Barbara A. Mark

Methodological Issues in Nurse Staffing Research

The purpose of this article is to identify and describe four issues in nurse staffing research that must be addressed before the evidence base for the relationship between nurse staffing and quality of care can be said to be theoretically and empirically sufficient. The issues are the need to build well-developed theory, use valid and reliable databases, appropriate risk-adjustment systems, and address issues of causal inference in nonexperimental research.

Nurse staffing and adverse events in hospitalized children

This study determined whether the number of hours of care provided by RNs was related to mortality and complications in hospitalized children. Administrative data (1996-2001) were used to examine discharges of 3.65 million pediatric patients in 286 general and childrens hospitals in California. A greater number of resource-adjusted hours of care provided by RNs was related to significantly reduced occurrences of postoperative pulmonary complications, postoperative pneumonia, and postoperative septicemia; the positive impact of increases in nurse staffing was of greater magnitude at institutions providing fewer resource-adjusted hours of RN care. There was also evidence of an impact of increases in nurse staffing on urinary tract infections, but it was statistically significant only for institutions with higher resource-adjusted hours of RN care. There was no statistically significant relationship between RN staffing and mortality. More hours of care provided by RNs was associated with improved quality of care for hospitalized pediatric patients.

Exploring organizational context and structure as predictors of medication errors and patient falls

Objectives: To examine relationships among organizational context (characteristics of the external, hospital, and nursing unit environments), organizational structure (unit capacity, work engagement, and work conditions), patient characteristics (age, sex, and health status), safety climate, and effectiveness (medication errors and falls) in acute care hospitals. Methods: Data came from 278 medical-surgical units at 143 hospitals that participated in the Outcomes Research in Nursing Administration Project II, a longitudinal multisite study. Results: Selected measures of the external, hospital, and nursing unit environment had significant influences on the organizational structure of nursing units, which in turn significantly predicted unit-level safety climate. However, structural measures had limited effects on medication errors and falls. Patient age and health status were associated with falls but not with medication errors. There was a significant structure-safety climate interaction, where units with higher levels of unit capacity but lower levels of safety climate reported fewer medication errors. In contrast, units with higher levels of unit capacity and higher levels of safety climate reported more falls. Conclusions: There are important influences of contextual, structural, and safety climate factors on both medication errors and falls. The limited effect of structure on effectiveness and the differential moderating effect of safety climate suggest that future studies may benefit from the use of theoretical models that are targeted more specifically to the explanation of a particular type of adverse event.

Measurement of patient outcomes: data availability and consistency across hospitals

In a random sample of 20 hospitals, the availability and consistency of five patient outcome indicators were examined, including medication administration errors, patient falls, occurrence of new decubitus ulcers, nosocomial infections, and unplanned readmission to the hospital. The results indicate that information about only two outcome indicators--medication errors and patient falls--were collected consistently by the sampled hospitals. The findings are discussed in the context of implications for the study of patient outcomes research.

What explains nurses' perceptions of staffing adequacy?

BackgroundMuch attention is being paid to the adequacy of nurse staffing in acute care hospitals, and much of the information relies on nurses’ perceptions about staffing adequacy. Yet, we know little about what influences these perceptions. ObjectivesWe examined the impact of hospital characteristics, nursing unit characteristics, nurse characteristics, and patient characteristics on nurses’ perceptions of staffing adequacy. We tested three different models, incorporating different conceptualizations that relate current and past characteristics to these perceptions. MethodThis was a secondary analysis of data from the Outcomes Research in Nursing Administration Project, a longitudinal study conducted in 60 hospitals in the Southeastern United States. ResultsPerceptions of staffing adequacy were influenced significantly by the hospital’s case mix index and growth in hospital admissions, by the number of beds on a unit, and by patient acuity. Further, current perceptions of staffing adequacy were significantly affected by prior perceptions. ConclusionBased on our results, we present potential interventions for administrators that may ameliorate some of the negative influences on nurses’ perceptions of staffing adequacy.

The Nurse’s Medication Day

The medication administration stage of the medication-use process is especially vulnerable to error because errors are least likely to be caught before reaching the patient. Medication administration, however, remains poorly understood. In this article we describe medication administration as observed in an ethnographic study conducted on one medical unit and one surgical unit. A central finding was that medication administration entailed a complex mixture of varied and often competing demands that temporally structured the nurses’ entire workday. Articulation work was evident in time management strategies nurses used to handle demands from institutional policies, technical devices, patients, the physical environment, and the medications themselves. The average number of doses of medication per patient was more than double the number policy groups have indicated. Medication administration is not simply the giving of drugs, nor does it have clearly defined temporal boundaries. Because of its inseparability from other nurses’ work, medication administration inherently entails interruption, thereby calling into question the current emphasis on reducing interruptions as a tactic to decrease medication errors.

A theoretical model for nursing systems outcomes research.

Nursing research on patient and administrative outcomes has typically examined the relationships between selected structural characteristics and outcomes, without taking into account the organizations context. In contrast, health services research has focused on the relationships between the organizations context and outcomes, most often mortality, without taking into account structural characteristics. Although widely used, both approaches develop fragmented knowledge. This article describes a comprehensive theoretical model that takes into account the relationships among the organizations context, its structure, and both patient and nursing administrative outcomes.

The emerging role of the nurse manager. Implications for educational preparation.

What trends are evident in redesigning the nurse manager role and what will it look like in the year 2000? The author compares data from several different sources in identifying trends. The data suggest that the nurse manager role will continue to increase in complexity and importance. Implications of trends for graduate programs preparing nurse managers and suggested guidelines for planning programs are detailed.

An examination of technical efficiency, quality, and patient safety in acute care nursing units

Using an innovative statistical approach—data envelopment analysis—the authors examined the technical efficiency of 226 medical, surgical, and medical—surgical nursing units in 118 randomly selected acute care hospitals. The authors used the inputs of registered nurse, licensed practical nurse, and unlicensed hours of care; operating expenses; and number of beds on the unit. Outputs included case mix adjusted discharges, patient satisfaction (as a quality measure), and the rates of medication errors and patient falls (as measures of patient safety). This study found that 60% of units were operating at less than full efficiency. Key areas for improvement included slight reductions in labor hours and large reductions in medication errors and falls. The study findings indicate the importance of improving patient safety as a mechanism to simultaneously improve nursing unit efficiency.

Characteristics of nursing practice models.

Are there differences among the nursing practice dimensions of the three major nursing practice models--team nursing, case management, and total patient care? The author, whose study found few differences, discusses reasons for the similarity among models and suggests approaches to designing future nursing practice models.