Herbert L. Smith

Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States

Objective To determine whether hospitals with a good organisation of care (such as improved nurse staffing and work environments) can affect patient care and nurse workforce stability in European countries. Design Cross sectional surveys of patients and nurses. Setting Nurses were surveyed in general acute care hospitals (488 in 12 European countries; 617 in the United States); patients were surveyed in 210 European hospitals and 430 US hospitals. Participants 33 659 nurses and 11 318 patients in Europe; 27 509 nurses and more than 120 000 patients in the US. Main outcome measures Nurse outcomes (hospital staffing, work environments, burnout, dissatisfaction, intention to leave job in the next year, patient safety, quality of care), patient outcomes (satisfaction overall and with nursing care, willingness to recommend hospitals). Results The percentage of nurses reporting poor or fair quality of patient care varied substantially by country (from 11% (Ireland) to 47% (Greece)), as did rates for nurses who gave their hospital a poor or failing safety grade (4% (Switzerland) to 18% (Poland)). We found high rates of nurse burnout (10% (Netherlands) to 78% (Greece)), job dissatisfaction (11% (Netherlands) to 56% (Greece)), and intention to leave (14% (US) to 49% (Finland, Greece)). Patients’ high ratings of their hospitals also varied considerably (35% (Spain) to 61% (Finland, Ireland)), as did rates of patients willing to recommend their hospital (53% (Greece) to 78% (Switzerland)). Improved work environments and reduced ratios of patients to nurses were associated with increased care quality and patient satisfaction. In European hospitals, after adjusting for hospital and nurse characteristics, nurses with better work environments were half as likely to report poor or fair care quality (adjusted odds ratio 0.56, 95% confidence interval 0.51 to 0.61) and give their hospitals poor or failing grades on patient safety (0.50, 0.44 to 0.56). Each additional patient per nurse increased the odds of nurses reporting poor or fair quality care (1.11, 1.07 to 1.15) and poor or failing safety grades (1.10, 1.05 to 1.16). Patients in hospitals with better work environments were more likely to rate their hospital highly (1.16, 1.03 to 1.32) and recommend their hospitals (1.20, 1.05 to 1.37), whereas those with higher ratios of patients to nurses were less likely to rate them highly (0.94, 0.91 to 0.97) or recommend them (0.95, 0.91 to 0.98). Results were similar in the US. Nurses and patients agreed on which hospitals provided good care and could be recommended. Conclusions Deficits in hospital care quality were common in all countries. Improvement of hospital work environments might be a relatively low cost strategy to improve safety and quality in hospital care and to increase patient satisfaction.

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.

Matching With Multiple Controls to Estimate Treatment Effects in Observational Studies

Matching to control for covariates in the estimation of treatment effects is not common in sociology, where multivariate data are most often analyzed using multiple regression and its generalizations. Matching can be a useful way to estimate these effects, especially when the treatment condition is comparatively rare in a population, and controls are numerous but mostly unlike the treatment cases. Matching on numerous covariates is abetted by the estimation of propensity scores, or functions of the probability that cases are treatments rather than controls. This procedure is illustrated in the estimation of the effects of an organizational innovation on Medicare mortality within hospitals; the data set is very large, but innovative hospitals few, and many of the remaining hospitals are quite unlike the hospitals constituting the treatment sub-sample. Results are based on a variance-components model that is extended to consider the effects of an additional covariate. They show effects of the organizational innovation comparable to those estimated via multiple regression models but with substantially reduced standard errors.

Husbands’ versus wives’ fertility goals and use of contraception: The influence of gender context in five Asian countries

Using data from Pakistan, India, Malaysia, Thailand, and the Philippines, we explore how gender context influences (1) husband-wife concordance in the demand for children and (2) the impact of each spouse’s fertility preferences on contraceptive use. We also explore whether the husband’s pronatalism can explain the wife’s unmet need for contraception. The results suggest that gender context has little net effect on couples’ concordance, but influences the relative weight of husbands’ and wives’ preferences in determining contraceptive use. Analysis of women’s unmet need for contraception suggests that the husbands’ pronatalism contributes to wives’ unmet need, but only to a relatively small degree, especially in settings where unmet need is high. This is the case because the proportion of couples with differing fertility goals is small in most communities.

Lower mortality in magnet hospitals.

Background:Although there is evidence that hospitals recognized for nursing excellence—Magnet hospitals—are successful in attracting and retaining nurses, it is uncertain whether Magnet recognition is associated with better patient outcomes than non-Magnets, and if so why. Objectives:To determine whether Magnet hospitals have lower risk-adjusted mortality and failure-to-rescue compared with non-Magnet hospitals, and to determine the most likely explanations. Method and Study Design:Analysis of linked patient, nurse, and hospital data on 56 Magnet and 508 non-Magnet hospitals. Logistic regression models were used to estimate differences in the odds of mortality and failure-to-rescue for surgical patients treated in Magnet versus non-Magnet hospitals, and to determine the extent to which differences in outcomes can be explained by nursing after accounting for patient and hospital differences. Results:Magnet hospitals had significantly better work environments and higher proportions of nurses with bachelor’s degrees and specialty certification. These nursing factors explained much of the Magnet hospital effect on patient outcomes. However, patients treated in Magnet hospitals had 14% lower odds of mortality (odds ratio 0.86; 95% confidence interval, 0.76–0.98; P=0.02) and 12% lower odds of failure-to-rescue (odds ratio 0.88; 95% confidence interval, 0.77–1.01; P=0.07) while controlling for nursing factors as well as hospital and patient differences. Conclusions:The lower mortality we find in Magnet hospitals is largely attributable to measured nursing characteristics but there is a mortality advantage above and beyond what we could measure. Magnet recognition identifies existing quality and stimulates further positive organizational behavior that improves patient outcomes.

Integrating theory and research on the institutional determinants of fertility.

This article links recent conceptual theories regarding the determinants of fertility with research designs appropriate for testing those theories. The most important causal factors in these theories—typically social or cultural institutions, occasionally emergent properties of the collective behavior of individuals—are properly conceptualized at the macro level. Research designs must therefore feature variation at this level and are at a minimum comparative. Noncomparative micro-level research designs will be misspecified from the standpoint of theory. A case is also made for continuing to incorporate the observation of individual-level behavior into any comprehensive research design. A focus on macro determinants of fertility does not imply that fertility outcomes are determined at the institutional level. Instead, there remains some process whereby systemic properties are translated into individual behaviors. Recommendations for comparative community-level studies are discussed. The multilevel analysis framework is reviewed as a paradigm for the conceptual features of cross-contextual analysis.

A decomposition of trends in the nonmarital fertility ratios of blacks and whites in the united states, 1960–1992

We use a method of standardization and decomposition developed by Das Gupta to update Smith and Cutright’s analysis of demographic factors responsible for increases in the nonmarital fertility ratio (illegitimacy ratio) among blacks and whites in the United States. We create standardized rates for each year between 1960 and 1992, and consistent, exhaustive decompositions of the nonmarital fertility ratio for any interval during this period in terms of four components: (1) the age distribution of women of reproductive age, (2) the proportion of women unmarried at each age, (3) the age-specific birth rates of married women, and (4) the age-specific birth rates of unmarried women. Nonmarital fertility ratios are much higher among blacks than among whites, but both increased monotonically from 1960 to 1992. During the last 10 years, each increased by nearly 10 percentage points. Increases in the proportion of women not married, at all ages, account for the preponderance of the increase in black nonmarital fertility ratios. Increasing rates of unmarried childbearing, however, have played a role during the most recent decade (1983–1992). For whites, from 1960 until 1975, declines in marital fertility were most important in producing increases in the proportion of children born out of wedlock. Since then, these proportions have increased primarily because of increases in unmarried women s birth rates, and secondarily because of declines in the proportion of women who are married. These trends are consistent with arguments that emphasize declining economic incentives to marry and reduced access to, and acceptability of, abortion.

Trends in the Effects of Family Background on Educational Attainment in the Philippines.

In order to assess trends in the effect of parental status as a determinant of educational outcomes, two distinct models are estimated for a succession of cohorts of Philippine men and women born in the first half of the 20th century. The linear models shows some decline across cohorts in the effects of background on years of schooling; the logistic response model, used to estimate the effects of background variables on specific grade progression probabilities, shows remarkable constancy over time. These results are consistent with an image of the educational system as an ever-expanding pie that is always sliced in the same proportions.

Has the Chinese family planning policy been successful in changing fertility preferences

Has China’s strict one-child policy been successful in changing fertility preferences? Using linked data from surveys conducted in four counties of northern China in 1991 and 1994, we compare reproductive behavior against prior fertility preferences and show when and where women change from wanting to not wanting more children. The acceptance of policy-sanctioned family size follows a development gradient and reflects the degree of enforcement. High acceptance occurs in the most urban, industrialized county and in the county with the most rigid family planning policy. Acceptance is weaker among women living in the poorest county and in the county where enforcement is most lenient.

Age-Period-Cohort Analysis and the Study of Deaths from Pulmonary Tuberculosis

Our purpose is both substantive and methodological. Substantively, we crystallize the results of prior research and expectations into an extended rationale for the application of the age-period-cohort accounting framework to the problem of understanding historical variability in the rate of tuberculosis mortality. This framework is then used to analyze a ninety year data series of tuberculosis mortality rates for the State of Massachusetts and a similar forty year series for the United States. The age-period-cohort accounting framework yields age effects with an expected pattern not well understood, period effects consistent with the advent of successful chemotherapeutic regimes after World War II, and steadily declining cohort effects whose interpretation has yet to be verified. In an attempt to pin down a possible interpretation, we show that cohort nativity composition affects the trend of cohort mortality in the Massachusetts series, and both level and trend in the United States series.