Chenjuan Ma

Hospital nursing and 30-day readmissions among Medicare patients with heart failure, acute myocardial infarction, and pneumonia.

Background:Provisions of the Affordable Care Act that increase hospitals’ financial accountability for preventable readmissions have heightened interest in identifying system-level interventions to reduce readmissions. Objectives:To determine the relationship between hospital nursing; that is, nurse work environment, nurse staffing levels, and nurse education, and 30-day readmissions among Medicare patients with heart failure, acute myocardial infarction, and pneumonia. Method and Design:Analysis of linked data from California, New Jersey, and Pennsylvania that included information on the organization of hospital nursing (ie, work environment, patient-to-nurse ratios, and proportion of nurses holding a BSN degree) from a survey of nurses, as well as patient discharge data, and American Hospital Association Annual Survey data. Robust logistic regression was used to estimate the relationship between nursing factors and 30-day readmission. Results:Nearly 1 quarter of heart failure index admissions [23.3% (n=39,954)], 19.1% (n=12,131) of myocardial infarction admissions, and 17.8% (n=25,169) of pneumonia admissions were readmitted within 30 days. Each additional patient per nurse in the average nurse’s workload was associated with a 7% higher odds of readmission for heart failure [odds ratio (OR)=1.07; confidence interval CI, 1.05–1.09], 6% for pneumonia patients (OR=1.06; CI, 1.03–1.09), and 9% for myocardial infarction patients (OR=1.09; CI, 1.05–1.13). Care in a hospital with a good versus poor work environment was associated with odds of readmission that were 7% lower for heart failure (OR=0.93; CI, 0.89–0.97), 6% lower for myocardial infarction (OR=0.94; CI, 0.88–0.98), and 10% lower for pneumonia (OR=0.90; CI, 0.85–0.96) patients. Conclusions:Improving nurses’ work environments and staffing may be effective interventions for preventing readmissions.

Neuraxial anesthesia decreases postoperative systemic infection risk compared with general anesthesia in knee arthroplasty.

BACKGROUND:Surgical stress has been shown to result in immune disturbance. Neuraxial anesthesia (NA) has long been hypothesized to blunt undesired surgical insults and thus limit immune compromise and improve surgical outcomes. We hypothesized that NA would decrease postoperative infectious complications compared with general anesthesia (GA) among knee arthroplasty patients. METHODS:We studied the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2010. There were 16,555 patients included in our final cohort, with 9167 patients receiving GA and 7388 patients receiving spinal or epidural anesthesia.. Outcomes of interest included infection-related 30-day postoperative complications, including surgical site–related infections, pneumonia, urinary tract infection, sepsis, septic shock, and a composite end point of any systemic infection. Multivariable logistic regression was performed to test for effect of anesthesia type while adjusting for the influence of preexisting comorbidities. RESULTS:The overall mortality was 0.24% and 0.15% among NA and GA subjects, respectively (P = 0.214). NA subjects had fewer unadjusted incidences of pneumonia (P = 0.035) and composite systemic infection (P = 0.006). After risk adjustment for preexisting comorbidities, NA was associated with lower odds of pneumonia (odds ratio = 0.51 [95% confidence interval, 0.29–0.90]) and lower odds of composite systemic infection (odds ratio = 0.77 [95% confidence interval, 0.64–0.92]). CONCLUSIONS:Our study suggested that NA was associated with lower adjusted odds of both pneumonia and a composite outcome of any systemic infectious complication within 30 days of surgery compared with GA.

Nurse employment contracts in Chinese hospitals: impact of inequitable benefit structures on nurse and patient satisfaction

PurposeOngoing 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.MethodsThis 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 ResultsHospital-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).ConclusionsOur 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.

Organization of Hospital Nursing and 30-day Readmissions in Medicare Patients Undergoing Surgery

Background:Growing scrutiny of readmissions has placed hospitals at the center of readmission prevention. Little is known, however, about hospital nursing—a critical organizational component of hospital service system—in relation to readmissions. Objectives:To determine the relationships between hospital nursing factors—nurse work environment, nurse staffing, and nurse education—and 30-day readmissions among Medicare patients undergoing general, orthopedic, and vascular surgery. Method and Design:We linked Medicare patient discharge data, multistate nurse survey data, and American Hospital Association Annual Survey data. Our sample included 220,914 Medicare surgical patients and 25,082 nurses from 528 hospitals in 4 states (California, Florida, New Jersey, and Pennsylvania). Risk-adjusted robust logistic regressions were used for analyses. Results:The average 30-day readmission rate was 10% in our sample (general surgery: 11%; orthopedic surgery: 8%; vascular surgery: 12%). Readmission rates varied widely across surgical procedures and could be as high as 26% (upper limb and toe amputation for circulatory system disorders). Each additional patient per nurse increased the odds of readmission by 3% (OR=1.03; 95% CI, 1.00–1.05). Patients cared in hospitals with better nurse work environments had lower odds of readmission (OR=0.97; 95% CI, 0.95–0.99). Administrative support to nursing practice (OR=0.96; 95% CI, 0.94–0.99) and nurse-physician relations (OR=0.97; 95% CI, 0.95–0.99) were 2 main attributes of the work environment that were associated with readmissions. Conclusions:Better nurse staffing and work environment were significantly associated with 30-day readmission, and can be considered as system-level interventions to reduce readmissions and associated financial penalties.

Wage, Work Environment, and Staffing: Effects on Nurse Outcomes

Research has shown that hospitals with better nurse staffing and work environments have better nurse outcomes—less burnout, job dissatisfaction, and intention to leave the job. Many studies, however, have not accounted for wage effects, which may confound findings. By using a secondary analysis with cross-sectional administrative data and a four-state survey of nurses, we investigated how wage, work environment, and staffing were associated with nurse outcomes. Logistic regression models, with and without wage, were used to estimate the effects of work environment and staffing on burnout, job dissatisfaction, and intent to leave. We discovered that wage was associated with job dissatisfaction and intent to leave but had little influence on burnout, while work environment and average patient-to-nurse ratio still have considerable effects on nurse outcomes. Wage is important for good nurse outcomes, but it does not diminish the significant influence of work environment and staffing on nurse outcomes.

The prevalence of infections and patient risk factors in home health care: A systematic review

BACKGROUND Home health care (HHC) has been the fastest growing health care sector for the past 3 decades. The uncontrolled home environment, increased use of indwelling devices, and the complexity of illnesses among HHC patients lead to increased risk for infections. METHODS A systematic review of studies evaluating infection prevalence and risk factors among adult patients who received HHC services was conducted and guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Literature was searched using Medline, PubMed, and the Cumulative Index to Nursing and Allied Health as well as hand searching. Two reviewers independently assessed study quality using validated quality assessment checklists. RESULTS Twenty-five studies met the inclusion criteria and were reviewed. The infection rates and identified risk factors for infections varied dramatically between studies. In general, patients receiving home parental nutrition treatments had higher infection rates than patients receiving home infusion therapy. The identified risk factors were limited by small sample sizes and other methodologic flaws. CONCLUSIONS Establishing a surveillance system for HHC infections, identifying patients at high risk for infections, tailoring HHC and patient education based on patient living conditions, and facilitating communication between different health care facilities will enhance infection control in HHC settings. Future studies should use a nationally representative sample and multivariate analysis for the identification of risk factors for infections.

Hospital Magnet Status, Unit Work Environment, and Pressure Ulcers

PURPOSE To identify how organizational nursing factors at different structural levels (i.e., unit-level work environment and hospital Magnet status) are associated with hospital-acquired pressure ulcers (HAPUs) in U.S. acute care hospitals. DESIGN A cross-sectional observational study used data from the National Database of Nursing Quality Indicators®. Responses from 33,845 registered nurses (RNs) were used to measure unit work environments. The unit of analysis was the nursing unit, and there were 1,381 units in 373 hospitals in the United States. METHODS Unit work environment was measured by the Practice Environment Scale of Nurse Working Index (PES-NWI). Multilevel logistic regressions were used to estimate the effects of unit work environment and hospital Magnet status on HAPUs. All models were controlled for hospital and unit characteristics when considering clustering of units within hospitals. RESULTS Magnet hospital units had 21% lower odds of having an HAPU than non-Magnet hospital units (95% confidence interval [CI], 0.64-0.98). With one unit increase of the PES-NWI score, units had 29% lower odds of having an HAPU (95% CI, 0.55-0.91). When including both hospital Magnet status and unit work environment in the model, hospital Magnet status no longer had a significant effect on HAPUs (odds ratio [OR] = 0.82; 95% CI, 0.66-1.02), whereas the significant effect of unit work environment persisted (OR = 0.73; 95% CI, 0.56-0.93). CONCLUSIONS Both hospital and unit environments were significantly associated with HAPUs, and the unit-level work environment can be more influential in reducing HAPUs. CLINICAL RELEVANCE Investment in the nurse work environments at both the hospital level and unit level has the potential to reduce HAPUs; and additional to hospital-level initiatives (e.g., Magnet recognition program), efforts targeting on-unit work environments deserve more attention.

Low Blood Zinc, Iron, and Other Sociodemographic Factors Associated with Behavior Problems in Preschoolers

Previous research supports the link among malnutrition, cognitive dysfunction, and behavioral outcomes; however, less research has focused on micronutrient deficiencies. This study investigates whether micronutrient deficiencies, specifically blood zinc and iron levels, will be associated with increased behavior problem scores, including internalizing and externalizing behaviors. 1314 Children (55% boys and 45% girls) from the Jintan Preschool Cohort in China participated in this study. Venous blood samples were collected and analyzed for zinc and iron when the children were 3–5 years old. Behavior problems were measured with the Child Behavior Checklist (CBCL), which was completed by the parents when children were in their last months of preschool (mean age 5.6 years). General linear multivariate modeling was used, with adjustment for important sociodemographic variables. The results indicate that low zinc levels alone (p = 0.024) and combined low zinc and iron levels (p = 0.022) are significantly associated with increased reports of total behavior problems. We did not find an association between low iron and behavior problems. With regards to sociodemographics, living in the suburbs is associated with increased internalizing problems, while higher mother’s education and being female were associated with decreased externalizing problems. This study suggests that micronutrient deficiencies and sociodemographic facts are associated with behavior problems in preschoolers.

Linking Unit Collaboration and Nursing Leadership to Nurse Outcomes and Quality of Care.

OBJECTIVE: The objective of this study is to identify the effects of unit collaboration and nursing leadership on nurse outcomes and quality of care. BACKGROUND: Along with the current healthcare reform, collaboration of care providers and nursing leadership has been underscored; however, empirical evidence of the impact on outcomes and quality of care has been limited. METHODS: Data from 29742 nurses in 1228 units of 200 acute care hospitals in 41 states were analyzed using multilevel linear regressions. Collaboration (nurse-nurse collaboration and nurse-physician collaboration) and nursing leadership were measured at the unit level. Outcomes included nurse job satisfaction, intent to leave, and nurse-reported quality of care. RESULTS: Nurses reported lower intent to leave, higher job satisfaction, and better quality of care in units with better collaboration and stronger nursing leadership. CONCLUSION: Creating a care environment of strong collaboration among care providers and nursing leadership can help hospitals maintain a competitive nursing workforce supporting high quality of care.

Nurse work environment and quality of care by unit types: A cross-sectional study

BACKGROUND Nursing unit is the micro-organization in the hospital health care system in which integrated patient care is provided. Nursing units of different types serve patients with distinct care goals, clinical tasks, and social structures and norms. However, empirical evidence is sparse on unit type differences in quality of care and its relation with nurse work environment. Nurse work environment has been found as an important nursing factor predicting nurse and patient outcomes. OBJECTIVES To examine the unit type differences in nurse-reported quality of care, and to identify the association between unit work environment and quality of care by unit types. METHODS This is a cross-sectional study using nurse survey data (2012) from US hospitals nationwide. The nurse survey collected data on quality of care, nurse work environment, and other work related information from staff nurses working in units of various types. Unit types were systematically classified across hospitals. The unit of analysis was the nursing unit, and the final sample included 7677 units of 14 unit types from 577 hospitals in 49 states in the US. Multilevel regressions were used to assess the relationship between nurse work environment and quality of care across and by unit types. RESULTS On average, units had 58% of the nurses reporting excellent quality of care and 40% of the nurses reporting improved quality of care over the past year. Unit quality of care varied by unit types, from 43% of the nurses in adult medical units to 73% of the nurses in interventional units rating overall quality of care on unit as excellent, and from 35% of the nurses in adult critical care units to 44% of the nurses in adult medical units and medical-surgical combined units reporting improved quality of care. Estimates from regressions indicated that better unit work environments were associated with higher quality of care when controlling various hospital and unit covariates; and this association persisted among units of different types. CONCLUSIONS Unit type differences exist in the overall quality of care as well as achievement in improving quality of care. The low rates of nurses reporting improvement in the quality of nursing care to patients suggest that further interventions focusing at the unit-level are needed for achieving high care quality. Findings from our study also suggest that improving nurse work environments can be an effective strategy to improve quality of care.