Rural hospital nursing: results of a national survey of nurse executives

Hospital-Acquired Conditions Reduction Program, Patient Safety, and Magnet Designation in the United States

OBJECTIVE

The aim of the study was to investigate the association between hospitals' nursing excellence accreditation and patient safety performance-measured by the Hospital-Acquired Conditions Reduction Program (HACRP).

METHODS

We linked data from the American Nursing Credentialing Center Magnet Recognition Program, Centers for Medicare and Medicaid Services HACRP, and the American Hospital Association annual survey from 2014 to 2016. We constrained the analysis to hospitals participating in Centers for Medicare and Medicaid Services' HACRP and deployed propensity score matching models to calculate the coefficients for our HACRP patient safety measures. These measures consisted of (a) patient safety indicator 90, (b) hospital-associated infection measures, and (c) total HAC scores. In addition, we used propensity score matching to assess HACRP scores between hospitals achieving Magnet recognition in the past 2 versus longer and within the past 5 years versus longer.

RESULTS

Our primary findings indicate that Magnet hospitals have an increased likelihood of experiencing lower patient safety indicator 90 scores, higher catheter-associated urinary tract infection and surgical site infection scores, and no different total HAC scores. Finally, when examining the impact of Magnet tenure, our analysis revealed that there were no differences in Magnet tenure.

CONCLUSIONS

Results indicate that the processes, procedures, and educational aspects associated with Magnet recognition seem to provide important improvements associated with care that is controlled by nursing practice. However, because these improvements do not differ when comparing total HAC scores nor Magnet hospitals with different tenure, there are likely opportunities for Magnet hospitals to continue process improvements focused on HACRP scores.

Challenges of implementing the accreditation model in military and university hospitals in Iran: a qualitative study

Background

The aim of this study was to present challenges of implementing the accreditation model in university and military hospitals in Iran.

Methods

In this qualitative study, purposive sampling was used to select hospital managers and implementers of the model working in 3 hospitals affiliated to Kerman University of Medical Sciences and in 3 military hospitals in Kerman, Iran. A total of 39 participants were interviewed, and semi-structured questionnaires and thematic analysis were used for data collection and analysis, respectively.

Results

In this study, 5 major codes and 17 subcodes were identified: (1) perspectives on accreditation model with 5 subcodes: a difficult and time-consuming model, less attention to the patient, accreditation as a way of money acquisition, not being cost-effective, and accreditation means incorrect documentation; (2) absence of appropriate executive policy, with 3 subcodes: lack of financial funds and personnel, disregarding local conditions in implementation and evaluation, and absence of the principle of unity of command; (3) training problems of the accreditation model, with 2 subcodes: absence of proper training and incoordination of training and evaluation; (4) human resources problems, with 3 subcodes: no profit for nonphysician personnel, heavy workload of the personnel, and physicians’ nonparticipation; (5) evaluation problems, with 4 subcodes: no precise and comprehensive evaluation, inconformity of authorities’ perspectives on evaluation, considerable change in evaluation criteria, and excessive reliance on certificates.

Conclusions

This study provided useful data on the challenges of implementing hospitals’ accreditation, which can be used by health policymakers to revise and modify accreditation procedures in Iran and other countries with similar conditions. The accreditation model is comprehensive and has been implemented to improve the quality of services and patients’ safety. The basic philosophy of hospital accreditation did not fully comply with the underlying conditions of the hospitals. The hospital staff considered accreditation as the ultimate goal rather than a means for achieving quality of service. The Ministry of Health and Medical Education performed accreditation hastily for all Iranian hospitals, while the hospitals were not prepared and equipped to implement the accreditation model.

Rural-urban differences in educational attainment among registered nurses: Implications for achieving an 80% BSN workforce

BACKGROUND

Multiple professional organizations and institutes recommend the Bachelor of Science in Nursing (BSN) degree as a minimum standard for registered nurse practice. Achieving this standard may be particularly challenging in rural areas, which tend to be more economically disadvantaged and have fewer opportunities for higher educational attainment compared to urban areas.

PURPOSE

Our primary objective was to provide updated information on rural-urban differences in educational attainment. We also examined rural-urban differences in employment type, salary, and demographics among registered nurses in different practice settings.

METHODS

Data were obtained from the 2011-2015 American Community Survey (ACS) Public Use Microdata Sample (PUMS). The sample included registered nurses (RN) between the ages of 18-64 years (n = 34,104) from all 50 states. Chi-square tests, t-tests, and multivariable logistic regression were used to examine the relationship between rurality and BSN preparedness and salary across practice settings.

RESULTS

Urban nurses were more likely to have a BSN degree than rural nurses (57.9% versus 46.1%, respectively; p < 0.0001), and BSN preparedness varied by state. In adjusted analysis, factors in addition to residence associated with BSN preparation included age, race, and region of the country. Differences in wages were experienced by nurses across practice settings with urban nurses generally earning significantly higher salaries across practice settings (p < 0.0001).

CONCLUSIONS

Strategies to advance nursing workforce education are needed in rural areas and may contribute to improved care quality and health outcomes.

Rural Hospital Nursing Skill Mix and Work Environment Associated With Frequency of Adverse Events

Introduction:

Although rural hospitals serve about one fifth of the United States, few studies have investigated relationships among nursing resources and rural hospital adverse events.

Objectives:

The purpose was to determine relationships among nursing skill mix (proportion of registered nurses [RNs] to all nursing staff), the work environment, and adverse events (medication errors, patient falls with injury, pressure ulcers, and urinary tract infections) in rural hospitals.

Methods:

Using a cross-sectional design, nurse survey data from a large study examining nurse organizational factors, patient safety, and quality from four U.S. states were linked to the 2006 American Hospital Association data. The work environment was measured using the Practice Environment Scale of the Nursing Work Index (PES-NWI). Nurses reported adverse event frequency. Data analyses were descriptive and inferential.

Results:

On average, 72% of nursing staff were RNs (range = 45%–100%). Adverse event frequency ranged from 0% to 67%, across 76 hospitals. In regression models, a 10-point increase in the proportion of RNs among all nursing staff and a one standard deviation increase in the PES-NWI score were significantly associated with decreased odds of frequent adverse events.

Conclusion

Rural hospitals that increase the nursing skill mix and improve the work environment may achieve reduced adverse event frequency.

Isolated, small, and large hospitals have fewer nursing resources than urban hospitals: Implications for rural health policy

OBJECTIVE

The purpose was to compare nurse education, patient-to-nurse staffing, nursing skill mix, and nurse work environments across hospitals depending on extent of rurality.

DESIGN

Cross-sectional, comparative, and descriptive.

SAMPLE

The final sample included 566 urban, 49 large, 18 small, and 9 isolated hospitals from California, Florida, and Pennsylvania.

MEASUREMENT

Data collected from large random samples from the 2005-2008 Multi-State Nursing Care and Patient Safety Study funded by the National Institute of Nursing Research and National Institutes of Health were linked to 2005-2006 American Hospital Association data. Rural-Urban Commuting Area codes developed by the University of Washington and the United States Department of Agriculture Economic Research Service were used to determine the extent of hospital rurality across the sample.

RESULTS

Hospital percentages of baccalaureate prepared nurses differed significantly among urban (38%), large (28%), small (31%), and isolated rural hospitals (21%). Patient-to-registered nurse ratios in urban (4.8), large (5.6), small (5.6), and isolated rural hospitals (7.3) differed. Rural hospital nursing skill mix differed, and was lowest in isolated rural hospitals (65%). Nursing foundations for quality care were poorer in large, small, and isolated rural hospitals.

CONCLUSION

Results support bolstering rural nursing resources in more remote locations, potentially through rural health policies.

Integrating Retired Registered Nurses Into a New Graduate Orientation Program

PURPOSE

The project goal of was to decrease new graduate nurse (NGN) attrition during the first year of employment by improving communication skills and providing additional mentoring for NGNs employed in a community hospital located in a rural area.

DESCRIPTION OF PROJECT

All NGNs participate in the Versant Residency Program. Even with this standardized residency program, exit interviews of NGNs who resigned during their first year of employment revealed 2 major issues: communication problems with patients and staff and perceived lack of support/mentoring from unit staff. A clinical nurse specialist-led nursing team developed an innovative program integrating retired nurses, Volunteer Nurse Ambassadors (VNAs), into the Versant Residency Program to address both of those issues.

OUTCOME

All NGNs mentored by a retired nurse remain employed in the hospital (100% retention). Before the VNA program, the retention rate was 37.5%. Both the NGNs and VNAs saw value in their mentor-mentee relationship. There have been no critical incidences or failure to rescue events involving NGNs mentored by a VNA.

CONCLUSION

Use of VNAs to support NGNs as they adjust to the staff nurse role can prevent attrition during their first year of nursing practice by providing additional support to the NGN.

Psychometric Testing of the Smoking Cessation Counseling Scale Among Magnet® Hospital Nurses

Psychometrics of the Smoking Cessation Counseling Scale, which measures adherence to evidence-based smoking cessation counseling practice, were originally estimated among rural hospital nurses. The purpose of this study was to estimate the scale's reliability, convergent validity, and factor structure among 289 nurses from 27 acute care Magnet® hospitals. The scale demonstrated acceptable estimates for internal consistency (Cronbach's α = .95, 95% CI = [0.94, 0.96]). Convergent validity was supported by the association with comfort in conducting smoking cessation counseling (coefficient = 3.58, 95% CI = [2.80, 4.37]) and shared vision (coefficient = 0.72, 95% CI = [0.02, 1.42]). A four-factor structure (standard care, basic counseling, advanced counseling, and referral to services) was identified. Findings supported the scale's reliability and convergent validity among Magnet® hospital nurses. Further testing is needed to confirm the four-factor structure and accumulate psychometric evidence among different nursing providers and health care settings to expand the use of the instrument.

Critical Care in Critical Access Hospitals

What began as a grant-funded demonstration project, as a means of bridging the gap in rural health care, has developed into a critical access hospital system comprising 1328 facilities across 45 states. A critical access hospital is not just a safety net for health care in a rural community. Such hospitals may also provide specialized services such as same-day surgery, infusion therapy, and intensive care. For hospitals located near the required minimum of 35 miles from a tertiary care center, management of critically ill patients may be a matter of stabilization and transfer. Critical access hospitals in more rural areas are often much farther from tertiary care; some of these hospitals are situated within frontier areas of the United States. This article describes the development of critical access hospitals, provision of care and services, challenges to critical care in critical access hospitals, and suggestions to address gaps in research and collaborative care.

Shared Vision Among Acute Care Magnet® Hospital Nurses

Psychometric testing of the Shared Vision (SV) scale that measures team efforts toward common patient-centered goals was initially estimated among rural hospital nurse executives. The purpose of this study was to estimate the scale’s reliability (internal consistency), convergent validity (Pearson correlation with Practice Environment Scale), and structural validity (ordinal confirmatory factor analysis) among acute care Magnet® hospital nurses. The study sample included 289 nurses from 27 acute care Magnet® hospitals. The scale demonstrated acceptable estimates for internal consistency (Cronbach’s α = .902, 95% confidence interval [CI] = [0.883, 0.919]), convergent validity ( r = .720, p < .001), and structural validity with a one-factor structure. The findings of this study supported the reliability and validity of the SV scale as a unidimensional construct in measuring SV among nurses in acute care Magnet® hospitals. Further testing among different nursing providers and health care settings is needed to accumulate evidence and expand use of the instrument.

A pilot study of staff nurses' perceptions of factors that influence quality of care in critical access hospitals

Knowledge is limited about quality of care (QOC) in rural hospitals, including the smallest hospitals, critical access hospitals. Staff nurses from 7 critical access hospitals identified items important for QOC across 4 levels of care: patients, microsystems, organizations, and environments. Several items were unique to critical access hospitals. Most QOC items were at the microsystem level, yet few of these items are routinely measured. These findings offer beginning evidence about how to advance QOC evaluations in rural hospitals.

Identifying the educational needs of emergency nurses in rural and critical access hospitals

This study was conducted to determine educational needs and identify potentially effective educational modalities for emergency nurses working in rural and critical access hospitals. Although 50% of all emergency department visits to critical access hospitals are low-acuity cases, the 4.0% transfer rate in critical access hospitals is significantly higher than the 1.5% overall transfer rate. Nursing issues include the required breadth and depth of skills needed by emergency nurses in recognizing, stabilizing, and transferring patients who require a higher level of care. Thirty-three emergency nurses practicing in rural or critical access hospitals were recruited for a focus group discussion of educational needs, barriers, and facilitators. The discussion was transcribed, and constant comparison was used to identify themes. Participants identified a need for further education in the care of critically ill patients, those who have undergone bariatric surgery, geriatric patients, those with traumatic injury, and those with mental health issues. Themes included educational isolation and limited availability of resources. Developing and delivering continuing education to this significantly isolated practice community is vital to safe patient care.