Sean P. Clarke

Effects of hospital care environment on patient mortality and nurse outcomes.

Objective: The objective of this study was to analyze the net effects of nurse practice environments on nurse and patient outcomes after accounting for nurse staffing and education. Background: Staffing and education have well-documented associations with patient outcomes, but evidence on the effect of care environments on outcomes has been more limited. Methods: Data from 10,184 nurses and 232,342 surgical patients in 168 Pennsylvania hospitals were analyzed. Care environments were measured using the practice environment scales of the Nursing Work Index. Outcomes included nurse job satisfaction, burnout, intent to leave, and reports of quality of care, as well as mortality and failure to rescue in patients. Results: Nurses reported more positive job experiences and fewer concerns with care quality, and patients had significantly lower risks of death and failure to rescue in hospitals with better care environments. Conclusion: Care environment elements must be optimized alongside nurse staffing and education to achieve high quality of care.

Nurse Burnout and Patient Satisfaction

BackgroundAmid a national nurse shortage, there is growing concern that high levels of nurse burnout could adversely affect patient outcomes. ObjectivesThis study examines the effect of the nurse work environment on nurse burnout, and the effects of the nurse work environment and nurse burnout on patients’ satisfaction with their nursing care. Research Design/SubjectsWe conducted cross-sectional surveys of nurses (N = 820) and patients (N = 621) from 40 units in 20 urban hospitals across the United States. MeasuresNurse surveys included measures of nurses’ practice environments derived from the revised Nursing Work Index (NWI-R) and nurse outcomes measured by the Maslach Burnout Inventory (MBI) and intentions to leave. Patients were interviewed about their satisfaction with nursing care using the La Monica-Oberst Patient Satisfaction Scale (LOPSS). ResultsPatients cared for on units that nurses characterized as having adequate staff, good administrative support for nursing care, and good relations between doctors and nurses were more than twice likely as other patients to report high satisfaction with their care, and their nurses reported significantly lower burnout. The overall level of nurse burnout on hospital units also affected patient satisfaction. ConclusionsImprovements in nurses’ work environments in hospitals have the potential to simultaneously reduce nurses’ high levels of job burnout and risk of turnover and increase patients’ satisfaction with their care.

Critical Role of Macrophage 12/15-Lipoxygenase for Atherosclerosis in Apolipoprotein E–Deficient Mice

Background—Mice lacking leukocyte type 12/15-lipoxygenase (12/15-LO) show reduced atherosclerosis in several models. 12/15-LO is expressed in a variety of cells, including vascular cells, adipocytes, macrophages, and cardiomyocytes. The purpose of this study was to determine which cellular source of 12/15-LO is important for atherosclerosis. Methods and Results—Bone marrow from 12/15-LO−/−/apoE−/− mice was transplanted into apoE−/− mice and vice versa. Deficiency of 12/15-LO in bone marrow cells protected apoE−/− mice fed a Western diet from atherosclerosis to the same extent as complete absence of 12/15-LO, although plasma 8,12-iso-iPF2&agr;-IV, a measure of lipid peroxidation, remained elevated. 12/15-LO−/−/apoE−/− mice regained the severity of atherosclerotic lesion typical of apoE−/− mice after replacement of their bone marrow cells with bone marrow from apoE−/− mice. Peritoneal macrophages obtained from wild-type but not 12/15-LO−/− mice caused endothelial activation in the presence of native LDL. Absence of 12/15-LO decreased the ability of macrophages to form foam cells when exposed to LDL. Conclusions—We conclude that macrophage 12/15-LO plays a dominant role in the development of atherosclerosis by promoting endothelial inflammation and foam cell formation.

Rationing of nursing care and its relationship to patient outcomes: the Swiss extension of the International Hospital Outcomes Study

OBJECTIVE To explore the association between implicit rationing of nursing care and selected patient outcomes in Swiss hospitals, adjusting for major organizational variables, including the quality of the nurse practice environment and the level of nurse staffing. Rationing was measured using the newly developed Basel Extent of Rationing of Nursing Care (BERNCA) instrument. Additional data were collected using an adapted version of the International Hospital Outcomes Study questionnaire. DESIGN Multi-hospital cross-sectional surveys of patients and nurses. SETTING Eight Swiss acute care hospitals PARTICIPANTS Nurses (1338) and patients (779) on 118 medical, surgical and gynecological units. MAIN OUTCOME MEASURES Patient satisfaction, nurse-reported medication errors, patient falls, nosocomial infections, pressure ulcers and critical incidents involving patients over the previous year. RESULTS Generally, nurses reported rarely having omitted any of the 20 nursing tasks listed in the BERNCA over their last 7 working days. However, despite relatively low levels, implicit rationing of nursing care was a significant predictor of all six patient outcomes studied. Although the adequacy of nursing resources was a significant predictor for most of the patient outcomes in unadjusted models, it was not an independent predictor in the adjusted models. Low nursing resource adequacy ratings were a significant predictor for five of the six patient outcomes in the unadjusted models, but not in the adjusted ones. CONCLUSION As a system factor in acute general hospitals, implicit rationing of nursing care is an important new predictor of patient outcomes and merits further study.

The relationship between inpatient cardiac surgery mortality and nurse numbers and educational level: Analysis of administrative data

BACKGROUND In most multicenter studies that examine the relationship between nurse staffing and patient safety, nurse-staffing levels are measured per hospital. This can obscure relationships between staffing and outcomes at the unit level and lead to invalid inferences. OBJECTIVE In the present study, we examined the association between nurse-staffing levels in nursing units that treat postoperative cardiac surgery patients and the in-hospital mortality of these patients. DESIGN-SETTING-PARTICIPANTS: We illustrated our approach by using administrative databases (Year 2003) representing all Belgian cardiac centers (n=28), which included data from 58 intensive care and 75 general nursing units and 9054 patients. METHODS We used multilevel logistic regression models and controlled for differences in patient characteristics, nursing care intensity, and cardiac procedural volume. RESULTS Increased nurse staffing in postoperative general nursing units was significantly associated with decreased mortality. Nurse staffing in postoperative intensive care units was not significantly associated with in-hospital mortality possibly due to lack of variation in ICU staffing across hospitals. CONCLUSION This study, together with the international body of evidence, suggests that nurse staffing is one of several variables influencing patient safety. These findings further suggest the need to study the impact of nurse-staffing levels on in-hospital mortality using nursing-unit-level specific data.

Practice environments and their associations with nurse-reported outcomes in Belgian hospitals: Development and preliminary validation of a Dutch adaptation of the Revised Nursing Work Index

AIM To study the relationship between nurse work environment, job outcomes and nurse-assessed quality of care in the Belgian context. BACKGROUND Work environment characteristics are important for attracting and retaining professional nurses in hospitals. The Revised Nursing Work Index (NWI-R) was originally designed to describe the professional nurse work environment in U.S. Magnet Hospitals and subsequently has been extensively used in research internationally. METHOD The NWI-R was translated into Dutch to measure the nurse work environment in 155 nurses across 13 units in three Belgian hospitals. Factor analysis was used to identify a set of coherent subscales. The relationship between work environments and job outcomes and nurse-assessed quality of care was investigated using logistic and linear regression analyses. RESULTS Three reliable, consistent and meaningful subscales of the NWI-R were identified: nurse-physician relations, nurse management at the unit level and hospital management and organizational support. All three subscales had significant associations with several outcome variables. Nurse-physician relations had a significant positive association with nurse job satisfaction, intention to stay the hospital, the nurse-assessed unit level quality of care and personal accomplishment. Nurse management at the unit level had a significant positive association with the nurse job satisfaction, nurse-assessed quality of care on the unit and in the hospital, and personal accomplishment. Hospital management and organizational support had a significant positive association with the nurse-assessed quality of care in the hospital and personal accomplishment. Higher ratings of nurse-physician relations and nurse management at the unit level had significant negative associations with both the Maslach Burnout Inventory emotional exhaustion and depersonalization dimensions, whereas hospital management and organizational support was inversely associated only with depersonalization scores. CONCLUSION A Dutch version of the NWI-R questionnaire produced comparable subscales to those found by many other researchers internationally. The resulting measures of the professional practice environment in Belgian hospitals showed expected relationships with nurse self-reports of job outcomes and perceptions of hospital quality.

Nurse staffing and patient outcomes in Belgian acute hospitals: Cross-sectional analysis of administrative data

BACKGROUND Studies have linked nurse staffing levels (number and skill mix) to several nurse-sensitive patient outcomes. However, evidence from European countries has been limited. OBJECTIVES This study examines the association between nurse staffing levels (i.e. acuity-adjusted Nursing Hours per Patient Day, the proportion of registered nurses with a Bachelors degree) and 10 different patient outcomes potentially sensitive to nursing care. DESIGN-SETTING-PARTICIPANTS: Cross-sectional analyses of linked data from the Belgian Nursing Minimum Dataset (general acute care and intensive care nursing units: n=1403) and Belgian Hospital Discharge Dataset (general, orthopedic and vascular surgery patients: n=260,923) of the year 2003 from all acute hospitals (n=115). METHODS Logistic regression analyses, estimated by using a Generalized Estimation Equation Model, were used to study the association between nurse staffing and patient outcomes. RESULTS The mean acuity-adjusted Nursing Hours per Patient Day in Belgian hospitals was 2.62 (S.D.=0.29). The variability in patient outcome rates between hospitals is considerable. The inter-quartile ranges for the 10 patient outcomes go from 0.35 for Deep Venous Thrombosis to 3.77 for failure-to-rescue. No significant association was found between the acuity-adjusted Nursing Hours per Patient Day, proportion of registered nurses with a Bachelors degree and the selected patient outcomes. CONCLUSION The absence of associations between hospital-level nurse staffing measures and patient outcomes should not be inferred as implying that nurse staffing does not have an impact on patient outcomes in Belgian hospitals. To better understand the dynamics of the nurse staffing and patient outcomes relationship in acute hospitals, further analyses (i.e. nursing unit level analyses) of these and other outcomes are recommended, in addition to inclusion of other study variables, including data about nursing practice environments in hospitals.

An International Perspective on Hospital Nurses’ Work Environments: The Case for Reform

The current nursing shortage, high hospital-nurse job dissatisfaction, and reports of uneven quality of hospital care are not uniquely American phenomena. This article presents reports from 43,000 nurses at more than 700 hospitals in the United States, Canada, England, Scotland, and Germany during 1998 and 1999. Nurses in countries with distinctly different health care systems report similar shortcomings in their work environments and the quality of hospital care. Although nurse and physician competence and nurse-physician relationships appear satisfactory, core problems in work design and workforce management threaten care provision. Resolving these issues, which are amenable to managerial intervention, is essential to preserve patient safety and provide care of consistently high quality.

Psychosocial factors as predictors of functional status at 1 year in patients with left ventricular dysfunction

Chronic heart failure patients often experience significant functional impairments. A better understanding of the biopsychosocial correlates of functional status may lead to interventions that improve quality of life in this population. Social isolation, mood disturbance, low socioeconomic status, and non-White ethnicity were evaluated as possible correlates of impaired functional status in 2,992 U.S. patients with left ventricular ejection fractions (LVEFs) </= 35%. Even after controlling for age and clinical characteristics, all of the psychosocial variables examined were significant predictors of risk for experiencing severe limitations in intermediate and social activities of daily living at 1 year, with adjusted odds ratios in the 1.5-2.0 range. The ability of psychosocial characteristics to predict future functional status was also independent of baseline functional status, comorbid medical conditions, and deterioration in heart failure signs and symptoms over the intervening year. These results suggest that psychosocial factors influence patient functional status even in the later phases of cardiac disease.

Validation of the basel extent of rationing of nursing care instrument

Background: Financial constraints and other forces affecting health care in many countries have led to nurses implicitly limiting their care in some instances. In the absence of an accepted definition and theoretical framework of implicit rationing of nursing care, a framework and the Basel Extent of Rationing of Nursing Care (BERNCA) instrument were developed. This instrument was used in the Swiss part of the International Hospital Outcome Study, in which implicit rationing of nursing care was studied. Objective: To examine the validity and reliability of the newly developed BERNCA instrument. Methods: Psychometric analysis was performed on data from 957 nurses in five Swiss acute care hospitals enrolled in a larger hospital organization study. An explanatory factor analysis with varimax rotation was used to investigate the instruments internal structure, Spearman correlations were used to test relationships between implicit rationing and two related concepts, and Cronbachs alpha and interitem correlations were used to test the reliability of the scale. Results: Expert feedback confirmed that the BERNCA covered the implicit rationing of nursing care domain adequately and that its questions were fully comprehensible. The single-factor solution confirmed the instruments unidimensional internal structure. A moderate to strong correlation in the expected direction was found between the BERNCA implicit rationing data and the quality of the nurse work environment as measured by the Nursing Work Index-Revised, particularly the perceived adequacy of nursing resources, although a significant but low correlation was also shown with patient-to-nurse ratios. Cronbachs alphas (.93) and interitem correlations indicated internal consistency and homogeneity. Discussion: Initial evidence of the validity and reliability of the BERNCA instrument was provided.