Jean Ann Seago

Longitudinal analyses of nurse staffing and patient outcomes: more about failure to rescue.

Background: Numerous studies have examined cross-sectional data to determine the relationships between nurse staffing and patient outcomes. Questions have been raised about some of the studies now in the literature regarding the use of the hospital as the unit of analysis and the cross-sectional design of the studies. Additionally, there is a concern that the primary outcomes being studied are negative. Objective: Objectives of this study are to (1) compare the relationships between nurse staffing and positive patient outcomes for 3 adult medical-surgical nursing units in one university teaching hospital across 4 years (16 fiscal quarters); and (2) explore the use of 2 new failure-to-rescue (FTR) rates as outcomes, specifically FTR from medication errors and FTR from decubitus ulcers. Design: This study uses secondary analyses of data viewed retrospectively with a longitudinal repeated-measures design to estimate the relationships between nurse staffing and the outcomes of interest. Results: Accounting for total dollars and case mix, all patient satisfaction measures increased as total hours of care per patient day increased, and as the skill mix became richer (more RN hours/total hours) there was a higher satisfaction with pain management and physical care requests. There was an increase in FTR from medication error as the non-RN (Other) hours of care per patient day increased and there was an increase in FTR from decubitus ulcers as patient severity increased. Conclusion: The overall conclusion is that it will likely be necessary to vary staffing hours and staffing mix depending on which positive patient outcome or outcomes you wish to achieve.

The nursing shortage: is it really about image?

EXECUTIVE SUMMARY A poor public “image” of the nurse is believed to contribute to nurse shortages. We surveyed more than 3,000 college students in science and math courses in a seven‐county region of Californias Central Valley to assess their perceptions of a career as a nurse in relation to a career as a physical therapist, a high school teacher, or a physician. Students generally had favorable perceptions of nursing, with two‐thirds agreeing that nursing has good income potential, job security, and interesting work. However, nursing lagged behind the other occupations in perceptions of independence at work and was more likely to be perceived as a “womens” occupation. Our findings suggest that these college students have generally gotten the message that nursing is a financially rewarding and desirable career, although they also perceive nursing to be less attractive on some important occupational characteristics such as job independence. Unless nursing training capacity expands substantially, the projected nurse shortage will occur. With continued aggressive marketing of nursing as a career, there is a risk of engendering a backlash from prospective students frustrated in their effort to find a slot in a nursing training program. Much work remains to be done to alter the image of nursing as a womens occupation and to transform the work environment of nurses to make a career in nursing more attractive.

The California experiment: alternatives for minimum nurse-to-patient ratios.

In making policy, it is ideal to study a problem, test solutions, and then implement the best solution. In California there is legislation regarding nurse staffing that requires implementation of a solution before the problem has been accurately stated and before alternative solutions have been tested. Assembly Bill 394 directs the California Department of Health Services to establish “minimum, specific, and numerical licensed nurse-to-patient ratios by licensed nurse classification and by hospital unit” and have these ratios in place January 1, 2002. This law is scheduled for implementation before there is specific evidence of optimal staffing levels for various patient populations. The author presents a comprehensive literature review of activities related to nurse staffing in the United States, provides data related to existing patient classification systems in California, and suggests an alternative to staffing ratios to protect consumers

Job strain among registered nurses and other hospital workers.

OBJECTIVE The authors describe factors associated with job strain for various job titles in the acute care hospital using the Karasek Job Strain Model, discuss the reliability and validity of the Job Content Questionnaire, and discuss use of the model to enhance the work environment. BACKGROUND The Karasek Job Strain Model has been used to describe many occupations in the United States and other countries. Some research indicates that occupations that arouse stress hormones are those in which employees have little job control or must complete psychologically demanding tasks, such as those under time pressure, and these positions can be describe as high-strain jobs. METHOD This descriptive correlational study was conducted at five tertiary care hospitals on the West Coast. A purposive volunteer sample of staff members working at least 20 hours per week in the adult medical-surgical and specialty nursing units was recruited. RESULTS Mean scores for each of the nursing units and the overall mean scores for the staff in the initial analysis fell into the Active Work quadrant of the Karasek Job Strain Model. When nursing job titles were analyzed, registered nurses had significantly higher Decision Latitude scores than did nurse assistants (P < 0.001) and clerical staff (P < 0.001), but there were no significant differences for Psychological Demands. CONCLUSIONS Working with nurse assistants to appropriately increase decision latitude related to their work has the potential to enhance the work environment by reducing job strain and improving staff health and morale.

Measuring Shortages of Hospital Nurses: How do you Know a Hospital with a Nursing Shortage When you See One?:

Lack of clarity in definitions of shortages of hospital registered nurses may cause problems for effective policy making, particularly if different measures for identifying a nurse shortage lead to different conclusions about which hospitals and regions are experiencing a shortage. The authors compared different methods of identifying hospitals and regions with a shortage of registered nurses, including both relatively subjective measures (e.g., a hospital administrator’s report of a nurse shortage) and more objective measures (e.g., number of registered nurses per inpatient year). Associations were strongest between self-reported shortage status and nursing vacancy rates and weaker for self-reported shortage status and registered nurses per inpatient year and overall regional supply of nurses. Different definitions of nursing shortage are not equally reliable in discriminating between hospitals and regions with and without nursing shortages. When faced with reports sounding an alarm about a hospital nursing shortage, policy makers should carefully consider the definition of shortage being used.

Work Group Culture, Stress, and Hostility: Correlations with Organizational Outcomes

Understanding your organizational culture is necessary if you are to be successful in making and surviving the necessary changes in current environments. Although organizational culture frequently has been studied in the business community, there are fewer studies of organizational or work group culture in hospital settings at the nursing unit level. The existing studies have emphasized the need to understand the individual work group culture before successfully implementing innovation and educational programs, or hiring and orienting new employees on nursing units. This descriptive, correlational study describes the relationships among work group culture, work-place stress, and hostility and nursing unit outcomes, specifically absenteeism and turnover. Implications of the findings include the idea that increasing decision latitude in workers may positively impact absenteeism.

Factors influencing stay in the postanesthesia care unit: a prospective analysis

STUDY OBJECTIVE To identify indicators of prolonged length of stay (LOS) in the postanesthesia care unit (PACU) and to test the following hypotheses: (1) that patient age, pain medication administration at the time of PACU admission, length of surgery, and cardiovascular, pulmonary, and pain responses postoperatively predict prolonged PACU LOS and (2) that cardiovascular and pulmonary symptoms preoperatively predict cardiovascular and pulmonary symptoms postoperatively. DESIGN Prospective, observational analysis. SETTING PACU of a university teaching hospital. PATIENTS 1,067 patients scheduled for surgery with general anesthesia between February and September 1996, 18 years of age or older. MEASUREMENT AND MAIN RESULTS 11.2% of the variation in prolonged PACU LOS can be predicted by age, pain medication at the time of PACU admission, and postoperative cardiovascular, pulmonary, and pain symptoms. A significant number of patients who did not report a prior history experienced postoperative cardiovascular and pulmonary symptoms. CONCLUSION Patient history and postoperative symptoms predict only a small percentage of prolonged PACU stays. Organizational factors may be a more important predictor of prolonged PACU stay. Additionally, assessment of cardiovascular and pulmonary history needs refinement to improve prediction of patient responses postoperatively.

Nurse staffing and hospital ownership in California.

Objective: The purpose of this study is to describe the relationship between nurse staffing and owner type or specific corporate owner in California acute care hospitals. Background: Little empirical data exist regarding nurse staffing as it relates to owner type or specific corporate owner. With minimum staffing ratios scheduled to be implemented in January 2004, this study provides baseline data for evaluating the impact of minimum staffing ratios in California. Methods: The study design is descriptive and cross-sectional. Data used in this study are for short-term general hospitals that reported to the California Office of Statewide Health Planning and Development database for fiscal years ending in 1997 through 1999. Six regression models were estimated using pooled data from the 3 years of data. Results: The most consistent significant findings are: increased patient days or patient discharges predict increased registered nurse (RN) hours; lower RN wages predict increased RN hours; higher technology scores predict increased RN hours; and in 1998 there was an across-the-board decrease in RN hours. Other significant findings include that for-profit hospitals and for-profit systems had fewer RN productive hours for medical-surgical nursing, and select corporate owners, unrelated to profit status, had consistently fewer RN productive hours for medical-surgical nursing. Conclusions/Implications: For-profit hospitals and systems behaved differently in the healthcare market environment of the late 1990s. Select nonprofit systems were also using significantly less RN staffing. Other findings support the implication that as technology sophistication increases, there will be a need for increased RN hours to manage the advanced technology. This runs counter to the argument that increasing technology will decrease the need for RN hours. Finally, as discharges go up, the need for RN hours increases.

A comparison of two patient classification instruments in an acute care hospital.

ObjectivePatient classification systems are alternately praised and vilified by staff nurses, nurse managers, and nurse executives. Most nurses agree that substantial resources are used to create or find, implement, manage, and maintain the systems, and that the predictive ability of the instruments is intermittent. The purpose of this study is to compare the predictive validity of two types of patient classification instruments commonly used in acute care hospitals in California. BackgroundAcute care hospitals in California are required by both the Joint Commission on Accreditation of Healthcare Organizations and California Title 22 to have a reliable and valid patient classification system (PCS). The two general types of systems commonly used are the summative task type PCS and the critical incident or criterion type PCS. There is little to assist nurse executives in deciding which type of PCS to choose. There is modest research demonstrating the validity and reliability of different PCSs but no published data comparing the predictive validity of the different types of systems. The unit of analysis is one patient shift called the study shift. The study shift is defined as the first day shift after the patient has been in the hospital for a full 24 hours. Data were collected using medical record review only. Both types, criterion and summative, of PCS data collection instruments were completed for all patients at both collection points. Each patient had a before and after score for each type of instrument. Three hundred forty-nine medical records for inpatients meeting the inclusion criteria were examined. ResultsThe average patient age was 76 years, the average length of stay was 6.6 days with an average of 6.7 secondary diagnoses recorded. Fifty-five percent of the sample was female and the most common primary diagnosis was CHF, followed by COPD, CVA, and pneumonia. There was a difference in mean summative predictor score and the mean summative actual score of 1.57 points with the predictor score higher (P = .001; CI = .62—-2.5). For the criterion instrument, 68.4% of the predictor criterion scores were in category 2 compared to 65.5% of the actual criterion scores. The criterion predictor agreed with the criterion actual score 45% of the time for category 1 patients, 87.3% of the time for category 2 patients, 77.1% of the time for category 3 patients and 72.7% of the time for category 4 patients, with an overall agreement between predictor and actual criterion scores of 79.9% (Kappa P < .001, indicating agreement is not by chance). ConclusionsThe most significant finding of this study is that there are virtually no differences in the predictive ability of summative versus criterion patient classification instruments. Using the same patients, both types of instruments predicted the actual score over 78% of the time.

How have mandated nurse staffing ratios affected hospitals? Perspectives from California hospital leaders.

&NA; In 1999, California became the first state to pass legislation mandating minimum nurse‐to‐patient ratios. Regulations detailing specific ratios by type of hospital unit were released in 2002, with phased‐in implementation beginning in 2004 and completed in 2008. These ratios were implemented at a time of severe registered nurse (RN) shortage in the state and a worsening financial position for many hospitals. This article presents an analysis of qualitative data from interviews with healthcare leaders about the impact of nurse staffing ratios. Twenty hospitals (including public, not‐for‐profit, and for‐profit institutions) representing major geographic regions of California were approached. Twelve agreed to participate; semistructured in‐person and telephone interviews were conducted with 23 hospital leaders. Several key themes emerged from the analysis. Most hospitals found it difficult and expensive to find more RNs to hire to meet the ratios. Meeting the staffing requirements on all units, at all times, was challenging and had negative impacts, such as a backlog of patients in the emergency department and a decrease of other ancillary staff. Hospital leaders do not believe that ratios have had an impact on patient quality of care.