Meg Johantgen

Comparison of Labor and Delivery Care Provided by Certified Nurse-Midwives and Physicians: A Systematic Review, 1990 to 2008

BACKGROUND Advanced practice nurses (APNs) in the United States could expand access to high-quality health care, particularly for underserved populations. Yet, there has been limited synthesis of the evidence related to their effectiveness as compared with other providers. The study reported here, part of a larger study that examined all four types of APNs, compares the labor and delivery care outcomes of certified nurse-midwives (CNMs) and physicians. DATA SOURCES PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Proquest (for dissertations), were searched for the years 1990 through 2008. STUDY ELIGIBILITY CRITERIA Only those articles where processes or outcomes of care were quantitatively compared between CNMs and physicians were included. For all APNs, 27,993 citations were reviewed. For CNMs, 21 articles representing 18 unique studies reported either infant or maternal outcomes. METHODS The systematic review followed established procedures (replicable search of relevant databases, sequential review to identify eligible studies, abstraction by two reviewers, assessment of quality, and grading of evidence). RESULTS For measures that relate to the processes of care (e.g., epidural, labor induction, episiotomy), lower use was found for CNMs. For many of the infant outcomes (e.g., low Apgar, low birth weight, neonatal intensive care unit admission), there were no differences between physicians and CNMs. Perineal lacerations were lower and breastfeeding was higher among women cared for by CNMs compared with physicians. LIMITATIONS The review addressed only CNMs practicing in the United States and outcomes measured during labor and delivery. The majority of study designs were observational and the models of care ranged from independent to shared, limiting the control for bias. Moreover, all reviewers were nurses. CONCLUSION Differences in practice between CNMs and MDs seem to be well documented, particularly in the use of technology. Yet, the findings provide evidence that care by CNMs is safe and effective. CNMs should be better utilized to address the projected health care workforce shortages.

Is there a relationship between service integration and differentiation and patient outcomes

Abstract Objective To examine the level of service integration within Maryland hospitals and service differentiation across the hospital system or network and its affect on heart failure patient clinical and economic outcomes. Data sources/Study setting Maryland Health Services Cost Review Commission Inpatient Data for 1997 and 1998 were used for secondary data analysis. Study design Retrospective cross sectional. Independent variables were the level of service integration and differentiation created from the 1998 American Hospital Association Annual Survey based on the work of Bazzoli et al. [1]. The primary dependent variables were readmission, in-hospital mortality, length of stay and costs. Data collection/Extraction methods Patients discharged from Maryland hospitals with a diagnosis that grouped to DRG 127 (heart failure) were extracted. Multivariate linear and logistic models clustered by hospital were used to analyse results at the patient level. Principal findings A higher likelihood of readmission was found as the level of Community Differentiation increased. Although costs were higher as Total Differentiation increased in 1998, these results were not validated by 1997 data. No significant relationship was found between integration of services and outcomes. Conclusions Similar outcomes were achieved regardless of the level of service integration or differentiation. Community hospitals produce similar patient outcomes at the same cost for this diagnosis.

A Comparison of Working Conditions Among Nurses in Magnet® and Non-magnet® Hospitals

Objectives: To compare working conditions (ie, schedule, job demands, and practice environment) of nurses working in American Nurses Credentialing Center-designated Magnet® and non-Magnet® hospitals. Background: Although nurse retention has been reported as more favorable among Magnet hospitals, controversy still exists on whether Magnet hospitals have better working conditions. Method: A secondary data analysis was conducted of the Nurses Worklife and Health Study using responses from the 837 nurses working in 171 hospitals: 14 Magnet and 157 non-Magnet facilities in the Wave 3 follow-up survey. Contingency tables and t tests compared working conditions by Magnet status. To accommodate clustering of nurses in hospitals, the Huber-White sandwich estimator was used to obtain robust SEs and variance estimates. Result: Nurses in Magnet hospitals were significantly less likely to report jobs that included mandatory overtime (P =.04) or on-call (P =.01), yet hours worked did not differ. They also reported significantly lower physical demands (P =.03), although the means for Magnet hospital nurses and non-Magnet nurses were quite similar (30.1 vs 31.0). Furthermore, comparison of the groups on nursing practice environment and perceived patient safety found no significant differences. Conclusion: Working conditions reported by nurses working in Magnet and non-Magnet hospitals varied little.

Associations between state regulations, training length, perceived quality and job satisfaction among certified nursing assistants: Cross-sectional secondary data analysis

BACKGROUND In the U.S., there are federal requirements on how much training and annual continuing education a certified nursing assistant must complete in order to be certified. The requirements are designed to enable them to provide competent and quality care to nursing home residents. Many states also require additional training and continuing education hours as improved nursing home quality indicators have been found to be related to increased training. OBJECTIVES This study investigated the associations among state level regulations, initial training quality and focus, and job satisfaction in certified nursing assistants. DESIGN Cross-sectional secondary data analysis. SETTINGS This study used the National Nursing Home Survey and National Nursing Assistant Survey as well as data on state regulations of certified nursing assistant training. PARTICIPANTS 2897 certified nursing assistants in 580 nursing homes who were currently working at a nursing home facility, who represented 680,846 certified nursing assistants in US. METHODS State regulations were related to initial training and job satisfaction among certified nursing assistants using chi square tests and binomial logistic regression models. Analyses were conducted using SAS-callable SUDAAN to correct for complex sampling design effects in the National Nursing Home Survey and National Nursing Assistant Survey. Models were adjusted for personal and facility characteristics. RESULTS Certified nursing assistants reporting high quality training were more likely to work in states requiring additional initial training hours (p=0.02) and were more satisfied with their jobs (OR=1.51, 95% CI=1.09-2.09) than those with low quality training. In addition, those with more training focused on work life skills were 91% more satisfied (OR=1.91, 95% CI=1.41-2.58) whereas no relationship was found between training focused on basic care skills and job satisfaction (OR=1.36, 95% CI=0.99-1.84). CONCLUSIONS Certified nursing assistants with additional initial training were more likely to report that their training was of high quality, and this was related to job satisfaction. Job satisfaction was also associated with receiving more training that focused on work life skills. Federal training regulations should reconsider additional hours for certified nursing assistant initial training, and include work life skills as a focus. As job satisfaction has been linked to nursing home turnover, attention to training may improve satisfaction, ultimately reducing staff turnover.

The importance of supervision in retention of CNAs

Certified nursing assistants (CNAs) provide the majority of direct care in nursing homes, yet recruiting and retaining CNAs has been difficult. Retaining CNAs is important because it has been linked to the better quality of resident care in nursing homes. In this study, the investigators examined the relationships of work-related and personal factors to CNA job satisfaction and intent to leave. Linked data from the 2004 National Nursing Home Survey and the 2004 National Nursing Assistant Survey were analyzed using multilevel logistic regression. Personal factors such as age, education, and job history, were related to intent to leave but not to job satisfaction. Supportive supervision was a significant predictor of both job satisfaction and intent to leave.

Turnover, staffing, skill mix, and resident outcomes in a national sample of US nursing homes.

OBJECTIVES: The authors examined the relationship of staff turnover to selected nursing home quality outcomes, in the context of staffing and skill mix. BACKGROUND: Staff turnover is a serious concern in nursing homes as it has been found to adversely affect care. When employee turnover is minimized, better care quality is more likely in nursing homes. METHODS: Data from the National Nursing Home Survey, a nationally representative sample of US nursing homes, were linked to Nursing Home Compare quality outcomes and analyzed using logistic regression. RESULTS: Nursing homes with high certified nursing assistant turnover had significantly higher odds of pressure ulcers, pain, and urinary tract infections even after controlling for staffing, skill mix, bed size, and ownership. Nurse turnover was associated with twice the odds of pressure ulcers, although this was attenuated when staffing was controlled. CONCLUSIONS: This study suggests turnover may be more important in explaining nursing home (NH) outcomes than staffing and skill mix and should therefore be given greater emphasis.

Are Nursing Home Survey Deficiencies Higher in Facilities With Greater Staff Turnover

OBJECTIVES To examine CNA and licensed nurse (RN+LPN/LVN) turnover in relation to numbers of deficiencies in nursing homes. DESIGN A secondary data analysis of information from the National Nursing Home Survey (NNHS) and contemporaneous data from the Online Survey, Certification and Reporting (OSCAR) database. Data were linked by facility as the unit of analysis to determine the relationship of CNA and licensed nurse turnover on nursing home deficiencies. SETTING The 2004 NNHS used a multistage sampling strategy to generate a final sample of 1174 nursing homes, which represent 16,100 NHs in the United States. PARTICIPANTS This study focused on the 1151 NNHS facilities with complete deficiency data. MEASUREMENTS Turnover was defined as the total CNAs/licensed nurse full-time equivalents (FTEs) who left during the preceding 3 months (full- and part-time) divided by the total FTE. NHs with high turnover were defined as those with rates above the 75th percentile (25.3% for CNA turnover and 17.9% for licensed nurse turnover) versus all other facilities. This study used selected OSCAR deficiencies from the Quality of Care, Quality of Life, and Resident Behavior categories, which are considered to be more closely related to nursing care. We defined NHs with high deficiencies as those with numbers of deficiencies above the 75th percentile versus all others. Using SUDAAN PROC RLOGIST, we included NNHS sampling design effects and examined associations of CNA/licensed nurse turnover with NH deficiencies, adjusting for staffing, skill mix, bed size, and ownership in binomial logistic regression models. RESULTS High CNA turnover was associated with high numbers of Quality of Care (OR 1.53, 95% CI 1.10-2.13), Resident Behavior (OR 1.42, 95% CI 1.03-1.97) and total selected deficiencies (OR 1.54, 95% CI 1.12-2.12). Licensed nurse turnover was significantly related to Quality of Care deficiencies (OR 2.06, 95% CI 1.50-2.82) and total selected deficiencies (OR 1.71, 95% CI 1.25-2.33). When both CNA turnover and licensed nurse turnover were included in the same model, high licensed nurse turnover was significantly associated with Quality of Care and total deficiencies, whereas CNA turnover was not associated with that category of deficiencies. CONCLUSION Turnover in nursing homes for both licensed nurses and CNAs is associated with quality problems as measured by deficiencies.

Registered Nurses’ Job Satisfaction in Navy Hospitals

Because of the increasing use of civilian registered nurses to supplement the nursing staff at U.S. Navy hospitals, it is imperative to understand the factors that influence satisfaction in both Navy and civilian nurses in military hospitals. This study sought to expand knowledge of satisfaction in hospital-based active duty Navy registered nurses and federal civilian nurses. Respondents completed a survey with a response rate of 42% (N=496). The survey was designed using well-known satisfaction models and included measures of work attitudes, work setting, and demographic characteristics. Linear regression models explained 51% of the variance in job satisfaction for Navy nurses and 55% for civilian nurses. Routinization had the strongest significant negative association with job satisfaction for Navy and civilian nurses. Supervisor support was significantly associated with satisfaction for Navy nurses although coworker support was a significant factor for civilians. These findings have implications for nurse administrators and health care executives who desire to retain nurse employees.

Policy Implications for Optimizing Advanced Practice Registered Nurse Use Nationally

This article examines the potential benefits of enhanced use of advanced practice registered nurses (APRNs) given health care workforce projections that predict an inadequate supply of certain types of providers. The conclusions of a systematic review comparing the effectiveness of care provided by APRNs with that of physicians alone or teams without APRNs indicate the viability of this approach. Allowing APRNs to assume roles that take full advantage of their educational preparation could mitigate the shortage of primary care physicians and improve care processes. The development of health care policy should be guided by patient-centric evidence rather than how care has been delivered in the past.

Credentialing: The need for a national research agenda

A national research agenda is needed to promote inquiry into the impact of credentialing on health care outcomes for nurses, patients, and organizations. Credentialing is used here to refer to individual credentialing, such as certification for nurses, and organizational credentialing, such as American Nurses Credentialing Center Magnet recognition for health care organizations or accreditation of providers of continuing education in nursing. Although it is hypothesized that credentialing leads to a higher quality of care, more uniform practice, and better patient outcomes, the research evidence to validate these views is limited. This article proposes a conceptual model in which both credentials and standards are posited to affect outcomes in health care. Potential research questions as well as issues in research design, measurement, data collection, and analysis are discussed. Credentialing in nursing has implications for the health care professions and national policy. A growing body of independent research that clarifies the relationship of credentialing in nursing to outcomes can make important contributions to the improvement of health care quality.