Donna Felber Neff

Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments.

Context:Better hospital nurse staffing, more educated nurses, and improved nurse work environments have been shown to be associated with lower hospital mortality. Little is known about whether and under what conditions each type of investment works better to improve outcomes. Objective:To determine the conditions under which the impact of hospital nurse staffing, nurse education, and work environment are associated with patient outcomes. Design, Setting, and Participants:Outcomes of 665 hospitals in 4 large states were studied through linked data from hospital discharge abstracts for 1,262,120 general, orthopedic, and vascular surgery patients, a random sample of 39,038 hospital staff nurses, and American Hospital Association data. Main Outcome Measures:A 30-day inpatient mortality and failure-to-rescue. Results:The effect of decreasing workloads by 1 patient/nurse on deaths and failure-to-rescue is virtually nil in hospitals with poor work environments, but decreases the odds on both deaths and failures in hospitals with average environments by 4%, and in hospitals with the best environments by 9% and 10%, respectively. The effect of 10% more Bachelors of Science in Nursing Degree nurses decreases the odds on both outcomes in all hospitals, regardless of their work environment, by roughly 4%. Conclusions:Although the positive effect of increasing percentages of Bachelors of Science in Nursing Degree nurses is consistent across all hospitals, lowering the patient-to-nurse ratios markedly improves patient outcomes in hospitals with good work environments, slightly improves them in hospitals with average environments, and has no effect in hospitals with poor environments.

Nurse reports from the frontlines: analysis of a statewide nurse survey.

BACKGROUND Registered nurses on the frontlines of care are increasingly burdened by changes in staffing, increased turnover, demands on their time and the continual need for advanced knowledge and training. We identify employment and environmental characteristics that may ultimately affect the quality of care METHODS Surveys were mailed to a random sample of all registered nurses licensed and residing in large southeastern US State. Responses from 10, 951 nurses providing direct patient care were compared to national findings. Descriptive statistics were used to examine demographics, the practice environment, nurse outcomes and the quality of care. RESULTS Nurses in this state are more racially diverse and less educated when compared to nurses nationally. Theses nurses report high levels of burnout and job dissatisfaction, and almost one-quarter intend to leave their jobs within the next year. The majority of nurses report good working relationships with physicians, but perceive problems with workplace management. CONCLUSION Nurses report inadequate resources and the administrative support necessary to provide quality care. The proportion of nurses with baccalaureate and graduate education qualifications is less than is needed now and certainly insufficient for the future. Policy efforts must address these issues to retain our nurse workforce and improve the quality of patient care.

The effects of nurse staffing on hospital financial performance: Competitive versus less competitive markets

BACKGROUND Hospitals facing financial uncertainty have sought to reduce nurse staffing as a way to increase profitability. However, nurse staffing has been found to be important in terms of quality of patient care and nursing-related outcomes. Nurse staffing can provide a competitive advantage to hospitals and as a result of better financial performance, particularly in more competitive markets. PURPOSE In this study, we build on the Resource-Based View of the Firm to determine the effect of nurse staffing on total profit margin in more competitive and less competitive hospital markets in Florida. METHODOLOGY/APPROACH By combining a Florida statewide nursing survey with the American Hospital Association Annual Survey and the Area Resource File, three separate multivariate linear regression models were conducted to determine the effect of nurse staffing on financial performance while accounting for market competitiveness. The analysis was limited to acute care hospitals. FINDINGS Nurse staffing levels had a positive association with financial performance (β = 3.3, p = .02) in competitive hospital markets, but no significant association was found in less competitive hospital markets. PRACTICE IMPLICATIONS Hospitals in more competitive hospital markets should reconsider reducing nursing staff, as these cost-cutting measures may be inefficient and negatively affect financial performance.

Utilization of non-US educated nurses in US hospitals: implications for hospital mortality

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.

Nurse managed center: access to primary health care for urban Native Americans.

Abstract Urban Native Americans represent a small, diverse minority with unique health needs. The purposes of this descriptive retrospective study were to describe (a) the characteristics and primary health problems of urban Native Americans who receive primary health care at an urban nurse managed center (NMC) and (b) the nursing interventions provided at an urban NMC to urban Native Americans. A sample of 334 participants patient data were abstracted from a computerized clinical data set and coded based on the Omaha Classification System. The majority were over 40 years of age, were female, were single, completed high school, and were poor and uninsured, and many were unemployed. The most frequent health problems were related to pain, cardiovascular symptoms, dentition problems, and respiratory illnesses. The most frequent nursing interventions were for surveillance of physical signs and symptoms. The NMC was an accessible source of primary health care for urban Native Americans in northeastern Ohio.

Certification and education as determinants of nurse practitioner scope of practice: An investigation of the rules and regulations defining NP scope of practice in the United States

Purpose and background In 2008, a consortium of advanced practice nursing organizations authored the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education. The documents aim is to provide guidance for states to adopt uniformity in the regulation of advanced practice registered nurse roles. Despite a target date to complete that work by 2015, there remains an extensive amount of variation in how states define the scope of practice (SOP) for nurse practitioners (NPs). Data sources Based on the National Council of State Boards of Nursing online database, state (N = 51 [includes the District of Columbia]) NP practice acts and/or rules and regulations documents were examined for language describing SOP for NPs consistent with the language of the advanced practice registered nurse (APRN) Consensus Model. Conclusions Results indicated that 18 states and the District of Columbia (37%) had specific regulations defining NP SOP by certification and/or educational preparation while 23 (45%) did not. The remaining nine states (18%) had SOP regulations that were interpreted as being ambiguous in relation to certification and/or educational preparation. Implications for practice The findings suggest much work is needed to ensure NP SOP accurately reflects NP board-certification and graduate educational preparation.Purpose and background:In 2008, a consortium of advanced practice nursing organizations authored the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education. The documents aim is to provide guidance for states to adopt uniformity in the regulation of advanced practice registered nurse roles. Despite a target date to complete that work by 2015, there remains an extensive amount of variation in how states define the scope of practice (SOP) for nurse practitioners (NPs). Data sources:Based on the National Council of State Boards of Nursing online database, state (N = 51 [includes the District of Columbia]) NP practice acts and/or rules and regulations documents were examined for language describing SOP for NPs consistent with the language of the advanced practice registered nurse (APRN) Consensus Model. Conclusions:Results indicated that 18 states and the District of Columbia (37%) had specific regulations defining NP SOP by certification and/or educational preparation while 23 (45%) did not. The remaining nine states (18%) had SOP regulations that were interpreted as being ambiguous in relation to certification and/or educational preparation. Implications for practice:The findings suggest much work is needed to ensure NP SOP accurately reflects NP board‐certification and graduate educational preparation.

The impact of nurse practitioner regulations on population access to care

BACKGROUND By 2025, experts estimate a significant shortage of primary care providers in the United States, and expansion of the nurse practitioner (NP) workforce may reduce this burden. However, barriers imposed by state NP regulations could reduce access to primary care. PURPOSE The objectives of this study were to examine the association between three levels of NP state practice regulation (independent, minimum restrictive, and most restrictive) and the proportion of the population with a greater than 30-min travel time to a primary care provider using geocoding. METHODS Logistic regression models were conducted to calculate the adjusted odds of having a greater than 30-min drive time. FINDINGS Compared with the most restrictive NP states, states with independent practice had 19.2% lower odds (p = .001) of a greater than 30-min drive to the closest primary care provider. DISCUSSION Allowing NPs full autonomy to practice may be a relatively simple policy mechanism for states to improve access to primary care.

Introduction to Special Issue on Patient-centered Care

There is a dearth of research on patient-centered care for individuals with mental illness. This caught my attention and therefore this special edition of Issues in Mental Health Nursing focuses on patient-centered care of individuals with mental illness. To set the stage, in the U.S. patient-centered care (PCC) was established as a philosophy of health care delivery by the 1985 American Nurses Association Code for Nurses where patients “themselves are the primary decision makers in matters concerning their own health, treatment, and wellbeing, and the goal of nursing actions is to support and enhance the patient’s responsibility and self-determination to the greatest extent possible” (p. 1, as cited in Lutz & Bowers, 2000). Bechel, Myers, and Smith (2000) defined PCC as health care that involves the patients in decision making, intensifies patient/provider communication and understanding and finally, includes caregivers/family members in the team. Psychiatric-mental health nurses who care for patients with mental illness embrace the principles and values of patientcentered care, but providing PCC presents challenges. In this issue, authors share experiences, strategies and insights into these challenges. The issue includes a balance of research findings, both qualitative and quantitative, and review of research related to PCC. Burmeister and colleagues examined the use of peer technology training with older adults to increase their opportunities for social connectedness. Bernoth et al. discussed program evaluation of community support workers through interviews with community dwelling older adults. The support workers provided care geared toward reducing functional deterioration and improving quality of life for these elders. A participatory care approach and integrated health teams were central to the program. Elder and her team presented results of interviews conducted with caregivers of individuals with Autism Spectrum Disorders (ASD) and community providers for the purpose of understanding stakeholders’ perceptions of barriers to treatment for individuals with ASD. Soltis-Jarrett reported project outcomes following