Nurse Staffing, the Clinical Work Environment, and Burn Patient Mortality

Nurses' intention to leave, nurse workload and in-hospital patient mortality in Italy: A descriptive and regression study

Higher nurse-to-patient ratios are associated with poor patient care and adverse nurse outcomes, including emotional exhaustion and intention to leave. We examined the effect of nurses' intention to leave and nurse-patient workload on in-hospital patient mortality in Italy. A multicentered descriptive and regression study using clinical data of patients aged 50 years or older with a hospital stay of at least two days admitted to surgical wards linked with nurse variables including workload and education levels, work environment, job satisfaction, intention to leave, nurses' perception of quality and safety of care, and emotional exhaustion. The final dataset included 15 hospitals, 1046 nurses, and 37,494 patients. A 10 % increase in intention to leave and an increase of one unit in nurse-patient workload increased likelihood of inpatient hospital mortality by 14 % (odds ratio 1.14; 1.02-1.27 95 % CI) and 3.4 % (odds ratio 1.03; 1.00-1.06 95 % CI), respectively. No other studies have reported a significant association between intention to leave and patient mortality. To improve patient outcomes, the healthcare system in Italy needs to implement policies on safe human resources policy stewardship, leadership, and governance to ensure nurse wellbeing, higher levels of safety, and quality nursing care.

Emergency Nurses' Reasons for Not Recommending Their Hospital to Clinicians as a Good Place to Work

Importance

Half of emergency nurses report high burnout and intend to leave their job in the next year. Whether emergency nurses would recommend their workplace to other clinicians may be an important indicator of a hospital's ability to recruit clinicians.

Objective

To examine why emergency nurses do not recommend their hospital to other clinicians as a good place to work.

Design, Setting, and Participants

This qualitative study used directed content analysis of open-text responses (n = 142) from the RN4CAST-NY/IL survey of registered nurses licensed in New York and Illinois between April 13 and June 22, 2021. Inductive and deductive analytic approaches guided study theme development informed by the Social Ecological Model. The collected data were analyzed from April to June 2023.

Main Outcomes and Measures

Nurses who answered "probably not" or "definitely not" to the survey question, "Would you recommend your place of employment as a good place to work?" were prompted to provide a rationale in an open-text response.

Results

In this qualitative study of 142 emergency nurses (mean [SD] age, 43.5 [12.5] years; 113 [79.6%] female; mean [SD] experience, 14.0 [12.2] years), 94 (66.2%) were licensed to work in New York and the other 48 (33.8%) in Illinois. Five themes and associated subthemes emerged from the data. Themes conveyed understaffing of nurses and ancillary support (theme 1: unlimited patients with limited support); inadequate responsiveness from unit management to work environment safety concerns (theme 2: unanswered calls for help); perceptions that nurses' licenses were in jeopardy given unsafe working conditions and compromised care quality (theme 3: license always on the line); workplace violence on a patient-to-nurse, clinician-to-nurse, and systems level (theme 4: multidimensional workplace violence); and nurse reports of being undervalued by hospital management and unfulfilled at work in delivering suboptimal care to patients in unsafe working conditions (theme 5: undervalued and unfulfilled).

Conclusions and Relevance

This study found that emergency department nurses did not recommend their workplace to other clinicians as a good place to work because of poor nurse and ancillary staffing, nonresponsive hospital leadership, unsafe working conditions, workplace violence, and a lack of feeling valued. These findings inform aspects of the work environment that employers can address to improve nurse recruitment and retention.

Mortality Among the Dementia Population in Not-For-Profit Hospitals with Better Nursing Resources

The dementia population has higher rates of mortality during hospital stays than those without dementia. The aim of this study is to examine the relationship between ownership status (i.e. for-profit vs. not-for-profit) and nursing resources (i.e. nurse work environment, nurse-to-patient staffing, and nurse education) on 30-day mortality among post-surgical older adults with dementia. A cross-sectional analysis of linked American Hospital Association, Medicare claims, and nurse survey data was conducted using multi-level logistic regression models. We examined these models to assess the relationship between ownership status and 30-day mortality after adjusting patient and hospital characteristics. We also analyzed the relationship between the hospital ownership status and the 30-day mortality, after considering the three nursing resources. Older adults with dementia who received care in hospitals with not-for-profit status were less likely to die within 30 days of admission following surgery compared to those treated in hospitals with for-profit hospital status (i.e. odds ratio 0.82, 95% confidence interval 0.73-0.92, p = <.001). In addition, the odds ratios estimating the association between ownership and mortality were similar across the different models of the three nursing resources with and without those controls (i.e. 0.88 vs. 0.83 vs. 0.82). Surgical patients with dementia had better outcomes when cared for in not-for-profit hospitals, particularly with greater levels of nurse education and nurse staffing. The relationship between profit status and mortality was partly explained by the lower levels of nurse staffing and education in for-profit vs. not-for-profit hospitals.

Left Without Being Seen: Nurse Work Environment and Timely Outcomes in New York and Illinois Emergency Departments

INTRODUCTION

This study determined the relationship between the emergency nurse work environment and emergency department patient left without being seen rates and lengths of stay.

METHODS

Cross-sectional analysis of 215 New York and Illinois emergency departments. The work environment (abbreviated Practice Environment Scale of the Nursing Work Index) was measured by emergency nurses in the 2021 RN4CAST-NY/IL survey and linked with outcomes from Hospital Compare. Regression models estimated the relationship between the nurse work environment and emergency department patient left without being seen rates, median length of stay (in minutes), and median behavioral health patient length of stay. Model coefficients were used to estimate expected additional care minutes gained if emergency department work environments improved.

RESULTS

"Mixed" work environments had the longest median overall length of stay (3.4 hours) and the highest median left without being seen rates (2.2%), while "poor" work environments had the longest median length of stay for behavioral health patients (6 hours). Improving the emergency department work environment from poor to mixed (and mixed to better) was associated with a 13-minute reduction in overall length of stay (P ≤ .05), a 33-minute reduction in behavioral health length of stay (P ≤ .01), and a 19% reduction in left without being seen rates (P ≤ .01). We estimated 11,824 to 41,071 additional patients could be seen in emergency departments associated with work environment improvements from "poor" to "better," depending on annual patient volumes.

DISCUSSION

Hospital administrators should consider investing in nurse work environments as a foundation to improve timely outcomes.

Moral distress among nurse leaders: A qualitative systematic review

Moral distress (MD) is well-documented within the nursing literature and occurs when constraints prevent a correct course of action from being implemented. The measured frequency of MD has increased among nurses over recent years, especially since the COVID-19 Pandemic. MD is less understood among nurse leaders than other populations of nurses. A qualitative systematic review was conducted with the aim to synthesize the experiences of MD among nurse leaders. This review involved a search of three databases (Medline, CINAHL, and APA PsychINFO) which resulted in the retrieval of 303 articles. PRISMA review criteria guided authors during the article review and selection process. Following the review, six articles were identified meeting review criteria and quality was assessed using the Critical Appraisal Skills Programme (CASP) Checklist for qualitative studies. No ethical review was required for this systematic review. The six studies included in this review originated from the United States, Brazil, Turkey, and Iran. Leadership roles ranged from unit-based leadership to executive leadership. Assigned quality scores based upon CASP criteria ranged from 6 to 9 (moderate to high quality). Three analytical themes emerged from the synthesis: (1) moral distress is consuming; (2) constrained by the system; and (3) adapt to overcome. The unique contributors of MD among nurse leaders include the leadership role itself and challenges navigating moral situations as they arise. The nurse leader perspective should be considered in the development of future MD interventions.

The association of the emergency department work environment on patient care and nurse job outcomes

Objective

To determine the association between emergency nurses' work environments and patient care quality and safety, and nurse burnout, intent to leave, and job dissatisfaction.

Methods

Cross-sectional study of 221 hospitals in New York and Illinois informed by surveys from 746 emergency nurses and 6932 inpatient nurses with linked data on hospital characteristics from American Hospital Association Annual Hospital Survey. The RN4CAST-NY/IL study surveyed all registered nurses in New York and Illinois between April and June 2021 about patient safety, care quality, burnout, intent to leave, and job dissatisfaction and aggregated their responses to specific hospitals where they practiced. Work environment quality was measured using the abbreviated Practice Environment Scale of the Nursing Work Index. Generalized estimating equations were used to determine the relationship between emergency nurses' work environments on patient care and nurse job outcomes.

Results

A total of 58% of emergency nurses reported high burnout, 39% reported job dissatisfaction, and 27% indicated intent to leave their job in the next year. Nurses in hospitals with good (vs mixed) or mixed (vs poor) emergency work environments were less likely to report unfavorable patient care quality and hospital safety grades, and were less likely to experience high burnout, job dissatisfaction, and intentions to leave the job, by factors ranging from odds ratio (OR) 0.21 (95% confidence interval [CI], 0.16-0.29) to OR 0.46 (95% CI, 0.34-0.61).

Conclusions

Given the complex and high stakes nature of emergency nursing care, leaders should place a high priority on organizational solutions targeting improved nurse staffing and work environments to advance better patient and clinician outcomes.

Occupational Burnout Symptoms and Its Relationship With Workload and Fear of the SARS-CoV-2 Pandemic Among Hospital Nurses

Introduction

The pandemic has intensified physical and psychological work demands experienced by nurses in a hospital environment. The purpose of this study was to examine personal and work environmental risk factors associated with occupational burnout among hospital nurses.

Methods

We conducted a cross-sectional from April to November 2020. Data from 831 nurses who worked professionally in four educational hospitals were compiled through survey questionnaires to report the prevalence of burnout, occupational and individual factors. Independent t-test and Mann–Whitney test measured the link between the scopes of occupational burnout and risk factors.

Results

About half of the participants indicated moderate symptoms of burnout. The fear of the nurses correlated significantly with emotional exhaustion (r = 0.71, p = 0.001), depersonalization (r = 0.67, p = 0.02), and personal accomplishment (r = 0.63, p = 0.05). Mental demand (r = 0.74, p = 0.01) and effort at work (r = 0.68, 0.001) correlated significantly with emotional exhaustion (r = 0.51, p = 0.03).

Conclusion

The findings indicated a high prevalence of burnout symptoms, particularly emotional exhaustion, among hospital nursing professionals. Occupational health services should consider burnout as an occupational-related condition and provide interventions to reduce workplace chronic stressors and burnout in hospitals.

Racial Disparities in Stroke Readmissions Reduced in Hospitals With Better Nurse Staffing

BACKGROUND

Racial minorities are disproportionately affected by stroke, with Black patients experiencing worse poststroke outcomes than White patients. A modifiable aspect of acute stroke care delivery not yet examined is whether disparities in stroke outcomes are related to hospital nurse staffing levels.

OBJECTIVES

The aim of this study was to determine whether 7- and 30-day readmission disparities between Black and White patients were associated with nurse staffing levels.

METHODS

We conducted a secondary analysis of 542 hospitals in four states. Risk-adjusted, logistic regression models were used to determine the association of nurse staffing with 7- and 30-day all-cause readmissions for Black and White ischemic stroke patients.

RESULTS

Our sample included 98,150 ischemic stroke patients (87% White, 13% Black). Thirty-day readmission rates were 10.4% (12.7% for Black patients, 10.0% for White patients). In models accounting for hospital and patient characteristics, the odds of 30-day readmissions were higher for Black than White patients. A significant interaction was found between race and nurse staffing, with Black patients experiencing higher odds of 30- and 7-day readmissions for each additional patient cared for by a nurse. In the best-staffed hospitals (less than three patients per nurse), Black and White stroke patients' disparities were no longer significant.

DISCUSSION

Disparities in readmissions between Black and White stroke patients may be linked to the level of nurse staffing in the hospitals where they receive care. Tailoring nurse staffing levels to meet the needs of Black ischemic stroke patients represents a promising intervention to address systemic inequities linked to readmission disparities among minority stroke patients.

Is Hospital Nurse Staffing Legislation in the Public's Interest?: An Observational Study in New York State

BACKGROUND

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.

OBJECTIVES

To examine variation in patient-to-nurse staffing in NY hospitals and its association with adverse outcomes (ie, mortality and avoidable costs).

RESEARCH DESIGN

Cross-sectional data on nurse staffing in 116 acute care general hospitals in NY are linked with Medicare claims data.

SUBJECTS

A total of 417,861 Medicare medical and surgical patients.

MEASURES

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.

RESULTS

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.

CONCLUSIONS

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.

Scale for the Environment Evaluation of Professional Nursing Practice: Construct validation

AIM

Testing the validity and reliability of the Scale for the Environment Evaluation of Professional Nursing Practice (SEE-Nursing Practice).

BACKGROUND

The environment of professional nursing practice is key to achieve better results for clients, nurses and institutions. Therefore, instruments enabling the assessment of all its attributes are required.

METHOD

Cross-sectional methodological study. The SEE-Nursing Practice, based on a previous qualitative study and literature review, was applied as a questionnaire. Exploratory and confirmatory factor analyses were used to assess construct validity.

RESULTS

A total of 752 nurses participated in the study. Exploratory factor analysis of the SEE-Nursing Practice led to a factor solution with 93 items and three subscales. The Structure, Process and Outcome subscales, respectively, have 43, 37 and 13 items, loaded in 6 factors, 6 factors and 2 factors and explaining 62.6%, 59.2% and 67.4% of the total variance. Cronbach's alpha of the overall scale and of the 3 subscales was greater than 0.90. Confirmatory factor analysis showed a good fit.

CONCLUSION

SEE-Nursing Practice is a good valid and reliable instrument.

IMPLICATIONS FOR NURSING MANAGEMENT

The SEE-Nursing Practice enables assessing practice environments and is a tool for nursing managers in the definition of strategies ensuring favourable environments for nursing care quality.