Jingjing Shang

Nurse employment contracts in Chinese hospitals: impact of inequitable benefit structures on nurse and patient satisfaction

PurposeOngoing economic and health system reforms in China have transformed nurse employment in Chinese hospitals. Employment of ‘bianzhi’ nurses, a type of position with state-guaranteed lifetime employment that has been customary since 1949, is decreasing while there is an increase in the contract-based nurse employment with limited job security and reduced benefits. The consequences of inequities between the two types of nurses in terms of wages and job-related benefits are unknown. This study examined current rates of contract-based nurse employment and the effects of the new nurse contract employment strategy on nurse and patient outcomes in Chinese hospitals.MethodsThis cross-sectional study used geographically representative survey data collected from 2008 to 2010 from 181 hospitals in six provinces, two municipalities, and one autonomous region in China. Logistic regression models were used to estimate the association between contract-based nurse utilization, dissatisfaction among contract-based nurses, nurse intentions to leave their positions, and patient satisfaction, controlling for nurse, patient, and hospital characteristics.Principal ResultsHospital-level utilization of contract-based nurses varies greatly from 0 to 91%, with an average of 51%. Contract-based nurses were significantly more dissatisfied with their remuneration and benefits than ‘bianzhi’ nurses who have more job security (P <0.01). Contract-based nurses who were dissatisfied with their salary and benefits were more likely to intend to leave their current positions (P <0.01). Hospitals with high levels of dissatisfaction with salary and benefits among contract-based nurses were rated lower and less likely to be recommended by patients (P < 0.05).ConclusionsOur results suggest a high utilization of contract-based nurses in Chinese hospitals, and that the inequities in benefits between contract-based nurses and ‘bianzhi’ nurses may adversely affect both nurse and patient satisfaction in hospitals. Our study provides empirical support for the ‘equal pay for equal work’ policy emphasized by the China Ministry of Health’s recent regulations, and calls for efforts in Chinese hospitals to eliminate the disparities between ‘bianzhi’ and contract-based nurses.

Nursing Practice Environment and Outcomes for Oncology Nursing

Background: It is commonly assumed that oncology nurses experience high job-related burnout and high turnover because their work involves inherent stressors such as caring for patients with serious and often life-threatening illness. Objectives: The objectives of this study were to examine the differences in outcomes such as job dissatisfaction and burnout between oncology nurses and medical-surgical nurses, and to identify factors that affect oncology nurse outcomes. Methods: A secondary analysis of nurse survey data collected in 2006 including 4047 nurses from 282 hospitals in 3 states was performed; t test and &khgr;2 test compared differences between oncology nurses and medical-surgical nurses in nurse outcomes and their assessments of nurse practice environment, as measured by the Practice Environment Scale of the Nursing Work Index. Logistic regression models estimated the effect of nurse practice environment on 4 nurse-reported outcomes: burnout, job dissatisfaction, intention to leave the current position, and perceived quality of care. Results: Oncology nurses reported favorable practice environments and better outcomes than did medical-surgical nurses. All 4 subscales of the Practice Environment Scale of the Nursing Work Index studied were significantly associated with outcomes. Specifically, nurses who reported favorable nursing foundations for quality of care (eg, active in-service or preceptorship programs) were less likely to report burnout and leave their current position. Conclusions: Better practice environments, including nurse foundations for quality care, can help to achieve optimal nurse outcomes. Implications for Practice: Improving hospital practice environments holds significant potential to improve nurse well-being, retention, and quality of care. Specifically, hospitals should consider preceptor programs and continuing education and increase nurses’ participation in hospital decision making.

Who will drop out and who will drop in: Exercise adherence in a randomized clinical trial among patients receiving active cancer treatment

Background:Adherence has significantly affected the efficacy of a randomized clinical trial (RCT) to test exercise interventions. Objective:The aims of this study were to analyze exercise-related adherence patterns among patients receiving active cancer treatment and to identify factors related to exercise adherence and contamination in both the intervention and control groups. Methods:This is a secondary analysis of data from an RCT of a home-based walking intervention for patients receiving active cancer treatment. Hierarchical Poisson regression analysis was used to identify factors related to exercise adherence and exercise contamination in the exercise intervention and control groups. Results:A total of 126 patients finished the study. Exercise adherence rate in the intervention group was 32.35%, whereas exercise contamination rate in the control group was 12.07%. Independent predictors of adherence for the exercise group were baseline physical fitness, pretreatment fatigue level, treatment-related mood disturbance, and marital status (P < .01); exercise history significantly predicted exercise contamination (P < .00) in the control group. Conclusion:Adherence remains an issue in an exercise RCT among patients on active cancer treatment. Adherence is related to symptom, physical function, and exercise history. Implications for Practice:Exercise researchers should consider stratifying samples based on pretreatment variables found to be significantly associated with outcome variables in this study to reduce confounding effects. Oncology clinicians can use the study findings to appropriately tailor strategies to encourage exercise adherence among patients receiving active cancer treatment so that these patients can receive the known benefits of exercise.

Impact of a Home-Based Walking Intervention on Outcomes of Sleep Quality, Emotional Distress, and Fatigue in Patients Undergoing Treatment for Solid Tumors

Exercise use among patients with cancer has been shown to have many benefits and few notable risks. The purpose of this study was to evaluate the impact of a home-based walking intervention during cancer treatment on sleep quality, emotional distress, and fatigue. Methods. A total of 138 patients with prostate (55.6%), breast (32.5%), and other solid tumors (11.9%) were randomized to a home-based walking intervention or usual care. Exercise dose was assessed using a five-item subscale of the Cooper Aerobics Center Longitudinal Study Physical Activity Questionnaire. Primary outcomes of sleep quality, distress, and fatigue were compared between the two study arms. Results. The exercise group (n = 68) reported more vigor (p = .03) than control group participants (n = 58). In dose response models, greater participation in aerobic exercise was associated with 11% less fatigue (p < .001), 7.5% more vigor (p = .001), and 3% less emotional distress (p = .03), after controlling for intervention group assignment, age, and baseline exercise and fatigue levels. Conclusion. Patients who exercised during cancer treatment experienced less emotional distress than those who were less active. Increasing exercise was also associated with less fatigue and more vigor. Home-based walking is a simple, sustainable strategy that may be helpful in improving a number of symptoms encountered by patients undergoing active treatment for cancer.

Hospital use of agency-employed supplemental nurses and patient mortality and failure to rescue.

OBJECTIVE To determine the association between the use of agency-employed supplemental registered nurses (SRNs) to staff hospitals and patient mortality and failure to rescue (FTR). DATA SOURCES Primary survey data from 40,356 registered nurses in 665 hospitals in four states in 2006 were linked with American Hospital Association and inpatient mortality data from state agencies for approximately 1.3 million patients. STUDY DESIGN Logistic regression models were used to examine the association between SRN use and 30-day in-hospital mortality and FTR, controlling for patient and hospital characteristics, nurse staffing, the proportion of nurses with bachelors degrees, and quality of the work environment. PRINCIPAL FINDINGS Before controlling for multiple nurse characteristics of hospitals, higher proportions of agency-employed SRNs in hospitals appeared to be associated with higher mortality (OR = 1.06) and FTR (OR = 1.05). Hospitals with higher proportions of SRNs have poorer work environments, however, and the significant relationships between SRNs and mortality outcomes were rendered insignificant when work environments were taken into account. CONCLUSIONS Higher use of SRNs does not appear to have deleterious consequences for patient mortality and may alleviate nurse staffing problems that could produce higher mortality.

The prevalence of infections and patient risk factors in home health care: A systematic review

BACKGROUND Home health care (HHC) has been the fastest growing health care sector for the past 3 decades. The uncontrolled home environment, increased use of indwelling devices, and the complexity of illnesses among HHC patients lead to increased risk for infections. METHODS A systematic review of studies evaluating infection prevalence and risk factors among adult patients who received HHC services was conducted and guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Literature was searched using Medline, PubMed, and the Cumulative Index to Nursing and Allied Health as well as hand searching. Two reviewers independently assessed study quality using validated quality assessment checklists. RESULTS Twenty-five studies met the inclusion criteria and were reviewed. The infection rates and identified risk factors for infections varied dramatically between studies. In general, patients receiving home parental nutrition treatments had higher infection rates than patients receiving home infusion therapy. The identified risk factors were limited by small sample sizes and other methodologic flaws. CONCLUSIONS Establishing a surveillance system for HHC infections, identifying patients at high risk for infections, tailoring HHC and patient education based on patient living conditions, and facilitating communication between different health care facilities will enhance infection control in HHC settings. Future studies should use a nationally representative sample and multivariate analysis for the identification of risk factors for infections.

Practice environments and job satisfaction and turnover intentions of nurse practitioners: Implications for primary care workforce capacity.

Background: Health care professionals, organizations, and policy makers are calling for expansion of the nurse practitioner (NP) workforce in primary care to assure timely access and high-quality care. However, most efforts promoting NP practice have been focused on state level scope of practice regulations, with limited attention to the organizational structures. Purpose: We examined NP practice environments in primary care organizations and the extent to which they were associated with NP retention measures. Methodology: Data were collected through mail survey of NPs practicing in 163 primary care organizations in Massachusetts in 2012. NP practice environment was measured by the Nurse Practitioner Primary Care Organizational Climate Questionnaire, which has four subscales: Professional Visibility, NP–Administration Relations, NP–Physician Relations, and Independent Practice and Support. Two global items measured job satisfaction and NPs’ intent to leave their job. We aggregated NP level data to organization level to attain measures of practice environments. Multilevel logistic regression models were used. Findings: NPs rated the relationship between NPs and physicians favorably, contrary to the relationship between NPs and administrators. All subscales measuring NP practice environment had similar influence on the outcome variables. With every unit increase in each standardized subscale score, the odds of job satisfaction factors increased about 20% whereas the odds of intention of turnover decreased about 20%. NPs from organizations with higher mean scores on the NP–Administration subscale had higher satisfaction with their jobs (OR = 1.24, 95% CI [1.12, 1.39]) and had lower intent to leave (OR = 0.79, 95% CI [0.70, 0.90]). Practice Implications: NPs were more likely to be satisfied with their jobs and less likely to report intent to leave if their organizations support NP practice, favorable relations with physicians and administration, and clear role visibility. Creating productive practice environments that can retain NPs is a potential strategy for increasing the primary care workforce capacity.

Linking Unit Collaboration and Nursing Leadership to Nurse Outcomes and Quality of Care.

OBJECTIVE: The objective of this study is to identify the effects of unit collaboration and nursing leadership on nurse outcomes and quality of care. BACKGROUND: Along with the current healthcare reform, collaboration of care providers and nursing leadership has been underscored; however, empirical evidence of the impact on outcomes and quality of care has been limited. METHODS: Data from 29742 nurses in 1228 units of 200 acute care hospitals in 41 states were analyzed using multilevel linear regressions. Collaboration (nurse-nurse collaboration and nurse-physician collaboration) and nursing leadership were measured at the unit level. Outcomes included nurse job satisfaction, intent to leave, and nurse-reported quality of care. RESULTS: Nurses reported lower intent to leave, higher job satisfaction, and better quality of care in units with better collaboration and stronger nursing leadership. CONCLUSION: Creating a care environment of strong collaboration among care providers and nursing leadership can help hospitals maintain a competitive nursing workforce supporting high quality of care.

Nurse practitioners as primary care providers: Creating favorable practice environments in New York State and Massachusetts

BACKGROUND Policy makers, health care organizations, and health professionals are calling for the expansion of the nurse practitioner (NP) workforce in primary care to ensure access to high-quality, cost-effective care. However, to date, little is known about NP practice environments in primary care settings and how they may affect the expansion of this workforce and their practice. PURPOSES The aims of this study were to investigate NP practice environments in two states, Massachusetts (MA) and New York State (NY), and determine the impact of state and organization on NP practice environment. METHODOLOGY A cross-sectional survey design was used. Practice environments were measured using the Nurse Practitioner Primary Care Organizational Climate Questionnaire in terms of NP-physician relations, NP-administration relations, support, NP role comprehension, and NP independent practice. In MA, 291 NPs were recruited from the Massachusetts Provider Database through mail surveys. In NY, 278 NPs were recruited from the NY Nurse Practitioner Association membership list through online surveys. Data were collected from May through September 2012. Descriptive statistics were computed. Multivariate analysis of variance was conducted to investigate the effect of state and organization type on NP practice environments. FINDINGS Nurse practitioners reported favorable relationships with physicians, deficiencies in their relationships with administrators, and lack of support. Nurse practitioners from MA reported better practice environments. Nurse practitioners from hospital-affiliated practices perceived poorer practice environments than did NPs practicing in physician offices and community health centers. PRACTICE IMPLICATIONS Optimal working relations with physicians and administration, access to resources, and clarity in NP role are necessary to create practice environments where NPs can function effectively as primary care providers.

Infection in home health care: Results from national Outcome and Assessment Information Set data

BACKGROUND Patients in home health care (HHC), the fastest growing health care sector, are at risk for infection. The existing research on infection in HHC is often limited by small sample sizes, local scope of inquiry, and a lack of current data. There is no national study examining agency-level infection rates. METHODS This secondary data analysis used a 20% random sample of the 2010 national Outcome and Assessment Information Set (OASIS) data. An infection case was identified when the HHC patient was hospitalized or received emergency care for respiratory infection, urinary tract infection, intravenous catheter-related infection, wound infection, or deterioration. Proportions of infection cases out of the total number of patients were calculated for the whole sample and for each HHC agency. RESULTS The final analysis included 199,462 patients from 8,255 HHC agencies. Approximately 3.5% of patients developed infections during their HHC stay, leading to emergency care treatment or hospitalization. Seventeen percent of unplanned hospitalizations among HHC patients were caused by infections. The agency-level infection rate ranged from 0%-34%, with an average of 3.5%. CONCLUSION To our knowledge, this is the first study to examine the proportion of hospitalizations or emergency care treatment caused by infection in HHC and the agency-level infection rate at a national level by using OASIS data. These data demonstrate that infection is a serious problem in HHC, and infection rates varied between agencies. The variance in agency level rates may be caused by differences in infection control policies and practices. Better infection surveillance system in HHC is needed to benchmark quality of care.