Ann Kutney-Lee

Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States

Objective To determine whether hospitals with a good organisation of care (such as improved nurse staffing and work environments) can affect patient care and nurse workforce stability in European countries. Design Cross sectional surveys of patients and nurses. Setting Nurses were surveyed in general acute care hospitals (488 in 12 European countries; 617 in the United States); patients were surveyed in 210 European hospitals and 430 US hospitals. Participants 33 659 nurses and 11 318 patients in Europe; 27 509 nurses and more than 120 000 patients in the US. Main outcome measures Nurse outcomes (hospital staffing, work environments, burnout, dissatisfaction, intention to leave job in the next year, patient safety, quality of care), patient outcomes (satisfaction overall and with nursing care, willingness to recommend hospitals). Results The percentage of nurses reporting poor or fair quality of patient care varied substantially by country (from 11% (Ireland) to 47% (Greece)), as did rates for nurses who gave their hospital a poor or failing safety grade (4% (Switzerland) to 18% (Poland)). We found high rates of nurse burnout (10% (Netherlands) to 78% (Greece)), job dissatisfaction (11% (Netherlands) to 56% (Greece)), and intention to leave (14% (US) to 49% (Finland, Greece)). Patients’ high ratings of their hospitals also varied considerably (35% (Spain) to 61% (Finland, Ireland)), as did rates of patients willing to recommend their hospital (53% (Greece) to 78% (Switzerland)). Improved work environments and reduced ratios of patients to nurses were associated with increased care quality and patient satisfaction. In European hospitals, after adjusting for hospital and nurse characteristics, nurses with better work environments were half as likely to report poor or fair care quality (adjusted odds ratio 0.56, 95% confidence interval 0.51 to 0.61) and give their hospitals poor or failing grades on patient safety (0.50, 0.44 to 0.56). Each additional patient per nurse increased the odds of nurses reporting poor or fair quality care (1.11, 1.07 to 1.15) and poor or failing safety grades (1.10, 1.05 to 1.16). Patients in hospitals with better work environments were more likely to rate their hospital highly (1.16, 1.03 to 1.32) and recommend their hospitals (1.20, 1.05 to 1.37), whereas those with higher ratios of patients to nurses were less likely to rate them highly (0.94, 0.91 to 0.97) or recommend them (0.95, 0.91 to 0.98). Results were similar in the US. Nurses and patients agreed on which hospitals provided good care and could be recommended. Conclusions Deficits in hospital care quality were common in all countries. Improvement of hospital work environments might be a relatively low cost strategy to improve safety and quality in hospital care and to increase patient satisfaction.

An Increase In The Number Of Nurses With Baccalaureate Degrees Is Linked To Lower Rates Of Postsurgery Mortality

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 studys 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.

Development of the Hospital Nurse Surveillance Capacity Profile.

Better patient outcomes are often achieved through effective surveillance, a primary function of nurses. The purpose of this article is to define, operationalize, measure, and evaluate the nurse surveillance capacity of hospitals. Nurse surveillance capacity is defined as the organizational features that enhance or weaken nurse surveillance. It includes a set of registered nurse (staffing, education, expertise, experience) and nurse practice environment characteristics. Empirical referents were extracted from existing survey data from 9,232 nurses in 174 hospitals. Using a ranking methodology, a Hospital Nurse Surveillance Capacity Profile was created for each hospital. Greater nurse surveillance capacity was significantly associated with better quality of care and fewer adverse events. The profile may assist administrators to improve nurse surveillance and patient outcomes.

Changes in patient and nurse outcomes associated with magnet hospital recognition

Background:Research has documented an association between Magnet hospitals and better outcomes for nurses and patients. However, little longitudinal evidence exists to support a causal link between Magnet recognition and outcomes. Objective:To compare changes over time in surgical patient outcomes, nurse-reported quality, and nurse outcomes in a sample of hospitals that attained Magnet recognition between 1999 and 2007 with hospitals that remained non-Magnet. Research Design:Retrospective, 2-stage panel design using 4 secondary data sources. Subjects:One hundred thirty-six Pennsylvania hospitals (11 emerging Magnets and 125 non-Magnets). Measures:American Nurses Credentialing Center Magnet recognition; risk-adjusted rates of surgical 30-day mortality and failure-to-rescue, nurse-reported quality measures, and nurse outcomes; the Practice Environment Scale of the Nursing Work Index. Methods:Fixed-effects difference models were used to compare changes in outcomes between emerging Magnet hospitals and hospitals that remained non-Magnet. Results:Emerging Magnet hospitals demonstrated markedly greater improvements in their work environments than other hospitals. On average, the changes in 30-day surgical mortality and failure-to-rescue rates over the study period were more pronounced in emerging Magnet hospitals than in non-Magnet hospitals, by 2.4 fewer deaths per 1000 patients (P<0.01) and 6.1 fewer deaths per 1000 patients (P=0.02), respectively. Similar differences in the changes for emerging Magnet hospitals and non-Magnet hospitals were observed in nurse-reported quality of care and nurse outcomes. Conclusions:In general, Magnet recognition is associated with significant improvements over time in the quality of the work environment, and in patient and nurse outcomes that exceed those of non-Magnet hospitals.

The effect of hospital electronic health record adoption on nurse-assessed quality of care and patient safety.

The aim of this study was to examine the effect of having a basic electronic health record (EHR) on nurse-assessed quality of care, including patient safety. Few large-scale studies have examined how adoption of EHRs may be associated with quality of care. A cross-sectional, secondary analysis of nurse and hospital survey data was conducted. The final sample included 16,352 nurses working in 316 hospitals in 4 states. Logistic regression models were used to evaluate the relationship between basic EHR adoption and nurse-assessed quality of care outcomes. Nurses working in hospitals with basic EHRs consistently reported that poor patient safety and other quality outcomes occurred less frequently than reported by nurses working in hospitals without an EHR. Our findings suggest that the implementation of a basic EHR may result in improved and more efficient nursing care, better care coordination, and patient safety.

Impact of critical care nursing on 30-day mortality of mechanically ventilated older adults.

Objectives:The mortality rate for mechanically ventilated older adults in ICUs is high. A robust research literature shows a significant association between nurse staffing, nurses’ education, and the quality of nurse work environments and mortality following common surgical procedures. A distinguishing feature of ICUs is greater investment in nursing care. The objective of this study is to determine the extent to which variation in ICU nursing characteristics—staffing, work environment, education, and experience—is associated with mortality, thus potentially illuminating strategies for improving patient outcomes. Design:Multistate, cross-sectional study of hospitals linking nurse survey data from 2006 to 2008 with hospital administrative data and Medicare claims data from the same period. Logistic regression models with robust estimation procedures to account for clustering were used to assess the effect of critical care nursing on 30-day mortality before and after adjusting for patient, hospital, and physician characteristics. Setting:Three hundred and three adult acute care hospitals in California, Florida, New Jersey, and Pennsylvania. Patients:The patient sample included 55,159 older adults on mechanical ventilation admitted to a study hospital. Interventions:None. Measurements and Main Results:Patients in critical care units with better nurse work environments experienced 11% lower odds of 30-day mortality than those in worse nurse work environments. Additionally, each 10% point increase in the proportion of ICU nurses with a bachelor’s degree in nursing was associated with a 2% reduction in the odds of 30-day mortality, which implies that the odds on patient deaths in hospitals with 75% nurses with a bachelor’s degree in nursing would be 10% lower than in hospitals with 25% nurses with a bachelor’s degree in nursing. Critical care nurse staffing did not vary substantially across hospitals. Staffing and nurse experience were not associated with mortality after accounting for these other nurse characteristics. Conclusions:Patients in hospitals with better critical care nurse work environments and higher proportions of critical care nurses with a bachelor’s degree in nursing experienced significantly lower odds of death.

The quality of hospital work environments and missed nursing care is linked to heart failure readmissions: a cross-sectional study of US hospitals

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.

The Critical Care Work Environment and Nurse-Reported Health Care–Associated Infections

BACKGROUND Critically ill patients are susceptible to health care-associated infections because of their illnesses and the need for intravenous access and invasive monitoring. The critical care work environment may influence the likelihood of infection in these patients. OBJECTIVE To determine whether or not the critical care nurse work environment is predictive of nurse-reported health care-associated infections. METHODS A retrospective, cross-sectional design was used with linked nurse and hospital survey data. Nurses assessed the critical care work environment and provided the frequencies of ventilator-associated pneumonias, urinary tract infections, and infections associated with central catheters. Logistic regression models were used to determine if critical care work environments were predictive of nurse-reported frequent health care-associated infections, with controls for nurse and hospital characteristics. Results The final sample consisted of 3217 critical care nurses in 320 hospitals. Compared with nurses working in poor work environments, nurses working in better work environments were 36% to 41% less likely to report that health care-associated infections occurred frequently. CONCLUSION Health care-associated infections are less likely in favorable critical care work environments. These findings, based on the largest sample of critical care nurses to date, substantiate efforts to focus on the quality of the work environment as a way to minimize the frequency of health care-associated infections.

Higher Quality of Care and Patient Safety Associated With Better NICU Work Environments.

The objective of this study was to investigate the associations between the neonatal intensive care unit (NICU) work environment, quality of care, safety, and patient outcomes. A secondary analysis was conducted of responses of 1247 NICU staff nurses in 171 hospitals to a large nurse survey. Better work environments were associated with lower odds of nurses reporting poor quality, safety, and outcomes. Improving the work environment may be a promising strategy to achieve safer settings for at-risk newborns.

Variations in postoperative complications according to race, ethnicity, and sex in older adults.

To explore differences in the incidence of postoperative complications between three racial and ethnic groups (white, black, Hispanic) before and after taking into account potentially confounding patient and hospital characteristics.