Association of Nurse Engagement and Nurse Staffing on Patient Safety.
ABSTRACT: BACKGROUND:Nurse engagement is a modifiable element of the work environment and has shown promise as a potential safety intervention. PURPOSE:Our study examined the relationship between the level of engagement, staffing, and assessments of patient safety among nurses working in hospital settings. METHODS:A secondary analysis of linked cross-sectional data was conducted using survey data of 26 960 nurses across 599 hospitals in 4 states. Logistic regression models were used to examine the association between nurse engagement, staffing, and nurse assessments of patient safety. RESULTS:Thirty-two percent of nurses gave their hospital a poor or failing patient safety grade. In 25% of hospitals, nurses fell in the least or only somewhat engaged categories. A 1-unit increase in engagement lowered the odds of an unfavorable safety grade by 29% (P < .001). Hospitals where nurses reported higher levels of engagement were 19% (P < .001) less likely to report that mistakes were held against them. Nurses in poorly staffed hospitals were 6% more likely to report that important information about patients "fell through the cracks" when transferring patients across units (P < .001). CONCLUSIONS:Interventions to improve nurse engagement and adequate staffing serve as strategies to improve patient safety.
Project description:OBJECTIVES:To determine whether there was variation in nurse staffing across hospitals in Queensland prior to implementation of nurse-to-patient ratio legislation targeting medical-surgical wards, and if so, the extent to which nurse staffing variation was associated with poor outcomes for patients and nurses. DESIGN:Analysis of cross-sectional data derived from nurse surveys linked with admitted patient outcomes data. SETTING:Public hospitals in Queensland. PARTICIPANTS:4372 medical-surgical nurses and 146?456 patients in 68 public hospitals. MAIN OUTCOME MEASURES:30-day mortality, quality and safety indicators, nurse outcomes including emotional exhaustion and job dissatisfaction. RESULTS:Medical-surgical nurse-to-patient ratios before implementation of ratio legislation varied significantly across hospitals (mean 5.52 patients per nurse; SD=2.03). After accounting for patient characteristics and hospital size, each additional patient per nurse was associated with 12% higher odds of 30-day mortality (OR=1.12; 95%?CI 1.01 to 1.26). Each additional patient per nurse was associated with poorer outcomes for nurses including 15% higher odds of emotional exhaustion (OR=1.15; 95%?CI 1.07 to 1.23) and 14% higher odds of job dissatisfaction (OR=1.14; 95%?CI 1.02 to 1.28), as well as higher odds of concerns about quality of care (OR=1.12; 95%?CI 1.01 to 1.25) and patient safety (OR=1.32; 95%?CI 1.11 to 1.57). CONCLUSIONS:Before ratios were implemented, nurse staffing varied considerably across Queensland hospital medical-surgical wards and higher nurse workloads were associated with patient mortality, low quality of care, nurse emotional exhaustion and job dissatisfaction. The considerable variation across hospitals and the link with outcomes suggests that taking action to improve staffing levels was prudent.
Project description:The objectives of this study were to examine differences in nurse engagement in shared governance across hospitals and to determine the relationship between nurse engagement and patient and nurse outcomes.There is little empirical evidence examining the relationship between shared governance and patient outcomes.A secondary analysis of linked cross-sectional data was conducted using nurse, hospital, and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey data.Engagement varied widely across hospitals. In hospitals with greater levels of engagement, nurses were significantly less likely to report unfavorable job outcomes and poor ratings of quality and safety. Higher levels of nurse engagement were associated with higher HCAHPS scores.A professional practice environment that incorporates shared governance may serve as a valuable intervention for organizations to promote optimal patient and nurse outcomes.
Project description:<h4>Objective</h4>To examine the associations between Medicaid expansion and nurse staffing ratios and hospital-wide readmission rates.<h4>Data sources</h4>Secondary data from the 2011-2016 Healthcare Cost Report Information System, the American Hospital Association Annual Survey, and the Hospital Compare data.<h4>Study design</h4>Difference-in-difference models are used to compare outcomes in hospitals located in states that expanded Medicaid with those located in nonexpansion states. The changes in nurse staffing ratios and hospital-wide readmission rates are calculated in each one of the postexpansion years (2014, 2015, and 2016), compared to pre-expansion.<h4>Principal findings</h4>Results indicate that nurse staffing ratios increased, whereas hospital-wide readmission rates declined in expansion states relative to nonexpansion states. Nurse staffing ratios increased by 0.33, 0.42, and 0.46 registered nurses hours per adjusted patient days in 2014, 2015, and 2016 in hospitals located in expansion states, compared with hospitals in nonexpansion states after expansion. This increase was statistically significant (P < .001) in 2015 and 2016, but marginally significant (P = .016) in 2014. Hospital-wide readmission rates statistically significantly decreased by 9, 16, and 18 per 10 000 patients (P < .001) in 2014, 2015, and 2016, respectively, in expansion vs nonexpansion states hospitals after expansion.<h4>Conclusions</h4>Medicaid expansion was associated with gradually improved hospitals' nurse staffing ratios and hospital-wide readmission rates from 2014 through 2016. The continued monitoring of quality measures of hospitals can help assess the impact of Medicaid expansion over a longer period of time.
Project description:<h4>Objective</h4>To examine the relationship between nurse staffing patterns and patients' experience of care in hospitals with a particular focus on staffing flexibility.<h4>Data sources/study setting</h4>The study sample comprised U.S. general hospitals between 2010 and 2012. Nurse staffing data came from the American Hospital Association Annual Survey, and patient experience data came from the Medicare Hospital Consumer Assessment of Healthcare Providers and Systems.<h4>Study design</h4>An observational research design was used entailing a pooled, cross-sectional data set. Regression models were estimated using generalized estimating equation (GEE) and hospital fixed effects. Nurse staffing patterns were assessed based on both levels (i.e., ratio of full-time equivalent nurses per 1,000 patient days) and composition (i.e., skill mix-percentage of registered nurses; staffing flexibility-percentage of part-time nurses).<h4>Principal findings</h4>All three staffing variables were significantly associated with patient experience in the GEE analysis, but only staffing flexibility was significant in the fixed-effects analysis. A higher percentage of part-time nurses was positively associated with patient experience. Multiplicative and nonlinear effects for the staffing variables were also observed.<h4>Conclusions</h4>Among three staffing variables, flexibility was found to be the most important relative to patient experience. Unobserved hospital characteristics appear to underlie patient experience as well as certain nurse staffing patterns.
Project description:<h4>Objectives</h4>To determine whether nurse staffing in California hospitals, where state-mandated minimum nurse-to-patient ratios are in effect, differs from two states without legislation and whether those differences are associated with nurse and patient outcomes.<h4>Data sources</h4>Primary survey data from 22,336 hospital staff nurses in California, Pennsylvania, and New Jersey in 2006 and state hospital discharge databases.<h4>Study design</h4>Nurse workloads are compared across the three states and we examine how nurse and patient outcomes, including patient mortality and failure-to-rescue, are affected by the differences in nurse workloads across the hospitals in these states.<h4>Principal findings</h4>California hospital nurses cared for one less patient on average than nurses in the other states and two fewer patients on medical and surgical units. Lower ratios are associated with significantly lower mortality. When nurses' workloads were in line with California-mandated ratios in all three states, nurses' burnout and job dissatisfaction were lower, and nurses reported consistently better quality of care.<h4>Conclusions</h4>Hospital nurse staffing ratios mandated in California are associated with lower mortality and nurse outcomes predictive of better nurse retention in California and in other states where they occur.
Project description:When California passed a law in 1999 establishing minimum nurse-to-patient staffing ratios for hospitals, it was feared that hospitals might respond by disproportionately hiring lower-skill licensed vocational nurses. This article examines nurse staffing ratios for California hospitals for the period 1997-2008. It compares staffing levels to those in similar hospitals in the United States. We found that California's mandate did not reduce the nurse workforce skill level as feared. Instead, California hospitals on average followed the trend of hospitals nationally by increasing their nursing skill mix, and they primarily used more highly skilled registered nurses to meet the staffing mandate. In addition, we found that the staffing mandate resulted in roughly an additional half-hour of nursing per adjusted patient day beyond what would have been expected in the absence of the policy. Policy makers in other states can look to California's experience when considering similar approaches to improving patient care.
Project description:<h4>Objective</h4>To determine whether and to what extent the lower mortality rates for patients undergoing abdominal aortic aneurysm (AAA) repair in high-volume hospitals is explained by better nursing.<h4>Data sources</h4>State hospital discharge data, Multi-State Nursing Care and Patient Safety Survey, and hospital characteristics from the AHA Annual Survey.<h4>Study design</h4>Cross-sectional analysis of linked patient outcomes for individuals undergoing AAA repair in four states.<h4>Data collection</h4>Secondary data sources.<h4>Principal findings</h4>Favorable nursing practice environments and higher hospital volumes of AAA repair are associated with lower mortality and fewer failures-to-rescue in main-effects models. Furthermore, nurse staffing interacts with volume such that there is no mortality advantage observed in high-volume hospitals with poor nurse staffing. When hospitals have good nurse staffing, patients in low-volume hospitals are 3.4 times as likely to die and 2.6 times as likely to die from complications as patients in high-volume hospitals (p < .001).<h4>Conclusions</h4>Nursing is part of the explanation for lower mortality after AAA repair in high-volume hospitals. Importantly, lower mortality is not found in high-volume hospitals if nurse staffing is poor.
Project description:Following deinstitutionalization, inpatient psychiatric services moved from state institutions to general hospitals. Despite the magnitude of these changes, evaluations of the quality of inpatient care environments in general hospitals are limited. This study examined the extent to which organizational factors of the inpatient psychiatric environments are associated with psychiatric nurse burnout. Organizational factors were measured by an instrument endorsed by the National Quality Forum. Robust clustered regression analysis was used to examine the relationship between organizational factors in 67 hospitals and levels of burnout for 353 psychiatric nurses. Lower levels of psychiatric nurse burnout was significantly associated with inpatient environments that had better overall quality work environments, more effective managers, strong nurse-physician relationships, and higher psychiatric nurse-to-patient staffing ratios. These results suggest that adjustments in organizational management of inpatient psychiatric environments could have a positive effect on psychiatric nurses' capacity to sustain safe and effective patient care environments.
Project description:<h4>Background</h4>There is strong evidence to show that lower nurse staffing levels in hospitals are associated with worse patient outcomes. One hypothesised mechanism is the omission of necessary nursing care caused by time pressure-'missed care'.<h4>Aim</h4>To examine the nature and prevalence of care left undone by nurses in English National Health Service hospitals and to assess whether the number of missed care episodes is associated with nurse staffing levels and nurse ratings of the quality of nursing care and patient safety environment.<h4>Methods</h4>Cross-sectional survey of 2917 registered nurses working in 401 general medical/surgical wards in 46 general acute National Health Service hospitals in England.<h4>Results</h4>Most nurses (86%) reported that one or more care activity had been left undone due to lack of time on their last shift. Most frequently left undone were: comforting or talking with patients (66%), educating patients (52%) and developing/updating nursing care plans (47%). The number of patients per registered nurse was significantly associated with the incidence of 'missed care' (p<0.001). A mean of 7.8 activities per shift were left undone on wards that are rated as 'failing' on patient safety, compared with 2.4 where patient safety was rated as 'excellent' (p < 0.001).<h4>Conclusions</h4>Nurses working in English hospitals report that care is frequently left undone. Care not being delivered may be the reason low nurse staffing levels adversely affects quality and safety. Hospitals could use a nurse-rated assessment of 'missed care' as an early warning measure to identify wards with inadequate nurse staffing.
Project description:<h4>Background</h4>The Safe Staffing for Quality Care Act under consideration in the New York (NY) state assembly would require hospitals to staff enough nurses to safely care for patients. The impact of regulated minimum patient-to-nurse staffing ratios in acute care hospitals in NY is unknown.<h4>Objectives</h4>To examine variation in patient-to-nurse staffing in NY hospitals and its association with adverse outcomes (ie, mortality and avoidable costs).<h4>Research design</h4>Cross-sectional data on nurse staffing in 116 acute care general hospitals in NY are linked with Medicare claims data.<h4>Subjects</h4>A total of 417,861 Medicare medical and surgical patients.<h4>Measures</h4>Patient-to-nurse staffing is the primary predictor variable. Outcomes include in-hospital mortality, length of stay, 30-day readmission, and estimated costs using Medicare-specific cost-to-charge ratios.<h4>Results</h4>Hospital staffing ranged from 4.3 to 10.5 patients per nurse (P/N), and averaged 6.3 P/N. After adjusting for potential confounders each additional patient per nurse, for surgical and medical patients, respectively, was associated with higher odds of in-hospital mortality [odds ratio (OR)=1.13, P=0.0262; OR=1.13, P=0.0019], longer lengths of stay (incidence rate ratio=1.09, P=0.0008; incidence rate ratio=1.05, P=0.0023), and higher odds of 30-day readmission (OR=1.08, P=0.0002; OR=1.06, P=0.0003). Were hospitals staffed at the 4:1 P/N ratio proposed in the legislation, we conservatively estimated 4370 lives saved and $720 million saved over the 2-year study period in shorter lengths of stay and avoided readmissions.<h4>Conclusions</h4>Patient-to-nurse staffing varies substantially across NY hospitals and higher ratios adversely affect patients. Our estimates of potential lives and costs saved substantially underestimate potential benefits of improved hospital nurse staffing.