EBSCOhost | | The Relationship of Nursing Workforce Characteristics to Patient Outcomes.
The purpose of this policy brief is to provide guidance on the relationships between educated nursing workforce on positive patient quality outcomes and . which explored the characteristics of the facilities where nurses were happy to work. nursing characteristics in hospitals on changes in risk-adjusted mortality and .. educated nurse workforce on outcomes for a general population of .. of the surgical oncology patient in relation to the multiple disease and. The relationship between nurse staffing and patient outcomes. mortality in both partial and marginal analyses, controlling for patient characteristics. for hospital and nursing administrators to use when restructuring the clinical workforce.
The patient population was finally established at 76 A further inclusion criterion was that nurses should have held their current post for at least 6 months the final sample of nurses was All analyses were made separately in each zone due to their different socioeconomic situation.
- The Relationship of Nursing Workforce Characteristics to Patient Outcomes.
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- Relationship of Nursing Characteristics to Quality Outcomes
The variable time from diagnosis, despite its importance, could not be included due to the low reliability of these data in information systems. Participation in Hospital affairs maximum score 36Nursing Foundations for Quality of Care maximum score 40Nurse Managers ability and support for nurses maximum score 20Staffing adequacy maximum score 16Nurse—physician Relationship maximum score The global score can range from 31 to The procedure of questionnaires administration has been described previously.
It has been built following the index methodology drawn up for the MEDEA project, 26 27 and values were categorised in quartiles Q1: Data analysis First, a descriptive analysis was conducted measure of central tendency and frequency distribution of patient and nurse characteristics.
Multilevel logistic regression models were adjusted to estimate the prevalence of poor HBP control and to identify the patient and nurse characteristics that are associated with poor HBP control.
The multilevel models are particularly appropriate when individuals clustered within groups and these groups share characteristics. Research on Patient Safety and Quality of C are The bulk of research on patient safety and quality of care addresses the impact of national nurse certification on surgical complications and morta lity rate.
This s tudy does not measure these outcomes and therefore, this section will focus on variab les consistent with this study. Nurse Certification and Nurse Sensitive Patient O utcomes Nurse sensitive patient outcomes are directly affected by nursing care and include pressure ulc ers, infection rates, falls, medication errors and restraint use The limited research available presents conflicting results. The studies that found a positive relationship between certification and pressure ulcer staging examined stagi ng processes comparing wound care certified nurses with non certified wound care nurses.
Whereas, the studies that found no relationship between certification and assessment of pressure ulcers resulted from retrospective chart reviews of intensive care pat ients comparing critical care certified nurses with non certified nurses. Nurses certified in wound, ostomy, and continence care exhibit higher knowledge score differences when compared with nurses with no wound care certification yet the relationship of k nowledge and actual practice remains blurred Bergquist Beringer, et.
The study used a web based program focusing on three aspects: The findings confirmed that certified nurses had higher rates for pressure ulcer identification, correctly staging ulcers, and rating severity of ulcers than nurses with no PAGE 38 38 certification.
Bergquist Beringer and colleagues repeated the study but included a comparison of web based with direct observation and again found that in direct observation, wound certified nurses had higher scores than noncertified nurses.
The Relationship of Nursing Workforce Characteristics to Patient Outcomes
The study included 31 hospitals with 39 of the nurse s certified in wound, ostomy, or continence care. However, both studies found no statistically significant difference in scores between certified and noncertified nurses when nurses evaluated the pressure ulcer in a case study. The samples of certified nu rses for both studies were small limiting generalizations. There are mixed results when researchers reviewed the impact of ICU certification on nurse sensitive outcomes.
Studies do not show agreement on the relationship of ICU nurse certification to press ure ulcer prevalen ce or blood stream infections. Kendall Gallagher and Blegen performed a cross sectional exploratory study that looked at the relationship between the proportion of certified intensive care nurses in a unit and six quality indicator s medication errors, falls, skin breakdown, central catheter infections, bloodstream infections, and urinary tract infections.
The researchers, controlling for the Medicare case index and magnet status environment, used a secondary data sample of 48 adul t ICU units in 29 hospitals with a total of patients. The proportion of certified nurses on the unit had an inverse relationship to fa as the number of certified nurses increased on a unit the number The total sample size for the studies patients and nurses were small and PAGE 39 39 geographically restricted with no clear in dication on the number and type of specialty nurse certification.
In contrast, Krapohl, Manojlovich, Redman, and Zhang performed a correlational descriptive study of ICU nurses in 25 different ICU units and examined the relationship between the number of certified ICU nurses and three nurse sensitive outcomes: There were no significant relationships with certification and any of the three nurse sensitive outcomes. Int erestin gly, Kendall Gallagher and Blege infections as those in the blood stream and central line infections as opposed to Krapohl and colleagues who did not separate these infections but rather combined them in the analysis.
This m ay explain the differences in outcome results. Both studies, however, found no effect on skin breakdown with increased numbers of certified ICU nurses. These findings are not consistent with previous studies that found positive correlation between nurses c ertified in wound therapy and decreased pressure ulcer prevalence Bergquist Beringer et al. Boltz and colleagues performed a descriptive retrospective study of 35 medical units and 9 medical surgic al units and found no relationship with nurse certification and injurious falls, pressure ulcer development, and restraint use.
However, certification was a sig nificant predictor of fall rate, such that, as the number of certified nurses increased on the unit, the number of falls decreased. These findings were consistent with Kendall findings on fall rates in intensive care units.
Both studies had small samples sizes and were limited to special ty nursing units. PAGE 40 40 There are sever al outcome studies that examined the effects of oncology nurse certification and the ability to assess, document, and treat nausea, vomiting, and pain critical to cancer patients. Findings are however conflicting.
Frank Stromberg et al. One hundred eighty one charts of 7 certified oncology nurses and 13 noncertified nurses were assessed. Documentation and interventions reviewed included the symptom management for chemotherapy induced patient factors such as pain, nausea, and fatigue; adverse patient outcomes from infections or skin breakdown and unexpected care issues requiring hospitalization or additional home visits.
The oncology certified nurses had more experience in RN years, oncology practice, and home care as opposed to the noncertified nurses. There were no significant differences in documentation of pain assessments initial or ongoinginitial fatigue assessment, or unplanned episodic care interventions between groups. Patients receiving care from certified nurses had more frequent documentation of ongoing fatigue assessment and infections, and fewer documentation entries of patient teaching than patients under t he care of noncertified nurses.
Because this study is limited by its retrospective chart review, a small sample size of both patients and nurses, and data from only one ho me care agency, it is difficult to generalize the results. The patients completed three questionnaires that addressed the following: The nurses completed questionnaires that measured nurses perceptions on the following: The researchers also conducted a chart audit to verify documentation on symptoms and management of chemotherapy induced nausea and vomiting.
Certified nurses had more continuing education and a higher knowledge base of chemotherapeutic nausea and pai n than noncertified nurses. The patient respondents indicated satisfaction with their care but were unable to differentiate care from a certif ied versus noncertified nurse. There was no significant differ ence in documentation, care, or management of cancer symptoms between the groups. This study was limited because it was conducted at one academic center and the sample size was small for certified and noncertified nurses.
Years of Nursing Experience Development of Experience The conventional thought is that experience over time leads to better performance and outcomes. Studies support this premise when comparing accident rates with novice and experienced drivers.
The relationship between nurse staffing and patient outcomes.
Unfortunately, the research is not as clear in studies dealing with nursing experie nce. Benner addressed the role of experiential learning w hen outlining the five stages of clinical proficiency and explaining how a nurse moves from one stage to another in developing co mpetence and clinical judgment. As a researcher, Benner is cautious in labeling a specific time frame for each stage explaining proficiency progression requires sequentially higher levels of competency, judgment, and intuitive decision making.
While exposure and repeated practice reinforces critical thinking and judgment, research is both limited and unclear in defining how and what impact years of nurse experi ence have on patient outcomes.
Rapid technological changes and exposu re to volumes of potential errors add to the confusion when relating outcomes to years of experience. Changes in technology, information, and organizational priorities demand continuous education and adaptability by the experienced health care practitioner For example, Choudhry, Fletcher, and Soumerai conducted an extensive review of literature for the purpose of exploring the relationship of years of physician experience to quality of care and mortality rates.
Despite limited ar ticles 62 address ing the PAGE 43 43 concern, they found a negative association between years of experience and quality of care, indicating as years of physician experience increased, performance and quality outcomes decreased.
Researchers hypothesized that senior physicians may lack continuing education and exposure to new modalities and treatments resulting in poor quality outcomes.
The Relationship of Nursing Workforce Characteristics to Patient Outcomes
When examining nurses, Atencio, Cohen, and Gorenberg found a decline in perceived autonomy and task orientation as years of nursing experience in creased. Atencio and colleagues performed a longitudinal, descriptive study on nurses with repeated surveys every 6 months for two years to determine their perceptions on autonomy, task or ientation, and intent to leave.
The nurses with less experience perceived more autonomy than experienced nurses in terms of freedom to make decisions, use of initiative for patient care issues, and independent functioning.
The nurses with less experience also perceived higher task orientation than experienced nurses in terms of perceived efficiency in the wor k unit, work oriented attitudes, and work completion as a priority Atenc io, et al Experience and Nurse Sensitive Outcomes Research is both limited and contradictory when exploring the relationship between nurse years of experience and nurse sensi tive outcomes.
The predominate focus of research on years of experience has been on 30 day mortality rates and failure to rescue Aiken et al.
The research found years of experience have no effect on mortality rates and failure to rescue. This PAGE 44 44 study explores the relationship of nurse experience to nurse sensitive outcomes other than mortality and failure to rescue.
The following section will address research examining the relationship of nursing experience with nurse sensitive ou tcomes pertinent to this study. Blegen,Vaughn, and Goode conducted a secondary analysis of data from two previous studies to examine the effect of years of experience and nurse education on falls and medication errors. The combine d data did support an inverse relationship of medication errors and years of exp erience, such that, the more experienced the nurse, the fewer medication errors.
An interesting finding from the secondary analysis was that more medication errors occurred on units with higher ratios of BSN nurses. The researchers explained the result as an effect of less experienced but mo re BSN graduates on the units. Repeated exposure over time to a volume of potential errors complicates the critique of years of experience t o patient outcome measurements, particular ly medication error tracking. Kendall Gallagher and Blegen reported an increase in medication errors with increased clinical nursing experience but explained the finding as a result of administeri ng more med ications over time.
Clarke, Rockett, Sloane, and Aiken expressed similar concerns when studying needlestick injuries. They studied nurses in 22 hospitals for the purpose of determining how staffing and organizational climate affe ct patient and nurse outcomes.
Part of the study involved questionnaire data on needl estick exposures and injuries. While the experienced nurse PAGE 45 45 had a higher exposure rate, the inexperienced nurse had a 1. Research on the relationship of years of nursing experience and fall rates are contradictory. Blegen, Goode, and Reed found a significant relationship between the nurse experience and rates of falls support ing the more experienced the nurse, the fewer the fall rate.
In contrast, Blegen and Vaughn found no significant relationship between years of experience and fall rate from the study of 39 units and 11 hospitals. In a more recent study, Dunton, Gajewski, Klaus, and Pierson conducted a review of 8 of the15 quality indicators from the NDNQI noting a lowering in the fall rate b y 1 percent for every increase in year of RN experience. In addition, an inverse relationship with years of experience and hospital acquired pressure ulcers HAPU indicating a decrease of pressure ulcers of 1.
In current research, there are conflicting findings concerning the relationship between nurse years of experience and their clinical assessment of patient care needs. James, Simpson, and Knox conducted a qualitative study of 54 ex pert labor the care of labor and the birth process provided the intuitive nursing knowledge necessary to make a differen ce in labor and birth outcomes.
The more experien ced the nurse, the better able the laboring mother was to proceed through the laboring and birth process. S imilarly, Ross and Bell studied nurses who worked in 10 critical access hospitals 30 beds or less to determine their comfort levels with eme rgency PAGE 46 46 interventions based on their years of experience and certification status.
Nurses who were certified and who had 6 or more years of experience reported higher levels of confidence 78 percent comfort level when compared to nurses with less ex perien ce and no certification. On the other hand, Considine, Botti, and Thomas conducted a literature review noting five studies investigating the relationship of knowledge and experience in triage decision making and found no significant relationship bet ween years of nursing experience, particularly emergency room nursing experie nce and triage decision making.
Similarly, Marcin, et al. Simulations were conducted in other studies to observe nurse reactions to emergent clinical situati ons.
There were limitat ions in this study in that these were not real time emergencies. Yang and Thompson studied the differences with student nurses and experienced nurses with paper based scenarios using manikin simulated patient scenarios. They found no significant dif ferences in nurse judgment for students or expert nurses. The study limitations includes use of only one hospital group of nurses, students from only one school of nursing, and the inability to mock emergency situations when using a paper based test with manikin simulations.
With limited confirmation on the impact of PAGE 47 47 years of experience on nurse sensitive outcomes, researchers turn to education as another possible indicator to eva luate quality of care. Education The Institute of Medicine recommended to increase the number of BSN prepared nurses from 50 percent to 80 percent of staff by based on research showing a positive relationship of educational level on patient care outcomes.
Research does confirm a relationship between educational level of the nurse and 30 day mortal ity and failure to rescue rates, such that, the an increase in the proportion of hospital BSN prepared nurses leads to a decrease in failure to rescue and mortality rate Aiken et al.
This study purposefully addresses other hospital bas ed nurse sensitive outcomes. There level on other nurse sensitive outcomes. Blegen, Vaughn, and Goode conducted a secondary analysis using data from two earlier studies for the purpose of determining the eff ect of education and experience on medication errors and fall rates. However, educational level was positive ly related to medication errors, such that, units with higher numbers of BSN nurses had hig her rates of medication errors.
While these data sets have information on a large number of patient outcomes, the nursing workforce indicators are quite limited. Second, analysts have obtained data from individual states or subsets of hospital surveys, administrative data, or hospital primary data collections. The California Nursing Outcomes Coalition Database and the Veterans Administration Nursing Outcomes Database are good examples of datasets that have unit-level information on both a variety of nursing workforce characteristic and patient outcomes for a subset of the nation's hospitals.
Third, some analysts have collected data from convenience samples of a small number of hospitals to which they have access. It is questionable whether findings from these convenience-sample studies can be generalized to larger populations. Finally, most studies are based on cross-sectional data sets.
These data sets do not allow the analyst to study trends or estimate lagged effects. Understanding these trends or lagged effects could contribute to a causal understanding of the relationship between nursing indicators and patient outcomes. In summary, advancing our knowledge of the relationship between nursing workforce attributes and patient outcomes will come from the use of data sets which support hierarchical analyses; additional attributes of the nursing workforce; unit-level data; and large, representative, longitudinal data sets.
The NDNQI was developed in a way that addresses many of the limitations encountered by researchers working with other data sets as described above. The NDNQI will support hierarchical models of multiple nursing workforce indicators and patient outcomes.
It is a large, longitudinal database, with unit-level data and national, although not representative, coverage. Over 1, hospital report quarterly data on nursing workforce characteristics, including process measures, and patient outcomes.
InoverRNs responded to the survey. NDNQI is a longitudinal database. Data were first reported to NDNQI for the third quarter of by 23 hospitals, and the number of reporting hospitals has grown steadily over the ensuing 31 quarters.
The RN Survey data have been collected annually since Data are collected for eight unit types: RN Survey data are collected for all hospital unit types, including outpatient and interventional units. NDNQI contains many structure, process, and outcomes indicators. Measures of unit structure include unit type and over two dozen characteristics of the nursing workforce, including but not limited to: Measures of nursing process include percent of patients with a risk assessment and, for those at risk, whether a prevention protocol was in place.
Outcome measures include the patient fall rate, injury fall rate, hospital-acquired pressure ulcer rate, psychiatric patient injury assault rate, prevalence of pediatric IV infiltration, completeness of the pain assessment cycle for pediatric patients, and restraint prevalence.
Data are collected on 8 of the 15 National Quality Forum Consensus measures, which have demonstrated reliability and validity. The reliability of satisfaction data from the RN survey is confirmed annually. The average response rate is 64 percent. Hospitals choose to participate in NDNQI because of their interest in the quality of nursing care and because they have the staff, data, and economic resources to participate. Due to differences in variable definitions and reference time period, however, the comparisons are not definitive.
Although the large sample sizes result in even minor differences achieving statistical significance, many of the characteristics are substantively different as well.