The Association of the Nurse Work Environment and Patient Safety in Pediatric Acute Care

Evaluating associations between patient-to-nurse ratios and mortality, process of care events and vital sign documentation on paediatric wards: a secondary analysis of data from the EPOCH cluster-randomised trial

OBJECTIVE

To describe the associations between patient-to-nurse staffing ratios and rates of mortality, process of care events and vital sign documentation.

DESIGN

Secondary analysis of data from the evaluating processes of care and outcomes of children in hospital (EPOCH) cluster-randomised trial.

SETTING

22 hospitals caring for children in Canada, Europe and New Zealand.

PARTICIPANTS

Eligible hospitalised patients were aged>37 weeks and <18 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was all-cause hospital mortality. Secondary outcomes included five events reflecting the process of care, collected for all EPOCH patients; the frequency of documentation for each of eight vital signs on a random sample of patients; four measures describing nursing perceptions of care.

RESULTS

A total of 217 714 patient admissions accounting for 849 798 patient days over the course of the study were analysed. The overall mortality rate was 1.65/1000 patient discharges. The median (IQR) number of patients cared for by an individual nurse was 3.0 (2.8-3.6). Univariate Bayesian models estimating the rate ratio (RR) for the patient-to-nurse ratio and the probability that the RR was less than one found that a higher patient-to-nurse ratio was associated with fewer clinical deterioration events (RR=0.88, 95% credible interval (CrI) 0.77-1.03; P (RR<1)=95%) and late intensive care unit admissions (RR=0.76, 95% CrI 0.53-1.06; P (RR<1)=95%). In adjusted models, a higher patient-to-nurse ratio was associated with lower hospital mortality (OR=0.77, 95% CrI=0.57-1.00; P (OR<1)=98%). Nurses from hospitals with a higher patient-to-nurse ratio had lower ratings for their ability to influence care and reduced documentation of most individual vital signs and of the complete set of vital signs.

CONCLUSIONS

The data from this study challenge the assumption that lower patient-to-nurse ratios will improve the safety of paediatric care in contexts where ratios are low. The mechanism of these effects warrants further evaluation including factors, such as nursing skill mix, experience, education, work environment and physician staffing ratios.

TRIAL REGISTRATION NUMBER

EPOCH clinical trial registered on clinical trial.gov NCT01260831; post-results.

High reliability pediatric heart centers: Always working toward getting better

PURPOSE OF REVIEW

The purpose of this review is to examine high reliability through the lens of a contemporary pediatric heart center, noting that continuous improvement, rather than perfection, should be embraced. Aiming to elevate topics with lesser attention, this review elaborates on key concepts and proposed considerations for maintaining a high reliability heart center.

RECENT FINDINGS

As provision of care reaches a new complexity, programs are called upon to evaluate how they can bring their teams into the future of pediatric cardiac care. Although much has been written about high reliability in healthcare, it has not been explored within pediatric heart centers. Practical application of high reliability enables a shared mental model and aligns teams toward eliminating patient harm. Suggested facilitators of high reliability within heart center teams include interprofessional collaboration, recognition of nursing expertise, psychological safety, and structural empowerment void of hierarchy.

SUMMARY

As the pediatric cardiac population evolves, care becomes more complex with a narrow margin of error. High reliability can guide continuous improvement. Acknowledging culture as the underpinning of all structure and processes allows teams to rebound from failure and supports the mission of rising to exceptional patient challenges.

Pediatric nurses' fatigue descriptions in occupational injury reports: A descriptive qualitative study1

Background

Despite the high risks associated with occupational fatigue in healthcare, few organizations require nurses to screen and report fatigue symptoms. As a result, little is known about if and how nurses would report fatigue while on the job.

Objective

To determine if hospital-based pediatric nurses reported fatigue as part of an active injury reporting method.

Methods

This secondary analysis of qualitative data used a descriptive design with content analysis. Data from the parent study were collected at a U.S. pediatric hospital where nurses verbally reported on-shift injuries or near misses and pre- and post-shift health status via a digital voice recorder. Researchers used content analysis to independently code data for nurses' references to fatigue. Codes were then analyzed for patterns and themes.

Results

Approximately 30% (n = 104) of participants reported fatigue-related content. Emergent themes were Work Stressors, Individual Risk Factors, Fatigue Descriptors, Adverse Outcomes from Fatigue, Fatigue Buffers, Descriptors for Buffered Fatigue, and Favorable Outcomes from Buffered Fatigue. Fatigue descriptions align with prior literature, demonstrating the accuracy of the voice recorder data collection method. In addition, nurses expressed uncertainty about the appropriateness of reporting fatigue symptoms.

Conclusion

Findings from this study support pediatric nurses will report fatigue, when provided an opportunity. Additional efforts are needed to better understand effective ways to improve fatigue reporting among nurses, including harnessing current technology for real-time reporting and how to change the culture around fatigue reporting.

The Social Ecology of Burnout: A framework for research on nurse practitioner burnout

BACKGROUND

The U.S. health system is burdened by rising costs, workforce shortages, and unremitting burnout. Well-being interventions have emerged in response, yet data suggest that the work environment is the problem. Nurse practitioner (NP) burnout is associated with structural and relational factors in the work environment, practice autonomy, and hierarchical leadership.

PURPOSE

We explore the unique social, cultural, and political environment in which NPs work through the lens of social ecology and present the Social Ecology of Burnout (SEB) framework.

METHODS

We review current burnout frameworks in the context of the NP practice environment and discuss the SEB, specifically exploring psychological safety and its influence on burnout.

FINDINGS

Psychological safety, work environment, and policy are presented within the SEB and solutions which empower NPs are considered.

DISCUSSION

Our framework can serve as a guide for future nursing research, practice, and policy.

Structural Equation Modeling of Associations Between Nursing Practice Environment And Missed Nursing Care: A Cross-sectional Study

BACKGROUND

Missed nursing care (MNC) negatively impacts the quality of patient care. There may be a relationship between the nursing practice environment (NPE) and MNC; however, this relationship has not been examined in developing countries during the COVID-19 pandemic.

PURPOSE

To determine the relationship between the NPE and MNC during the COVID-19 pandemic.

METHODS

A cross-sectional study of 300 participants was conducted in 4 teaching hospitals in Iran. Data were collected using a demographic and clinical form, the Nursing Professional Practice Environment Questionnaire, and MISSCARE survey and analyzed using structural equation modeling.

RESULTS

The hypothesized model was well fit, showing that 1 unit improvement of the NPE domains of patient-centered care , effective leadership , and policy transparency decreased MNC by 0.18, 0.12, and 0.05, respectively.

CONCLUSION

The model confirmed the association between the dimensions of the NPE and MNC. These findings can assist health policymakers and nursing managers in improving the NPE.

Differences in Nurses' Satisfaction and Demand for Spatial Design Among Different Departments of Nursing Units: A Case Study in China

OBJECTIVES

The study aimed to extend original research and identify operational and space-related requirements for specialization from the perspectives of nursing behavior and process.

BACKGROUND

Studies related to the specialty of different nursing units have been widely conducted in nursing science, while few studies have explored the specialized requirements for the physical environments of nursing units in different departments.

METHOD

Questionnaire survey data were collected from 125 nurses in 11 clinical departments, and nurse shadowing (approximately 68 hr) was conducted in four clinical departments.

RESULTS

The questionnaire survey showed that satisfaction with care activity, visibility, and physical environment within the existing nursing unit environment was rated differently among different departments of nursing units. However, nurses in different groups of age, education, work experience, and position indicated no statistically significant difference. Behavioral observations demonstrated that the spatial and temporal distributions of activities, spatial linkages, and communication patterns varied in distinct departments.

CONCLUSION

This research found that nurses in different departments had different evaluations of satisfaction and environmental characteristics. It also explains the differences in nursing work behaviors and processes found in various departments and sheds light on specialized requirements from the behavior perspective. The findings could help optimize the design of efficient and satisfactory nursing units in different departments.

Left Without Being Seen: Nurse Work Environment and Timely Outcomes in New York and Illinois Emergency Departments

INTRODUCTION

This study determined the relationship between the emergency nurse work environment and emergency department patient left without being seen rates and lengths of stay.

METHODS

Cross-sectional analysis of 215 New York and Illinois emergency departments. The work environment (abbreviated Practice Environment Scale of the Nursing Work Index) was measured by emergency nurses in the 2021 RN4CAST-NY/IL survey and linked with outcomes from Hospital Compare. Regression models estimated the relationship between the nurse work environment and emergency department patient left without being seen rates, median length of stay (in minutes), and median behavioral health patient length of stay. Model coefficients were used to estimate expected additional care minutes gained if emergency department work environments improved.

RESULTS

"Mixed" work environments had the longest median overall length of stay (3.4 hours) and the highest median left without being seen rates (2.2%), while "poor" work environments had the longest median length of stay for behavioral health patients (6 hours). Improving the emergency department work environment from poor to mixed (and mixed to better) was associated with a 13-minute reduction in overall length of stay (P ≤ .05), a 33-minute reduction in behavioral health length of stay (P ≤ .01), and a 19% reduction in left without being seen rates (P ≤ .01). We estimated 11,824 to 41,071 additional patients could be seen in emergency departments associated with work environment improvements from "poor" to "better," depending on annual patient volumes.

DISCUSSION

Hospital administrators should consider investing in nurse work environments as a foundation to improve timely outcomes.

Relationships among psychological safety, the principles of high reliability, and safety reporting intentions in pediatric nursing

PURPOSE

The purpose of this study was to explore relationships among psychological safety, the principles of high reliability, and safety reporting intentions in pediatric nursing. Patient safety events are underreported and costly. To promote reporting, many healthcare organizations have adopted the high reliability framework with strategies to foster team psychological safety.

DESIGN

A web-based survey was distributed through the Society of Pediatric Nurses and the National Pediatric Nurse Scientist Collaborative. Data were collected from 244 pediatric nurses using a demographic form, Safety Organizing Scale, Team Psychological Safety Scale, and Intention to Report Safety Events Scale. Data were analyzed using logistic and linear regression.

RESULTS

Psychological safety and perception of working in a high reliability organization (HRO) showed positive statistically significant relationships with reporting intentions (p = 0.034). Odds of nurses achieving highest reporting intention scores increased by a factor of 0.3 with each practice year.

CONCLUSIONS

Psychological safety was found to be a predictor for intention to report safety events among pediatric nurses. Findings also demonstrated that nurses' perceptions of whether they worked in a high reliability setting also profoundly affect their attitude towards reporting.

PRACTICE IMPLICATIONS

Focusing organizational efforts on cultivating psychological safety and embedding the high reliability framework into professional practice may significantly affect attitudes towards safety event reporting.

Nurse Work Environment and Hospital-Onset Clostridioides difficile Infection

BACKGROUND

Clostridioides difficile is the leading cause of hospital-onset diarrhea and is associated with increased lengths of stay and mortality. While some hospitals have successfully reduced the burden of C. difficile infection (CDI), many still struggle to reduce hospital-onset CDI. Nurses-because of their close proximity to patients-are an important resource in the prevention of hospital-onset CDI.

OBJECTIVE

Determine whether there is an association between the nurse work environment and hospital-onset CDI.

METHODS

Survey data of 2016 were available from 15,982 nurses employed in 353 acute care hospitals. These data, aggregated to the hospital level, provided measures of the nurse work environments. They were merged with 2016 hospital-onset CDI data from Hospital Compare, which provided our outcome measure-whether a hospital had a standardized infection ratio (SIR) above or below the national average SIR. Hospitals above the average SIR had more infections than predicted when compared to the national average.

RESULTS

In all, 188 hospitals (53%) had SIRs higher than the national average. The odds of hospitals having higher than average SIRs were significantly lower, with odds ratios ranging from 0.35 to 0.45, in hospitals in the highest quartile for all four nurse work environment subscales (managerial support, nurse participation in hospital governance, physician-nurse relations, and adequate staffing) than in hospitals in the lowest quartile.

CONCLUSIONS

Findings show an association between the work environment of nurses and hospital-onset CDI. A promising strategy to lower hospital-onset CDI and other infections is a serious and sustained commitment by hospital leaders to significantly improve nurse work environments.

Association between the Nursing Practice Environment and Safety Perception with Patient Safety Culture during COVID-19

AIMS

In this study, we aimed to identify the relationship between nursing practice environments (NPEs) and safety perceptions with patient safety culture (PSC) during COVID-19.

DESIGN

We conducted a quantitative, non-experimental, correlational, and cross-sectional study. We interviewed 211 nurses from Peru using two scales: PES-NWI and HSOPSC. We used the Shapiro-Wilk test and Spearman's coefficient and estimated two regression models.

RESULTS

NPE was reported as favorable by 45.5% of the participants, and PSC was reported as neutral by 61.1%. Safety perception, the workplace, and NPE predict PSC. All NPE factors were correlated with PSC. However, safety perception, support of nurses subscale, the nurse manager's ability, and leadership were predictors of PSC.

CONCLUSION

To promote a safe work culture, health institutions should foster leadership that prioritizes safety, strengthens managers' abilities, encourages interprofessional collaboration, and considers nurses' feedback for constant improvement.

Exploring the relationship between nursing work environment and medical error reporting among Jordanian nurses: a cross-sectional study

Objectives

This study was conducted to explore the relationship between the nursing work environment and medical error reporting practices among Jordanian nurses.

Methods

This study was a cross-sectional survey of 334 participants who were conveniently selected from three types of hospitals (private, teaching and public) in Amman city, Jordan. The data were collected using a standardized questionnaire which was adopted from previous studies and consisted of three main sections including demographics, nursing work environment (The Practice Environment Scale-Nursing Work Index) and medical error reporting practices (incident reporting practice scale). SPSS version 26 was used for data analysis.

Key findings

The study findings detected a strong positive relationship between the nursing work environment and medical error reporting practices. ‘Nurse’s participation in hospital affairs’ showed the highest impact on medical error reporting practices among nurses. Based on the regression model, the nursing work environment explained 65.1% of variations in nurses’ medical error reporting practices. It was found that medical error reporting practices were statistically different across marital status and hospital type.

Conclusions

Based on data analysis findings, the nursing work environment was statistically strongly correlated to medical error reporting practices. To improve medical error reporting practices among nurses, decision-makers and hospital administrators should redesign their nursing work environment to create a more positive and favourable work environment.

Nursing Resources Linked to Postsurgical Outcomes for Patients With Opioid Use Disorder

To determine whether better nursing resources (ie, nurse education, staffing, work environment) are each associated with improved postsurgical outcomes for patients with opioid use disorder (OUD).

Impact of COVID-19 on professional nursing practice environments and patient safety culture

AIM

To analyze the impact of COVID-19 on professional nursing practice environments and patient safety culture.

BACKGROUND

The relationship between work environments and patient safety has been internationally recognized. In 2020, the pandemic imposed enormous challenges, yet the impact on these variables remains unknown.

METHOD

Quantitative observational study, conducted in a Portuguese hospital, with 403 registered nurses. A self-completion questionnaire was used.

RESULTS

The impact on the Structure and Outcome components of nursing professional practice environments was positive. Although the Process component remained favorable to quality of care, a negative trend was confirmed in almost all dimensions. The results regarding safety culture showed weaknesses; "teamwork within units" was the only dimension that maintained a positive culture.

CONCLUSION

Positive responses regarding patient safety were significantly associated with the quality of the nursing professional practice environment. To promoting positive professional environments, the need to invest in all dimensions of safety culture emerges.

IMPLICATIONS FOR NURSING MANAGEMENT

Improving professional nursing practice environments can be achieved through managers' investment in the participation and involvement of nurses in the policies and functioning of institutions, as well as promoting an open, fair, and participatory safety culture that encourages reporting events and provides adequate support for professionals.

Self-Care in Nurses

The health of nurses impacts the care of patients in healthcare settings today both inside and outside of hospitals. Many papers are written about nurses' burnout, depression, poor physical and mental health, weight gain, unhealthy eating patterns, back injury, moral negativity, and lack of job satisfaction. However, little attention has been paid to self-care in nurses. The goal of this paper is to discuss the importance of nurses caring for themselves as they work under stressful conditions regularly. Job satisfaction is necessary for nurses to have a healthy work-life balance and a desire to go to work. There are evidence-based interventions that can make a difference in a nurse's quality of life that can be implemented independently or within the work setting. Suggestions made by researchers include working less than 40 hr/week in a clinical setting, working a consistent time of day without rotations, expressing emotions, taking time to exercise, participating in a support group, and incorporating a place designated as a sanctuary in the clinical setting. Personal ways to improve health include preparing healthy meals before working a shift, getting proper sleep, utilizing cognitive behavioral therapy, participating in mindfulness training, and practicing stress reduction techniques.

Nurse Burnout Syndrome and Work Environment Impact Patient Safety Grade

BACKGROUND

Burnout impacts nurses' health as well as brain structures and functions including cognitive function, which could lead to work performance and patient safety issues. Yet, few organization-level factors related to patient safety have been identified.

PURPOSE

This study examined nurse-reported patient safety grade and its relationship to both burnout and the nursing work environment.

METHODS

A cross-sectional electronic survey was conducted among nurses (N = 928) in acute care Alabama hospitals.

RESULTS

In multilevel ordinal mixed-effects models with nurses nested within hospitals, all burnout dimensions of the Copenhagen Burnout Inventory (OR for +1 SD ranging 0.63-0.78; P < .05) and work environment (OR for +1 SD ranging 4.35-4.89; P < .001) were related to the outcome of patient safety grade after controlling for nurse characteristics.

CONCLUSIONS

Results indicate that health care organizations may reduce negative patient safety ratings by reducing nurse burnout and improving the work environment at the organization level.

Association of Clinical Nursing Work Environment with Quality and Safety in Maternity Care in the United States

PURPOSE

Maternal outcomes in the United States are the poorest of any high-income country. Efforts to improve the quality and safety of maternity care are frequently reported by individual hospitals, limiting generalizability. The purpose of this study is to describe maternity care quality and safety in hospitals in four states.

STUDY DESIGN AND METHODS

This cross-sectional study is a secondary analysis of the Panel Study of Effects of Changes in Nursing on Patient Outcomes data. Registered nurses reported on maternity unit quality, safety, and work environment. Descriptive statistics and clustered linear regressions were used.

RESULTS

The sample included 1,165 nurses reporting on 166 units in California, New Jersey, Pennsylvania, and Florida in 2015. One-third of nurses, on average, gave their units an overall safety grade of "excellent," but this decreased to less than one-sixth of nurses in units with poor work environments. Overall, 65% of nurses reported that their mistakes were held against them. A good work environment, compared with poor, was significantly associated with fewer nurses grading safety as poor (β -35.6, 95% CI -42.9 - -28.3).

CLINICAL IMPLICATIONS

Our research found that the nurses in the majority of hospitals with maternity units in four states representing a quarter of the nation's annual births felt their units do not provide excellent quality care and have a less than optimal safety climate.

Nurse Burnout Predicts Self-Reported Medication Administration Errors in Acute Care Hospitals

BACKGROUND

Every one out of 10 nurses reported suffering from high levels of burnout worldwide. It is unclear if burnout affects job performance, and in turn, impairs patient safety, including medication safety. The purpose of this study is to determine whether nurse burnout predicts self-reported medication administration errors (MAEs).

METHODS

A cross-sectional study using electronic surveys was conducted from July 2018 through January 2019, using the Copenhagen Burnout Inventory. Staff registered nurses (N = 928) in acute care Alabama hospitals (N = 42) were included in this study. Descriptive statistics, correlational, and multilevel mixed-modeling analyses were examined.

RESULTS

All burnout dimensions (Personal, Work-related, and Client-related Burnout) were significantly correlated with age (r = -0.17 to -0.21), years in nursing (r = -0.10 to -0.17), years of hospital work (r = -0.07 to -0.10), and work environment (r = -0.24 to -0.57). The average number of self-reported MAEs in the last 3 months was 2.13. Each burnout dimension was a statistically significant predictor of self-reported MAEs (p < .05).

CONCLUSIONS

Nurse burnout is a significant factor in predicting MAEs. This study provides important baseline data for actionable interventions to improve nursing care delivery, and ultimately health care, for Alabamians.

Nurse Staffing, the Clinical Work Environment, and Burn Patient Mortality

The complexity of modern burn care requires an integrated team of specialty providers working together to achieve the best possible outcome for each burn survivor. Nurses are central to many aspects of a burn survivor's care, including physiologic monitoring, fluid resuscitation, pain management, infection prevention, complex wound care, and rehabilitation. Research suggests that in general, hospital nursing resources, defined as nurse staffing and the quality of the work environment, relate to patient mortality. Still, the relationship between those resources and burn mortality has not been previously examined. This study used a multivariable risk-adjusted regression model and a linked, cross-sectional claims database of more than 14,000 adults (≥18 years) thermal burn patients admitted to 653 hospitals to evaluate these relationships. Hospital nursing resources were independently reported by more than 29,000 bedside nurses working in the study hospitals. In the high burn patient-volume hospitals (≥100/y) that care for the most severe burn injuries, each additional patient added to a nurse's workload is associated with 30% higher odds of mortality (P < .05, 95% CI: 1.02-1.94), and improving the work environment is associated with 28% lower odds of death (P < .05, 95% CI: 0.07-0.99). Nursing resources are vital in the care of burn patients and are a critical, yet previously omitted, variable in the evaluation of burn outcomes. Attention to nurse staffing and improvement to the nurse work environment is warranted to promote optimal recovery for burn survivors. Given the influence of nursing on mortality, future research evaluating burn patient outcomes should account for nursing resources.

A cross-sectional multisite exploration of Italian paediatric nurses' reported burnout and its relationship to perceptions of clinical safety and adverse events using the RN4CAST@IT-Ped

AIM

To explore Italian paediatric nurses' reported burnout and its relationship to their perceptions of safety and adverse events.

DESIGN

A cross-sectional study using the RN4CAST@IT-Ped database with a web-based survey design.

METHODS

The RN4CAST@IT-Ped questionnaire was used to collect data in 2017. This comprised three main components: three dimensions (22 items) of the Maslach Burnout Inventory including emotional exhaustion, depersonalization and personal accomplishment. Participants also scored an overall grade of patient safety and estimated the occurrence of adverse clinical events.

RESULTS

Nurses (N = 2,243) reported high levels of burnout. Most rated clinical safety as high. The risk of adverse events ranged from 1.3-12.4%. The degree of burnout appeared to influence the perception of safety and adverse events.

CONCLUSION

The association between nurses' burnout and perceptions of higher rates of adverse events and reduced safety in clinical practice is an important finding. However, it is unclear whether this was influenced by a negative state of mind, and whether reduced safety and increased adverse events negatively influenced nurses' well-being, thus leading to burnout. Regardless, the association between nurses' burnout and these quality concepts needs further exploration to examine the effect, if any, on burnout and safety, and identify supportive mechanisms for nurses.

IMPACT

The association between reported burnout and perception of safety and risk of adverse events in Italian paediatric nurses has been reported for the first time. Nurses reporting burnout are at greater risk of intensely negative perceptions of clinical safety and adverse events. This is an important finding as perceptions can influence practice and behaviours. Quality measures in children's clinical environments need to go beyond obvious indicators to examine nurses' well-being as this also influences quality and safety.

Prevalence of Continuous Pulse Oximetry Monitoring in Hospitalized Children With Bronchiolitis Not Requiring Supplemental Oxygen

IMPORTANCE

US national guidelines discourage the use of continuous pulse oximetry monitoring in hospitalized children with bronchiolitis who do not require supplemental oxygen.

OBJECTIVE

Measure continuous pulse oximetry use in children with bronchiolitis.

DESIGN, SETTING, AND PARTICIPANTS

A multicenter cross-sectional study was performed in pediatric wards in 56 US and Canadian hospitals in the Pediatric Research in Inpatient Settings Network from December 1, 2018, through March 31, 2019. Participants included a convenience sample of patients aged 8 weeks through 23 months with bronchiolitis who were not receiving active supplemental oxygen administration. Patients with extreme prematurity, cyanotic congenital heart disease, pulmonary hypertension, home respiratory support, neuromuscular disease, immunodeficiency, or cancer were excluded.

EXPOSURES

Hospitalization with bronchiolitis without active supplemental oxygen administration.

MAIN OUTCOMES AND MEASURES

The primary outcome, receipt of continuous pulse oximetry, was measured using direct observation. Continuous pulse oximetry use percentages were risk standardized using the following variables: nighttime (11 pm to 7 am), age combined with preterm birth, time after weaning from supplemental oxygen or flow, apnea or cyanosis during the present illness, neurologic impairment, and presence of an enteral feeding tube.

RESULTS

The sample included 3612 patient observations in 33 freestanding children's hospitals, 14 children's hospitals within hospitals, and 9 community hospitals. In the sample, 59% were male, 56% were white, and 15% were black; 48% were aged 8 weeks through 5 months, 28% were aged 6 through 11 months, 16% were aged 12 through 17 months, and 9% were aged 18 through 23 months. The overall continuous pulse oximetry monitoring use percentage in these patients, none of whom were receiving any supplemental oxygen or nasal cannula flow, was 46% (95% CI, 40%-53%). Hospital-level unadjusted continuous pulse oximetry use ranged from 2% to 92%. After risk standardization, use ranged from 6% to 82%. Intraclass correlation coefficient suggested that 27% (95% CI, 19%-36%) of observed variation was attributable to unmeasured hospital-level factors.

CONCLUSIONS AND RELEVANCE

In a convenience sample of children hospitalized with bronchiolitis who were not receiving active supplemental oxygen administration, monitoring with continuous pulse oximetry was frequent and varied widely among hospitals. Because of the apparent absence of a guideline- or evidence-based indication for continuous monitoring in this population, this practice may represent overuse.

Safety and Quality of Pediatric Care in Freestanding Children's and General Hospitals

OBJECTIVES

The purpose of this study was to evaluate quality and safety of care in acute pediatric settings from the perspectives of nurses working at the bedside and to investigate hospital-level factors associated with more favorable quality and safety.

METHODS

Using data from a large survey of registered nurses in 330 acute care hospitals, we described nurses' assessments of safety and quality of care in inpatient pediatric settings, including freestanding children's hospitals (FCHs) (n = 21) and general hospitals with pediatric units (n = 309). Multivariate logistic regression models were used to estimate the effects of being a FCH on favorable reports on safety and quality before and after adjusting for hospital-level and nurse characteristics and Magnet status.

RESULTS

Nurses in FCHs were more likely to report favorably on quality and safety after we accounted for hospital-level and individual nurse characteristics; however, adjusting for a hospital's Magnet status rendered associations between FCHs and quality and safety insignificant. Nurses in Magnet hospitals were more likely to report favorably on quality and safety.

CONCLUSIONS

Quality and safety of pediatric care remain uneven; however, the organizational attributes of Magnet hospitals explain, in large part, more favorable quality and safety in FCHs compared with pediatric units in general acute care hospitals. Modifiable features of the nurse work environment common to Magnet hospitals hold promise for improving quality and safety of care. Transforming nurse work environments to keep patients safe, as recommended by the National Academy of Medicine 20 years ago, remains an unfinished agenda in pediatric inpatient settings.