Eileen T. Lake

Effects of hospital care environment on patient mortality and nurse outcomes.

Objective: The objective of this study was to analyze the net effects of nurse practice environments on nurse and patient outcomes after accounting for nurse staffing and education. Background: Staffing and education have well-documented associations with patient outcomes, but evidence on the effect of care environments on outcomes has been more limited. Methods: Data from 10,184 nurses and 232,342 surgical patients in 168 Pennsylvania hospitals were analyzed. Care environments were measured using the practice environment scales of the Nursing Work Index. Outcomes included nurse job satisfaction, burnout, intent to leave, and reports of quality of care, as well as mortality and failure to rescue in patients. Results: Nurses reported more positive job experiences and fewer concerns with care quality, and patients had significantly lower risks of death and failure to rescue in hospitals with better care environments. Conclusion: Care environment elements must be optimized alongside nurse staffing and education to achieve high quality of care.

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.

Organization and outcomes of inpatient AIDS care.

The establishment of AIDS hospitals and AIDS units within hospitals has been controversial. Unlike other specialty care, AIDS care arrangements were initially developed as much to segregate AIDS patients from other patients and staff as to provide the best possible care. Ten years after many of these units opened, little evidence was available about whether the benefits of aggregating AIDS patients outweighed the potential hazards of segregating people from the mainstream of hospital care. This Issue Brief describes a national study to determine how different organizational settings affect the outcomes of inpatient AIDS care.

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.

Advancing the science of patient safety

Despite a decades worth of effort, patient safety has improved slowly, in part because of the limited evidence base for the development and widespread dissemination of successful patient safety practices. The Agency for Healthcare Research and Quality sponsored an international group of experts in patient safety and evaluation methods to develop criteria to improve the design, evaluation, and reporting of practice research in patient safety. This article reports the findings and recommendations of this group, which include greater use of theory and logic models, more detailed descriptions of interventions and their implementation, enhanced explanation of desired and unintended outcomes, and better description and measurement of context and of how context influences interventions. Using these criteria and measuring and reporting contexts will improve the science of patient safety.

Patient Falls: Association With Hospital Magnet Status and Nursing Unit Staffing

The relationships between hospital Magnet® status, nursing unit staffing, and patient falls were examined in a cross-sectional study using 2004 National Database of Nursing Quality Indicators (NDNQI®) data from 5,388 units in 108 Magnet and 528 non-Magnet hospitals. In multivariate models, the fall rate was 5% lower in Magnet than non-Magnet hospitals. An additional registered nurse (RN) hour per patient day was associated with a 3% lower fall rate in ICUs. An additional licensed practical nurse (LPN) or nursing assistant (NA) hour was associated with a 2-4% higher fall rate in non-ICUs. Patient safety may be improved by creating environments consistent with Magnet hospital standards.

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.

Are Patient Falls and Pressure Ulcers Sensitive to Nurse Staffing

Research has demonstrated an association between more nurses and more qualified nursing staff in hospitals and better patient outcomes. Patient falls and pressure ulcers have been advanced as nursing-sensitive outcomes. This article evaluates the state of the science linking nurse staffing to falls and pressure ulcers. Studies that employed multivariate analysis to discern the effect of nurse staffing on patient falls and pressure ulcers in hospitals were evaluated. Eleven studies that met inclusion criteria were contrasted on their data sources and measures, data analysis, risk adjustment, and results. The evidence of an effect of nursing hours or skill mix on patient falls and pressure ulcers is equivocal. Substantial differences in research methods across studies may account for the mixed findings. Two study types were identified based on the level at which nurse staffing was measured, hospital or nursing unit, which exhibited systematic differences in measures and methods. Improvements in measurement and methods are suggested.

Nurse Staffing and NICU Infection Rates

IMPORTANCE There are substantial shortfalls in nurse staffing in US neonatal intensive care units (NICUs) relative to national guidelines. These are associated with higher rates of nosocomial infections among infants with very low birth weights. OBJECTIVE To study the adequacy of NICU nurse staffing in the United States using national guidelines and analyze its association with infant outcomes. DESIGN Retrospective cohort study. Data for 2008 were collected by web survey of staff nurses. Data for 2009 were collected for 4 shifts in 4 calendar quarters (3 in 2009 and 1 in 2010). SETTING Sixty-seven US NICUs from the Vermont Oxford Network, a national voluntary network of hospital NICUs. PARTICIPANTS All inborn very low-birth-weight (VLBW) infants, with a NICU stay of at least 3 days, discharged from the NICUs in 2008 (n = 5771) and 2009 (n = 5630). All staff-registered nurses with infant assignments. EXPOSURES We measured nurse understaffing relative to acuity-based guidelines using 2008 survey data (4046 nurses and 10 394 infant assignments) and data for 4 complete shifts (3645 nurses and 8804 infant assignments) in 2009-2010. MAIN OUTCOMES AND MEASURES An infection in blood or cerebrospinal fluid culture occurring more than 3 days after birth among VLBW inborn infants. The hypothesis was formulated prior to data collection. RESULTS Hospitals understaffed 31% of their NICU infants and 68% of high-acuity infants relative to guidelines. To meet minimum staffing guidelines on average would require an additional 0.11 of a nurse per infant overall and 0.34 of a nurse per high-acuity infant. Very low-birth-weight infant infection rates were 16.4% in 2008 and 13.9% in 2009. A 1 standard deviation-higher understaffing level (SD, 0.11 in 2008 and 0.08 in 2009) was associated with adjusted odds ratios of 1.39 (95% CI, 1.19-1.62; P < .001) in 2008 and 1.40 (95% CI, 1.19-1.65; P < .001) in 2009. CONCLUSIONS AND RELEVANCE Substantial NICU nurse understaffing relative to national guidelines is widespread. Understaffing is associated with an increased risk for VLBW nosocomial infection. Hospital administrators and NICU managers should assess their staffing decisions to devote needed nursing care to critically ill infants.

Organizational determinants of work outcomes and quality care ratings among Army Medical Department registered nurses.

The Practice Environment Scale of the Nursing Work Index, the Maslach Burnout Inventory, and several single-item measures were administered to registered nurses (RNs) working within 23 U.S.-based Army Medical Department (AMEDD) hospitals. Data were analyzed with logistic regression for nested data. Unfavorable nursing practice environments had a substantial association with job dissatisfaction (OR 13.75, p < .01), emotional exhaustion (OR 12.70, p < .01), intent to leave (OR 3.03, p < .01), and fair to poor quality of care (OR 10.66, p < .01). This study provides the first system-wide analyses of nursing practice environments in AMEDD hospitals in the U.S. Similar to findings in civilian samples, poor quality work environments are associated with less favorable RN work outcomes and quality of care ratings.