Joanne Spetz

Baccalaureate education in nursing and patient outcomes.

OBJECTIVES: The aim of this study was to examine the effects of registered nurse (RN) education by determining whether nurse-sensitive patient outcomes were better in hospitals with a higher proportion of RNs with baccalaureate degrees. BACKGROUND: The Future of Nursing report recommends increasing the percentage of RNs with baccalaureate degrees from 50% to 80% by 2020. Research has linked RN education levels to hospital mortality rates but not with other nurse-sensitive outcomes. METHODS: This was a cross-sectional study that, with the use of data from 21 University HealthSystem Consortium hospitals, analyzed the association between RN education and patient outcomes (risk-adjusted patient safety and quality of care indicators), controlling for nurse staffing and hospital characteristics. RESULTS: Hospitals with a higher percentage of RNs with baccalaureate or higher degrees had lower congestive heart failure mortality, decubitus ulcers, failure to rescue, and postoperative deep vein thrombosis or pulmonary embolism and shorter length of stay. CONCLUSION: The recommendation of the Future of Nursing report to increase RN education levels is supported by these findings.

Nurse staffing effects on patient outcomes: safety-net and non-safety-net hospitals.

BackgroundNurse staffing has been linked to hospital patient outcomes; however, previous results were inconsistent because of variations in measures of staffing and were only rarely specific to types of patient care units. ObjectiveTo determine the relationship between nurse staffing in general and intensive care units and patient outcomes and determine whether safety net status affects this relationship. Research DesignA cross-sectional design used data from hospitals belonging to the University HealthSystem Consortium. SubjectsData were available for approximately 1.1 million adult patient discharges and staffing for 872 patient care units from 54 hospitals. MeasuresTotal hours of nursing care [Registered Nurses (RNs), Licensed Practical Nurses, and assistants] determined per inpatient day (TotHPD) and RN skill mix were the measures of staffing; Agency for Healthcare Research and Quality risk-adjusted safety and quality indicators were the outcome measures. ResultsTotHPD in general units was associated with lower rates of congestive heart failure mortality (P<0.05), failure to rescue (P<0.10), infections (P<0.01), and prolonged length of stay (P<0.01). RN skill mix in general units was associated with reduced failure to rescue (P<0.01) and infections (P<0.05). TotHPD in intensive care units was associated with fewer infections (P<0.05) and decubitus ulcers (P<0.10). RN skill mix was associated with fewer cases of sepsis (P<0.01) and failure to rescue (P<0.05). Safety-net status was associated with higher rates of congestive heart failure mortality, decubitus ulcers, and failure to rescue. ConclusionsHigher nurse staffing protected patients from poor outcomes; however, hospital safety-net status introduced complexities in this relationship.

How Many Nurses per Patient? Measurements of Nurse Staffing in Health Services Research

OBJECTIVE To compare alternative measures of nurse staffing and assess the relative strengths and limitations of each measure. DATA SOURCES/STUDY SETTING Primary and secondary data from 2000 and 2002 on hospital nurse staffing from the American Hospital Association, California Office of Statewide Health Planning and Development, California Nursing Outcomes Coalition, and the California Workforce Initiative Survey. STUDY DESIGN Hospital-level and unit-level data were compared using summary statistics, t-tests, and correlations. DATA COLLECTION/EXTRACTION METHODS Data sources were matched for each hospital. When possible, hospital units or types of units were matched within each hospital. Productive nursing hours and direct patient care hours were converted to full-time equivalent employment and to nurse-to-patient ratios to compare nurse staffing as measured by different surveys. PRINCIPAL FINDINGS The greatest differences in staffing measurement arise when unit-level data are compared with hospital-level aggregated data reported in large administrative databases. There is greater dispersion in the data obtained from publicly available, administrative data sources than in unit-level data; however, the unit-level data sources are limited to a select set of hospitals and are not available to many researchers. CONCLUSIONS Unit-level data collection may be more precise. Differences between databases may account for differences in research findings.

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.

Physician incentives and the timing of cesarean sections: evidence from California.

Objectives.The timing of cesarean sections is studied to examine how physician convenience and financial incentives play a role in the decision to perform a cesarean section. Methods.Using birth certificate and hospital financial data from California, the likelihood of cesarean sections being performed at particular times of day was examined, controlling for maternal characteristics and the mother’s insurance coverage. Two diagnoses associated with cesarean sections are examined separately: fetal distress and prolonged/dysfunctional labor. The hypotheses are that cesarean sections performed for physician convenience are more likely to occur in the evening hours and that type of insurance will affect the incentive to perform cesarean sections to obtain leisure. Results.The probability of cesarean sections for patients insured by a group-model HMO is more stable during the course of a day than that for patients insured by all other insurance plans. Group-model HMO patients with previous cesarean sections are less likely to have cesarean sections in the evening hours and are less likely to be diagnosed with fetal distress or prolonged/dysfunctional labor. Conclusions.The differences in cesarean sections and diagnosis rates between group-model HMO patients and other patients could arise from several mechanisms: group-model HMOs provide consistent financial incentives to their staff, they may be better able to guide physician practice, and they might provide staff support to physicians so there is less leisure-based incentive to perform cesarean sections. In contrast, nongroup-model HMOs do not appear to reduce the incentive of physicians to maximize leisure relative to traditional insurance.

What should we expect from California's minimum nurse staffing legislation?

In 1999, California passed the first legislation in the United States to establish minimum staffing levels in hospitals for registered nurses (RNs) and licensed vocational nurses. The author provides estimates of the increase in RN expenditures required by this mandate, by hospital size and for regions of California. Issues related to the implementation of minimum ratios also are discussed. Attention must be paid to other staffing regulations, special concerns of rural hospitals, the possibility that minimum ratios result in lower RN staffing, and the effect of the nursing shortage on the ability of hospitals to meet requirements.

Comparison of patient outcomes in Magnet® and non-Magnet hospitals.

Objective: This study compared patient outcomes and staffing in Magnet® and non-Magnet hospitals. Background: The pursuit of Magnet designation is a highly regarded program for improving staff and patient outcomes. Research has confirmed that Magnet hospitals provide positive work environments for nurses. Research related to patient outcomes in Magnet hospitals is scarce, and results vary. Methods: The University Health Systems Consortium provided the clinical and operational databases for the study. Using bivariate and multivariate analyses, a comparison of patient outcomes and nurse staffing in general units and ICUs of Magnet and non-Magnet hospitals was studied. Outcomes: Non-Magnet hospitals had better patient outcomes than Magnet hospitals. Magnet hospitals had slightly better outcomes for pressure ulcers, but infections, postoperative sepsis, and postoperative metabolic derangement outcomes were worse in Magnet hospitals. Magnet hospitals also had lower staffing numbers. Conclusions: Magnet hospitals in this study had less total staff and a lower RN skill mix compared with non-Magnet hospitals, which contributed to the outcomes.

California's Minimum Nurse-to-patient Ratios: The First Few Months

The author examines the history and early implementation of specific minimum nurse-to-patient ratios in all units of acute-care hospitals in California. After reviewing preliminary forecasts of the effects of the ratios, the effects of the regulations in the first few months of their implementation are studied. Future concerns and needs for research are explored to provide guidance about issues that nursing leaders must address when considering minimum nurse-to-patient ratios.

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.

Patient turnover and the relationship between nurse staffing and patient outcomes

High patient turnover (patient throughput generated by admissions, discharges, and transfers) contributes to increased demands and resources for care. We examined how the relationship between registered nurse (RN) staffing and failure-to-rescue (FTR) varied with patient turnover levels by analyzing quarterly data from the University HealthSystem Consortium. The data included 42 hospitals, representing 759 nursing units and about 1 million inpatients. Higher RN staffing was associated with lower FTR. When patient turnover increased from 48.6% to 60.7% on nonintensive units (non-ICUs), the beneficial effect of non-ICU RN staffing on FTR was reduced by 11.5%. RN staffing should be adjusted according to patient turnover because turnover increases patient care demand beyond that presented by patient count, and outcomes may be adversely affected.