Julie Sochalski

Hospital nurse practice environments and outcomes for surgical oncology patients.

OBJECTIVE To examine the effect of nursing practice environments on outcomes of hospitalized cancer patients undergoing surgery. DATA SOURCES Secondary analysis of cancer registry, inpatient claims, administrative and nurse survey data collected in Pennsylvania for 1998-1999. STUDY DESIGN Nurse staffing (patient to nurse ratio), educational preparation (proportion of nurses holding at least a bachelors degree), and the practice environment (Practice Environment Scale of the Nursing Work Index) were calculated from a survey of nurses and aggregated to the hospital level. Logistic regression models predicted the odds of 30-day mortality, complications, and failure to rescue (death following a complication). PRINCIPAL FINDINGS Unadjusted death, complication, and failure to rescue rates were 3.4, 35.7, and 9.3 percent, respectively. Nurse staffing and educational preparation of registered nurses were significantly associated with patient outcomes. After adjusting for patient and hospital characteristics, patients in hospitals with poor nurse practice environments had significantly increased odds of death (odds ratio, 1.37; 95 percent confidence interval, 1.07-1.76) and of failure to rescue (odds ratio, 1.48; 95 percent confidence interval, 1.07-2.03). Receipt of care in National Cancer Institute-designated cancer centers significantly decreased the odds of death, which can be explained partly by better nurse practice environments. CONCLUSIONS This study is one of the first to examine the predictive validity of the National Quality Forums endorsed measure of the nurse practice environment. Improvements in the quality of nurse practice environments could reduce adverse outcomes for hospitalized surgical oncology patients.

Organization and outcomes of inpatient AIDS care.

The establishment of AIDS hospitals and AIDS units within hospitals has been controversial. Unlike other specialty care, AIDS care arrangements were initially developed as much to segregate AIDS patients from other patients and staff as to provide the best possible care. Ten years after many of these units opened, little evidence was available about whether the benefits of aggregating AIDS patients outweighed the potential hazards of segregating people from the mainstream of hospital care. This Issue Brief describes a national study to determine how different organizational settings affect the outcomes of inpatient AIDS care.

What Works In Chronic Care Management: The Case Of Heart Failure

The evidence base of what works in chronic care management programs is underdeveloped. To fill the gap, we pooled and reanalyzed data from ten randomized clinical trials of heart failure care management programs to discern how program delivery methods contribute to patient outcomes. We found that patients enrolled in programs using multi-disciplinary teams and in programs using in-person communication had significantly fewer hospital readmissions and readmission days than routine care patients had. Our study offers policymakers and health plan administrators important guideposts for developing an evidence base on which to build effective policy and programmatic initiatives for chronic care management.

Is more better?: the relationship between nurse staffing and the quality of nursing care in hospitals.

ObjectiveThe objective of this study was to examine the effects of nurse staffing and process of nursing care indicators on assessments of the quality of nursing care. Research DesignThis study examined the variation in inpatient hospital staff nurses’ assessments of the quality of nursing care and the effects of nurse staffing (patient workload), patient safety problems (medication errors and patient falls with injuries), and unfinished care (number of nursing tasks left undone) on the variation in those assessments. Secondary analysis of a survey of nurses using multivariate regression models was undertaken. SubjectsData were derived from a 1999 statewide survey of 8670 inpatient staff nurses working in acute care hospitals in Pennsylvania. ResultsQuality of nursing care ratings were significantly associated with the number of patients who nurses care for, rates of unfinished care for those patients, and the frequency of patient safety problems. The effect of patient workload on quality ratings was attenuated substantially by the effects of unfinished care and patient safety problems. Unfinished care had the strongest relationship of all, with over 40% of the variation in quality ratings associated with the number of tasks left undone. ConclusionsAssessments of the quality of nursing are associated with both structural (workload) and process of care indicators (unfinished clinical care and patient safety problems), with the relationship strongest between process of care and quality. Explicating the interrelationship between structure and process of care is key to understanding the influence of both on quality. Studies that assess the causal influence of these features on quality of care and patient outcomes are warranted.

The migration of nurses: trends and policies

This paper examines the policy context of the rise in the international mobility and migration of nurses. It describes the profile of the migration of nurses and the policy context governing the international recruitment of nurses to five countries: Australia, Ireland, Norway, the United Kingdom, and the United States. We also examine the policy challenges for workforce planning and the design of health systems infrastructure. Data are derived from registries of professional nurses, censuses, interviews with key informants, case studies in source and destination countries, focus groups, and empirical modelling to examine the patterns and implications of the movement of nurses across borders. The flow of nurses to these destination countries has risen, in some cases quite substantially. Recruitment from lower-middle income countries and low-income countries, as defined by The World Bank, dominate trends in nurse migration to the United Kingdom, Ireland, and the United States, while Norway and Australia, primarily register nurses from other high-income countries. Inadequate data systems in many countries prevent effective monitoring of these workforce flows. Policy options to manage nurse migration include: improving working conditions in both source and destination countries, instituting multilateral agreements to manage the flow more effectively, and developing compensation arrangements between source and destination countries. Recommendations for enhancements to workforce data systems are provided.

International Nurse Migration: Lessons From the Philippines

Developed countries facing nursing shortages have increasingly turned to aggressive foreign nurse recruitment, primarily from developing nations, to offset their lagging domestic nurse supplies and meet growing health care demands. Few donor nations are prepared to manage the loss of their nurse workforce to migration. The sole country with an explicit nurse export policy and the worlds leading donor of nurse labor—the Philippines—is itself facing serious provider maldistribution and countrywide health disparities. Examining the historical roots of Philippines nurse migration provides lessons from which other nurse exporting countries may learn. The authors discuss factors that have predicated nurse migration and policies that have eased the way. Furthermore, the authors analyze how various stakeholders influence migratory patterns, the implications of migration for nurses and the public in their care, and the challenges that future social policy and political systems face in addressing global health issues engendered by unfettered recruitment of nurses and other health workers.

Hospital organisation and outcomes.

Hospital reorganisation and work redesign is being widely implemented. According to anecdotal and media accounts, a target of restructuring eVorts is often the workforce, of which nursing personnel (registered nurses, licenced practical nurses, and nurse aides) represent 37% of United States hospital employees. Hospital restructuring initiatives are altering nursing work force patterns by changing organisational and structural variables such as the number, types, and mix of nursing personnel available to provide care to patients. 4 As a result, individual nurses and professional organisations have expressed concern over the potential impact of these activities on patient care and nurse stress and burnout, and there is at least one recent study documenting a decline in nurses’ job satisfaction and higher nurse turnover associated with hospital restructuring. Reports in the media echo nurses’ concerns and describe elimination of registered nurses’ positions, lay oVs, substitution with unlicenced assistive personnel, adverse patient incidents, and deteriorating working conditions for hospital nurses. 7 These claims were supported in the United States by a national survey of registered nurses which reported widespread reductions in hospital nurse staYng, leading to unsafe staYng levels, eroding quality of patient care, and threatening patient safety. Nurses’ perceive a deterioration in care that has resulted from hospital reorganisation, but empirical evidence is lacking. 7 9 10 The widespread organisational restructuring and reengineering initiatives sweeping the hospital industry represent a target of opportunity for studying the impact of variation in staYng and organisation on patient outcomes, and for implementing the findings of such studies to improve patient outcomes. In this essay, we identify research that has been done by various investigators on hospital organisation and patient outcomes, describe some of our own recent research on that relation, and comment on where, in our estimation, additional research is needed.

The association between nursing factors and patient mortality in the Veterans Health Administration: the view from the nursing unit level.

Context:Nurse staffing is not the same across an entire hospital. Nursing care is delivered in geographically-based units, with wide variation in staffing levels. In particular, staffing in intensive care is much richer than in nonintensive care acute units. Objective:To evaluate the association of in-hospital patient mortality with registered nurse staffing and skill mix comparing hospital and unit level analysis using data from the Veterans Health Administration (VHA). Design, Settings, and Patients:A retrospective observational study using administrative data from 129,579 patients from 453 nursing units (171 ICU and 282 non-ICU) in 123 VHA hospitals. Methods:We used hierarchical multilevel regression models to adjust for patient, unit, and hospital characteristics, stratifying by whether or not patients had an ICU stay during admission. Main Outcome Measure:In-hospital mortality. Results:Of the 129,579 patients, mortality was 2.9% overall: 6.7% for patients with an ICU stay compared with 1.6% for those without. Whether the analysis was done at the hospital or unit level affected findings. RN staffing was not significantly associated with in-hospital mortality for patients with an ICU stay (OR, 1.02; 95% CI, 0.99–1.03). For non-ICU patients, increased RN staffing was significantly associated with decreased mortality risk (OR, 0.91; 95% CI, 0.86–0.96). RN education was not significantly associated with mortality. Conclusions:Our findings suggest that the association between RN staffing and skill mix and in-hospital patient mortality depends on whether the analysis is conducted at the hospital or unit level. Variable staffing on non-ICU units may significantly contribute to in-hospital mortality risk.

Quality of Care, Nurse Staffing, and Patient Outcomes:

Widespread reports of declining levels of quality of care and patient safety in hospitals, an escalation in calls for legislation mandating minimum nurse staffing ratios, and growing levels of nurse burnout and a looming nursing shortage have focused attention on the working conditions that nurses face and their implications for patient outcomes. This article reports on the preliminary results of an international study on how nurse staffing levels and the nursing practice environment affect the quality of care and patient outcomes in hospitals. Surveys of staff nurses working in acute care hospitals in Pennsylvania reveal that one out of every five staff nurses reported the quality of care on their unit as fair or poor. Workload played a role in these quality assessments, but it was the consequences of workload, such as the reports of unfinished nursing at the end of the last shift and the frequency of adverse events among patients, that played a much more prominent role.

Hospital Restructuring in the United States, Canada, and Western Europe An Outcomes Research Agenda

OBJECTIVES This article describes the extent and nature of hospital restructuring across the United States, Canada, and Western Europe, countries with differently organized and financed health-care systems, and assesses the feasibility of international research on the outcomes of hospital restructuring. METHODS The conceptual background, context, and focus for the Bellagio conference on Hospital Restructuring in North America and Western Europe held in November 1996 is provided, illustrating key issues on hospital and workforce trends using the US data with international comparisons. RESULTS Hospital systems internationally are undertaking very similar restructuring interventions, particularly ones aimed at reducing labor expenses through work redesign. Nursing has been a prime target for work redesign, resulting in changes in numbers and skill mix of nursing staff as well as fundamental reorganizing of clinical care at the inpatient unit level. Yet little is known about the outcomes of such organizational interventions and there are few efforts in place to critically evaluate these actions. CONCLUSIONS Restructuring of the hospital workforce and redesign of work in inpatient settings is widespread and markedly similar across North American and Europe, and warrants systematic study. Cross-national studies of the impact of restructuring inpatient care on patient outcomes would yield valuable lessons about the cost-quality tradeoffs in hospital redesign and re-engineering, as well as inform national planning about the numbers and types of nurses needed in the coming decades.