Christopher R. Friese

Hospital nurse practice environments and outcomes for surgical oncology patients.

OBJECTIVE To examine the effect of nursing practice environments on outcomes of hospitalized cancer patients undergoing surgery. DATA SOURCES Secondary analysis of cancer registry, inpatient claims, administrative and nurse survey data collected in Pennsylvania for 1998-1999. STUDY DESIGN Nurse staffing (patient to nurse ratio), educational preparation (proportion of nurses holding at least a bachelors degree), and the practice environment (Practice Environment Scale of the Nursing Work Index) were calculated from a survey of nurses and aggregated to the hospital level. Logistic regression models predicted the odds of 30-day mortality, complications, and failure to rescue (death following a complication). PRINCIPAL FINDINGS Unadjusted death, complication, and failure to rescue rates were 3.4, 35.7, and 9.3 percent, respectively. Nurse staffing and educational preparation of registered nurses were significantly associated with patient outcomes. After adjusting for patient and hospital characteristics, patients in hospitals with poor nurse practice environments had significantly increased odds of death (odds ratio, 1.37; 95 percent confidence interval, 1.07-1.76) and of failure to rescue (odds ratio, 1.48; 95 percent confidence interval, 1.07-2.03). Receipt of care in National Cancer Institute-designated cancer centers significantly decreased the odds of death, which can be explained partly by better nurse practice environments. CONCLUSIONS This study is one of the first to examine the predictive validity of the National Quality Forums endorsed measure of the nurse practice environment. Improvements in the quality of nurse practice environments could reduce adverse outcomes for hospitalized surgical oncology patients.

Variations in Nursing Practice Environments Relation to Staffing and Hospital Characteristics

Background: While improvements in nursing practice environments are considered essential to address the nursing shortage, relatively little is known about the nursing practice environments in most hospitals. Objectives: The objectives of this study are to describe variations in nursing practice environments across hospitals and to examine their associations to hospital bed size, community size, teaching intensity, and nurse staffing levels. Methods: The research design was cross-sectional analyses of nurse survey and administrative data for 156 Pennsylvania hospitals from 1999. For comparative reference, nurse survey data from earlier years from two small samples of nursing magnet hospitals were analyzed. The nursing practice environment was measured by the Practice Environment Scale of the Nursing Work Index (PES-NWI). Results: Nursing practice environments varied greatly among the hospitals studied. The nursing practice environments of the small samples of magnet hospitals were superior to those of the Pennsylvania sample. About 17% of the hospitals in the Pennsylvania sample had favorable practice environments. Pennsylvania hospitals with better practice environments had higher RN-to-bed ratios. Practice environment differences were not associated with hospital bed size or community size. Hospitals with a modest teaching level had less favorable environments. Discussion: Considerable variation exists in the quality of hospital nursing practice environments. Five out of six hospitals are targets for improvement. Favorable nursing practice environments can be achieved in a wide variety of hospital settings.

HOSPITAL VARIATION IN MISSED NURSING CARE

Quality of nursing care across hospitals is variable, and this variation can result in poor patient outcomes. One aspect of quality nursing care is the amount of necessary care that is omitted. This article reports on the extent and type of nursing care missed and the reasons for missed care. The MISSCARE Survey was administered to nursing staff (n = 4086) who provide direct patient care in 10 acute care hospitals. Missed nursing care patterns as well as reasons for missing care (labor resources, material resources, and communication) were common across all hospitals. Job title (ie, registered nurse vs nursing assistant), shift worked, absenteeism, perceived staffing adequacy, and patient work loads were significantly associated with missed care. The data from this study can inform quality improvement efforts to reduce missed nursing care and promote favorable patient outcomes.

Nurse Practice Environments and Outcomes: Implications for Oncology Nursing

PURPOSE/OBJECTIVES To examine practice environments and outcomes of nurses working in oncology units or Magnet hospitals and to understand the association between the two. DESIGN Secondary analysis of survey data collected in 1998. SETTING Medical and surgical units of 22 hospitals, of which 7 were recognized by the American Nurses Credentialing Center Magnet program. SAMPLE 1,956 RNs, of whom 305 worked in oncology units. METHODS Chi-square tests compared nurse-reported outcomes by work setting, analysis of variance tested practice environment differences by setting, and logistic regression estimated the effects of practice environment, specialty, and Magnet status on outcomes. MAIN RESEARCH VARIABLES Practice environments, emotional exhaustion, job satisfaction, and quality of care. FINDINGS Oncology nurses had superior outcomes compared with nononcology nurses. Emotional exhaustion was significantly lower among oncology nurses working in Magnet hospitals. Scores on the Collegial Nurse-Physician Relations subscale were highest among oncology nurses. Outcomes were associated with Practice Environment Scale of the Nursing Work Index scores and Magnet status. Oncology nurses with favorable collegial nurse-physician relations were twice as likely to report high-quality care. CONCLUSIONS Oncology nurses benefit from working in American Nurses Credentialing Center Magnet hospitals. Adequate staffing and resources are necessary to achieve optimal outcomes. Collegial nurse-physician relations appear to be vital to optimal oncology practice settings. IMPLICATIONS FOR NURSING In addition to pursuing American Nurses Credentialing Center Magnet recognition, nurse managers should assess practice environments and target related interventions to improve job satisfaction and retention. High-priority areas for interventions include ensuring adequate staff and resources, promoting nurse-physician collaboration, and strengthening unit-based leadership.

Hospital characteristics, clinical severity, and outcomes for surgical oncology patients

BACKGROUND Patients and payers wish to identify hospitals with good surgical oncology outcomes. Our objective was to determine whether differences in outcomes explained by hospital structural characteristics are mitigated by differences in patient severity. METHODS Using hospital administrative and cancer registry records in Pennsylvania, we identified 24,618 adults hospitalized for cancer-related operations. Colorectal, prostate, endometrial, ovarian, head and neck, lung, esophageal, and pancreatic cancers were studied. Outcome measures were 30-day mortality and failure to rescue (FTR) (30-day mortality preceded by a complication). After severity of illness adjustment, we estimated logistic regression models to predict the likelihood of both outcomes. In addition to American Hospital Association survey data, we externally verified hospitals with National Cancer Institute (NCI) cancer center or Commission on Cancer (COC) cancer program status. RESULTS Patients in hospitals with NCI cancer centers were significantly younger and less acutely ill on admission (P < .001). Patients in high volume hospitals were younger, had lower admission acuity, yet had more advanced cancer (P < .001). Unadjusted 30-day mortality rates were lower in NCI-designated hospitals (3.76% vs 2.17%;P = .01). Risk-adjusted FTR rates were significantly lower in NCI-designated hospitals (4.86% vs 3.51%;P = .03). NCI center designation was a significant predictor of 30-day mortality when considering patient and hospital characteristics (OR, 0.68; 95% CI, 0.47-0.97;P = .04). We did not find significant outcomes effects based on COC cancer program approval. CONCLUSION Patient severity of illness varies significantly across hospitals, which may explain the outcome differences observed. Severity adjustment is crucial to understanding outcome differences. Outcomes were better than predicted for NCI-designated hospitals.

Factors associated with receipt of breast cancer adjuvant chemotherapy in a diverse population-based sample

PURPOSE Disparities in receipt of adjuvant chemotherapy may contribute to higher breast cancer fatality rates among black and Hispanic women compared with non-Hispanic whites. We investigated factors associated with receipt of chemotherapy in a diverse population-based sample. PATIENTS AND METHODS Women diagnosed with breast cancer between August 2005 and May 2007 (N = 3,252) and reported to the Detroit, Michigan, or Los Angeles County Surveillance, Epidemiology, and End Results (SEER) registry were recruited to complete a survey. Multivariable analyses examined factors associated with chemotherapy receipt. RESULTS The survey was sent to 3,133 patients; 2,290 completed a survey (73.1%), and 1,403 of these patients were included in the analytic sample. In multivariable models, disease characteristics were significantly associated with the likelihood of receiving chemotherapy. Low-acculturated Hispanics were more likely to receive chemotherapy than non-Hispanic whites (odds ratio [OR], 2.00; 95% CI, 1.31 to 3.04), as were high-acculturated Hispanics (OR, 1.43; 95% CI, 1.03 to 1.98). Black women were less likely to receive chemotherapy than non-Hispanic whites, but the difference was not significant (OR, 0.83; 95% CI, 0.64 to 1.08). Increasing age (even in women age < 50 years) and Medicaid insurance were associated with lower rates of chemotherapy receipt. CONCLUSION In this population-based sample, disease characteristics were strongly associated with receipt of chemotherapy, indicating that clinical benefit guides most treatment decisions. We found no compelling evidence that black women and Hispanics receive chemotherapy at lower rates. Interventions that address chemotherapy use rates according to age and insurance status may improve quality of systemic treatment.

Breast Biopsy Patterns and Outcomes in Surveillance, Epidemiology, and End Results-Medicare Data

Despite known benefits to needle biopsy for suspicious breast lesions, variability in the use of this technique has been documented in practice. We sought to study the use of needle biopsy and open surgical biopsy in women with breast cancer, predictors of needle biopsy use, and the effect of biopsy choice on overall number of surgical procedures needed to treat breast cancer.

Neutropenia: State of the Knowledge Part I

PURPOSE/OBJECTIVES To review neutrophil physiology, consequences of chemotherapy-induced neutropenia (CIN), CIN risk assessment models, national practice guidelines, the impact of febrile neutropenia and infection, and what is known and unknown about CIN. DATA SOURCES Extensive review and summary of published neutropenia literature, guidelines, meta-analyses, currently funded National Institutes of Health and Oncology Nursing Society studies, and invited expert panel symposium presentations. DATA SYNTHESIS A comprehensive review of current literature regarding CIN risk assessment, practice guidelines, management, impact on dose-dense and dose-intense cancer treatment, complications, costs related to hospitalizations, and treatment strategies has been compiled. CONCLUSIONS CIN is the most common dose-limiting toxicity of cancer therapy. Medical practice guidelines and risk assessment models for appropriate use of myeloid growth factors and management of febrile neutropenia have been developed to assess patients for CIN complications prechemotherapy and during CIN episodes. CIN affects patients, families, practitioners, and the healthcare system. Although much is known about this common chemotherapy complication, a great deal remains to be learned. IMPLICATIONS FOR NURSING CIN is a serious and global problem in patients receiving cancer therapy. Oncology nurses need to critically analyze their own practices when assessing, managing, and educating patients and families about CIN.

Putting Evidence Into Practice: Prevention of Infection

The prevention of infection is an important outcome to measure in patients with cancer because infectious complications are a significant cause of morbidity and mortality. Nurses play a vital role in the prevention of infection in patients with cancer through nursing practice, research, and patient education. However, many common nursing interventions to prevent infection are based on tradition or expert opinion and have not been subjected to scientific examination. The 2005 Oncology Nursing Society Prevention of Infection Outcomes Intervention Project Team reviewed, critiqued, and summarized the research evidence for nursing interventions to prevent infections in patients with cancer. Pharmacologic and nonpharmacologic interventions were included because many advanced practice nurses prescribe medications. This article is an evidence-based review of nursing interventions to prevent infection in patients with cancer.

Failure to Rescue in the Surgical Oncology Population: Implications for Nursing and Quality Improvement

PURPOSE/OBJECTIVES To analyze the frequency, type, and correlates of postoperative complications for surgical patients with cancer to illustrate practical application of the failure to rescue concept in oncology nursing practice. DESIGN Secondary analysis of inpatient claims. SETTING Data obtained from the Pennsylvania Health Care Cost Containment Council were linked with data from the Pennsylvania Cancer Registry. SAMPLE 24,618 patients with solid tumors hospitalized for tumor-directed surgery in 164 acute care hospitals from 1998-1999. METHODS Frequency distributions examined the incidence of each complication, the proportion of patients who died with the complication, and complication frequency by tumor type. Chi-square tests compared the frequency of complications for patients who were admitted routinely or via the emergency department. MAIN RESEARCH VARIABLES 30-day mortality, postoperative complications, and tumor type. FINDINGS The most frequent complication in the sample was gastrointestinal bleeding (13.2%); however, 37.1% of patients who died had respiratory compromise as a complication. Admission through the emergency department was significantly associated with experiencing a complication (71.9% versus 43.9%). CONCLUSIONS Treatable but serious postoperative complications are frequent and can be fatal in the surgical oncology population. Complication frequency and fatality vary significantly by cancer type. IMPLICATIONS FOR NURSING The complications studied are detectable by nurses and can be managed successfully with timely intervention. Recognition of complications at an early stage and evidence-based management may assist nurses in patient rescue and, ultimately, improve quality of care.