Linda Burnes Bolton

Impact of California’s Licensed Nurse-Patient Ratios on Unit-Level Nurse Staffing and Patient Outcomes

This article presents the first analysis of the impact of mandated minimum-staffing ratios on nursing hours of care and skill mix in adult medical and surgical and definitive-observation units in a convenience sample of 68 acute hospitals participating in the California Nursing Outcomes Coalition project. Findings, stratified by unit type and hospital size, reveal expected changes as hospitals made observable efforts toward regulatory compliance. These data cannot affirm compliance with ratios per shift, per unit, at all times; however, they give evidence of overall compliance. Assessment of the impacts of the mandated ratios on two common indicators of patient care quality, the incidence of patient falls and the prevalence of pressure ulcers, did not reveal significant changes despite research linking nurse staffing with these measures. These findings contribute to understanding unit level impacts of regulatory staffing mandates and the preliminary effect of this legislation on core quality of care indicators.

Mandated Nurse Staffing Ratios in California: A Comparison of Staffing and Nursing-Sensitive Outcomes Pre- and Postregulation:

This article examines the impact of mandated nursing ratios in California on key measures of nursing quality among adults in acute care hospitals. This study is a follow-up and extension of our first analysis exploring nurse staffing and nursing-sensitive outcomes comparing 2002 pre-ratios regulation data to 2004 postratios regulation data. For the current study we used postregulation ratios data from 2004 and 2006 to assess trends in staffing and outcomes. Findings for nurse staffing affirmed the trends noted in 2005 and indicated that changes in nurse staffing were consistent with expected increases in the proportion of licensed staff per patient. This report includes an exploratory examination of the relationship between staffing and nursing-sensitive patient outcomes. However anticipated improvements in nursing-sensitive patient outcomes were not observed. This report contributes to the growing understanding of the impacts of regulatory staffing mandates on hospital operations and patient outcomes.

Nurse staffing and patient perceptions of nursing care.

Objective To examine the relationship between nurse staffing and patient perceptions of nursing care in a convenience sample of 40 California hospitals. Background Growing concern about the adequacy of nurse staffing has led to an increased emphasis on research exploring the relationships between nurse staffing and patient outcomes. Patient satisfaction with nursing care is one of the 21 indicators identified by the American Nurses Association as having a strong “theoretical link to the availability and quality of professional nursing services in hospital settings.” This prospective study examined the relationship between nurse staffing and patient perceptions of nursing care in multiple hospitals using common definitions of both nurse staffing and patient perceptions of care. Methods Nurse staffing (structural variables) and patient perceptions of nursing care (outcome variables) from hospitals participating in both the ongoing California Nursing Outcomes Coalition statewide database project and the statewide Patients’ Evaluation of Performance in California project, with data available on both measures for the same time periods, were examined. Analytic methods included both descriptive and inferential statistics. Results Hospitals with wide ranges of staffing levels showed similar results in patient perceptions of nursing care. Regression analysis revealed a statistically significant relationship between nursing hours per patient day, and 1 of the 6 dimensions of care measured (“respect for patient’s values, preferences, and expressed needs”). Conclusions Nurse staffing alone showed a significant but weak relationship to patient perceptions of their care, indicating that staffing is likely only one of several relevant variables influencing patient perceptions of their nursing care. This research contributes data to the body of knowledge regarding nurse staffing. It is essential that nurse executives integrate results from this and other studies in developing strategic and tactical staffing plans that yield positive patient care outcomes.

Vaginal birth after cesarean: clinical risk factors associated with adverse outcome.

OBJECTIVE The objective of the study was to identify vaginal birth after cesarean (VBAC) success rates and maternal and neonatal complication rates for selected antenatal conditions. STUDY DESIGN This was a population-based cohort study using administrative discharge data for women delivering in California hospitals during 2002. RESULTS Among 41,450 women, 29.72% (12,320 of 41,450) had maternal, fetal, or placental conditions complicating pregnancy. Attempted VBAC rates and VBAC success rates varied widely by these clinical condition, ranging from 10% to 73%. The VBAC success rate for low-risk women (no conditions) was 73.76% vs 50.31% for high-risk women (at least 1 condition), P < .0001. Absolute rates of maternal and neonatal complications were low (less than 1-2%), and the rate of adverse events was higher in the high-risk clinical group as compared with the low-risk clinical group. CONCLUSION Variation in rates of VBAC success and childbirth morbidities can be partially attributed to clinical factors complicating pregnancy. Women without such conditions show improved VBAC success and fewer maternal and neonatal complications.

The Impact of Nursing Interventions Overview of Effective Interventions, Outcomes, Measures, and Priorities for Future Research

The purpose of this article is to present findings from a review of published systematic/integrative reviews and meta-analyses on nursing interventions and patient outcomes in acute care settings. A literature search was conducted for the period 1999-2005, producing 4,000 systematic/integrative reviews and 500 meta-analyses covering seven topics selected by the authors: elder care, caregivers, developmental care of neonates and infants, symptom management, pressure ulcer prevention/treatment, incontinence, and staffing. The association between nursing care interventions/processes and patient outcomes in acute care settings was found to be limited in the articles reviewed. The strongest evidence was for the use of patient risk-assessment tools and interventions implemented by nurses to prevent patient harm. We observed significant variation in methods to measure the effect of independent variables (nursing interventions) on patient outcomes. Results indicate the need for more research measuring the effect of specific nursing interventions that may impact acute care patient outcomes.

Early recognition of risk factors for adverse outcomes during hospitalization among Medicare patients: a prospective cohort study

BackgroundThere is a persistently high incidence of adverse events during hospitalization among Medicare beneficiaries. Attributes of vulnerability are prevalent, readily apparent, and therefore potentially useful for recognizing those at greatest risk for hospital adverse events who may benefit most from preventive measures. We sought to identify patient characteristics associated with adverse events that are present early in a hospital stay.MethodsAn interprofessional panel selected characteristics thought to confer risk of hospital adverse events and measurable within the setting of acute illness. A convenience sample of 214 Medicare beneficiaries admitted to a large, academic medical center were included in a quality improvement project to develop risk assessment protocols. The data were subsequently analyzed as a prospective cohort study to test the association of risk factors, assessed within 24 hours of hospital admission, with falls, hospital-acquired pressure ulcers (HAPU) and infections (HAI), adverse drug reactions (ADE) and 30-day readmissions.ResultsMean age = 75(±13.4) years. Risk factors with highest prevalence included >4 active comorbidities (73.8%), polypharmacy (51.7%), and anemia (48.1%). One or more adverse hospital outcomes occurred in 46 patients (21.5%); 56 patients (26.2%) were readmitted within 30 days. Cluster analysis described three adverse outcomes: 30-day readmission, and two groups of in-hospital outcomes. Distinct regression models were identified: Weight loss (OR = 3.83; 95% CI = 1.46, 10.08) and potentially inappropriate medications (OR = 3.05; 95% CI = 1.19, 7.83) were associated with falls, HAPU, procedural complications, or transfer to intensive care; cognitive impairment (OR = 2.32; 95% CI = 1.24, 4.37), anemia (OR = 1.87; 95% CI = 1.00, 3.51) and weight loss (OR = 2.89; 95% CI = 1.38, 6.07) were associated with HAI, ADE, or length of stay >7 days; hyponatremia (OR = 3.49; 95% CI = 1.30, 9.35), prior hospitalization within 30 days (OR = 2.66; 95% CI = 1.31, 5.43) and functional impairment (OR = 2.05; 95% CI = 1.02, 4.13) were associated with 30-day readmission.ConclusionsPatient characteristics recognizable within 24 hours of admission can be used to identify increased risk for adverse events and 30-day readmission.

The business case for TCAB.

Estimates of cost savings with sustained improvement.

A magnet nursing service approach to nursing's role in quality improvement.

The heightened focus on quality and the rise of health care consumerism are manifestations of numerous interrelated dynamics, especially including the aging of the “baby boomers” and greater prevalence of chronic conditions, the explosion of biomedical scientific knowledge and technology, changes in prevailing methods of health care financing, a recent prolonged period of economic prosperity, widespread concerns about patient safety, return of disproportionate health care cost, and the democratization of medical knowledge consequent to widespread use of the Internet. Quality improvement in nursing was first introduced by Florence Nightingale during the Crimean War. Today, nursing quality continues to look at process, but has evolved to an emphasis on patient care outcomes. This article discusses nursing quality structure, processes, and outcomes at a large, teaching, tertiary medical center in Los Angeles, California. The medical center is one of two designated magnet nursing services in California. Nursings role in achieving clinical and service quality for patients, communities, and staff are essential characteristics of magnet-designated nursing service organizations.

The Development of TCAB

ight years ago the Robert Wood Johnson Foundation (RWJF) became interested in what may become our country’s worst nursing shortage. The RWJF report, published in April 2002 (available at www. rwjf.org/files/publications/other/NursingReport.pdf) made bold recommendations to address the shortage. To improve the quality of care in this country, it said,we will have to reinvent or redefine the role of nurses and the ways they are educated. The RWJF also analyzed why nurses were leaving the profession and what positions they most commonly vacated. They found that most nurses were unhappy with their work environments, but the busiest turnstiles seemed to be at the doors of medical–surgical units. As a result, theRWJF asked the Institute for Healthcare Improvement (IHI) to help it devise a plan to improve hospital work environments so more nurses might come to and remain at medical–surgical units. That plan was the Transforming Care at the Bedside (TCAB) initiative. TCAB began in 2003 with a demonstration project. Nurses on one medical–surgical unit at the University of Pittsburgh Medical Center in Shadyside, Pennsylvania; Seton Northwest Hospital in Austin, Texas; and Kaiser Permanente Roseville Medical Center in California brainstormed about improving their work environments so they could spend more time at the bedside. Following the TCAB framework, they developed solutions targeting patient-centered care, value-added processes, vitality and teamwork, and safe and reliable care. Solutions—usually very simple ones—were tried in small, rapid-cycle tests of change and adopted, adapted, or abandoned. The three-hospital demonstration project was a great success. It led to a 13-hospital demonstration. Now, only a few years later, about 160 hospitals have taken part in some aspect of an “official” TCAB program led by theRWJF, the IHI, or theAmericanOrganization of Nurse Executives. The U.S. Department of Veterans Affairs is testing its own version of TCAB this year in more than 40 hospitals. The unofficial count of hospitals that have adopted theTCABprocess amounts to many hundreds in the United States and abroad. TCAB is nowanationalmovement to engage frontline staff in devising changes that will improve nurses’ delivery of care and daily work lives. Across the country, nurses, physicians, and hospital executives are calling for their facilities to adopt TCAB to improve patient care; increase retention of staff nurses; and provide safe, reliable, patientcentered, andvalue-based care. Providers, patients, and administrative leaders all want to participate in a process that can both increase nurses’ time for direct patient care and improve the care itself. Many TCAB hospitals are working with schools of nursing to help them incorporate TCAB principles and processes into their curricula. These schools’ graduates will help to shape how care is provided at U.S. hospitals. Nursing students are learning that nurses can be directly responsible for theirwork environment; they do not have to accept the status quo! TCAB provides blueprints for eliminating the waste in care delivery, improving job satisfaction and nurse retention, enhancing communication and collaborationamong teammembers, and improvingpatient care. TCAB changes how hospital executives, educational institutions, patients, physicians, and nurses organize anddeliver inpatient care. It doesn’t take much: being willing to listen to nurses and patients, engaging frontline staff, conducting rapid-cycle tests of change, identifying changes to adopt and spread, and aligning the aspirations of direct patient care providers with institutional goals. These little investments can achieve much for patients, staff, and society. For a toolkit on how to implement TCAB, go to the RWJF’s virtual TCAB site at www.rwjf.org/ qualityequality/product.jsp?id=30051.

Ten steps for managing organizational change.

Managing interdepartmental relations in healthcare organizations is a major challenge for nursing administrators. The authors describe the implementation process of an organization-wide change effort involving individuals from departments throughout the medical center. These strategies can serve as a model to guide effective planning in other institutions embarking on change projects, resulting in smoother and more effective implementation of interdepartmental change.