an intention to leave their job; 82·8% of respondents reported their job to be highly stressful, and 81·2% reported their quality of working life to be low. Binary logistic regression analysis indicated that age (p = 0·006), clinical experience (p = 0·005), duty stressors (p = 0·040), interpersonal relations stressors, (p = 0·029) communication (p = 0·007), motivation (p = 0·006), job security (p = 0·040) and job pride (p = 0·011) were factors affecting turnover intention.

CONCLUSION

Occupational stress and quality of working life are associated with turnover intention amongst nurses working in critical care units. Further research is needed to determine the generalizability of these results to other settings and countries and to identify interventions that could reduce occupational stress and improve the quality of working life so that turnover intention might be reduced.

RELEVANCE TO CLINICAL PRACTICE

The findings of this research suggest that lower perceived occupational stress and higher quality of working life will result in less reported turnover intention in critical care unit nurses.

Capacity building in burns and mental health care

Delivery of safe quality care in health is augmented by better research capacity building. This can include financial investment in research and system development, and, mostly notably, human capacity to undertake research. Establishing capacity to undertake research warrants attention to a range of activities to build and sustain health professions' impact on health outcomes. This editorial reflects on burns and mental health care to identify challenges for capacity building. These challenges range from resource restrictions, organisational culture and identification of enablers to assess broader health impact. Strategies to promote capacity building for practice include harmonisation of international standards, financial resourcing to build research capacity in low and middle-income countries, effectively implemented and monitored training, any involvement of multiple perspectives in design and delivery.

High Medicaid Nursing Homes: Organizational and Market Factors Associated With Financial Performance

High Medicaid nursing homes (85% and higher of Medicaid residents) operate in resource-constrained environments. High Medicaid nursing homes (on average) have lower quality and poorer financial performance. However, there is significant variation in performance among high Medicaid nursing homes. The purpose of this study is to examine the organizational and market factors that may be associated with better financial performance among high Medicaid nursing homes. Data sources included Long-Term Care Focus (LTCFocus), Centers for Medicare and Medicaid Services' (CMS) Medicare Cost Reports, CMS Nursing Home Compare, and the Area Health Resource File (AHRF) for 2009-2015. There were approximately 1108 facilities with high Medicaid per year. The dependent variables are nursing homes operating and total margin. The independent variables included size, chain affiliation, occupancy rate, percent Medicare, market competition, and county socioeconomic status. Control variables included staffing variables, resident quality, for-profit status, acuity index, percent minorities in the facility, percent Medicaid residents, metropolitan area, and Medicare Advantage penetration. Data were analyzed using generalized estimating equations with state and year fixed effects. Results suggest that organizational and market slack resources are associated with performance differentials among high Medicaid nursing homes. Higher financial performing facilities are characterized as having nurse practitioners/physician assistants, more beds, higher occupancy rate, higher Medicare and Medicaid census, and being for-profit and located in less competitive markets. Higher levels of Registered Nurse (RN) skill mix result in lower financial performance in high Medicaid nursing homes. Policy and managerial implications of the study are discussed.

Nursing in Chilean Hospitals: A Research Agenda to Inform Health Policies and Improve Patient Outcomes

Introduction:

The ongoing challenge for Chilean hospitals of meeting population health needs merits attention to the health care workforce. No studies have explored how nursing might contribute to addressing this challenge. International research shows that organizational characteristics of the nursing workforce and practice environment are associated with patient outcomes. Chile lacks actionable evidence that applies to its context of care.

Method:

First, a review of international literature was developed to synthesize evidence on the association between organizational characteristics of the nursing workforce and patient outcomes. Second, a review of literature and other nonacademic sources was performed to describe the context of care and data pertaining to nurses in Chilean hospitals. Third, a research agenda for efficient utilization of the hospital nursing workforce in Chile was proposed.

Results:

International evidence shows that low patient-to-nurse ratios, high skill mix, and good practice environments are associated with better patient outcomes. Chilean hospitals have financial constraints that greatly influence the context of nursing practice and the scarce data about nursing organization call for greater attention.

Conclusion:

The establishment and implementation of a research agenda is needed to build local evidence regarding effective organization of nurses to inform policies and to improve patient outcomes in Chile.

Resource Dependency and Hospital Performance in Hospital Value-Based Purchasing

To help influence the health care environment as well as the flow of resources into and out of hospitals, the Centers for Medicare & Medicaid Services has implemented a performance incentive initiative called the Hospital Value-Based Purchasing (HVBP) program. As such, this study utilizes the lens of Resource Dependency Theory to evaluate the effect of the external environment on hospital performance as measured by the HVBP program. This study utilizes data from the 2014 American Hospital Association (AHA) Annual Survey database, 2014 Area Health Resource File (AHRF), the 2014 Medicare Final Rule Standardizing File, and the 2014 Medicare Hospital Compare database. The associations between external environment and hospital performance are assessed through multiple regression analysis. Hospital performance scores in the HVBP program are sensitive to environmental factors; however, not all domains are influenced to the same degree. It would seem that hospitals do not have either the same ability or motivation to make changes in each of the value-based purchasing domains. Ultimately, the findings from this study indicate that environmental forces do play a role in hospitals' performance in the HVBP program.

Recognition and assessment of resident' deterioration in the nursing home setting: A critical ethnography

AIMS AND OBJECTIVES

To explore the recognition and assessment of resident deterioration in the nursing home setting.

BACKGROUND

There is a dearth of research exploring how nurses and personal-care-assistants manage a deteriorating nursing home resident.

DESIGN

Critical ethnography.

METHODS

Observation and semi-structured interviews with 66 participants (general medical practitioners, nurses, personal-care-assistants, residents and family members) in two Australian nursing homes. The study has been reported in accordance with the Consolidated Criteria for Reporting Qualitative Research guidelines.

RESULTS

The value of nursing assessment is poorly recognised in the nursing home setting. A lack of clarity regarding the importance of nursing assessments associated with resident care has contributed to a decreasing presence of registered nurses and an increasing reliance on personal-care-assistants who had inadequate skills and knowledge to recognise signs of deterioration. Registered nurses experienced limited organisational support for autonomous decision-making and were often expected to undertake protocol-driven decisions that contributed to potentially avoidable hospital transfers.

CONCLUSIONS

Nurses need to demonstrate the importance of assessment, in association with day-to-day resident care and demand standardised, regulated, educational preparation of an appropriate workforce who are competent in undertaking this role. Workforce structures that enhance familiarity between nursing home staff and residents could result in improved resident outcomes. The value of nursing assessment, in guiding decisions at the point of resident deterioration, warrants further consideration.

A computational application for multi-skill nurse staffing in hospital units

Background

Approaches to nurse staffing are commonly concerned with determining the minimum number of care hours according to the illness severity of patients. However, there is a gap in the literature considering multi-skill and multi-shift nurse staffing. This study addresses nurse staffing per skill category, at a strategical decision level, by considering the organization of work in shifts and coping with variability in demand.

Methods

We developed a method to determine the nursing staff levels in a hospital, given the required patient assistance. This method relies on a new mathematical model for complying with the legislation and guidelines while minimizing salary costs. A spreadsheet-based tool was developed to embed the model and to allow simulating different scenarios and evaluating the impact of demand fluctuations, thus supporting decision-making on staff dimensioning.

Results

Experiments were carried out considering real data from a Brazilian hospital unit. The results obtained by the model support the current total staff level in the unit under study. However, the distribution of staff among different skill categories revealed that the current real situation can be improved.

Conclusions

The method allows the determining of staff level per shift and skill depending on the mix of patients’ illness severity. Hospital management is offered the possibility of optimizing the staff level using a spreadsheet, a tool most managers are familiar with. In addition, it is possible to evaluate the implications of decisions on workforce dimensioning by simulating different demand scenarios. This tool can be easily adapted to other hospitals, using local rules and legislation.

Electronic supplementary material

The online version of this article (10.1186/s12911-018-0638-2) contains supplementary material, which is available to authorized users.

Does efficiency and quality of care affect hospital closures?

In recent decades, a large number of hospitals in Pennsylvania and across the United States have been forced to close entirely, or to transform their beds for alternative uses including outpatient care. Hospital closures have severe repercussions for the stakeholders. A better understanding of hospital closures could help take corrective measures to alleviate the adverse impact closures have on communities. Using Pennsylvania Department of Health data compiled from various sources, we address the following questions: Are less efficient hospitals less likely to survive in the long run? What are the effects of quality of care on hospital closures? Does teaching status and location (urban or rural) have any impact on the probability of hospital closure? The result demonstrates several factors of varying significance affect hospital closures/survivals. Hospitals with higher ratio of registered nurses per bed, higher operating margin, lower percentage of revenues from Medicare and Medicaid, and lower competition were less likely to close. Efficiency measures such as DEA efficiency, cost per patient day, and cost per discharge were not found to have a significant impact on hospital closures. The results suggest that hospital administrators may focus more on quality of care and less on cost reduction and efficiency.

When Patients and Their Families Feel Like Hostages to Health Care

Patients are often reluctant to assert their interests in the presence of clinicians, whom they see as experts. The higher the stakes of a health decision, the more entrenched the socially sanctioned roles of patient and clinician can become. As a result, many patients are susceptible to "hostage bargaining syndrome" (HBS), whereby they behave as if negotiating for their health from a position of fear and confusion. It may manifest as understating a concern, asking for less than what is desired or needed, or even remaining silent against one's better judgment. When HBS persists and escalates, a patient may succumb to learned helplessness, making his or her authentic involvement in shared decision making almost impossible. To subvert HBS and prevent learned helplessness, clinicians must aim to be sensitive to the power imbalance inherent in the clinician-patient relationship. They should then actively and mindfully pursue shared decision making by helping patients trust that it is safe to communicate their concerns and priorities, ask questions about the available clinical options, and contribute knowledge of self to clinical decisions about their care. Hostage bargaining syndrome is an insidious psychosocial dynamic that can compromise quality of care, but clinicians often have the power to arrest it and reverse it by appreciating, paradoxically, how patients' perceptions of their power as experts play a central role in the care they provide.

Nurse Staffing Patterns and Patient Experience of Care: An Empirical Analysis of U.S. Hospitals

OBJECTIVE

To examine the relationship between nurse staffing patterns and patients' experience of care in hospitals with a particular focus on staffing flexibility.

DATA SOURCES/STUDY SETTING

The study sample comprised U.S. general hospitals between 2010 and 2012. Nurse staffing data came from the American Hospital Association Annual Survey, and patient experience data came from the Medicare Hospital Consumer Assessment of Healthcare Providers and Systems.

STUDY DESIGN

An observational research design was used entailing a pooled, cross-sectional data set. Regression models were estimated using generalized estimating equation (GEE) and hospital fixed effects. Nurse staffing patterns were assessed based on both levels (i.e., ratio of full-time equivalent nurses per 1,000 patient days) and composition (i.e., skill mix-percentage of registered nurses; staffing flexibility-percentage of part-time nurses).

PRINCIPAL FINDINGS

All three staffing variables were significantly associated with patient experience in the GEE analysis, but only staffing flexibility was significant in the fixed-effects analysis. A higher percentage of part-time nurses was positively associated with patient experience. Multiplicative and nonlinear effects for the staffing variables were also observed.

CONCLUSIONS

Among three staffing variables, flexibility was found to be the most important relative to patient experience. Unobserved hospital characteristics appear to underlie patient experience as well as certain nurse staffing patterns.

Hospital ownership, decisions on supervisory board characteristics, and financial performance

BACKGROUND

Dynamic and complex transformations in the hospital market increase the relevance of good corporate governance. However, hospital performance and the characteristics of supervisory boards differ depending on ownership. The question therefore arises whether hospital owners can influence performance by addressing supervisory board characteristics.

PURPOSE

The objective of this study is to explain differences in the financial performance of hospitals with regard to ownership by studying the size and composition of supervisory boards.

METHODOLOGY

The AMADEUS database was used to collect information on hospital financial performance in 2009 and 2010. Business and quality reports, hospital websites, and data from health insurer were used to obtain information on hospital and board characteristics. The resulting sample consisted of 175 German hospital corporations. We utilized ANOVA and regression analysis to test a mediation hypothesis that investigated whether decisions regarding board size and composition were associated with financial performance and could explain performance differences.

FINDINGS

Financial performance and board size and composition depend on ownership. An increase in board size and greater politician participation were negatively associated with all five tested measures of financial performance. Furthermore, an increase in physician participation was positively associated with one dimension of financial performance, whereas one negative relationship was identified for nurse and economist participation. For clerics, no associations were found.

PRACTICE IMPLICATIONS

Decisions concerning board size and composition are important as they relate to hospital financial performance. We contribute to existing research by showing that, in addition to board size and physician participation, the participation of other professionals can also influence financial performance.

The Relationship Between HR Capabilities and Quality of Patient Care: The Mediating Role of Proactive Work Behaviors

Based on theoretical frameworks of resource-based theory, dynamic capabilities, and behavioral perspective on human resource management, we developed a multidimensional construct of human resource (HR) capabilities and tested its relationship with quality of patient care using a national sample of U.S. hospitals. The data on HR capabilities were collected from senior managers (421 individuals nested in 279 hospitals) representing both the administrative and clinical sides of the hospitals. The data on quality of patient care were gathered from two unique sources - patients of 207 hospitals who reported the data via the Hospital Consumer Assessment of Healthcare Providers and Systems Survey and 421 senior managers of 279 hospitals. Our analyses using structural equation modeling suggests that the positive relationship of HR capabilities with quality of patient care is mediated by proactive behaviors of health care workers. Implications of the study findings for research and practice are discussed.

Texas Nurse Staffing Trends Before and After Mandated Nurse Staffing Committees

This article describes the evolution of mandated nurse staffing committees in Texas from 2002 to 2009 and presents a study that analyzed nurse staffing trends in Texas using a secondary analysis of hospital staffing data (N = 313 hospitals) from 2000 to 2012 obtained from the American Hospital Association Annual Survey. Nurse staffing patterns based on three staffing variables for registered nurses (RNs), licensed vocational nurses (LVNs), and total licensed nurses were identified: full-time equivalents per 1,000 adjusted patient days, productive hours per adjusted patient day, and RN skill mix. Similar to national trends between 2000 and 2012, most Texas hospitals experienced an increase in RN and total nurse staffing, decrease in LVN staffing, and an increase in RN skill mix. The magnitude of total nurse staffing changes in Texas (5% increase) was smaller than national trends (13.6% increase). Texas's small, rural, government hospitals and those with the highest preregulation staffing levels experienced the least change in staffing between 2000 and 2012: median change of 0 to .13 full-time equivalents per 1,000 adjusted patient days and median change in productive hours per patient day of 0 to .23. The varying effects of staffing committees in different organizational contexts should be considered in future staffing legislative proposals and other policy initiatives.

Correlation between adequate nursing staff and the hospital performance: Case Study in Tehran University of Medical Sciences Hospitals

Background: As the biggest collection among various collections of hospital employees, nurses perform a vital role in the progress of the hospital actions and the improvement of community health. Objectives: This research intended to find the relationship between the shortage of nursing workforce and hospitals performance of Tehran's Medical Sciences University. Materials and Methods: The current analysis was a cross-sectional definitive research, which was conducted in selected educational hospices associated to Tehran University of Medical Sciences during the year 2010. While using three researcher-made questionnaires, information was obtained from all clinical, paraclinical, commercial, managerial and support units of hospitals. Information was investigated according to the patterns of Iran's Healthcare Ministry and Medical Education by employing Excel software. Pabon Lasso model was used for performance measurement during the year 2010. The mixture of 3 indicators was applied to determine the period of stay, bed occupancy time and bed turnover. Results: The outcomes revealed that the personnel of nursing, in the 18 hospital wards (66.67%) were at levels below the standards, just one ward (3.7%) reached the standards requirements, and the remainder of the hospital wards (29.62%) were at greater levels than the standard requirements. Both hospitals were near the value 4 in the Pabon Lasso model. The correlation analysis among the nursing shortage and performance showed a meaningful relationship (P<0.05). Conclusion: Frequently, the examined hospices were challenged with a shortage of nursing workforce and the dissemination of workforce was not suitable. A decent supervision of workforce in conformity with the shortage of staff compensated and achieved the rules needed for the hospital's nursing workforce and this would guide to an improvement in the performance of the hospitals' actions and could present gratification for the personnel.

Use of Electronic Health-Related Datasets in Nursing and Health-Related Research

Datasets of gigabyte size are common in medical sciences. There is increasing consensus that significant untapped knowledge lies hidden in these large datasets. This review article aims to discuss Electronic Health-Related Datasets (EHRDs) in terms of types, features, advantages, limitations, and possible use in nursing and health-related research. Major scientific databases, MEDLINE, ScienceDirect, and Scopus, were searched for studies or review articles regarding using EHRDs in research. A total number of 442 articles were located. After application of study inclusion criteria, 113 articles were included in the final review. EHRDs were categorized into Electronic Administrative Health-Related Datasets and Electronic Clinical Health-Related Datasets. Subcategories of each major category were identified. EHRDs are invaluable assets for nursing the health-related research. Advanced research skills such as using analytical softwares, advanced statistical procedures, dealing with missing data and missing variables will maximize the efficient utilization of EHRDs in research.

Patient turnover and nursing employment in Massachusetts hospitals before and after health insurance reform: implications for the Patient Protection and Affordable Care Act

The Affordable Care Act is modeled after Massachusetts insurance reforms enacted in 2006. A linear mixed effect model examined trends in patient turnover and nurse employment in Massachusetts, New York, and California nonfederal hospitals from 2000 to 2011. The linear mixed effect analysis found that the rate of increase in hospital admissions was significantly higher in Massachusetts hospitals (p<.001) than that in California and New York (p=.007). The rate of change in registered nurses full-time equivalent hours per patient day was significantly less (p=.02) in Massachusetts than that in California and was not different from zero. The rate of change in admissions to registered nurses full-time equivalent hours per patient day was significantly greater in Massachusetts than California (p=.001) and New York (p<.01). Nurse staffing remained flat in Massachusetts, despite a significant increase in hospital admissions. The implications of the findings for nurse employment and hospital utilization following the implementation of national health insurance reform are discussed.