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Hovsepian VE, Sloane DM, Muir KJ, McHugh MD. Mortality Among the Dementia Population in Not-For-Profit Hospitals with Better Nursing Resources. J Aging Soc Policy 2024:1-15. [PMID: 38293888 DOI: 10.1080/08959420.2023.2297596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 10/23/2023] [Indexed: 02/01/2024]
Abstract
The dementia population has higher rates of mortality during hospital stays than those without dementia. The aim of this study is to examine the relationship between ownership status (i.e. for-profit vs. not-for-profit) and nursing resources (i.e. nurse work environment, nurse-to-patient staffing, and nurse education) on 30-day mortality among post-surgical older adults with dementia. A cross-sectional analysis of linked American Hospital Association, Medicare claims, and nurse survey data was conducted using multi-level logistic regression models. We examined these models to assess the relationship between ownership status and 30-day mortality after adjusting patient and hospital characteristics. We also analyzed the relationship between the hospital ownership status and the 30-day mortality, after considering the three nursing resources. Older adults with dementia who received care in hospitals with not-for-profit status were less likely to die within 30 days of admission following surgery compared to those treated in hospitals with for-profit hospital status (i.e. odds ratio 0.82, 95% confidence interval 0.73-0.92, p = <.001). In addition, the odds ratios estimating the association between ownership and mortality were similar across the different models of the three nursing resources with and without those controls (i.e. 0.88 vs. 0.83 vs. 0.82). Surgical patients with dementia had better outcomes when cared for in not-for-profit hospitals, particularly with greater levels of nurse education and nurse staffing. The relationship between profit status and mortality was partly explained by the lower levels of nurse staffing and education in for-profit vs. not-for-profit hospitals.
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Affiliation(s)
- Vaneh E Hovsepian
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Douglas M Sloane
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - K Jane Muir
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA, USA
| | - Matthew D McHugh
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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Muir KJ, Sloane DM, Aiken LH, Hovsepian V, McHugh MD. The association of the emergency department work environment on patient care and nurse job outcomes. J Am Coll Emerg Physicians Open 2023; 4:e13040. [PMID: 37781503 PMCID: PMC10537505 DOI: 10.1002/emp2.13040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 08/23/2023] [Accepted: 08/31/2023] [Indexed: 10/03/2023] Open
Abstract
Objective To determine the association between emergency nurses' work environments and patient care quality and safety, and nurse burnout, intent to leave, and job dissatisfaction. Methods Cross-sectional study of 221 hospitals in New York and Illinois informed by surveys from 746 emergency nurses and 6932 inpatient nurses with linked data on hospital characteristics from American Hospital Association Annual Hospital Survey. The RN4CAST-NY/IL study surveyed all registered nurses in New York and Illinois between April and June 2021 about patient safety, care quality, burnout, intent to leave, and job dissatisfaction and aggregated their responses to specific hospitals where they practiced. Work environment quality was measured using the abbreviated Practice Environment Scale of the Nursing Work Index. Generalized estimating equations were used to determine the relationship between emergency nurses' work environments on patient care and nurse job outcomes. Results A total of 58% of emergency nurses reported high burnout, 39% reported job dissatisfaction, and 27% indicated intent to leave their job in the next year. Nurses in hospitals with good (vs mixed) or mixed (vs poor) emergency work environments were less likely to report unfavorable patient care quality and hospital safety grades, and were less likely to experience high burnout, job dissatisfaction, and intentions to leave the job, by factors ranging from odds ratio (OR) 0.21 (95% confidence interval [CI], 0.16-0.29) to OR 0.46 (95% CI, 0.34-0.61). Conclusions Given the complex and high stakes nature of emergency nursing care, leaders should place a high priority on organizational solutions targeting improved nurse staffing and work environments to advance better patient and clinician outcomes.
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Affiliation(s)
- K. Jane Muir
- National Clinician Scholars ProgramUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Center for Health Outcomes and Policy ResearchSchool of NursingUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- The Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Douglas M. Sloane
- Center for Health Outcomes and Policy ResearchSchool of NursingUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Linda H. Aiken
- Center for Health Outcomes and Policy ResearchSchool of NursingUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- The Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Vaneh Hovsepian
- Center for Health Outcomes and Policy ResearchSchool of NursingUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- The Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Matthew D. McHugh
- Center for Health Outcomes and Policy ResearchSchool of NursingUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- The Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
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Aiken LH, Lasater KB, Sloane DM, Pogue CA, Fitzpatrick Rosenbaum KE, Muir KJ, McHugh MD. Physician and Nurse Well-Being and Preferred Interventions to Address Burnout in Hospital Practice: Factors Associated With Turnover, Outcomes, and Patient Safety. JAMA Health Forum 2023; 4:e231809. [PMID: 37418269 PMCID: PMC10329209 DOI: 10.1001/jamahealthforum.2023.1809] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 05/04/2023] [Indexed: 07/08/2023] Open
Abstract
Importance Disruptions in the hospital clinical workforce threaten quality and safety of care and retention of health professionals. It is important to understand which interventions would be well received by clinicians to address the factors associated with turnover. Objectives To determine well-being and turnover rates of physicians and nurses in hospital practice, and to identify actionable factors associated with adverse clinician outcomes, patient safety, and clinicians' preferences for interventions. Design, Setting, and Participants This was a cross-sectional multicenter survey study conducted in 2021 with 21 050 physicians and nurses at 60 nationally distributed US Magnet hospitals. Respondents described their mental health and well-being, associations between modifiable work environment factors and physician and nurse burnout, mental health, hospital staff turnover, and patient safety. Data were analyzed from February 21, 2022, to March 28, 2023. Main Outcomes and Measures Clinician outcomes (burnout, job dissatisfaction, intent to leave, turnover), well-being (depression, anxiety, work-life balance, health), patient safety, resources and work environment adequacy, and clinicians' preferences for interventions to improve their well-being. Results The study sample comprised responses from 15 738 nurses (mean [SD] age, 38.4 [11.7] years; 10 887 (69%) women; 8404 [53%] White individuals) practicing in 60 hospitals, and 5312 physicians (mean [SD] age, 44.7 [12.0] years; 2362 [45%] men; 2768 [52%] White individuals) practicing in 53 of the same hospitals, with an average of 100 physicians and 262 nurses per hospital and an overall clinician response rate of 26%. High burnout was common among hospital physicians (32%) and nurses (47%). Nurse burnout was associated with higher turnover of both nurses and physicians. Many physicians (12%) and nurses (26%) rated their hospitals unfavorably on patient safety, reported having too few nurses (28% and 54%, respectively), reported having a poor work environment (20% and 34%, respectively), and lacked confidence in management (42% and 46%, respectively). Fewer than 10% of clinicians described their workplace as joyful. Both physicians and nurses rated management interventions to improve care delivery as more important to their mental health and well-being than interventions directed at improving clinicians' mental health. Improving nurse staffing was ranked highest among interventions (87% of nurses and 45% of physicians). Conclusions and Relevance This cross-sectional survey study of physicians and nurses practicing in US Magnet hospitals found that hospitals characterized as having too few nurses and unfavorable work environments had higher rates of clinician burnout, turnover, and unfavorable patient safety ratings. Clinicians wanted action by management to address insufficient nurse staffing, insufficient clinician control over workload, and poor work environments; they were less interested in wellness programs and resilience training.
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Affiliation(s)
- Linda H. Aiken
- Center for Health Outcomes and Policy Research, School of Nursing, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Karen B. Lasater
- Center for Health Outcomes and Policy Research, School of Nursing, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Douglas M. Sloane
- Center for Health Outcomes and Policy Research, School of Nursing, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Colleen A. Pogue
- Center for Health Outcomes and Policy Research, School of Nursing, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Kathleen E. Fitzpatrick Rosenbaum
- Center for Health Outcomes and Policy Research, School of Nursing, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - K. Jane Muir
- Center for Health Outcomes and Policy Research, School of Nursing, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Matthew D. McHugh
- Center for Health Outcomes and Policy Research, School of Nursing, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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Jung OS, Aiken LH, Sloane DM, Fridkin SK, Li Y, Kang YJ, Becker ER, Joski PJ, Cimiotti JP. Nurse Work Environment and Hospital-Onset Clostridioides difficile Infection. Med Care 2023; 61:360-365. [PMID: 37167557 PMCID: PMC10168114 DOI: 10.1097/mlr.0000000000001854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
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.
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Affiliation(s)
- Olivia S. Jung
- Rollins School of Public Health, Emory University, Atlanta, GA
- Laboratory of Innovation Science at Harvard, Harvard University, Cambridge
- Healthcare Transformation Lab, Massachusetts General Hospital, Boston, MA
| | - Linda H. Aiken
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PA
| | - Douglas M. Sloane
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PA
| | - Scott K. Fridkin
- Rollins School of Public Health, Emory University, Atlanta, GA
- School of Medicine, Emory University
| | - Yin Li
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA
| | - Yu Jin Kang
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA
| | | | - Peter J. Joski
- Rollins School of Public Health, Emory University, Atlanta, GA
| | - Jeannie P. Cimiotti
- Rollins School of Public Health, Emory University, Atlanta, GA
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA
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Aiken LH, Sloane DM, McHugh MD, Pogue CA, Lasater KB. A repeated cross-sectional study of nurses immediately before and during the COVID-19 pandemic: Implications for action. Nurs Outlook 2023; 71:101903. [PMID: 36588039 PMCID: PMC9729649 DOI: 10.1016/j.outlook.2022.11.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/21/2022] [Accepted: 11/30/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND The shortage of nursing care in US hospitals has become a national concern. PURPOSE The purpose of this manuscript was to determine whether hospital nursing care shortages are primarily due to the pandemic and thus likely to subside or due to hospital nurse understaffing and poor working conditions that predated it. METHODS This study used a repeated cross-sectional design before and during the pandemic of 151,335 registered nurses in New York and Illinois, and a subset of 40,674 staff nurses employed in 357 hospitals. FINDINGS No evidence was found that large numbers of nurses left health care or hospital practice in the first 18 months of the pandemic. Nurses working in hospitals with better nurse staffing and more favorable work environments prior to the pandemic reported significantly better outcomes during the pandemic. DISCUSSION Policies that prevent chronic hospital nurse understaffing have the greatest potential to stabilize the hospital nurse workforce at levels supporting good care and clinician wellbeing.
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Affiliation(s)
- Linda H. Aiken
- Corresponding author: Linda H. Aiken, Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104-4217
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Riman KA, Harrison JM, Sloane DM, McHugh MD. Work Environment and Operational Failures Associated With Nurse Outcomes, Patient Safety, and Patient Satisfaction. Nurs Res 2023; 72:20-29. [PMID: 36097000 PMCID: PMC9772247 DOI: 10.1097/nnr.0000000000000626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Operational failures, defined as the inability of the work system to reliably provide information, services, and supplies needed when, where, and to who, are a pervasive problem in U.S. hospitals that disrupt nurses' ability to provide safe and effective care. OBJECTIVES We examined the relationship between operational failures, patient satisfaction, nurse-reported quality and safety, and nurse job outcomes (e.g., burnout and job satisfaction) and whether differences in hospital work environments explained the relationship. METHODS We conducted a cross-sectional analysis using population-based survey data from 11,709 registered nurses in 415 hospitals who participated in the RN4CAST-US nurse survey (2015-2016) and the 2016 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The RN4CAST-US nurse survey focused on hospital quality and safety, job outcomes, and hospital work environments. The HCAHPS survey collected publicly reported patient data on their satisfaction with their care. Operational failures were evaluated using an eight-item composite measure that assessed missing supplies, orders, medication, missing/wrong patient diet, electronic documentation problems, insufficient staff, and time spent on workarounds and nonnursing tasks. Multilevel regression models were used to test the hypothesized relationships. RESULTS Operational failures were associated with low patient satisfaction scores, poor quality and safety outcomes, and poor nurse job outcomes, and those associations were partly accounted for by hospital work environments. DISCUSSION Operational failures prevent high-quality care and positive patient and nurse outcomes. Operational failures and the hospital work environment should be targeted simultaneously to maximize quality improvement efforts. Hospital leadership should work with frontline staff to identify and target the sources of operational failures in nursing units. Improvements to hospital work environments may reduce the occurrence of operational failures.
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Sermeus W, Aiken LH, Ball J, Bridges J, Bruyneel L, Busse R, De Witte H, Dello S, Drennan J, Eriksson LE, Griffiths P, Kohnen D, Köppen J, Lindqvist R, Maier CB, McHugh MD, McKee M, Rafferty AM, Schaufeli WB, Sloane DM, Alenius LS, Smith H. A workplace organisational intervention to improve hospital nurses' and physicians' mental health: study protocol for the Magnet4Europe wait list cluster randomised controlled trial. BMJ Open 2022; 12:e059159. [PMID: 35902190 PMCID: PMC9341186 DOI: 10.1136/bmjopen-2021-059159] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION The increasing burden of mental distress reported by healthcare professionals is a matter of serious concern and there is a growing recognition of the role of the workplace in creating this problem. Magnet hospitals, a model shown to attract and retain staff in US research, creates positive work environments that aim to support the well-being of healthcare professionals. METHODS AND ANALYSIS Magnet4Europe is a cluster randomised controlled trial, with wait list controls, designed to evaluate the effects of organisational redesign, based on the Magnet model, on nurses' and physicians' well-being in general acute care hospitals, using a multicomponent implementation strategy. The study will be conducted in more than 60 general acute care hospitals in Belgium, England, Germany, Ireland, Norway and Sweden. The primary outcome is burnout among nurses and physicians, assessed in longitudinal surveys of nurses and physicians at participating hospitals. Additional data will be collected from them on perceived work environments, patient safety and patient quality of care and will be triangulated with data from medical records, including case mix-adjusted in-hospital mortality. The process of implementation will be evaluated using qualitative data from focus group and key informant interviews. ETHICS AND DISSEMINATION This study was approved by the Ethics Committee Research UZ/KU Leuven, Belgium; additionally, ethics approval is obtained in all other participating countries either through a central or decentral authority. Findings will be disseminated at conferences, through peer-reviewed manuscripts and via social media. TRIAL REGISTRATION NUMBER ISRCTN10196901.
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Affiliation(s)
- Walter Sermeus
- Department of Public Health and Primary Care, Katholieke Universiteit Leuven, Leuven, Flanders, Belgium
| | - Linda H Aiken
- Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jane Ball
- Faculty of Health Sciences, University of Southampton, Southampton, Hampshire, UK
| | - Jackie Bridges
- Faculty of Health Sciences, University of Southampton, Southampton, Hampshire, UK
| | - Luk Bruyneel
- Department of Public Health and Primary Care, Katholieke Universiteit Leuven, Leuven, Flanders, Belgium
| | - Reinhard Busse
- Department of Healthcare Management, Technical University of Berlin, Berlin, Germany
| | - Hans De Witte
- Occupational & Organisational Psychology and Professional Learning, Katholieke Universiteit Leuven, Leuven, Flanders, Belgium
- Optentia Research Unit, North-West University, Potchefstroom, South Africa
| | - Simon Dello
- Department of Public Health and Primary Care, Katholieke Universiteit Leuven, Leuven, Flanders, Belgium
| | - Jonathan Drennan
- School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Lars E Eriksson
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Peter Griffiths
- Faculty of Health Sciences, University of Southampton, Southampton, Hampshire, UK
| | - Dorothea Kohnen
- Occupational & Organisational Psychology and Professional Learning, Katholieke Universiteit Leuven, Leuven, Flanders, Belgium
| | - Julia Köppen
- Department of Healthcare Management, Technical University of Berlin, Berlin, Germany
| | - Rikard Lindqvist
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Claudia Bettina Maier
- Department of Healthcare Management, Technical University of Berlin, Berlin, Germany
| | - Matthew D McHugh
- Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Martin McKee
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Wilmar B Schaufeli
- Occupational & Organisational Psychology and Professional Learning, Katholieke Universiteit Leuven, Leuven, Flanders, Belgium
- Department of Psychology, Utrecht University, Utrecht, The Netherlands
| | - Douglas M Sloane
- Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lisa Smeds Alenius
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Herbert Smith
- Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Cimiotti JP, Becker ER, Li Y, Sloane DM, Fridkin SK, West AB, Aiken LH. Association of Registered Nurse Staffing With Mortality Risk of Medicare Beneficiaries Hospitalized With Sepsis. JAMA Health Forum 2022; 3:e221173. [PMID: 35977257 PMCID: PMC9142874 DOI: 10.1001/jamahealthforum.2022.1173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 04/03/2022] [Indexed: 11/17/2022] Open
Abstract
Question Is registered nurse workload associated with mortality among Medicare beneficiaries who are admitted to an acute care hospital with a diagnosis of sepsis? Findings In this cross-sectional study of 1958 acute care hospitals and 702 140 Medicare beneficiaries with a diagnosis of sepsis, an increase in registered nurse hours per patient day was associated with a 3% decrease in 60-day mortality in these older adults, a finding that was statistically significant. Meaning The study results suggest that the hours of care provided by registered nurses is likely associated with the outcomes of patients with a diagnosis of sepsis. Importance Sepsis is a major physiologic response to infection that if not managed properly can lead to multiorgan failure and death. The US Centers for Medicare & Medicaid Services (CMS) requires that hospitals collect data on core sepsis measure Severe Sepsis and Septic Shock Management Bundle (SEP-1) in an effort to promote the early recognition and treatment of sepsis. Despite implementation of the SEP-1 measure, sepsis-related mortality continues to challenge acute care hospitals nationwide. Objective To determine if registered nurse workload was associated with mortality in Medicare beneficiaries admitted to an acute care hospital with sepsis. Design, Setting, and Participants This cross-sectional study used 2018 data from the American Hospital Association Annual Survey, CMS Hospital Compare, and Medicare claims on Medicare beneficiaries age 65 to 99 years with a primary diagnosis of sepsis that was present on admission to 1 of 1958 nonfederal, general acute care hospitals that had data on CMS SEP-1 scores and registered nurse workload (indicated by registered nurse hours per patient day [HPPD]). Patients with sepsis were identified based on 29 International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes. Data were analyzed throughout 2021. Exposures SEP-1 score and registered nurse staffing. Main Outcomes and Measures The patient outcome of interest was mortality within 60 days of admission. Hospital characteristics included number of beds, ownership, teaching status, technology status, rurality, and region. Patient characteristics included age, sex, transfer status, intensive care unit admission, palliative care, do-not-resuscitate order, and a series of 29 comorbid diseases based on the Elixhauser Comorbidity Index. Results In total, 702 140 Medicare beneficiaries (mean [SD] age, 78.2 [8.7] years; 360 804 women [51%]) had a diagnosis of sepsis. The mean SEP-1 score was 56.1, and registered nurse HPPD was 6.2. In a multivariable regression model, each additional registered nurse HPPD was associated with a 3% decrease in the odds of 60-day mortality (odds ratio, 0.97; 95% CI 0.96-0.99) controlling for SEP-1 score and hospital and patient characteristics. Conclusions and Relevance The results of this cross-sectional study suggest that hospitals that provide more registered nurse hours of care could likely improve SEP-1 bundle compliance and decrease the likelihood of mortality in Medicare beneficiaries with sepsis.
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Affiliation(s)
- Jeannie P. Cimiotti
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Edmund R. Becker
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Yin Li
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | | | - Scott K. Fridkin
- Rollins School of Public Health, Emory University, Atlanta, Georgia
- School of Medicine, Emory University, Atlanta, Georgia
| | - Anna Beth West
- School of Medicine, Emory University, Atlanta, Georgia
- VA Quality Scholars Program, Atlanta VA Health Care System, Atlanta, Georgia
| | - Linda H. Aiken
- School of Nursing, University of Pennsylvania, Philadelphia
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Dierkes AM, Aiken LH, Sloane DM, Cimiotti JP, Riman KA, McHugh MD. Hospital nurse staffing and sepsis protocol compliance and outcomes among patients with sepsis in the USA: a multistate cross-sectional analysis. BMJ Open 2022; 12:e056802. [PMID: 35318235 PMCID: PMC8943766 DOI: 10.1136/bmjopen-2021-056802] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Sepsis is a serious inflammatory response to infection with a high death rate. Timely and effective treatment may improve sepsis outcomes resulting in mandatory sepsis care protocol adherence reporting. How the impact of patient-to-nurse staffing compares to sepsis protocol compliance and patient outcomes is not well understood. This study aimed to determine the association between hospital sepsis protocol compliance, patient-to-nurse staffing ratios and patient outcomes. DESIGN A cross-sectional study examining hospital nurse staffing, sepsis protocol compliance and sepsis patient outcomes, using linked data from nurse (2015-2016, 2020) and hospital (2017) surveys, and Centers for Medicare and Medicaid Services Hospital Compare (2017) and corresponding MedPAR patient claims. SETTING 537 hospitals across six US states (California, Florida, Pennsylvania, New York, Illinois and New Jersey). PARTICIPANTS 252 699 Medicare inpatients with sepsis present on admission. MEASURES The explanatory variables are nurse staffing and SEP-1 compliance. Outcomes are mortality (within 30 and 60 days of index admission), readmissions (within 7, 30, and 60 days of discharge), admission to the intensive care unit (ICU) and lengths of stay (LOS). RESULTS Sepsis protocol compliance and nurse staffing vary widely across hospitals. Each additional patient per nurse was associated with increased odds of 30-day and 60-day mortality (9% (OR 1.09, 95% CI 1.05 to 1.13) and 10% (1.10, 95% CI 1.07 to 1.14)), 7-day, 30-day and 60-day readmission (8% (OR 1.08, 95% CI 1.05 to 1.11, p<0.001), 7% (OR 1.07, 95% CI 1.05 to 1.10, p<0.001), 7% (OR 1.07, 95% CI 1.05 to 1.10, p<0.001)), ICU admission (12% (OR 1.12, 95% CI 1.03 to 1.22, p=0.007)) and increased relative risk of longer LOS (10% (OR 1.10, 95% CI 1.08 to 1.12, p<0.001)). Each 10% increase in sepsis protocol compliance was associated with shorter LOS (2% ([OR 0.98, 95% CI 0.97 to 0.99, p<0.001)) only. CONCLUSIONS Outcomes are more strongly associated with improved nurse staffing than with increased compliance with sepsis protocols.
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Affiliation(s)
- Andrew M Dierkes
- Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
| | - Linda H Aiken
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Douglas M Sloane
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Jeannie P Cimiotti
- Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, Georgia, USA
| | - Kathryn A Riman
- Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Matthew D McHugh
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
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Abstract
Despite concerted research and clinical efforts, sepsis remains a common, costly, and often fatal occurrence. Little evidence exists for the relationship between institutional nursing resources and the incidence and outcomes of sepsis after surgery. The objective of this study was to examine whether hospital nursing resource quality is associated with postsurgical sepsis incidence and survival. This cross-sectional, secondary data analysis used registered nurses' reports on hospital nursing resources-staffing, education, and work environment-and multivariate logistic regressions to model their association with risk-adjusted postsurgical sepsis and mortality in 568 hospitals across four states. Better work environment quality was associated with lower odds of sepsis. While the likelihood of death among septic patients was nearly seven times that of non-septic patients, better nursing resources were associated with reduced mortality for all patients. Whereas the preponderance of sepsis research has focused on clinical interventions to prevent and treat sepsis, this study describes organizational characteristics hospital administrators may modify through organizational change targeting nurse staffing, education, and work environments to improve patient outcomes.
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Affiliation(s)
- Andrew M. Dierkes
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Linda H. Aiken
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Douglas M. Sloane
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Matthew D. McHugh
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
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Abstract
BACKGROUND Evidence indicates hospitals with better registered nurse (RN) staffing have better patient outcomes. Whether involving more nurse practitioners (NPs) in inpatient care produces better outcomes is largely unknown. OBJECTIVE The objective of this study was to determine whether the presence of more NPs produces better inpatient outcomes net of RN staffing. RESEARCH DESIGN This was a 2015-2016 cross-sectional data on 579 hospitals linked from: (1) RN4CAST-US nurse surveys; (2) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient surveys; (3) surgical patient discharge abstracts; (4) Medicare Spending per Beneficiary (MSPB) reports; (5) American Hospital Association (AHA) Annual Survey. Hospitals were grouped according to their NP/beds ratios [<1 NP/100 beds (N=132), 1-2.99 NPs/100 beds (N=279), and 3+ NPs/100 beds (N=168)]. SUBJECTS RNs randomly sampled nurses from licensure lists yielded 22,273 RNs in study hospitals; discharge data for 1.4 million surgical patients; HCAHPS data for 86% of study hospitals. MEASURES Mortality, readmissions, lengths of stay, MSPB, patient experience, and quality reported by patients and nurses. RESULTS After adjustments, patients in hospitals with 3+ NPs/100 beds had lower odds than patients in hospitals with <1 NP/100 beds of 30-day mortality [odds ratio (OR)2=0.76; 95% confidence interval (CI)=0.67-0.82; P<0.001] and 7-day readmissions (OR2=0.90; 95% CI=0.86-0.96; P<0.001), shorter average length of stay (incident rate ratio2=0.92; 95% CI=0.88-0.96; P<0.001) and 5.4% lower average MSPB (95% CI=3.8%-7.1%). Patients and nurses in the hospitals with higher NP/bed ratios were significantly more likely to report better care quality and safety, and nurses reported lower burnout, higher job satisfaction, greater intentions of staying in their jobs. CONCLUSIONS Having more NPs in hospitals has favorable effects on patients, staff nurse satisfaction, and efficiency. NPs add value to existing labor resources.
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Affiliation(s)
- Linda H Aiken
- Center for Health Outcomes and Policy Research, The University of Pennsylvania School of Nursing
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Douglas M Sloane
- Center for Health Outcomes and Policy Research, The University of Pennsylvania School of Nursing
| | - Heather M Brom
- Center for Health Outcomes and Policy Research, The University of Pennsylvania School of Nursing
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Villanova University M. Louise Fitzpatrick College of Nursing, Villanova
| | - Barbara A Todd
- Center for Health Outcomes and Policy Research, The University of Pennsylvania School of Nursing
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Hilary Barnes
- Center for Health Outcomes and Policy Research, The University of Pennsylvania School of Nursing
- School of Nursing, University of Delaware, Newark, DE
| | - Jeannie P Cimiotti
- Center for Health Outcomes and Policy Research, The University of Pennsylvania School of Nursing
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA
| | - Regina S Cunningham
- Center for Health Outcomes and Policy Research, The University of Pennsylvania School of Nursing
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Matthew D McHugh
- Center for Health Outcomes and Policy Research, The University of Pennsylvania School of Nursing
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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Kutney-Lee A, Brooks Carthon M, Sloane DM, Bowles KH, McHugh MD, Aiken LH. Electronic Health Record Usability: Associations With Nurse and Patient Outcomes in Hospitals. Med Care 2021; 59:625-631. [PMID: 33797506 PMCID: PMC8187272 DOI: 10.1097/mlr.0000000000001536] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Electronic health record (EHR) usability issues represent an emerging threat to the wellbeing of nurses and patients; however, few large studies have examined these relationships. OBJECTIVE To examine associations between EHR usability and nurse job (burnout, job dissatisfaction, and intention to leave) and surgical patient (inpatient mortality and 30-day readmission) outcomes. METHODS A cross-sectional analysis of linked American Hospital Association, state patient discharge, and nurse survey data was conducted. The sample included 343 hospitals, 1,281,848 surgical patients, and 12,004 nurses. Logistic regression models were used to assess relationships between EHR usability and outcomes, before and after accounting for EHR adoption level (comprehensive vs. basic or less) and other confounders. RESULTS In fully adjusted models, nurses who worked in hospitals with poorer EHR usability had significantly higher odds of burnout [odds ratio (OR), 1.41; 95% confidence interval (CI), 1.21-1.64], job dissatisfaction (OR, 1.61; 95% CI, 1.37-1.90) and intention to leave (OR, 1.31; 95% CI, 1.09-1.58) compared with nurses working in hospitals with better usability. Surgical patients treated in hospitals with poorer EHR usability had significantly higher odds of inpatient mortality (OR, 1.21; 95% CI, 1.09-1.35) and 30-day readmission (OR, 1.06; 95% CI, 1.01-1.12) compared with patients in hospitals with better usability. Comprehensive EHR adoption was associated with higher odds of nurse burnout (OR, 1.14; 95% CI, 1.01-1.28). CONCLUSION Employing EHR systems with suboptimal usability was associated with higher odds of adverse nurse job outcomes and surgical patient mortality and readmission. EHR usability may be more important to nurse job and patient outcomes than comprehensive EHR adoption.
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Affiliation(s)
- Ann Kutney-Lee
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing
- Corporal Michael J. Crescenz VA Medical Center
| | - Margo Brooks Carthon
- Center for Health Outcomes and Policy Research, Leonard Davis Institute for Health Economics
| | - Douglas M Sloane
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing
| | - Kathryn H Bowles
- NewCourtland Center for Transitions and Health, Leonard Davis Institute for Health Economics, University of Pennsylvania School of Nursing, Philadelphia, PA
| | - Matthew D McHugh
- Center for Health Outcomes and Policy Research, Leonard Davis Institute for Health Economics
| | - Linda H Aiken
- Center for Health Outcomes and Policy Research, Leonard Davis Institute for Health Economics
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Lasater KB, Sloane DM, McHugh MD, Cimiotti JP, Riman KA, Martin B, Alexander M, Aiken LH. Evaluation of hospital nurse-to-patient staffing ratios and sepsis bundles on patient outcomes. Am J Infect Control 2021; 49:868-873. [PMID: 33309843 DOI: 10.1016/j.ajic.2020.12.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/02/2020] [Accepted: 12/03/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Despite nurses' responsibilities in recognition and treatment of sepsis, little evidence documents whether patient-to-nurse staffing ratios are associated with clinical outcomes for patients with sepsis. METHODS Using linked data sources from 2017 including MEDPAR patient claims, Hospital Compare, American Hospital Association, and a large survey of nurses, we estimate the effect of hospital patient-to-nurse staffing ratios and adherence to the Early Management Bundle for patients with Severe Sepsis/Septic Shock SEP-1 sepsis bundles on patients' odds of in-hospital and 60-day mortality, readmission, and length of stay. Logistic regression is used to estimate mortality and readmission, while zero-truncated negative binomial models are used for length of stay. RESULTS Each additional patient per nurse is associated with 12% higher odds of in-hospital mortality, 7% higher odds of 60-day mortality, 7% higher odds of 60-day readmission, and longer lengths of stay, even after accounting for patient and hospital covariates including hospital adherence to SEP-1 bundles. Adherence to SEP-1 bundles is associated with lower in-hospital mortality and shorter lengths of stay; however, the effects are markedly smaller than those observed for staffing. DISCUSSION Improving hospital nurse staffing over and above implementing sepsis bundles holds promise for significant improvements in sepsis patient outcomes.
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Affiliation(s)
- Karen B Lasater
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.
| | - Douglas M Sloane
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PA
| | - Matthew D McHugh
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | | | - Kathryn A Riman
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Brendan Martin
- National Council of State Boards of Nursing, Chicago, IL
| | | | - Linda H Aiken
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Lasater KB, Sloane DM, McHugh MD, Porat-Dahlerbruch J, Aiken LH. Changes in proportion of bachelor's nurses associated with improvements in patient outcomes. Res Nurs Health 2021; 44:787-795. [PMID: 34128242 DOI: 10.1002/nur.22163] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/18/2021] [Accepted: 06/03/2021] [Indexed: 11/11/2022]
Abstract
This study uses data from two cross-sections in time (2006, 2016) to determine whether changes over time in hospital employment of bachelor's of science in nursing (BSN) nurses is associated with changes in patient outcomes. Data sources include nurse survey data, American Hospital Association Annual Survey data, and patient administrative claims data from state agencies in California, Florida, New Jersey, and Pennsylvania. The study sample included general surgical patients aged 18-99 years admitted to one of the 519 study hospitals. Multilevel logistic regression and truncated negative binomial models were used to estimate the cross-sectional and longitudinal effects of the proportion of hospital BSN nurses on patient outcomes (i.e., in-hospital mortality, 7- and 30-day readmissions, length of stay). Between 2006 and 2016, the average proportion of BSN nurses in hospitals increased from 41% to 56%. Patients in hospitals that increased their proportion of BSN nurses over time had significantly reduced odds of risk-adjusted mortality (odds ratio [OR]: 0.95, 95% confidence interval [CI]: 0.92-0.98), 7-day readmission (OR: 0.96, 95% CI: 0.94-0.99) and 30-day readmission (OR: 0.98, 95% CI: 0.95-1.00), and shorter lengths of stay (incident rate ratio [IRR]: 0.98, 95% CI: 0.97-0.99). Longitudinal findings of an association between increased proportions of BSN nurses and improvements in patient outcomes corroborate previous cross-sectional research, suggesting that a better educated nurse workforce may add value to hospitals and patients.
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Affiliation(s)
- Karen B Lasater
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Douglas M Sloane
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew D McHugh
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua Porat-Dahlerbruch
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Linda H Aiken
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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15
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McHugh MD, Aiken LH, Sloane DM, Windsor C, Douglas C, Yates P. Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals. Lancet 2021; 397:1905-1913. [PMID: 33989553 PMCID: PMC8408834 DOI: 10.1016/s0140-6736(21)00768-6] [Citation(s) in RCA: 109] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 03/21/2021] [Accepted: 03/25/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Substantial evidence indicates that patient outcomes are more favourable in hospitals with better nurse staffing. One policy designed to achieve better staffing is minimum nurse-to-patient ratio mandates, but such policies have rarely been implemented or evaluated. In 2016, Queensland (Australia) implemented minimum nurse-to-patient ratios in selected hospitals. We aimed to assess the effects of this policy on staffing levels and patient outcomes and whether both were associated. METHODS For this prospective panel study, we compared Queensland hospitals subject to the ratio policy (27 intervention hospitals) and those that discharged similar patients but were not subject to ratios (28 comparison hospitals) at two timepoints: before implementation of ratios (baseline) and 2 years after implementation (post-implementation). We used standardised Queensland Hospital Admitted Patient Data, linked with death records, to obtain data on patient characteristics and outcomes (30-day mortality, 7-day readmissions, and length of stay [LOS]) for medical-surgical patients and survey data from 17 010 medical-surgical nurses in the study hospitals before and after policy implementation. Survey data from nurses were used to measure nurse staffing and, after linking with standardised patient data, to estimate the differential change in outcomes between patients in intervention and comparison hospitals, and determine whether nurse staffing changes were related to it. FINDINGS We included 231 902 patients (142 986 in intervention hospitals and 88 916 in comparison hospitals) assessed at baseline (2016) and 257 253 patients (160 167 in intervention hospitals and 97 086 in comparison hospitals) assessed in the post-implementation period (2018). After implementation, mortality rates were not significantly higher than at baseline in comparison hospitals (adjusted odds ratio [OR] 1·07, 95% CI 0·97-1·17, p=0·18), but were significantly lower than at baseline in intervention hospitals (0·89, 0·84-0·95, p=0·0003). From baseline to post-implementation, readmissions increased in comparison hospitals (1·06, 1·01-1·12, p=0·015), but not in intervention hospitals (1·00, 0·95-1·04, p=0·92). Although LOS decreased in both groups post-implementation, the reduction was more pronounced in intervention hospitals than in comparison hospitals (adjusted incident rate ratio [IRR] 0·95, 95% CI 0·92-0·99, p=0·010). Staffing changed in hospitals from baseline to post-implementation: of the 36 hospitals with reliable staffing measures, 30 (83%) had more than 4·5 patients per nurse at baseline, with the number decreasing to 21 (58%) post-implementation. The majority of change was at intervention hospitals, and staffing improvements by one patient per nurse produced reductions in mortality (OR 0·93, 95% CI 0·86-0·99, p=0·045), readmissions (0·93, 0·89-0·97, p<0·0001), and LOS (IRR 0·97, 0·94-0·99, p=0·035). In addition to producing better outcomes, the costs avoided due to fewer readmissions and shorter LOS were more than twice the cost of the additional nurse staffing. INTERPRETATION Minimum nurse-to-patient ratio policies are a feasible approach to improve nurse staffing and patient outcomes with good return on investment. FUNDING Queensland Health, National Institutes of Health, National Institute of Nursing Research.
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Affiliation(s)
- Matthew D McHugh
- School of Nursing, Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, PA, USA.
| | - Linda H Aiken
- School of Nursing, Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, PA, USA
| | - Douglas M Sloane
- School of Nursing, Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, PA, USA
| | - Carol Windsor
- School of Nursing, Queensland University of Technology, Kelvin Grove, QLD, Australia; Centre for Healthcare Transformation, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Clint Douglas
- School of Nursing, Queensland University of Technology, Kelvin Grove, QLD, Australia; Centre for Healthcare Transformation, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia; Metro North Hospital and Health Service, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Patsy Yates
- School of Nursing, Queensland University of Technology, Kelvin Grove, QLD, Australia; Centre for Healthcare Transformation, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
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Lasater KB, Aiken LH, Sloane DM, French R, Anusiewicz CV, Martin B, Reneau K, Alexander M, McHugh MD. Is Hospital Nurse Staffing Legislation in the Public's Interest?: An Observational Study in New York State. Med Care 2021; 59:444-450. [PMID: 33655903 PMCID: PMC8026733 DOI: 10.1097/mlr.0000000000001519] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Safe Staffing for Quality Care Act under consideration in the New York (NY) state assembly would require hospitals to staff enough nurses to safely care for patients. The impact of regulated minimum patient-to-nurse staffing ratios in acute care hospitals in NY is unknown. OBJECTIVES To examine variation in patient-to-nurse staffing in NY hospitals and its association with adverse outcomes (ie, mortality and avoidable costs). RESEARCH DESIGN Cross-sectional data on nurse staffing in 116 acute care general hospitals in NY are linked with Medicare claims data. SUBJECTS A total of 417,861 Medicare medical and surgical patients. MEASURES Patient-to-nurse staffing is the primary predictor variable. Outcomes include in-hospital mortality, length of stay, 30-day readmission, and estimated costs using Medicare-specific cost-to-charge ratios. RESULTS Hospital staffing ranged from 4.3 to 10.5 patients per nurse (P/N), and averaged 6.3 P/N. After adjusting for potential confounders each additional patient per nurse, for surgical and medical patients, respectively, was associated with higher odds of in-hospital mortality [odds ratio (OR)=1.13, P=0.0262; OR=1.13, P=0.0019], longer lengths of stay (incidence rate ratio=1.09, P=0.0008; incidence rate ratio=1.05, P=0.0023), and higher odds of 30-day readmission (OR=1.08, P=0.0002; OR=1.06, P=0.0003). Were hospitals staffed at the 4:1 P/N ratio proposed in the legislation, we conservatively estimated 4370 lives saved and $720 million saved over the 2-year study period in shorter lengths of stay and avoided readmissions. CONCLUSIONS Patient-to-nurse staffing varies substantially across NY hospitals and higher ratios adversely affect patients. Our estimates of potential lives and costs saved substantially underestimate potential benefits of improved hospital nurse staffing.
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Affiliation(s)
- Karen B. Lasater
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Linda H. Aiken
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Douglas M. Sloane
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania
| | - Rachel French
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Colleen V. Anusiewicz
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Brendan Martin
- National Council of State Boards of Nursing, Chicago, IL
| | - Kyrani Reneau
- National Council of State Boards of Nursing, Chicago, IL
| | | | - Matthew D. McHugh
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Brooks Carthon M, Brom H, McHugh M, Sloane DM, Berg R, Merchant R, Girotra S, Aiken LH. Better Nurse Staffing Is Associated With Survival for Black Patients and Diminishes Racial Disparities in Survival After In-Hospital Cardiac Arrests. Med Care 2021; 59:169-176. [PMID: 33201082 PMCID: PMC7855314 DOI: 10.1097/mlr.0000000000001464] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Racial disparities in survival among patients who had an in-hospital cardiac arrest (IHCA) have been linked to hospital-level factors. OBJECTIVES To determine whether nurse staffing is associated with survival disparities after IHCA. RESEARCH DESIGN Cross-sectional data from (1) the American Heart Association's Get With the Guidelines-Resuscitation database; (2) the University of Pennsylvania Multi-State Nursing Care and Patient Safety Survey; and (3) The American Hospital Association annual survey. Risk-adjusted logistic regression models, which took account of the hospital and patient characteristics, were used to determine the association of nurse staffing and survival to discharge for black and white patients. SUBJECTS A total of 14,132 adult patients aged 18 and older between 2004 and 2010 in 75 hospitals in 4 states. RESULTS In models that accounted for hospital and patient characteristics, the odds of survival to discharge was lower for black patients than white patients [odds ratio (OR)=0.70; 95% confidence interval (CI), 0.61-0.82]. A significant interaction was found between race and medical-surgical nurse staffing for survival to discharge, such that each additional patient per nurse lowered the odds of survival for black patients (OR=0.92; 95% CI, 0.87-0.97) more than white patients (OR=0.97; 95% CI, 0.93-1.00). CONCLUSIONS Our findings suggest that disparities in IHCA survival between black and white patients may be linked to the level of medical-surgical nurse staffing in the hospitals in which they receive care and that the benefit of being admitted to hospitals with better staffing may be especially pronounced for black patients.
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Affiliation(s)
- Margo Brooks Carthon
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing
| | - Heather Brom
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing
| | - Matthew McHugh
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing
| | - Douglas M. Sloane
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing
| | - Robert Berg
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care, Children’s Hospital of Philadelphia
| | - Raina Merchant
- Department of Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Saket Girotra
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Iowa Carver College of Medicine Comprehensive Access Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Medical Center, Iowa City, IA
| | - Linda H. Aiken
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing
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Lake ET, Riman KA, Sloane DM. Improved work environments and staffing lead to less missed nursing care: A panel study. J Nurs Manag 2020; 28:2157-2165. [PMID: 32017302 PMCID: PMC7590500 DOI: 10.1111/jonm.12970] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/24/2020] [Accepted: 01/30/2020] [Indexed: 11/28/2022]
Abstract
AIM To document how changes in the hospital work environment and nurse staffing over time are associated with changes in missed nursing care. BACKGROUND Missed nursing care is considered an indicator of poorer care quality and has been associated with worse patient care experiences and health outcomes. Several systematic reviews of cross-sectional studies report that nurses in hospitals with supportive work environments and higher staffing miss less care. Causal evidence demonstrating these relationships is needed. METHODS This panel study utilized secondary data from 23,650 nurses surveyed in 2006 and 14,935 surveyed in 2016 in 458 hospitals from a four-state survey of random samples of licensed nurses. RESULTS Over the 10-year period, most hospitals exhibited improved work environments, better nurse staffing and more missed care. In hospitals with improved work environments or nurse staffing, the prevalence and frequency of missed care decreased significantly. The effect on missed care of changes in the work environment was greater than that of nurse staffing. CONCLUSIONS Changes in the hospital work environment and staffing influence missed care. IMPLICATIONS FOR NURSING MANAGEMENT Modifications in the work environment and staffing are strategies to mitigate care compromise. Nurse managers should investigate work settings in order to identify weaknesses.
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Affiliation(s)
- Eileen T Lake
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kathryn A Riman
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Douglas M Sloane
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
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Harrison JM, Aiken LH, Sloane DM, Brooks Carthon JM, Merchant RM, Berg RA, McHugh MD. In Hospitals With More Nurses Who Have Baccalaureate Degrees, Better Outcomes For Patients After Cardiac Arrest. Health Aff (Millwood) 2020; 38:1087-1094. [PMID: 31260358 DOI: 10.1377/hlthaff.2018.05064] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In 2010, prompted by compelling evidence that demonstrated better patient outcomes in hospitals with higher percentages of nurses with a bachelor of science in nursing (BSN), the Institute of Medicine recommended that 80 percent of the nurse workforce be qualified at that level or higher by 2020. Using data from the American Heart Association's Get With the Guidelines-Resuscitation registry (for 2013-18), RN4CAST-US hospital nurse surveys (2015-16), and the American Hospital Association (2015), we found that each 10-percentage-point increase in the hospital share of nurses with a BSN was associated with 24 percent greater odds of surviving to discharge with good cerebral performance among patients who experienced in-hospital cardiac arrest. Lower patient-to-nurse ratios on general medical and surgical units were also associated with significantly greater odds of surviving with good cerebral performance. These findings contribute to the growing body of evidence that supports policies to increase access to baccalaureate-level education and improve hospital nurse staffing.
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Affiliation(s)
- Jordan M Harrison
- Jordan M. Harrison ( ) is a research fellow in the Center for Health Outcomes and Policy Research, a National Clinical Scholar in the Perelman School of Medicine, and an associate fellow in the Leonard Davis Institute of Health Economics, all at the University of Pennsylvania, in Philadelphia
| | - Linda H Aiken
- Linda H. Aiken is the Claire M. Fagin Leadership Professor of Nursing, a professor of sociology, director of the Center for Health Outcomes and Policy Research, and a senior fellow in the Leonard Davis Institute of Health Economics, all at the University of Pennsylvania
| | - Douglas M Sloane
- Douglas M. Sloane is an adjunct professor at the Center for Health Outcomes and Policy Research, University of Pennsylvania
| | - J Margo Brooks Carthon
- J. Margo Brooks Carthon is an associate professor in the Center for Health Outcomes and Policy Research and a senior fellow in the Leonard Davis Institute of Health Economics, University of Pennsylvania
| | - Raina M Merchant
- Raina M. Merchant is an associate professor of emergency medicine in the Perelman School of Medicine, director of the Penn Medicine Center for Digital Health, and a senior fellow in the Leonard Davis Institute of Health Economics, all at the University of Pennsylvania
| | - Robert A Berg
- Robert A. Berg is a professor of anesthesiology and critical care at the Children's Hospital of Philadelphia
| | - Matthew D McHugh
- Matthew D. McHugh is a professor of nursing, the Independence Chair for Nursing Education, associate director of the Center for Health Outcomes and Policy Research, and a senior fellow in the Leonard Davis Institute of Health Economics, all at the University of Pennsylvania
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- The American Heart Association's Get With the Guidelines-Resuscitation Investigators are acknowledged at the end of the article
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Lasater KB, Aiken LH, Sloane DM, French R, Martin B, Reneau K, Alexander M, McHugh MD. Chronic hospital nurse understaffing meets COVID-19: an observational study. BMJ Qual Saf 2020; 30:639-647. [PMID: 32817399 PMCID: PMC7443196 DOI: 10.1136/bmjqs-2020-011512] [Citation(s) in RCA: 131] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/25/2020] [Accepted: 08/02/2020] [Indexed: 12/12/2022]
Abstract
Introduction Efforts to enact nurse staffing legislation often lack timely, local evidence about how specific policies could directly impact the public’s health. Despite numerous studies indicating better staffing is associated with more favourable patient outcomes, only one US state (California) sets patient-to-nurse staffing standards. To inform staffing legislation actively under consideration in two other US states (New York, Illinois), we sought to determine whether staffing varies across hospitals and the consequences for patient outcomes. Coincidentally, data collection occurred just prior to the COVID-19 outbreak; thus, these data also provide a real-time example of the public health implications of chronic hospital nurse understaffing. Methods Survey data from nurses and patients in 254 hospitals in New York and Illinois between December 2019 and February 2020 document associations of nurse staffing with care quality, patient experiences and nurse burnout. Results Mean staffing in medical-surgical units varied from 3.3 to 9.7 patients per nurse, with the worst mean staffing in New York City. Over half the nurses in both states experienced high burnout. Half gave their hospitals unfavourable safety grades and two-thirds would not definitely recommend their hospitals. One-third of patients rated their hospitals less than excellent and would not definitely recommend it to others. After adjusting for confounding factors, each additional patient per nurse increased odds of nurses and per cent of patients giving unfavourable reports; ORs ranged from 1.15 to 1.52 for nurses on medical-surgical units and from 1.32 to 3.63 for nurses on intensive care units. Conclusions Hospital nurses were burned out and working in understaffed conditions in the weeks prior to the first wave of COVID-19 cases, posing risks to the public’s health. Such risks could be addressed by safe nurse staffing policies currently under consideration.
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Affiliation(s)
- Karen B Lasater
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA .,Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, USA
| | - Linda H Aiken
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, USA
| | - Douglas M Sloane
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rachel French
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, USA
| | - Brendan Martin
- National Council of State Boards of Nursing, Chicago, Illinois, USA
| | - Kyrani Reneau
- National Council of State Boards of Nursing, Chicago, Illinois, USA
| | | | - Matthew D McHugh
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, USA
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Abstract
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.
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Affiliation(s)
- Amanda P Bettencourt
- The National Clinician Scholars Program, Department of Systems, Populations, and Leadership, The University of Michigan School of Nursing, Ann Arbor
| | - Matthew D McHugh
- Center for Health Outcomes and Policy Research
- Leonard Davis Institute of Health Economics
| | | | - Linda H Aiken
- Center for Health Outcomes and Policy Research
- Leonard Davis Institute of Health Economics
- School of Nursing, University of Pennsylvania, Philadelphia
- School of Arts and Sciences, University of Pennsylvania, Philadelphia
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Abstract
Introduction The current shortage of physicians in the United States has potential to dramatically limit access to healthcare. Nurse practitioners (NPs) can provide a cost-effective solution to the shortage, yet few states allow NPs to practice independently. Purpose The purpose of this study was to provide an up-to-date description of the NP workforce and to identify the professional and organizational factors associated with NP care quality. Methods Cross-sectional survey data from a sample of NPs actively employed in four states with reduced or restricted practice (California, Florida, New Jersey, and Pennsylvania) was used. NPs were categorized into acute and primary care. Regression models were fit to estimate the odds of three measures of care quality: overall quality of patient care, NP confidence that patients and their caregivers can manage their care at home, and whether NPs would recommend their practice facility to family and friends. Results Receiving support from administrative staff and physicians was associated with an increase in the three measures of quality. The greatest effects were seen in primary care settings. Conclusion It is imperative that legislators and healthcare administrators implement policies that provide NPs with an environment that supports clinical practice and enhances care delivery.
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Affiliation(s)
| | - Yin Li
- Nell Hodgson Woodruff School of Nursing, Emory University
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Aiken LH, Sloane DM, Barnes H, Cimiotti JP, Jarrín OF, McHugh MD. Nurses' And Patients' Appraisals Show Patient Safety In Hospitals Remains A Concern. Health Aff (Millwood) 2019; 37:1744-1751. [PMID: 30395515 DOI: 10.1377/hlthaff.2018.0711] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Institute of Medicine concluded in To Err Is Human in 1999 that transformation of nurse work environments was needed to reduce patient harm. We studied 535 hospitals in four large states at two points in time between 2005 and 2016 to determine the extent to which their work environments improved, and whether positive changes were associated with greater progress in patient safety. Survey data from thousands of nurses and patients showed that patient safety remains a serious concern. Only 21 percent of study hospitals showed sizable improvements (of more than 10 percent) in work environment scores, while 7 percent had worse scores. For hospitals in which clinical care environments improved, patients and nurses reported improvements in patient safety indicators. These included increases in percentages of patients rating their hospital favorably (a change of 11 percent) and stating that they would definitely recommend the hospital (8 percent) and in percentages of nurses reporting excellent quality of care (15 percent) and giving the hospital a favorable grade on patient safety (15 percent). Where work environments deteriorated, fewer nurses (-19 percent) gave a favorable grade on patient safety. Failure to improve hospital work environments may be hampering progress on patient safety.
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Affiliation(s)
- Linda H Aiken
- Linda H. Aiken ( ) is the Claire M. Fagin Leadership Professor of Nursing, professor of sociology, director of the Center for Health Outcomes and Policy Research, and a senior fellow at the Leonard Davis Institute of Health Economics, all at the University of Pennsylvania, in Philadelphia
| | - Douglas M Sloane
- Douglas M. Sloane is an adjunct professor at the Center for Health Outcomes and Policy Research and the School of Nursing, University of Pennsylvania
| | - Hilary Barnes
- Hilary Barnes is an assistant professor in the School of Nursing, University of Delaware, in Newark
| | - Jeannie P Cimiotti
- Jeannie P. Cimiotti is an associate professor in the School of Nursing, Emory University, in Atlanta, Georgia
| | - Olga F Jarrín
- Olga F. Jarrín is an assistant professor in the School of Nursing, Institute for Health, Health Care Policy, and Aging Research at Rutgers, the State University of New Jersey, in New Brunswick
| | - Matthew D McHugh
- Matthew D. McHugh is a professor of nursing, the Independence Chair for Nursing Education, associate director of the Center for Health Outcomes and Policy Research, and a senior fellow at the Leonard Davis Institute of Health Economics, all at the University of Pennsylvania
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Kutney-Lee A, Sloane DM, Bowles KH, Burns LR, Aiken LH. Electronic Health Record Adoption and Nurse Reports of Usability and Quality of Care: The Role of Work Environment. Appl Clin Inform 2019; 10:129-139. [PMID: 30786302 DOI: 10.1055/s-0039-1678551] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Despite evidence suggesting higher quality and safer care in hospitals with comprehensive electronic health record (EHR) systems, factors related to advanced system usability remain largely unknown, particularly among nurses. Little empirical research has examined sociotechnical factors, such as the work environment, that may shape the relationship between advanced EHR adoption and quality of care. OBJECTIVE The objective of this study was to examine the independent and joint effects of comprehensive EHR adoption and the hospital work environment on nurse reports of EHR usability and nurse-reported quality of care and safety. METHODS This study was a secondary analysis of nurse and hospital survey data. Unadjusted and adjusted logistic regression models were used to assess the relationship between EHR adoption level, work environment, and a set of EHR usability and quality/safety outcomes. The sample included 12,377 nurses working in 353 hospitals. RESULTS In fully adjusted models, comprehensive EHR adoption was associated with lower odds of nurses reporting poor usability outcomes, such as dissatisfaction with the system (odds ratio [OR]: 0.75; 95% confidence interval [CI]: 0.61-0.92). The work environment was associated with all usability outcomes with nurses in better environments being less likely to report negatively. Comprehensive EHRs (OR: 0.83; 95% CI: 0.71-0.96) and better work environments (OR: 0.47; 95% CI: 0.42-0.52) were associated with lower odds of nurses reporting fair/poor quality of care, while poor patient safety grade was associated with the work environment (OR: 0.50; 95% CI: 0.46-0.54), but not EHR adoption level. CONCLUSION Our findings suggest that adoption of a comprehensive EHR is associated with more positive usability ratings and higher quality of care. We also found that-independent of EHR adoption level-the hospital work environment plays a significant role in how nurses evaluate EHR usability and whether EHRs have their intended effects on improving quality and safety of care.
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Affiliation(s)
- Ann Kutney-Lee
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, United States.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, United States
| | - Douglas M Sloane
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, United States
| | - Kathryn H Bowles
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, United States
| | - Lawton R Burns
- The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Linda H Aiken
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, United States
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Lasater KB, Sloane DM, McHugh MD, Aiken LH. Quality of End-of-Life Care and Its Association with Nurse Practice Environments in U.S. Hospitals. J Am Geriatr Soc 2019; 67:302-308. [PMID: 30506666 PMCID: PMC6367037 DOI: 10.1111/jgs.15671] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 09/18/2018] [Accepted: 09/26/2018] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The purpose of this study is twofold: (1) to describe the quality of end-of-life care in US hospitals from the perspective of hospital nurses; and (2) to evaluate the relationship between the nurse practice environment and end-of-life care quality. DESIGN Cross-sectional analysis of multiple linked secondary data sources. PARTICIPANTS AND SETTING A total of 12,870 direct care registered nurses in 491 acute-care hospitals. MEASUREMENTS Measures of end-of-life care quality and nurse practice environment were derived from the 2016 RN4CAST-US survey of nurses. Nurses reported on end-of-life care quality for patients for whom death within a year would not be surprising. Nurse practice environment was measured using the Practice Environment Scale of the Nursing Work Index, a National Quality Forum validated scale. RESULTS Most nurses gave their hospitals an unfavorable evaluation of end-of-life care overall (58%) and said patients often experience painful procedures that were unlikely to change their outcome (53%). The best predictor of poor quality was the nurse practice environment. Nurses in the best environments were 55% less likely than nurses in poor environments to rate their hospital's overall end-of-life care quality unfavorably (odds ratio = 0.45; 95% confidence interval = 0.39-0.52; P < .001). CONCLUSION Quality of end-of-life care in US hospitals is imperfect and is significantly worse in hospitals with poor nurse practice environments than in hospitals with the best environments. This study reinforces the importance of nurses in providing high-quality end-of-life care. J Am Geriatr Soc 67:302-308, 2019.
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Affiliation(s)
- Karen B. Lasater
- Assistant Professor of Nursing, Senior Fellow, Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania
| | - Douglas M. Sloane
- Adjunct Professor of Nursing, Senior Fellow, Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania
| | - Matthew D. McHugh
- The Independence Chair for Nursing Education Professor of Nursing Associate Director, Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania
| | - Linda H. Aiken
- Claire M. Fagin Leadership Professor in Nursing, Professor of Sociology, School of Arts and Sciences, Director, Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania
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Sloane DM, Smith HL, McHugh MD, Aiken LH. Effect of Changes in Hospital Nursing Resources on Improvements in Patient Safety and Quality of Care: A Panel Study. Med Care 2018; 56:1001-1008. [PMID: 30363019 PMCID: PMC6231998 DOI: 10.1097/mlr.0000000000001002] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Evidence shows hospitals with better nursing resources have better outcomes but few studies have shown that outcomes change over time within hospitals as nursing resources change. OBJECTIVES To determine whether changes in nursing resources over time within hospitals are related to changes in quality of care and patient safety. RESEARCH DESIGN Multilevel logistic response models, using data from a panel of 737 hospitals in which cross-sections of nurse informants surveyed in 2006 and 2016, were used to simultaneously estimate longitudinal and cross-sectional associations between nursing resources, quality of care, and patient safety. MEASURES Nursing resources included hospital-level measures of work environments, nurse staffing, and nurse education. Care quality was measured by overall rating of care quality, confidence in patients managing care after discharge, confidence in management resolving patient care problems; patient safety was measured by patient safety grade, concern with mistakes, and freedom to question authority. RESULTS After taking into account cross-sectional differences between hospitals, differences among nurses within hospitals, and potential confounding variables, changes within hospitals in nursing resources were associated with significant changes in quality of care and patient safety. Improvements in work environment of 1 SD decrease odds of unfavorable quality care and patient safety by factors ranging from 0.82 to 0.97. CONCLUSIONS Improvements within hospitals in work environments, nurse staffing, and educational composition of nurses coincide with improvements in quality of care and patient safety. Cross-sectional results closely approximate longitudinal panel results.
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Affiliation(s)
- Douglas M. Sloane
- Center for Health Outcomes and Policy Research, Leonard Davis Institute of Health Economics, University of Pennsylvania School of Nursing,
| | - Herbert L. Smith
- Department of Sociology, Population Studies Center, Center for Health Outcomes and Policy Research, Leonard Davis Institute of Health Economics, University of Pennsylvania,
| | - Matthew D. McHugh
- Center for Health Outcomes and Policy Research, Leonard Davis Institute of Health Economics, University of Pennsylvania School of Nursing,
| | - Linda H. Aiken
- Center for Health Outcomes and Policy Research, Leonard Davis Institute of Health Economics, University of Pennsylvania School of Nursing,
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Aiken LH, Sloane DM, Ball J, Bruyneel L, Rafferty AM, Griffiths P. Patient satisfaction with hospital care and nurses in England: an observational study. BMJ Open 2018; 8:e019189. [PMID: 29326193 PMCID: PMC5781188 DOI: 10.1136/bmjopen-2017-019189] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 09/07/2017] [Accepted: 09/13/2017] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVES To inform healthcare workforce policy decisions by showing how patient perceptions of hospital care are associated with confidence in nurses and doctors, nurse staffing levels and hospital work environments. DESIGN Cross-sectional surveys of 66 348 hospital patients and 2963 inpatient nurses. SETTING Patients surveyed were discharged in 2010 from 161 National Health Service (NHS) trusts in England. Inpatient nurses were surveyed in 2010 in a sample of 46 hospitals in 31 of the same 161 trusts. PARTICIPANTS The 2010 NHS Survey of Inpatients obtained information from 50% of all patients discharged between June and August. The 2010 RN4CAST England Nurse Survey gathered information from inpatient medical and surgical nurses. MAIN OUTCOME MEASURES Patient ratings of their hospital care, their confidence in nurses and doctors and other indicators of their satisfaction. Missed nursing care was treated as both an outcome measure and explanatory factor. RESULTS Patients' perceptions of care are significantly eroded by lack of confidence in either nurses or doctors, and by increases in missed nursing care. The average number of types of missed care was negatively related to six of the eight outcomes-ORs ranged from 0.78 (95% CI 0.68 to 0.90) for excellent care ratings to 0.86 (95% CI 0.77 to 0.95) for medications completely explained-positively associated with higher patient-to-nurse ratios (b=0.15, 95% CI 0.10 to 0.19), and negatively associated with better work environments (b=-0.26, 95% CI -0.48 to -0.04). CONCLUSIONS Patients' perceptions of hospital care are strongly associated with missed nursing care, which in turn is related to poor professional nurse (RN) staffing and poor hospital work environments. Improving RN staffing in NHS hospitals holds promise for enhancing patient satisfaction.
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Affiliation(s)
- Linda H Aiken
- School of Nursing, University of Pennsylvania, Center for Health Outcomes and Policy Research, Philadelphia, Pennsylvania, USA
| | - Douglas M Sloane
- School of Nursing, University of Pennsylvania, Center for Health Outcomes and Policy Research, Philadelphia, Pennsylvania, USA
| | - Jane Ball
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Luk Bruyneel
- University of Leuven, Leuven Institute for Healthcare Policy, Leuven, Belgium
| | - Anne Marie Rafferty
- Florence Nightingale School of Nursing and Midwifery, King's College London, London, UK
| | - Peter Griffiths
- Faculty of Health Sciences, University of Southampton, Southampton, UK
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Aiken LH, Sloane DM, Lake ET, Agosto P, Roberts KE. Is Magnet recognition associated with improved outcomes among critically ill children treated at freestanding children's hospitals? J Crit Care 2017; 43:372. [PMID: 29079325 DOI: 10.1016/j.jcrc.2017.10.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 10/13/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Linda H Aiken
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PA, United States.
| | - Douglas M Sloane
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PA, United States
| | - Eileen T Lake
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PA, United States
| | - Paula Agosto
- Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Kathryn E Roberts
- Children's Hospital of Philadelphia, Philadelphia, PA, United States
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Abstract
INTRODUCTION For over half a century, hospitals in the United States have actively recruited foreign-educated nurses (FENs) in response to nurse shortages in hospitals and nursing homes. Little attention has been paid to the quality of care in the United States related to employment of FENs. AIMS The purpose of this retrospective study was to determine whether employment of FENs in U.S. hospitals is associated with patient care experience. METHOD This study used cross-sectional data from three sources in 425 hospitals in four large states to evaluate the relationship between patient perceptions of care and hospital employment of FENs. The study linked data from publicly reported patient experience of care surveys, nurse surveys, and administrative data using unique hospital identifiers common across the data sets. RESULTS Patient-reported care experience was found to be more negative in hospitals employing more FENs, after controls for other possible explanations. Each 10% increase in FENs was associated with a decrease in the percentage of patients who would recommend their hospital and a decrease in the percentage of patients giving favorable reports on five nursing-specific aspects of patient experience. CONCLUSIONS The results of this study suggest that employment of substantial numbers of nurses educated outside the United States may have implications for quality of care. The findings suggest that research on the outcomes of transition programs for FENs would be useful to inform regulatory policies.
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Affiliation(s)
- Hayley D Germack
- Postdoctoral Fellow in the National Clinician Scholars Program at the Yale University School of Medicine
| | - Matthew D McHugh
- Professor and Independence Chair for Nursing Education, Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing
| | - Douglas M Sloane
- Adjunct Professor, Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing
| | - Linda H Aiken
- The Claire M. Fagin Leadership Professor of Nursing, Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing
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Ball JE, Bruyneel L, Aiken LH, Sermeus W, Sloane DM, Rafferty AM, Lindqvist R, Tishelman C, Griffiths P. Post-operative mortality, missed care and nurse staffing in nine countries: A cross-sectional study. Int J Nurs Stud 2017; 78:10-15. [PMID: 28844649 PMCID: PMC5826775 DOI: 10.1016/j.ijnurstu.2017.08.004] [Citation(s) in RCA: 265] [Impact Index Per Article: 37.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 08/04/2017] [Accepted: 08/08/2017] [Indexed: 12/12/2022]
Abstract
Background Variation in post-operative mortality rates has been associated with differences in registered nurse staffing levels. When nurse staffing levels are lower there is also a higher incidence of necessary but missed nursing care. Missed nursing care may be a significant predictor of patient mortality following surgery. Aim Examine if missed nursing care mediates the observed association between nurse staffing levels and mortality. Method Data from the RN4CAST study (2009–2011) combined routinely collected data on 422,730 surgical patients from 300 general acute hospitals in 9 countries, with survey data from 26,516 registered nurses, to examine associations between nurses’ staffing, missed care and 30-day in-patient mortality. Staffing and missed care measures were derived from the nurse survey. A generalized estimation approach was used to examine the relationship between first staffing, and then missed care, on mortality. Bayesian methods were used to test for mediation. Results Nurse staffing and missed nursing care were significantly associated with 30-day case-mix adjusted mortality. An increase in a nurse’s workload by one patient and a 10% increase in the percent of missed nursing care were associated with a 7% (OR 1.068, 95% CI 1.031–1.106) and 16% (OR 1.159 95% CI 1.039–1.294) increase in the odds of a patient dying within 30 days of admission respectively. Mediation analysis shows an association between nurse staffing and missed care and a subsequent association between missed care and mortality. Conclusion Missed nursing care, which is highly related to nurse staffing, is associated with increased odds of patients dying in hospital following common surgical procedures. The analyses support the hypothesis that missed nursing care mediates the relationship between registered nurse staffing and risk of patient mortality. Measuring missed care may provide an ‘early warning’ indicator of higher risk for poor patient outcomes.
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Affiliation(s)
- Jane E Ball
- Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet (KI), Stockholm, Sweden; University of Southampton & National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Wessex, Southampton, United Kingdom.
| | - Luk Bruyneel
- KU Leuven Institute for Healthcare Policy, University of Leuven, Leuven, Belgium
| | - Linda H Aiken
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA 19104, USA
| | - Walter Sermeus
- KU Leuven Institute for Healthcare Policy, University of Leuven, Leuven, Belgium
| | - Douglas M Sloane
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA 19104, USA
| | - Anne Marie Rafferty
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, England, United Kingdom
| | | | - Carol Tishelman
- LIME Karolinska Institutet & Innovation Centre, Karolinska University Hospital, Stockholm, Sweden
| | - Peter Griffiths
- Chair of Health Services Research, University of Southampton, & National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Wessex, Southampton, United Kingdom
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Germack HD, Griffiths P, Sloane DM, Rafferty AM, Ball JE, Aiken LH. Patient satisfaction and non-UK educated nurses: a cross-sectional observational study of English National Health Service Hospitals. BMJ Open 2015; 5:e009483. [PMID: 26634400 PMCID: PMC4680004 DOI: 10.1136/bmjopen-2015-009483] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To examine whether patient satisfaction with nursing care in National Health Service (NHS) hospitals in England is associated with the proportion of non-UK educated nurses providing care. DESIGN Cross-sectional analysis using data from the 2010 NHS Adult Inpatient Survey merged with data from nurse and hospital administrator surveys. Logistic regression models with corrections for clustering were used to determine whether the proportions of non-UK educated nurses were significantly related to patient satisfaction before and after taking account of other hospital, nursing and patient characteristics. SETTING 31 English NHS trusts. PARTICIPANTS 12,506 patients 16 years of age and older with at least one overnight stay that completed a satisfaction survey; 2962 bedside care nurses who completed a nurse survey; and 31 NHS trusts. MAIN OUTCOME MEASURE Patient satisfaction. RESULTS The percentage of non-UK educated nurses providing bedside hospital care, which ranged from 1% to 52% of nurses, was significantly associated with patient satisfaction. After controlling for potential confounding factors, each 10-point increase in the percentage of non-UK educated nurses diminished the odds of patients reporting good or excellent care by 12% (OR=0.88), and decreased the odds of patients agreeing that they always had confidence and trust in nurses by 13% (OR=0.87). Other indicators of patient satisfaction also revealed lower satisfaction in hospitals with higher percentages of non-UK educated nurses. CONCLUSIONS Use of non-UK educated nurses in English NHS hospitals is associated with lower patient satisfaction. Importing nurses from abroad to substitute for domestically educated nurses may negatively impact quality of care.
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Affiliation(s)
- Hayley D Germack
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Peter Griffiths
- National Institute for Health Research Collaboration for Applied Leadership in Health Research Wessex, University of Southampton, Southampton, UK
| | - Douglas M Sloane
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Anne Marie Rafferty
- National Nursing Research Unit, Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK
| | - Jane E Ball
- National Institute for Health Research Collaboration for Applied Leadership in Health Research Wessex, University of Southampton, Southampton, UK
| | - Linda H Aiken
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
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Stimpfel AW, Sloane DM, McHugh MD, Aiken LH. Hospitals Known for Nursing Excellence Associated with Better Hospital Experience for Patients. Health Serv Res 2015; 51:1120-34. [PMID: 26369862 DOI: 10.1111/1475-6773.12357] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To examine the relationship between Magnet recognition, an indicator of nursing excellence, and patients' experience with their hospitalization reported in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. DATA SOURCES This secondary analysis includes cross-sectional data from the 2010 HCAHPS survey, the American Hospital Association, and the American Nurses Credentialing Center. STUDY DESIGN We conducted a retrospective observational study. DATA COLLECTION Using common hospital identifiers, we created a matched set of 212 Magnet hospitals and 212 non-Magnet hospitals. PRINCIPAL FINDINGS Patients in Magnet hospitals gave their hospitals higher overall ratings, were more likely to recommend their hospital, and reported more positive care experiences with nurse communication. CONCLUSIONS Magnet recognition is associated with better patient care experiences, which may positively enhance reimbursement for hospitals.
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Affiliation(s)
| | - Douglas M Sloane
- Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, PA
| | - Matthew D McHugh
- Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, PA
| | - Linda H Aiken
- Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, PA
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Bruyneel L, Li B, Ausserhofer D, Lesaffre E, Dumitrescu I, Smith HL, Sloane DM, Aiken LH, Sermeus W. Organization of Hospital Nursing, Provision of Nursing Care, and Patient Experiences With Care in Europe. Med Care Res Rev 2015; 72:643-64. [PMID: 26062612 DOI: 10.1177/1077558715589188] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 05/06/2015] [Indexed: 11/15/2022]
Abstract
This study integrates previously isolated findings of nursing outcomes research into an explanatory framework in which care left undone and nurse education levels are of key importance. A moderated mediation analysis of survey data from 11,549 patients and 10,733 nurses in 217 hospitals in eight European countries shows that patient care experience is better in hospitals with better nurse staffing and a more favorable work environment in which less clinical care is left undone. Clinical care left undone is a mediator in this relationship. Clinical care is left undone less frequently in hospitals with better nurse staffing and more favorable nurse work environments, and in which nurses work less overtime and are more experienced. Higher proportions of nurses with a bachelor's degree reduce the effect of worse nurse staffing on more clinical care left undone.
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Affiliation(s)
| | - Baoyue Li
- Erasmus University Rotterdam, Rotterdam, Netherlands
| | | | - Emmanuel Lesaffre
- Katholieke Universiteit Leuven, Leuven, Belgium Erasmus University Rotterdam, Rotterdam, Netherlands
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Carthon JMB, Lasater KB, Sloane DM, Kutney-Lee A. The quality of hospital work environments and missed nursing care is linked to heart failure readmissions: a cross-sectional study of US hospitals. BMJ Qual Saf 2015; 24:255-63. [PMID: 25672342 DOI: 10.1136/bmjqs-2014-003346] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Threats to quality and patient safety may exist when necessary nursing care is omitted. Empirical research is needed to determine how missed nursing care is associated with patient outcomes. AIM The aim of this study was to examine the relationship between missed nursing care and hospital readmissions. METHODS Cross-sectional examination, using three linked data sources-(1) nurse survey, (2) patient discharge data from three states (California, New Jersey and Pennsylvania) and (3) administrative hospital data- from 2005 to 2006. We explored the incidence of 30-day readmission for 160 930 patients with heart failure in 419 acute care hospitals in the USA. Logistic regression was used to assess the effect of missed care on the odds of readmission, adjusting for patient and hospital characteristics. RESULTS The most frequently missed nursing care activities across all hospitals in our sample included talking to and comforting patients (42.0%), developing and updating care plans (35.8%) and educating patients and families (31.5%). For 4 of the 10 studied care activities, each 10 percentage-point increase in the number of nurses reporting having missed the activity was associated with an increase in the odds of readmission by 2-8% after adjusting for patient and hospital characteristics. However, missed nursing care was no longer a significant predictor of readmission once adjusting for the nurse work environment, except in the case of the delivery of treatments and procedures (OR 1.08, 95% CI 1.02 to 1.14). CONCLUSIONS Missed care is an independent predictor of heart failure readmissions. However, once adjusting for the quality of the nurse work environment, this relationship is attenuated. Improvements in nurses' working conditions may be one strategy to reduce care omissions and improve patient outcomes.
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Affiliation(s)
- J Margo Brooks Carthon
- Center for Health Outcomes & Policy Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Karen B Lasater
- Center for Health Outcomes & Policy Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Douglas M Sloane
- Center for Health Outcomes & Policy Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ann Kutney-Lee
- Center for Health Outcomes & Policy Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Cho E, Sloane DM, Kim EY, Kim S, Choi M, Yoo IY, Lee HS, Aiken LH. Effects of nurse staffing, work environments, and education on patient mortality: an observational study. Int J Nurs Stud 2015; 52:535-42. [PMID: 25213091 PMCID: PMC4286441 DOI: 10.1016/j.ijnurstu.2014.08.006] [Citation(s) in RCA: 174] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 07/22/2014] [Accepted: 08/15/2014] [Indexed: 01/04/2023]
Abstract
BACKGROUND While considerable evidence has been produced showing a link between nursing characteristics and patient outcomes in the U.S. and Europe, little is known about whether similar associations are present in South Korea. OBJECTIVE To examine the effects of nurse staffing, work environment, and education on patient mortality. METHODS This study linked hospital facility data with staff nurse survey data (N=1024) and surgical patient discharge data (N=76,036) from 14 high-technology teaching hospitals with 700 or more beds in South Korea, collected between January 1, 2008 and December 31, 2008. Logistic regression models that corrected for the clustering of patients in hospitals were used to estimate the effects of the three nursing characteristics on risk-adjusted patient mortality within 30 days of admission. RESULTS Risk-adjusted models reveal that nurse staffing, nurse work environments, and nurse education were significantly associated with patient mortality (OR 1.05, 95% CI 1.00-1.10; OR 0.52, 95% CI 0.31-0.88; and OR 0.91, CI 0.83-0.99; respectively). These odds ratios imply that each additional patient per nurse is associated with an 5% increase in the odds of patient death within 30 days of admission, that the odds of patient mortality are nearly 50% lower in the hospitals with better nurse work environments than in hospitals with mixed or poor nurse work environments, and that each 10% increase in nurses having Bachelor of Science in Nursing Degree is associated with a 9% decrease in patient deaths. CONCLUSIONS Nurse staffing, nurse work environments, and percentages of nurses having Bachelor of Science in Nursing Degree in South Korea are associated with patient mortality. Improving hospital nurse staffing and work environments and increasing the percentages of nurses having Bachelor of Science in Nursing Degree would help reduce the number of preventable in-hospital deaths.
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Affiliation(s)
- Eunhee Cho
- Nursing Policy Research Institute, Yonsei University College of Nursing, Seoul, South Korea
| | - Douglas M Sloane
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, PA, USA
| | - Eun-Young Kim
- Dong-A University, Department of Nursing, Busan, South Korea.
| | - Sera Kim
- Health Insurance Review & Assessment Service, Seoul, South Korea
| | - Miyoung Choi
- National Evidence-Based Healthcare Collaborating Agency, Seoul, South Korea
| | - Il Young Yoo
- Nursing Policy Research Institute, Yonsei University College of Nursing, Seoul, South Korea
| | - Hye Sun Lee
- Department of Biostatistics, Yonsei University College of Medicine, Seoul, South Korea
| | - Linda H Aiken
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, PA, USA
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Poghosyan L, Aiken LH, Sloane DM. Corrigendum to “Factor structure of the Maslach burnout inventory: An analysis of data from large scale cross-sectional surveys of nurses from eight countries” [Int. J. Nurs. Stud. 46 (2009) 894–902]. Int J Nurs Stud 2014. [DOI: 10.1016/j.ijnurstu.2014.02.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Affiliation(s)
- Linda H Aiken
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA 19104, USA.
| | - Douglas M Sloane
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA 19104, USA
| | - Luk Bruyneel
- Centre for Health Services and Nursing Research, Catholic University Leuven, Leuven, Belgium
| | - Peter Griffiths
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Walter Sermeus
- Centre for Health Services and Nursing Research, Catholic University Leuven, Leuven, Belgium
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Aiken LH, Sloane DM, Bruyneel L, Van den Heede K, Griffiths P, Busse R, Diomidous M, Kinnunen J, Kózka M, Lesaffre E, McHugh MD, Moreno-Casbas MT, Rafferty AM, Schwendimann R, Scott PA, Tishelman C, van Achterberg T, Sermeus W. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet 2014; 383:1824-30. [PMID: 24581683 PMCID: PMC4035380 DOI: 10.1016/s0140-6736(13)62631-8] [Citation(s) in RCA: 1181] [Impact Index Per Article: 118.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Austerity measures and health-system redesign to minimise hospital expenditures risk adversely affecting patient outcomes. The RN4CAST study was designed to inform decision making about nursing, one of the largest components of hospital operating expenses. We aimed to assess whether differences in patient to nurse ratios and nurses' educational qualifications in nine of the 12 RN4CAST countries with similar patient discharge data were associated with variation in hospital mortality after common surgical procedures. METHODS For this observational study, we obtained discharge data for 422,730 patients aged 50 years or older who underwent common surgeries in 300 hospitals in nine European countries. Administrative data were coded with a standard protocol (variants of the ninth or tenth versions of the International Classification of Diseases) to estimate 30 day in-hospital mortality by use of risk adjustment measures including age, sex, admission type, 43 dummy variables suggesting surgery type, and 17 dummy variables suggesting comorbidities present at admission. Surveys of 26,516 nurses practising in study hospitals were used to measure nurse staffing and nurse education. We used generalised estimating equations to assess the effects of nursing factors on the likelihood of surgical patients dying within 30 days of admission, before and after adjusting for other hospital and patient characteristics. FINDINGS An increase in a nurses' workload by one patient increased the likelihood of an inpatient dying within 30 days of admission by 7% (odds ratio 1·068, 95% CI 1·031-1·106), and every 10% increase in bachelor's degree nurses was associated with a decrease in this likelihood by 7% (0·929, 0·886-0·973). These associations imply that patients in hospitals in which 60% of nurses had bachelor's degrees and nurses cared for an average of six patients would have almost 30% lower mortality than patients in hospitals in which only 30% of nurses had bachelor's degrees and nurses cared for an average of eight patients. INTERPRETATION Nurse staffing cuts to save money might adversely affect patient outcomes. An increased emphasis on bachelor's education for nurses could reduce preventable hospital deaths. FUNDING European Union's Seventh Framework Programme, National Institute of Nursing Research, National Institutes of Health, the Norwegian Nurses Organisation and the Norwegian Knowledge Centre for the Health Services, Swedish Association of Health Professionals, the regional agreement on medical training and clinical research between Stockholm County Council and Karolinska Institutet, Committee for Health and Caring Sciences and Strategic Research Program in Care Sciences at Karolinska Institutet, Spanish Ministry of Science and Innovation.
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Affiliation(s)
- Linda H Aiken
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA, USA.
| | - Douglas M Sloane
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Luk Bruyneel
- Centre for Health Services and Nursing Research, Catholic University Leuven, Leuven, Belgium
| | - Koen Van den Heede
- Centre for Health Services and Nursing Research, Catholic University Leuven, Leuven, Belgium
| | - Peter Griffiths
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Reinhard Busse
- Department of Health Care Management, WHO Collaborating Centre for Health Systems, Research and Management, Berlin University of Technology, Berlin, Germany
| | | | - Juha Kinnunen
- Department of Health Policy and Management, University of Eastern Finland, Kuopio, Finland
| | - Maria Kózka
- Institute of Nursing and Midwifery, Faculty of Health Science, Jagiellonian University Collegium Medicum, Krakow, Poland
| | - Emmanuel Lesaffre
- Leuven Biostatistics and Statistical Bioinformatics Centre, KU Leuven, Leuven, Belgium
| | - Matthew D McHugh
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - M T Moreno-Casbas
- Nursing and Healthcare Research Unit, Institute of Health Carlos III, Madrid, Spain
| | - Anne Marie Rafferty
- Florence Nightingale School of Nursing and Midwifery, King's College, London
| | | | - P Anne Scott
- School of Nursing and Human Sciences, Dublin City University, Dublin, Ireland
| | - Carol Tishelman
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Theo van Achterberg
- Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Center, IQ Healthcare, HB Nijmegen, Netherlands
| | - Walter Sermeus
- Centre for Health Services and Nursing Research, Catholic University Leuven, Leuven, Belgium
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Kutney-Lee A, Sloane DM, Aiken LH. An increase in the number of nurses with baccalaureate degrees is linked to lower rates of postsurgery mortality. Health Aff (Millwood) 2014; 32:579-86. [PMID: 23459738 DOI: 10.1377/hlthaff.2012.0504] [Citation(s) in RCA: 125] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
An Institute of Medicine report has called for registered nurses to achieve higher levels of education, but health care policy makers and others have limited evidence to support a substantial increase in the number of nurses with baccalaureate degrees. Using Pennsylvania nurse survey and patient discharge data from 1999 and 2006, we found that a ten-point increase in the percentage of nurses holding a baccalaureate degree in nursing within a hospital was associated with an average reduction of 2.12 deaths for every 1,000 patients--and for a subset of patients with complications, an average reduction of 7.47 deaths per 1,000 patients. We estimate that if all 134 hospitals in our study had increased the percentage of their nurses with baccalaureates by ten points during our study's time period, some 500 deaths among general, orthopedic, and vascular surgery patients might have been prevented. The findings provide support for efforts to increase the production and employment of baccalaureate nurses.
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Affiliation(s)
- Ann Kutney-Lee
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA.
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Shang J, You L, Ma C, Altares D, Sloane DM, Aiken LH. Nurse employment contracts in Chinese hospitals: impact of inequitable benefit structures on nurse and patient satisfaction. Hum Resour Health 2014; 12:1. [PMID: 24418223 PMCID: PMC3896777 DOI: 10.1186/1478-4491-12-1] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 12/20/2013] [Indexed: 05/07/2023]
Abstract
PURPOSE Ongoing economic and health system reforms in China have transformed nurse employment in Chinese hospitals. Employment of 'bianzhi' nurses, a type of position with state-guaranteed lifetime employment that has been customary since 1949, is decreasing while there is an increase in the contract-based nurse employment with limited job security and reduced benefits. The consequences of inequities between the two types of nurses in terms of wages and job-related benefits are unknown. This study examined current rates of contract-based nurse employment and the effects of the new nurse contract employment strategy on nurse and patient outcomes in Chinese hospitals. METHODS This cross-sectional study used geographically representative survey data collected from 2008 to 2010 from 181 hospitals in six provinces, two municipalities, and one autonomous region in China. Logistic regression models were used to estimate the association between contract-based nurse utilization, dissatisfaction among contract-based nurses, nurse intentions to leave their positions, and patient satisfaction, controlling for nurse, patient, and hospital characteristics. PRINCIPAL RESULTS Hospital-level utilization of contract-based nurses varies greatly from 0 to 91%, with an average of 51%. Contract-based nurses were significantly more dissatisfied with their remuneration and benefits than 'bianzhi' nurses who have more job security (P <0.01). Contract-based nurses who were dissatisfied with their salary and benefits were more likely to intend to leave their current positions (P <0.01). Hospitals with high levels of dissatisfaction with salary and benefits among contract-based nurses were rated lower and less likely to be recommended by patients (P < 0.05). CONCLUSIONS Our results suggest a high utilization of contract-based nurses in Chinese hospitals, and that the inequities in benefits between contract-based nurses and 'bianzhi' nurses may adversely affect both nurse and patient satisfaction in hospitals. Our study provides empirical support for the 'equal pay for equal work' policy emphasized by the China Ministry of Health's recent regulations, and calls for efforts in Chinese hospitals to eliminate the disparities between 'bianzhi' and contract-based nurses.
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Affiliation(s)
- Jingjing Shang
- School of Nursing, Columbia University, 617 West 168th Street, New York, NY 10032, USA
| | - Liming You
- School of Nursing, Sun Yat-sen University, 74 Zhongshan 2 Road, Guangzhou 510089, China
| | - Chenjuan Ma
- The National Database of Nursing Quality Indicators, University of Kansas, 3901 Rainbow Blvd, Kansas City, KS 66160, USA
| | - Danielle Altares
- School of Nursing, University of Pennsylvania, 420 Guardian Drive, Philadelphia, PA 19104, USA
| | - Douglas M Sloane
- School of Nursing, University of Pennsylvania, 420 Guardian Drive, Philadelphia, PA 19104, USA
| | - Linda H Aiken
- School of Nursing, University of Pennsylvania, 420 Guardian Drive, Philadelphia, PA 19104, USA
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Stimpfel AW, Sloane DM, Aiken LH. The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction. Health Aff (Millwood) 2013; 31:2501-9. [PMID: 23129681 DOI: 10.1377/hlthaff.2011.1377] [Citation(s) in RCA: 227] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Extended work shifts of twelve hours or longer are common and even popular with hospital staff nurses, but little is known about how such extended hours affect the care that patients receive or the well-being of nurses. Survey data from nurses in four states showed that more than 80 percent of the nurses were satisfied with scheduling practices at their hospital. However, as the proportion of hospital nurses working shifts of more than thirteen hours increased, patients' dissatisfaction with care increased. Furthermore, nurses working shifts of ten hours or longer were up to two and a half times more likely than nurses working shorter shifts to experience burnout and job dissatisfaction and to intend to leave the job. Extended shifts undermine nurses' well-being, may result in expensive job turnover, and can negatively affect patient care. Policies regulating work hours for nurses, similar to those set for resident physicians, may be warranted. Nursing leaders should also encourage workplace cultures that respect nurses' days off and vacation time, promote nurses' prompt departure at the end of a shift, and allow nurses to refuse to work overtime without retribution.
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Affiliation(s)
- Amy Witkoski Stimpfel
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
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Abstract
OBJECTIVE To determine whether, and under what circumstance, US hospital employment of non-US-educated nurses is associated with patient outcomes. DESIGN Observational study of primary data from 2006 to 2007 surveys of hospital nurses in four states (California, Florida, New Jersey and Pennsylvania). The direct and interacting effects of hospital nurse staffing and the percentage of non-US-educated nurses on 30-day surgical patient mortality and failure-to-rescue were estimated before and after controlling for patient and hospital characteristics. PARTICIPANTS Data from registered nurse respondents practicing in 665 hospitals were pooled with patient discharge data from state agencies. MAIN OUTCOMES MEASURE(S) Thirty-day surgical patient mortality and failure-to-rescue. RESULTS The effect of non-US-educated nurses on both mortality and failure-to-rescue is nil in hospitals with lower than average patient to nurse ratios, but pronounced in hospitals with average and poor nurse to patient ratios. In hospitals in which patient-to-nurse ratios are 5:1 or higher, mortality is higher when 25% or more nurses are educated outside of the USA than when <25% of nurses are non-US-educated. Moreover, the effect of having >25% non-US-educated nurses becomes increasingly deleterious as patient-to-nurse ratios increase beyond 5:1. CONCLUSIONS Employing non-US-educated nurses has a negative impact on patient mortality except where patient-to-nurse ratios are lower than average. Thus, US hospitals should give priority to achieving adequate nurse staffing levels, and be wary of hiring large percentages of non-US-educated nurses unless patient-to-nurse ratios are low.
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Affiliation(s)
- Donna Felber Neff
- University of Florida College of Nursing, Health Professions, Nursing and Pharmacy Complex, PO Box 100187, Gainesville, FL 32610-1087, USA.
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Tubbs-Cooley HL, Cimiotti JP, Silber JH, Sloane DM, Aiken LH. An observational study of nurse staffing ratios and hospital readmission among children admitted for common conditions. BMJ Qual Saf 2013; 22:735-42. [PMID: 23657609 PMCID: PMC3756461 DOI: 10.1136/bmjqs-2012-001610] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Background Hospital patient-to-nurse staffing ratios are associated with quality outcomes in adult patient populations but little is known about how these factors affect paediatric care. We examined the relationship between staffing ratios and all-cause readmission (within 14 days, 15–30 days) among children admitted for common medical and surgical conditions. Methods We conducted an observational cross-sectional study of readmissions of children in 225 hospitals by linking nurse surveys, inpatient discharge data and information from the American Hospital Association Annual Survey. Registered Nurses (N=14 194) providing direct patient care in study hospitals (N=225) and children hospitalised for common conditions (N=90 459) were included. Results Each one patient increase in a hospital's average paediatric staffing ratio increased a medical child's odds of readmission within 15–30 days by a factor of 1.11, or by 11% (95% CI 1.02 to 1.20) and a surgical child's likelihood of readmission within 15–30 days by a factor of 1.48, or by 48% (95% CI 1.27 to 1.73). Children treated in hospitals with paediatric staffing ratios of 1 : 4 or less were significantly less likely to be readmitted within 15–30 days. There were no significant effects of nurse staffing ratios on readmissions within 14 days. Discussion Children with common conditions treated in hospitals in which nurses care for fewer patients each are significantly less likely to experience readmission between 15 and 30 days after discharge. Lower patient-to-nurse ratios hold promise for preventing unnecessary hospital readmissions for children through more effective predischarge monitoring of patient conditions, improved discharge preparation and enhanced quality improvement success.
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Aiken LH, Sloane DM, Bruyneel L, Van den Heede K, Sermeus W. Nurses’ reports of working conditions and hospital quality of care in 12 countries in Europe. Int J Nurs Stud 2013; 50:143-53. [DOI: 10.1016/j.ijnurstu.2012.11.009] [Citation(s) in RCA: 420] [Impact Index Per Article: 38.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Revised: 10/31/2012] [Accepted: 11/08/2012] [Indexed: 11/25/2022]
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Aiken LH, Shang J, Xue Y, Sloane DM. Hospital use of agency-employed supplemental nurses and patient mortality and failure to rescue. Health Serv Res 2012; 48:931-48. [PMID: 23216367 DOI: 10.1111/1475-6773.12018] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To determine the association between the use of agency-employed supplemental registered nurses (SRNs) to staff hospitals and patient mortality and failure to rescue (FTR). DATA SOURCES Primary survey data from 40,356 registered nurses in 665 hospitals in four states in 2006 were linked with American Hospital Association and inpatient mortality data from state agencies for approximately 1.3 million patients. STUDY DESIGN Logistic regression models were used to examine the association between SRN use and 30-day in-hospital mortality and FTR, controlling for patient and hospital characteristics, nurse staffing, the proportion of nurses with bachelor's degrees, and quality of the work environment. PRINCIPAL FINDINGS Before controlling for multiple nurse characteristics of hospitals, higher proportions of agency-employed SRNs in hospitals appeared to be associated with higher mortality (OR = 1.06) and FTR (OR = 1.05). Hospitals with higher proportions of SRNs have poorer work environments, however, and the significant relationships between SRNs and mortality outcomes were rendered insignificant when work environments were taken into account. CONCLUSIONS Higher use of SRNs does not appear to have deleterious consequences for patient mortality and may alleviate nurse staffing problems that could produce higher mortality.
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Affiliation(s)
- Linda H Aiken
- School of Nursing, Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Wiltse Nicely KL, Sloane DM, Aiken LH. Lower mortality for abdominal aortic aneurysm repair in high-volume hospitals is contingent upon nurse staffing. Health Serv Res 2012; 48:972-91. [PMID: 23088426 DOI: 10.1111/1475-6773.12004] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE To determine whether and to what extent the lower mortality rates for patients undergoing abdominal aortic aneurysm (AAA) repair in high-volume hospitals is explained by better nursing. DATA SOURCES State hospital discharge data, Multi-State Nursing Care and Patient Safety Survey, and hospital characteristics from the AHA Annual Survey. STUDY DESIGN Cross-sectional analysis of linked patient outcomes for individuals undergoing AAA repair in four states. DATA COLLECTION Secondary data sources. PRINCIPAL FINDINGS Favorable nursing practice environments and higher hospital volumes of AAA repair are associated with lower mortality and fewer failures-to-rescue in main-effects models. Furthermore, nurse staffing interacts with volume such that there is no mortality advantage observed in high-volume hospitals with poor nurse staffing. When hospitals have good nurse staffing, patients in low-volume hospitals are 3.4 times as likely to die and 2.6 times as likely to die from complications as patients in high-volume hospitals (p < .001). CONCLUSIONS Nursing is part of the explanation for lower mortality after AAA repair in high-volume hospitals. Importantly, lower mortality is not found in high-volume hospitals if nurse staffing is poor.
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Affiliation(s)
- Kelly L Wiltse Nicely
- Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, PA 19104-4217, USA.
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Cimiotti JP, Aiken LH, Sloane DM, Wu ES. Nurse staffing, burnout, and health care-associated infection. Am J Infect Control 2012; 40:486-90. [PMID: 22854376 DOI: 10.1016/j.ajic.2012.02.029] [Citation(s) in RCA: 432] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Revised: 02/13/2012] [Accepted: 02/13/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Each year, nearly 7 million hospitalized patients acquire infections while being treated for other conditions. Nurse staffing has been implicated in the spread of infection within hospitals, yet little evidence is available to explain this association. METHODS We linked nurse survey data to the Pennsylvania Health Care Cost Containment Council report on hospital infections and the American Hospital Association Annual Survey. We examined urinary tract and surgical site infection, the most prevalent infections reported and those likely to be acquired on any unit within a hospital. Linear regression was used to estimate the effect of nurse and hospital characteristics on health care-associated infections. RESULTS There was a significant association between patient-to-nurse ratio and urinary tract infection (0.86; P = .02) and surgical site infection (0.93; P = .04). In a multivariate model controlling for patient severity and nurse and hospital characteristics, only nurse burnout remained significantly associated with urinary tract infection (0.82; P = .03) and surgical site infection (1.56; P < .01) infection. Hospitals in which burnout was reduced by 30% had a total of 6,239 fewer infections, for an annual cost saving of up to $68 million. CONCLUSIONS We provide a plausible explanation for the association between nurse staffing and health care-associated infections. Reducing burnout in registered nurses is a promising strategy to help control infections in acute care facilities.
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Abstract
Despite the estimated 1.8 million children admitted to hospitals annually, little is known about the quality of care and the adequacy of resources in hospitals that care for acutely ill infants and children. Using survey data from 3,819 pediatric nurses working in 498 hospitals, we found that nursing resources vary significantly across different types of hospitals that care for children. Nurses working in a children's hospital within a hospital, and on a pediatric unit in a general hospital were more likely than nurses in freestanding children's hospitals to report inadequate nursing resources. We also found that inadequate nursing resources were associated with surveillance left undone and missed changes in patients' condition. These findings have implications for the quality and safety of pediatric care.
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You LM, Aiken LH, Sloane DM, Liu K, He GP, Hu Y, Jiang XL, Li XH, Li XM, Liu HP, Shang SM, Kutney-Lee A, Sermeus W. Hospital nursing, care quality, and patient satisfaction: cross-sectional surveys of nurses and patients in hospitals in China and Europe. Int J Nurs Stud 2012; 50:154-61. [PMID: 22658468 DOI: 10.1016/j.ijnurstu.2012.05.003] [Citation(s) in RCA: 196] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Revised: 04/16/2012] [Accepted: 05/05/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND This study provides a comprehensive evaluation of nurse resources in Chinese hospitals and the link between nurse resources and nurse and patient outcomes. METHODS Survey data were used from 9688 nurses and 5786 patients in 181 Chinese hospitals to estimate associations between nurse workforce characteristics and nurse and patient outcomes in China. Nurse and patient assessments in China were compared with a similar study in Europe. RESULTS Thirty-eight percent of nurses in China had high burnout and 45% were dissatisfied with their jobs. Substantial percentages of nurses described their work environment and the quality of care on their unit as poor or fair (61% and 29%, respectively) and graded their hospital low on patient safety (36%). These outcomes tend to be somewhat poorer in China than in Europe, though fewer nurses in China gave their hospitals poor safety grades. Nurses in Chinese hospitals with better work environments and higher nurse-assessed safety grades had lower odds of high burnout and job dissatisfaction (ORs ranged from 0.56 to 0.75) and of reporting poor or fair quality patient care (ORs ranged from 0.54 to 0.74), and patients in such hospitals were more likely to rate their hospital highly, to be satisfied with nursing communications, and to recommend their hospitals (significant ORs ranged from 1.24 to 1.40). Higher patient-to-nurse ratios were associated with poorer nurse outcomes (each additional patient per nurse increases both burnout and dissatisfaction by a factor of 1.04) and higher likelihoods of nurses reporting poor or fair quality of care (OR=1.05), but were unrelated to patient outcomes. Higher percentages of baccalaureate nurses were strongly related to better patient outcomes, with each 10% increase in the percent of baccalaureate nurses increasing patient satisfaction, high ratings, and willingness to recommend their hospital by factors ranging from 1.11 to 1.13. INTERPRETATION Nursing is important in quality and safety of hospital care and in patients' perceptions of their care. Improving quality of hospital work environments and expanding the number of baccalaureate-prepared nurses hold promise for improving hospital outcomes in China.
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Affiliation(s)
- Li-ming You
- Sun Yat-sen University, School of Nursing, Guangzhou, China.
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