John M. Welton

Examining lateral violence in the nursing workforce.

The decision to examine the phenomenon of lateral violence within the nursing workforce of a southeastern tertiary care medical center evolved from the strong response of attendees to a nursing presentation on lateral violence. This paper describes the development and testing of the Lateral Violence in Nursing Survey. This questionnaire, designed to measure perceived incidence and severity of lateral violence, was administered online to 663 nursing staff participants. Forty-six percent of the study participants reported lateral violence as a “very serious” or “somewhat serious” problem, and 65% reported frequently observing lateral violence behaviors among coworkers. Education and effective leadership were found to mediate oppressive and negative behaviors, whereas ineffective leadership was found to exacerbate lateral violence.

Nurse Staffing, Nursing Intensity, Staff Mix, and Direct Nursing Care Costs Across Massachusetts Hospitals

Objective: This study describes the distribution of patient-to-registered nurse (RN) ratios, RN intensity of care, total staff intensity of care, RN to total staff skill mix percent, and RN costs per patient day in 65 acute community hospitals and 9 academic medical centers in Massachusetts. Methods: We conducted a retrospective secondary analysis of the Patients First database published by the Massachusetts Hospital Association for planned nurse staffing in 601 inpatient nursing units in the state for 2005 using a multivariate linear statistical model controlling for hospital type and unit type. Nursing unit types were identified as adult and pediatric medical/surgical, step down, critical care, neonatal level II, and neonatal level III/IV nurseries. Results: Medical centers had significantly higher case-mix index (1.72 vs 1.20, P < .001), longer lengths of stay (5.18 vs 4.19, P < .001), more beds (574 vs 147, P < .001), discharges (31,597 vs 7,248, P < .001), and patient days (161,440 vs 31,020, P < .001) compared with to community hospitals. Medical centers had significantly lower patient-to-RN ratios (3.22 vs 4.64, P < .001), higher nursing intensity and total nursing staff intensity (9.62 vs 7.43/11.75 vs 9.87, both P < .001), higher percent of RN to all staff mix (79% vs 71%, P < .001), and higher RN costs per patient day (

Nursing diagnoses, diagnosis-related group, and hospital outcomes.

385 vs

Advocating for standardized nursing languages in electronic health records

297, P < .001) compared with to community hospitals. There were significant differences in adult med/surg units between community hospitals and medical centers for patient-to-RN staffing ratios (5.25 vs 4.08), nursing intensity (5.1 vs 6.2 hours daily), skill mix (67% vs 73% RN), and RN costs per patient day (

Implications of Medicare reimbursement changes related to inpatient nursing care quality.

203 vs

Adjustment of Inpatient Care Reimbursement for Nursing Intensity

248, all P < .001). There were no significant differences between the adult step-down units. Conclusion: The significant differences between community hospitals and medical centers, unit type, as well as the high degree of variability in patient-to-RN ratios, nursing intensity, skill mix, and RN costs per patient day suggest that nursing resource expenditure at Massachusetts hospitals is complex and affected by case mix, unit size, and complexity of care.

Nursing intensity billing.

Background and objective: There are no nursing centric data in the hospital discharge abstract. This study investigates whether adding nursing data in the form of nursing diagnoses to medical diagnostic data in the discharge abstract can improve overall explanation of variance in commonly studied hospital outcomes. Method: A retrospective analyses of 123,241 sequential patient admissions to a university hospital in a Midwestern city was performed. Two data sets were combined: (1) a daily collection of patient assessments by nurses using nursing diagnosis terminology (NDX); and (2) the summary discharge information from the hospital discharge abstract including diagnosis-related group (DRG) and all payer refined DRG (APR-DRG). Each of 61 daily NDX observations were collapsed as frequency of occurrence for the hospital stay and inserted into the discharge abstract. NDX was then compared to both DRG and APR-DRG across 5 hospital outcome variables using multivariate regression or logistic regression. Results and conclusions: In all statistical models, DRG, APR-DRG, and NDX were significantly associated with the 5 hospital outcome variables (P <.0001). When NDX was added to models containing either the DRG or the APR-DRG, explanatory power (R2) and model discrimination (c statistic) improved by 30% to 146% across the outcome variables of hospital length of stay, ICU length of stay, total charges, probably of death, and discharge to a nursing home (P <.0001). The findings support the contention that nursing care is an independent predictor of patient hospital outcomes. These nursing data are not redundant with the medical diagnosis, in particular, the DRG. The findings support the argument for including nursing care data in the hospital discharge abstract. Further study is needed to clarify which nursing data are the best fit for the current hospital discharge abstract data collection scheme.

Estimating Nursing Intensity and Direct Cost Using the Nurse-Patient Assignment

“For 40 years, people have been waiting for the breakthrough of EHR, Electronic Health Record, systems. The current combination of driving forces, standards developments, and technological progress has finally brought us to a point where substantial progress can be made on this road.”1 Recent reports from the Institute of Medicine (IOM) demand that electronic records support patient care that is timely, efficient, equitable, and free of mistakes.2-4 Nurse executives, as central coordinators of patient care, have the capacity to meet this imperative through advocacy of, and contribution to, the use of stan-

Testing an Inpatient Nursing Intensity Billing Model

Recent changes to the inpatient prospective payment system by the Centers for Medicare and Medicaid Services will negatively affect reimbursement to hospitals for patients who develop certain types of nursing-sensitive, hospital-acquired conditions such as pressure ulcers, falls with injuries, or nosocomial infections. The author examines the effects of the new payment policy on inpatient nursing care and addresses ways to improve quality and minimize financial impacts to hospitals.

Hospital Nursing Workforce Costs, Wages, Occupational Mix,and Resource Utilization.

The Centers for Medicare and Medicaid Services has begun an ambitious recalibration of the inpatient prospective payment system, the first since its introduction in 1983. Unfortunately, inpatient nursing care has been overlooked in the new payment system and continues to be treated as a fixed cost and billed at a set per-diem “room and board” fee despite the known variability of nursing intensity across different care settings and diagnoses. This article outlines the historical influences regarding costing, billing, and reimbursement of inpatient nursing care and provides contemporary evidence about the variability of nursing intensity and costs at acute care hospitals in the United States. A remedy is proposed to overcome the existing limitations of the Inpatient Prospective Payment System by creating a new nursing cost center and nursing intensity adjustment by DRG for each routine-and intensive-care day of stay to allow independent costing, billing, and reimbursement of inpatient nursing care.